Fractures & Dislocations of the Upper Limb

Fractures & Dislocations of the Upper Limb

• Elbow dislocations account for 10% to 25% of elbow injuries. They are second only to shoulder dislocations in adults.
• Elbow dislocations are categorized as simple or complex.
• Simple dislocations involve ligamentous injuries only, without fractures. They can be anterior or posterior.
• Posterior dislocations are the most common type. They can be further categorized by the direction of the dislocated ulna (posterior, posteromedial, posterolateral, or direct lateral).
• Complex dislocations include associated fractures, frequently involving the radial head, coronoid process of the ulna, and the olecranon. The "terrible triad" is a common complex dislocation with these three elements, and possible posterior lateral dislocation of the elbow joint.
• Nerve and blood vessel damage such as ulnar/median neuropraxia and possible brachial artery injury may be associated with complex dislocations.
• Ulnar collateral ligament tears can also accompany elbow dislocations.

Mechanism of Injury

• Posterior elbow dislocations (PEDs) are most common in children under 10 years old, usually resulting from falls on an outstretched hand or elbow.
• Forceful unlocking of the olecranon from the trochlea is involved.
• Axial compression, valgus stress, arm abduction, and forearm supination can contribute to PEDs.
• Anterior dislocations usually result from direct force to the posterior forearm during elbow flexion.

Treatment

• Simple posterior dislocations are treated by closed reduction under sedation, then fixation in a plaster cast or posterior splint, holding the elbow at 90 degrees for 2-3 weeks. Active range-of-motion exercises are started as soon as possible.
• Complex or unstable dislocations, significant soft tissue or bone damage will need open reduction with or without internal fixation, and often ulnar collateral ligament repair.

Reduction of Posterior Elbow Dislocation

• Palm-palm technique: The physician grasps the patient's hand, with palms together and fingers interlocked, and places their elbow in the patient's antecubital fossa.
• The physician pushes down on the patient's distal humerus to distract the dislocation.
• By pulling the posteriorly dislocated elbow back into its proper anatomical position using gentle pressure to the olecranon.

Rehabilitation Considerations

• Avoid prolonged immobilization, as it can lead to post-traumatic elbow stiffness.
• Early active range of motion (ROM) is key for recovery.
• The elbow is splinted for 5 to 7 days to promote soft tissue healing.
• Ice and compressive dressings manage swelling.
• A hinged elbow brace is applied, with ranges of motion from 30 to 90 degrees, increasing gradually.
• Active ROM exercises are initiated to promote muscle activation and stability.

Additional Considerations (Up to 2 Weeks Post-Injury)

• Avoid passive range of motion (ROM), as it can increase swelling and inflammation.
• Avoid valgus stress to the elbow to promote healing of the medial collateral ligament (MCL).
• Avoid abduction and external rotation of the arm.
• Avoid forced terminal extension.
• Resistive exercises are avoided, as they exert tension on healing ligamentous structures.

Radial Head Fracture

• Radial head fractures typically occur from indirect trauma, often after a fall on an outstretched arm.
• A fall affecting the abducted arm during 0-80 degrees of elbow flexion often results in a valgus pronation stress, forcing the radial head against the capitulum of the humerus.
• Common complications include limited range of motion (ROM) and maximal tenderness over the radial head. (10-15 degrees of ROM limitation is common)
• Fracture types are classified by displacement and comminution (Type I-IV).
• Treatment depends on fracture type. Type I usually involves immobilization; more complex types typically involve open reduction and internal fixation (ORIF) or radial head excision.

Forearm Bone Shaft Fractures

• These injuries include Monteggia fractures (proximal ulna fracture with radial head dislocation) and Galeazzi fractures (distal radius fracture with inferior radioulnar joint dislocation). Both injuries often require surgical intervention (ORIF).