1. INJURIES AROUND THE
ELBOW
BY
M.S. ORTHO
ASST. PROF. OF ORTHOPAEDICS
O.M.C/O.G.H. HYDERABAD
MEMBER OF IORA
Orthopaedic Rheumatologist and
Interventional pain specialist

2. ELBOW DISLOCATION

3. EPIDEMIOLOGY
 Accounts for 11% to 28% of injuries to the elbow.
 Posterior dislocation is most common.
 Simple dislocations are those without fracture.
 Complex dislocations are those that occur with
an associated fracture and represent just under
50% of elbow dislocations.
 Highest incidence in the 10- to 20-year old age
group associated with sports injuries

4. MECHANISM OF INJURY
 Anterior dislocation: A direct force strikes the
posterior forearm with the elbow in a flexed
position.
 Posterir dislocation:combination of elbow
hyperextension,valgus stress and forearm
supination
 Capsuloligamentous structures of elbow may be
injured which progress from medial to lateral

5. CLINICAL FEATURES
• pain
• gross swelling
• deformity-s shaped
• tenderness
• abnormal mobility
• decreased range of motion

6. CLINICAL EVALUATION
• Elbow joint shows gross swelling and
instability
• 3 point bony relationship is lost
• Neurovascular examination especially vascular
compromise should be looked for before and
after manipulation or reduction

7. ASSOCIATED INJURIES
• Associated fractures of the radial head or the
coronoid process of the ulna may be present
• Uncomonly the ulnar nerve and anterior
interroseus branch of the median nerve may
be involved

8. RADIOGRAPHIC EVALUATION
• Standard anteroposterior and lateral
radiographs of the elbow should be obtained.

9. CLASSIFICATION
 Simple versus complex (associated with fracture)
 According to the direction of displacement of the
ulna relative to the humerus :
 Posterior
 Posterolateral
 Posteromedial
 Lateral
 Medial
 Anterior

10. TREATMENT PRINCIPLES
 Restorationof inherent bony stability of the
elbow joint
 trochlear notch(coronoid and olecranon )
 radial head
 lateral collateral ligament more imp than MCL
 the elbow should not redislocate before
reaching 45 degrees of flexion from a fully flexed
position
 the elbow should be able to go to 30 degrees
before substantial subluxation or dislocation

11. TREATMENT
 Simple Elbow Dislocation
 Nonoperative
 Under sedation and adequate analgesia correction of medial or
lateral displacement followed by longitudinal traction and flexion is
usually successful for posterior dislocations (parvins method
/meynquigleys method
 Check neurovascular status and range of motion
 Postreduction radiographs are essential.
 Postreduction management should consist of a posterior splint at
90 degrees and elevation.
 A hinged elbow brace through a stable arc of motion may be
indicated in cases of instability without associated fracture.
 Recovery of motion and strength may require 3 to 6 months

12. Operative
 Unstable elbow
 The elbow cannot be held in a concentrically reduced
position
 redislocates before postreduction radiography
 Dislocates later in spite of splint immobilization
 We can do
 (1) open reduction and repair of soft tissues back to
the distal humerus
 (2) hinged external fixation
 (3) cross-pinning of the joint.

13. COMPLICATIONS
 Loss of motion (extension): This is associated
with prolonged immobilization.
 Neurologic compromise:
 Exploration is recommended if no recovery is seen
after 3 months following electromyography.
 Vascular injury: The brachial artery is most
commonly disrupted during injury.
If, after reduction, perfusion is not reestablished,
angiography is indicated to identify the lesion, with
arterial reconstruction when indicated.

14. COMPLICATIONS
Compartment syndrome(volkman contracture)
Myositis ossificans
Due to excessive manipulation and soft tissue
injury
Indomethacin and local radiation therapy
prophylactically
Instability associated with terrible triad of
elbow

15. FRACTURE RADIUS HEAD

16. INTRODUCTION
• COMMON IN ATHLETS
• SIDE SWIPE INJURIES
• DIRECT BLOW ON THE ELBOW WHEN
FALL OFF SKATE BOARD
• HIGH ENERGY TRAUMA OCCURS IN
MOTOR CYCLE COLLISION
• ANY OTHER DIRECT INJURY TO
ELBOW, HAND, WRIST, OR SHOULDER
CAN AFFECT THE ELBOW TOO

