The elbow and forearm - fractures and dislocation

elbow role

lengthening and shortening upper limb to reach and bring objects near the body

forearm role

positioning of the hand

anatomy of elbow and forearm

trochlea and ulnar articulate, capitulum and head of radius articulature

ulnar collateral ligament bands

anterior, posterior and oblique

ulnar collateral ligament inserts on

medial epicondyle of humerus and onto ulna

UCL role

primary stabilizer of elbow, anterior is primary stabilizer and most often implicated in valgus stress injuries of throwers

any malalignment of the elbow or calcification will

lead to decreased motion

radial collateral ligament originates on

lateral humeral epicondyle and extends across the lateral joint space inserting on proximal head of radius and annular ligament (less often injured)

antecubital space

location of brachial artery and median nerve (traumatic injuries can impact nerves)

flexion of elbow

140

supination of elbow

80-90

pronation of elbow

80-90

extension endfeel

cartilaginous, capsular with slow fulcrum motion (contact of olecranon process and fossa)

flexion endfeel

soft tissue approximation, cartilaginous if patient is thin (coronoid and coronoid fossa)

capsular pattern of elbow

flexion, extension (pronation/supination not affected unless severe long term situation)

conditions presenting with elbow capsular pattern

OA and RA

conditions presenting in noncapsular pattern of elbow

loose body in joint (springy), OA with loose body, ligamentous sprain

alignment of elbow

physiological valgus/carrying angle of 5 deg in men, 10-15 deg in women

humeroulnar joint resting position

70 deg flexion, 10 deg supinated

humeroulnar joint close packed postion

full extension

radiohumeral resting position

full extension, full supination

radiohumeral close packed postion

90 flexion

proximal radioulnar joint resting position

70 deg flexion, 35 deg supination

proximal radioulnar joint close packed position

max pronation or supination

distal radioulnar joint resting position

10 deg supination

distal radioulnar joint close packed postion

max pronation or supination

the most freqeunt elbow injuries are

fractures and dislocations

elbow rehab is difficulty following traumatic injury

due to bleeding and resulting fibrosis - challenging to regain normal motion - want to avoid stiffness

most freqeunt site of abnormal bone on bone endfeel

elbow

supracondylar fracture

fracture of humerus above condyles, usually via trauma

treatment of supracondyler fracture

ORIF to permit early motion, sling 3-4 weeks for comfort and take off for ROM, followed by comprehensive rehab of strength and function

complications of supracondylar fracture

potentially limb threatening due to network of nerves and blood vessels, volkmanns ischemic contracture, myositis ossificans

humeral medial epicondyle fracture

fracture/avulsion of medial epicondylar epiphysis (wrist flexor insertion), common in adolescents, usually due to direct trauma or repetitive valgus stress overload with pithcing

treatment of humeral medial epicondyle fracture

ORIF followed by rehab, motion started 5-10 days later, throwing in 3-4 months, screw eventually removed to avoid future soft tissue irritation

if casted, elbow ROM is

difficult to recover and chance of nonunion subsequenctly requiring surgery - not best option (required with displacement)

radial head fracture

fracture of radial head (lots of variety), usually due to FOOSH causing compression between radial head and capitulum

treatment for radial head fracture

early motion if not displaced, if displaced ORIF then early motion and rehab, resection if comminution and potential head replacement

complications of radial head fracture

resultant length of radius - loss of articulation with varying lengths can cause wrist pain - can do radiograph to cornfirm

olecranon fracture

fracture/avulsion of olecranon process, usually due to direct trauma and sometimes from forceful contraction of biceps

treatment of olecranon fracture

ORIF and prolonged rehab

complex fracture

multiple fractures potentially affecting distal end of humerus and proximal ends of radius and ulna, usually due to significant direct trauma

treatment for complex fracture

ORIF followed by rehab

complications of complex fracture

permanent limited ROM, permanent malalignments

to measure alignment of elbow

condyles form straight line in elbow extension, condyles and olecranon form equal triangle in flexion

