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Questions and Answers
Elbow dislocations constitute ___% to ___% of all injuries to the elbow.
Elbow dislocations constitute ___% to ___% of all injuries to the elbow.
10, 25
Among injuries to the upper extremity, dislocation of the elbow is second only to dislocation of the ___.
Among injuries to the upper extremity, dislocation of the elbow is second only to dislocation of the ___.
shoulder
Simple dislocations of the elbow are those in which the injury is only ___ without any associated fractures.
Simple dislocations of the elbow are those in which the injury is only ___ without any associated fractures.
ligamentous
Posterior dislocation is by far the most common and is further subdivided by the direction of the dislocated ___.
Posterior dislocation is by far the most common and is further subdivided by the direction of the dislocated ___.
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The 'terrible triad' elbow dislocation includes injuries to the coronoid process, radial head, and posterior lateral dislocation of the elbow ___.
The 'terrible triad' elbow dislocation includes injuries to the coronoid process, radial head, and posterior lateral dislocation of the elbow ___.
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In children under 10 years, PEDs are the most common type of joint ___.
In children under 10 years, PEDs are the most common type of joint ___.
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Simple posterior dislocation treatment includes closed reduction under sedation and fixation in plaster cast or posterior ___.
Simple posterior dislocation treatment includes closed reduction under sedation and fixation in plaster cast or posterior ___.
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Active range of motion exercise should be started early as much as possible for ___ posterior dislocation.
Active range of motion exercise should be started early as much as possible for ___ posterior dislocation.
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Complex or unstable elbow dislocation may require open reduction with or without internal ______.
Complex or unstable elbow dislocation may require open reduction with or without internal ______.
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The palm-palm technique involves grasping the patient's hand with palms ______ and fingers interlocked.
The palm-palm technique involves grasping the patient's hand with palms ______ and fingers interlocked.
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For simple elbow dislocations, early active ______ is key to preventing post-traumatic stiffness.
For simple elbow dislocations, early active ______ is key to preventing post-traumatic stiffness.
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A hinged elbow brace should be applied from ______ to 90 degrees starting from day 5 to 7.
A hinged elbow brace should be applied from ______ to 90 degrees starting from day 5 to 7.
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Passive ROM should be avoided in the first ______ weeks after the injury to reduce swelling.
Passive ROM should be avoided in the first ______ weeks after the injury to reduce swelling.
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Radial head fractures usually occur from a fall on an abducted arm with minimal or moderate ______ of the elbow joint.
Radial head fractures usually occur from a fall on an abducted arm with minimal or moderate ______ of the elbow joint.
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At 6 to 8 weeks, ______ exercises can begin to restore strength to the elbow.
At 6 to 8 weeks, ______ exercises can begin to restore strength to the elbow.
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Radial head fractures may result in swelling at the ______ aspect of the elbow.
Radial head fractures may result in swelling at the ______ aspect of the elbow.
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Type I fractures require immobilization in plaster cast for ______ weeks.
Type I fractures require immobilization in plaster cast for ______ weeks.
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Type IV fractures involve radial head fracture associated with an ______ dislocation.
Type IV fractures involve radial head fracture associated with an ______ dislocation.
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Monteggia fracture involves a fracture of the upper third of the ulna with anterior displacement of the upper fragment of the ______.
Monteggia fracture involves a fracture of the upper third of the ulna with anterior displacement of the upper fragment of the ______.
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Galeazzi fracture-dislocation is a fracture of the distal 1/3rd of the radius with dislocation of the inferior ______ joint.
Galeazzi fracture-dislocation is a fracture of the distal 1/3rd of the radius with dislocation of the inferior ______ joint.
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Phase I of rehabilitation for both bone forearm fractures involves placing the patient into a ______.
Phase I of rehabilitation for both bone forearm fractures involves placing the patient into a ______.
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In the first phase of rehabilitation, edema control and ROM of ______ are encouraged.
In the first phase of rehabilitation, edema control and ROM of ______ are encouraged.
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In Phase II of rehabilitation, active and active-assisted ROM of elbow, forearm, and ______ is included.
In Phase II of rehabilitation, active and active-assisted ROM of elbow, forearm, and ______ is included.
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Lifting and twisting restrictions are lifted in Phase III once union has been ______.
Lifting and twisting restrictions are lifted in Phase III once union has been ______.
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Colle's fracture primarily affects older ______.
Colle's fracture primarily affects older ______.
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A fall on a dorsi flexed wrist typically leads to a Colle's ______.
A fall on a dorsi flexed wrist typically leads to a Colle's ______.
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Early complications of Colles fracture include radial artery ______.
Early complications of Colles fracture include radial artery ______.
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Malunion in a Colles' fracture can lead to a permanent loss of full wrist ______.
Malunion in a Colles' fracture can lead to a permanent loss of full wrist ______.
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The typical deformity associated with a Colle's fracture is known as the ______ Fork.
The typical deformity associated with a Colle's fracture is known as the ______ Fork.
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Complex regional pain syndrome (CRPS) is a form of chronic ______ that affects limbs.
