4. Introduction
• Most common fractures of elbow
• Isolated or as part of more complex elbow injury
• Common in ages group 20 - 60 years
• Most fractures are treated conservatively
• Nonunion and fracture displacement are rare
5. Applied Anatomy
• Hinged joint supported by strong collateral
ligaments
• Radial head articulates with Capitulum
• Medial ulna articulates with trochlea
• Neurovascular structures running down arm pass
anterior and posterior to joint
9. Biceps
Brachialis
Ulnar nerve
Median nerve
Brachial artery
Radial nerve
Joint capsule of elbow
Brachioradialis
Arcade of Frohse
Deep branch of radial nerve
Superficial branch
of radial nerve
Radial artery
Biceps tendon
Ulnar artery
Median nerve
Anterior interosseous nerve
Musculocutaneous
nerve
10. PATHOANATOMY
• Concave dish of radial head
articulates with capitellum
• Flattened articular margin
articulates with sigmoid
(radial) notch of ulna
11. PATHOANATOMY
• Nonarticular margin(1/3rd ) - more rounded and
often devoid of cartilage
• “safe zone” for placement of a plate on the
nonarticular margin
• Vascular supply of the radial head is supplied by
branches of the radial recurrent artery
12. Mechanisms of Injury for Radial
Head Fractures
• Low energy mechanisms fall from standing
height
• Higher-energy fractures like Sports, motor
vehicle collisions
1. Valgus load
Impaction of radial head into the capitellum
Fracture of radial head
Associated with Rupture of the MCL
13. …..contd
2. Trauma
Postero-lateral rotatory subluxation of radial head
Redial head impaction over capitellum
Fracture of anterior portion of radial head,
Associated with rupture of LCL.
14. …..contd
High velocity Trauma
An axial forearm load
Radial head impaction with capitellum
Radial head fracture
May be associate With fracture of coronoid or
rupture of the interosseous membrane and distal
radioulnar joint ligaments
15. Associated Injuries with Radial
Head Fractures
• Tears of LCLs and/or MCLs
• Dislocations of elbow
• Fractures of the coronoid, capitellum, olecranon
• Rupture of the interosseous membrane
16. Signs and Symptoms
• Pain
• Swelling
• Stiffness of elbow
• Ecchymosis
• Tenderness over lateral epicondyle or medial
epicondyle
17. Signs and Symptoms
• Loss of terminal extension
• Shoulder and wrist joint examined for associated
injuries
• May associate with Distal radio-ulnar joint
tenderness and instability
22. MRI
• While magnetic resonance imaging may be useful
to define the presence of associated collateral
ligament injuries
23. Classification
Mason
Type I : fracture as a fissure or marginal sector
fracture without displacement;
Type II : as a marginal sector fracture with
displacement
Type III :as a comminuted fracture involving the
whole head
Type IV : injury was subsequently described
which includes any radial head fracture
associated with an elbow dislocation
27. Non operative treatment
• Most radial head fractures are treated conservatively
(Mason types I and II)
• Nonunion and fracture displacement are rare
• Undisplaced or minimally displaced radial head
fractures
• Radial head fractures without motion impairment
28. …..contd
• Immobilized for 2 or 3 days for comfort
• Active motion is encouraged
• Aspiration of hemarthrosis
• Careful radiographic and clinical follow-up
30. Operative treatment
• Younger patients with three or fewer fragments
• Displaced fracture > 2 mm
• Fracture involving >30% of the articular surface
• Mason types II and III fractures
• Radial head fractures with motion impairment
31. TREATMENT OF MASON
TYPE II FRACTURES
• Mini-fragment screws, with or without buttress plate
placed
• If remaining articular surface is small, resection with
radial head replacement is necessary
• If the elbow is stable, resection without replacement
has shown good results
32.
33. TREATMENT OF MASON
TYPE III FRACTURES
• High velocity injury
• May occur with elbow dislocation
• Less frequently appropriate for ORIF
• Radial head resection may be a good option
• Prosthetic replacement with metallic implants
34. ….contd
• Unreconstructable comminuted - Radial head
arthroplasty
• Contraindication Radial head arthroplasty
Gross wound contamination
Radial neck cannot be reconstructed
Capitellum is deficient or missing
37. • Expose radiohumeral
joint.
• Elevate brachioradialis
and extensor carpi
radialis longus muscles
• Incise capsule to expose
lateral aspect of the
elbow joint.
38. LATERAL J-SHAPED APPROACH
TO THE ELBOW (KOCHER)
• Incision
• Separate ecu from
anconeus
• Divide distal fibers
anconeus
• Reflect common origin of
extensor muscles
• Incise the joint capsule
longitudinally
39. Postoperative Care:
• Arm placed in molded above elbow back slab at 90º
• At 3 to 7 days, splint removed and arm supported sling
• Active and active assisted exercise are begun
• Discontinue sling at 3 weeks
• Strengthening performed after fracture healing is
secure
• Indomethacin for a 3-week period in order to prevent
heterotopic ossification.