17. SYMPTOMS
• HISTORY OF TRAUMA
• PAIN
• SWELLING
• MOVEMENTS OF THE JOINT PAINFUL,
DECREASED
• WRIST PAIN (ESSEX-LOPRESTI INJURY

18. MASON CLASSIFICATION
• Type I: Non-displaced fractures
• Type II: Marginal fractures with displacement
(impaction, depression, angulation)
• Type III: Comminuted fractures involving the
entire head
• Type IV: Associated with dislocation of the
elbow (Johnston)

19. CLASSIFICTION

20. TREATMENT GOALS
• Correction of any block to forearm rotation
• Early range of elbow and forearm motion
• Stability of the forearm and elbow
• Limitation of the potential for ulnohumeral
and radiocapitellar arthrosis, although the
latter seems uncommon

21. TREATMENT
Nonoperative
• Most isolated fractures of the radial head can be
treated non-operatively.
• Symptomatic management consists of a sling
and early range of motion, 24 to 48 hours after
injury, as pain subsides.
• Aspiration of the radiocapitellar joint with or
without injection of local anesthesia has been
advocated by some authors for pain relief.

22. OPERATIVE
• Except Mason type I
• ORIF with screw
• KOCHER’S Approach for radial head #
• Excision of radial head
• MAC LAUGHLIN’S CRITERIA for immediate
excision:
1. Angulation >30°
2. Depression>3mm
3. Involvement of head >1/3 rd

24. Type III:
• Radial head excision is indicated with in first 24
hrs.
• Excised head is replaced with prosthesis
Type IV:
• Prompt reduction of the dislocation is must
• Assess status of the head. If it meets the Mac
Laughlin’s criteria for excision, do it within 24 hrs.

28. COMPLICATIONS
• Injury to posterior interosseous nerve
• Osteoarthritis
• Elbow stiffness

29. OLECRANON FRACTURE
• Uncommon in children
• Comparable to # patella
• Mechanism of injury:
DIRECT: Fall on the point of elbow
INDIRECT: Forcible triceps contraction

30. COLTON’S CLASSIFICATION (MODIFIED
SCHTAZKER)
• UNDISPLACED #
• DISPLACED #
• AVULSION #
• TRANSVERSE/OBLIQUE #
• FRACTURE DISLOCATION (MONTEGGIA)
• COMMINUTED #

32. MAYO CLASSIFICATION
Type I:
Fractures are nondisplaced or minimally
displaced and are subclassified as either
noncomminuted (type 1A) or comminuted
(type 1B). Treatment is nonoperative.

33. Type II:
Fractures have displacement of the proximal
fragment without elbow instability; these
fractures require operative treatment.
– Type IIA fractures, which are noncomminuted,
can be treated by tension band wire fixation.
– Type IIB fractures are comminuted and require
plate fixation

35. TREATMENT
• Avulsion # - TBW/LS
• Transverse# - TBW/LS
• Transverse# with comm.- Plate& Screws with
Bone grafting
• Oblique #: Plate/LS
• Communition#: Plate/TBW/Excision
• Fracture Dislocation: Wire/LS/Plate
• Extensile posterior approach

36. TBW

39. COMPLICATIONS
• Hardware failure occurs in 1% to 5%.
• Infection occurs in 0% to 6%.
• Pin migration occurs in 15%.
• Ulnar neuritis occurs in 2% to 12%.
• Heterotopic ossification occurs in 2% to 13%.
• Nonunion occurs in 5%.
• Decreased range of motion: This may
complicate up to 50% of cases

40. Fracture neck of radius
• Constitutes 5-10% of all elbow #s
• Mech of injury
fall on outstretched hand with elbow
extended and forearm supinated.
• Associated with
post dislocastion of elbow
prox radial physis (salter haris type II)

41. • X ray

42. • Classification- steinberg et al
based on initial angulation
translation
mild(0-30 degree, < 30% )
modetrate(30-60,<50% )
severe (>60,>50%)

43. • Treatment
- conservative for
< 30 degree
-percutaneus
reduction technique
with k wires
or Lag screw

44. -ORIF with k wires/ cc screws
severe angulation
failed closed /percutaneus
methods

45. • Complications
depends on initial angulation
-decreased range of motion
-avascular necrosis
-premature physial closure
-cubitus valgus