ROM exercises post elbow fracture

low load long duration stretches for plastic organization and reorganization of tissue, do with forearm pronated with shoulder IR to lock humerus into position, STM, dynamic constant passive stretching devices

strength exercises post elbow fracture

isometrics - isotonics - plyometrics - bias toward eccentric (use band to fully work muscle group through range, not hammer)

most classic forearm fractures

night stick, both bone forearm, menteggias, galeazzis

night stick fracture

isolated fracture of ulnar via direct trauma

treatment of night stick fracture

splint or ORIF followed by rehab

both bone froearm fracture

fracture of midshaft of both radius and ulna via direct trauma

both bone forearm fracture treatment

ORIF followed by rehab

monteggia's fracture

fracture of ulnar with dislocation of head of radius via direct trauma

treatment of moteggias fracture

ORIF followed by rehab

galeazzis fracture

fracture of distal shaft of radius with subluxation/dislocation of distal RU joint via direct trauma

treatment for galeazzis fracture

ORIF followed by rehab

colles fracture

fracture at distal end of radius with dorsal displacemetn of distal segment - most common fracture of wrist/silver fork deformity, FOOSH

treatment of colles fracture

typically external reduction and immobilization followed by rehab (plate on dorsal forearm), or ORIF but may not regain most optimal ROM

smith fracture

fracture of distal end of radius with ventral displacement of distal segment, rare/garden spade deformity, FOOSH

treatment of smith fracture

typically external reduction and immobilization followed by rehab

with all forearm fractures

the resultant length of radius and ulna is primary concern to maintain anatomical relationship of distal ends of radius and ulna at wrist

elbow dislocation

most common in posterior direction, usually via FOOSH or external force resulting in elbow hyperextension

treatment of elbow dislocation

careful reduction in ER due to potential injury to local vascular or neurological structures, following reduction possibly immobilize if fracture or unstable, ORIF if fracture, followed by rehab, early motion when possible followed by progressive rehab, bracing or taping to prevent hyperextension for athletes

most elbow dislocations dont have

fracture or instability - no surgery or immobilization needed usually

casting leads to

stability at the expense of decreased mobility

short immobilization leads to

increased mobility at the expense of stability

complications of elbow fractures

fractures most often in radial head, volkmann's ischemic contracture or myositis ossificans

radial head adult dislocation

most often combined with monteggia fracture, isolated is rare due to strength of annular ligament, usually via forced pronation for isolated

treatment of adult radial head dislocation

open reduction followed by prolonged period of immobilization then rehab (radiograph in many angles if suspicious as its hard to see)

radial head dislocation in children

radial head slips in distal direction out of annular ligament (children have more laxity and less formation), nursemaid's elbow, usually via traction with pronation

radial head dislocation in children can occur via

lifting or pulling child by hand with elbow extended and forearm pronated, traction forces on radius - hold child by forearm for better distribution of forces over ulna and radius

treatment of radial head dislocation

easily reduced by pushing the forearm upwards and rotating it alternately into supination and pronation, reduction may be followed by wearing sling with elbow flexed and supinated, educate on avoidance

myositis ossifican

ossification of brachialis muscle secondary to injury to brachialis muscle or supracondylar fracture with related soft tissue injuries affecting brachialis or elbow dislocation with related soft tissue injuries affecting brachialis

due to injury occuring at interface of brachialis and humerus

repair process may include ossification of soft tissue

occurence of myositis ossificans are associated with

repeated injuries or prolonged inflammation

treatment for myositis ossificans

prevention through avoidance of repetitive injuries or prolonged inflamamtion (avoid re-injury, avoid heart and massage during acute painful stages, gental ROM within tolerance)

natural history of myositis ossificans - metabolically active stage

progressive calcification of brachialis over several weeks/months, continued pain and difficulty with ROM, palpable mass if large enough, monitored with bone scan for increased metabolic activity in region - relative rest and gentle ROM to maintain motion and control inflammation

natural history of myositis ossificans - once no longer metabolically active

treat with progressive ROM and strength, therapeutic ultrasound may help break up calcification, surgical removal possible if continued pain and dysfunction (risk reoccurence postop)

volkmann's ischemic contracture

vascular compromise at elbow or forearm due to injury or compression of brachial artery, decreased vascular supply to wrist flexors leads to necrosis and fibrous changes of muscle tissue

volkmanns ischemic contracture looks like

hand/wrist and fingers into flexion except MCPs due to passive tension on extensor digitorum

volkmanns ischemic contracture can be secondary to

excessive swelling constrained by cast resulting in decreased BF or brachial artery injury following supracondylar fracture or elbow dislocation (compartment syndrome)

signs/symptoms of volkmann's fracture

ischemic pain, white/blue coloration of forearm and hand, absence of distal pulse

fibrosis of forearm musculature with volkmanns will lead to classic deformity of

flexion contracture at wrist, hyperextension of MCP (unopposed extensors), flexion contracture of IP joints

treatment for volkmanns

exercises for PROM and AROM, splinting in functional hand position to prevent deformity, vascular surgery if necessary

functional position of hand

wrist in 20 deg extension, MCP in 45 deg of flexion, IP in extension and thumb in 40 deg extension/abduction