41. Introduction
• Accounts for 8% to 10% of all elbow fractures
• younger individuals - high-energy trauma
• older individuals - simple fall
• May associate with transolecranon fracture
dislocations
42. PATHOANATOMY AND
APPLIED ANATOMY
• Contributes to two articulations
Ulnohumeral joint
Proximal radioulnar joint
• Triceps tendon insertion onto at tip of olecranon
43. Mechanisms of Injury for
Posterior Ulna Fractures
• Result from either direct or indirect elbow trauma
Direct trauma - falling on the tip of the elbow
Indirect trauma - falling on partially flexed
elbow with indirect forces generated by triceps
muscle avulsing olecranon
• Higher energy trauma
motor vehicle collisions
44. Associated Injuries
• Given the subcutaneous location of the olecranon,
open fractures are not uncommon and have a
reported rate of 2% to 30% of fractures.
• Transolecranon fracture-dislocations may be
associated
• with injuries to the coronoid process or segmental
fractures
• of the ulna
45. Signs and Symptoms
• Pain
• Swelling and deformity
• Look for associated injuries
shoulder, forearm, wrist, or hand injuries
vascular status
forearm compartments
47. Classification of Olecranon
Fractures
Mayo classification
Type I (undisplaced)
Type II(displaced but stable)
Type III (unstable)
• Each group subdivided into
Comminuted (A) fractures
Non-comminuted (B) fractures
50. Nonoperative Treatment
• Nondisplaced fracture or minimally displaced
fracture
• Significant medical comorbidities
• Techniques
Immobilised for 2 to 3 weeks
Gentle active-assisted flexion is started
avoiding active extension
At 6 weeks, active motion against gravity
Resistive exercises started at 3 months
51. Operative Treatment
• Majority of olecranon fractures are treated
surgically
• Most fractures are displaced
• Comminuted fractures are associated with elbow
instability
52. • Simple olecranon fractures without comminution
–Tension-band wiring,
–Plating
53. Tension Band Wiring Technique
• Create compression at articular end at fracture site
• Simple transverse olecranon fractures
• Contraindication
Oblique fracture
Comminuted fracture
Fracture distal to the sigmoid notch
• Poorer outcomes
elbow instability
fractures of the coronoid and radial head
54. Olecranon plating
• Advantage
comminute fractures
distal olecranon fractures
Complex fracture-dislocations.
• Allows lag screw fixation of the
olecranon
• Provides good stability needed to
obtain union
• Initiate an early range of motion
56. Approach
Tension Band Wiring
• Position
• Posterior midline incision
• Fasciocutaneous flaps are raised
• Ulnar nerve protected
• Plane between ECU and FCU
developed
• Subcutaneous border of the ulna is
exposed
• Fracture reduced extending elbow
fractures commonly have associated injuries to the collateral ligaments and may have associated fractures of the coronoid, capitellum, or proximal ulna. In highenergy
trauma, dislocations of the elbow and/or forearm can also occur
The majority of radial head and neck fractures are minimally displaced and are isolated injuries. These fractures typically have a good functional
outcome with nonsurgical treatment.
The anterior and posterior ligaments are mainly thickened sections in the capsule,
The medial and lateral approaches, therefore, avoid the obvious neurovascular dangers, but provide limited access to the elbow because of
its bony configuration. Anterior and posterior approaches provide better access to the joint, but may
endanger the key neurovascular structures.
Four groups of muscles cross the elbow joint:
Anteriorly, the flexors of the elbow, which are supplied by the musculocutaneous nerve
Posteriorly, the extensor of the elbow, which is supplied by the radial nerve
Medially, the flexor-pronator group of muscles (the flexors of the wrist and fingers, and the pronators of the forearm), which are supplied by the median and ulnar nerves. They arise from the medial epicondyle of the humerus.
Laterally, the extensors of the wrist and fingers, and the supinators of the forearm, which are supplied by the radial and posterior interosseous nerves. They arise from the lateral epicondyle of the humerus.
the so-called Essex–Lopresti injury
Anteroposterior and lateral radiographs are typically sufficient to diagnose most displaced radial head fractures
A Greenspan view is taken with the forearm in neutral rotation and the radiographic beam angled 45 degrees cephalad; this view provides
visualization of the radiocapitellar articulation
CT can be helpful to better characterize the size, location, and displacement of radial head fractures.It is also useful to assess concomitant injuries of the coronoid, capitellum
In the setting where there is a block to forearm rotation in a patient with radiographically undisplaced or minimally displaced fracture, the patient should be re-evaluated several days after injury when the elbow is less painful
Alternatively,aspiration of the hemarthrosis and injection of local anesthetic can be used to check for the presence of a mechanical block to rotation(A chondral flap of capitellar cartilage can be the cause of limited rotation and cannot be detected on imaging, typically noted at surgery)
Active motion is encouraged with the use of a sling or collar and cuff between exercises.
Aspiration of the hemarthrosis can be considered for initial pain relief
Careful radiographic and clinical follow-up is required to monitor for fracture displacement and recovery of motion
The best candidates for internal fixation are younger patients with good-quality bone with three or fewer fragments
mini-fragment screws, with or without buttress plate placed in the “safe zone” (area of radial head that does not articulate with the ulna)
These fractures often are part of a more severe injury and may occur with elbow dislocation and other injuries about the elbow
Prosthetic replacement with metallic implants has provided good results at short-term follow-up.
Before resection of the radial head, elbow and forearm instability must be ruled out
Long-term arthrosis, valgus elbow instability, and longitudinal forearm instability have led many to avoid radial resection in younger patients.
Radial head arthroplasty is preferred in the setting of unreconstructable comminuted radial head fractures due to the high incidence of associated ligamentous and bony injuries
Avoid radial nerve injury where it enters the interval between the brachialis and brachioradialis muscles
separate the common origin of the extensor muscles from the lateral epicondyle together with a thin flake of bone,
Reflect the common origin distally and expose the radiohumeral joint
POSTOPERATIVE CARE.
The arm is placed in a molded posterior plaster splint at 90 degrees.
At 3 to 7 days, the splint is removed and the arm is supported in a sling.
At about that time, active and active-assisted exercises are begun.
The patient should discontinue the sling at 3 weeks, gradually increasing the exercises as tolerated.
Forceful manipulation of the elbow is never permitted.
The greater sigmoid notch is covered with articular cartilage and comprises the ulnar articulation of the ulnohumeral joint.
Radially, there is a small area of cartilage that articulates with the radial head at the proximal radioulnar joint.
Triceps tendon has a broad insertion onto the proximal ulna near the subcutaneous border
fractures may result from either direct or indirect elbow trauma
Result from a direct blow to the olecranon
Transolecranon fracture-dislocations are typically the result of higher energy trauma such as a fall from a height, assaults, or motor vehicle collisions
Anteroposterior, lateral, and radiocapitellar radiographs
CT may be useful to evaluate the pattern of associated coronoid or radial head fracture to aid with preoperative
planning; however, it is not commonly required
Mayo classification
divides olecranon fractures into three groups based on fracture displacement and elbow stability
Since these injuries involve an articular surface, the majority of proximal ulna fractures are treated operatively. However, a
nondisplaced fracture or a minimally displaced fracture that remains reduced with the elbow flexed may be treated nonoperatively
significant medical comorbidities that are poor surgical candidates
The goal of treatment of olecranon fractures is restoration of function without pain. With displaced fractures, loss of
active extension is common. Anatomic reduction and stable internal fixation are vital for both function and prevention of
arthrosis. Implementation of an early range-of-motion program will decrease the chances of posttraumatic arthrofibrosis
making stable internal fixation that will tolerate motion mandatory
Tension band wiring has been proved to be a useful technique in simple transverse olecranon fractures
without comminution. It is contraindicated in fractures that are oblique, comminuted, or distal to the sigmoid notch
Plate fixation has the advantage of maintaining fixation in fractures with comminution, distal fractures, and complex fracture-dislocations
create compression at the articular end of an olecranon fracture when the dorsal cortex is tensioned under flexion of elbow joint.
Poorer outcomes have been noted in patients with elbow instability and fractures of the coronoid and radial head
Allows lag screw fixation of the olecranon anatomically reconstruct the proximal ulna
Provides good stability needed to obtain union and initiate an early range of motion program to promote maximal function
Newer precontoured plates provide more screw options for the proximal segment, have locking screw capabilities, and can contain a
bend to match the proximal ulnar anatomy for extended fractures
significantly greater compression than tension bands in the treatment of transverse olecranon fractures. Reconstruction
Posterior midline incision
Full thickness medial and lateral fasciocutaneous flaps are raised
Ulnar nerve should be identified so that it can be protected during the case
Plane between ECU and FCU developed
Subcutaneous border of the ulna is exposed
The fracture is reduced by extending the elbow
Inspect the articular surface and reduce the fracture
■ Insert Kirschner wire provisional fixation, consider lag screw fixation if possible
■ Position the plate (ideally precontoured for the olecranon) over the proximal fragment on top of the triceps insertion.
■ Place the proximal screw in intramedullary fashion to cross the fracture site if possible.
■ Use an adequate number of screws proximally and distally.
■ Confirm reduction and screw passage with fluoroscopy.
■ Close the wound in layers and splint the elbow in extension with an anterior plaster slab.