Complex regional pain syndrome (CRPS) is a form of chronic ______ that affects limbs.
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Volkman ischemic ______ is a late complication of Colles fracture.
Volkman ischemic ______ is a late complication of Colles fracture.
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In a Colle's fracture, the distal fragment may displace radially, causing a sprain of the ulnar collateral ______.
In a Colle's fracture, the distal fragment may displace radially, causing a sprain of the ulnar collateral ______.
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Complex regional pain syndrome (CRPS) typically develops after an injury, a surgery, a stroke or a ______.
Complex regional pain syndrome (CRPS) typically develops after an injury, a surgery, a stroke or a ______.
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Type 1 complex regional pain syndrome (CRPS 1) was formerly known as ______.
Type 1 complex regional pain syndrome (CRPS 1) was formerly known as ______.
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CRPS 1 may also develop in the absence of an identifiable ______.
CRPS 1 may also develop in the absence of an identifiable ______.
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Treatment of CRPS patients depends on early recognition, early intervention of physical therapy besides anti-inflammatory agents and ______.
Treatment of CRPS patients depends on early recognition, early intervention of physical therapy besides anti-inflammatory agents and ______.
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Mirror therapy involves placing both hands into a box with a mirror separating the two compartments, allowing the patient to watch the reflection of their unaffected ______.
Mirror therapy involves placing both hands into a box with a mirror separating the two compartments, allowing the patient to watch the reflection of their unaffected ______.
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An undisplaced fracture may be treated with a ______ alone.
An undisplaced fracture may be treated with a ______ alone.
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One of the primary focuses in early rehab is to limit pain and the amount of ______ present in the wrist and hand region.
One of the primary focuses in early rehab is to limit pain and the amount of ______ present in the wrist and hand region.
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The focus in the beginning of rehabilitation is to mobilize the ______, which is indicated approximately 7-8 weeks post fracture.
The focus in the beginning of rehabilitation is to mobilize the ______, which is indicated approximately 7-8 weeks post fracture.
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A Smith fracture results in anterior displacement of the distal fragment of the _____.
A Smith fracture results in anterior displacement of the distal fragment of the _____.
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During rehabilitation after surgery, active and active assisted wrist exercises are focused on regaining range of motion, especially in ______ and radial deviation.
During rehabilitation after surgery, active and active assisted wrist exercises are focused on regaining range of motion, especially in ______ and radial deviation.
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The mechanism of injury for a radial styloid fracture involves compression of the scaphoid against the ______.
The mechanism of injury for a radial styloid fracture involves compression of the scaphoid against the ______.
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The main cause of scaphoid fractures is a fall on an outstretched hand with a radially ______ wrist.
The main cause of scaphoid fractures is a fall on an outstretched hand with a radially ______ wrist.
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Barton’s fracture is an intra-articular distal radius fracture with ______ displacement.
Barton’s fracture is an intra-articular distal radius fracture with ______ displacement.
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The typical deformity observed in a Smith fracture is described as a ______ spade.
The typical deformity observed in a Smith fracture is described as a ______ spade.
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Management of scaphoid fractures typically includes cast immobilization for non-displaced fractures and surgical ______ for displaced cases.
Management of scaphoid fractures typically includes cast immobilization for non-displaced fractures and surgical ______ for displaced cases.
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Progressive stretching can begin during rehabilitation after approximately _____ to 8 weeks post-op.
Progressive stretching can begin during rehabilitation after approximately _____ to 8 weeks post-op.
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Study Notes
Upper Limb Fractures & Dislocations
- Elbow dislocations comprise 10% to 25% of elbow injuries. Among upper extremity injuries in adults, elbow dislocation ranks second only to shoulder dislocations.
- Elbow dislocations are categorized as simple or complex. Simple dislocations involve only ligamentous damage without fractures. Posterior dislocations are the most common type, further classified based on the ulna's displacement direction (posterior, posteromedial, posterolateral, direct lateral).
- Complex elbow dislocations involve associated fractures, most commonly of the radial head, coronoid process of the ulna, and the olecranon. The "terrible triad" refers to a combination of these injuries. These types of dislocations can be accompanied by nerve or vascular injuries (ulnar/median neuropraxia, possible brachial artery injury). Ulnar collateral ligament tears sometimes accompany elbow dislocations.
- In children under 10, posterior elbow dislocations (PEDs) are more common, usually due to falling onto an outstretched hand or elbow.
Mechanism of Injury
- Posterior elbow dislocation mechanisms include axial compression, valgus stress, arm abduction, and forearm supination.
- Anterior elbow dislocations arise from direct force to the posterior forearm with the elbow flexed.
Treatment
- Simple posterior dislocations are reduced under sedation and immobilized in a plaster cast or splint with the elbow at 90° for 2-3 weeks. Active range-of-motion exercises are encouraged early.
- Complex or unstable dislocations, involving severe soft tissue or bony entrapment, require open reduction with or without internal fixation, and sometimes ulnar collateral ligament repair.
Reduction of Posterior Elbow Dislocation
- The palm-palm technique is a common method to reduce posterior elbow dislocations. It involves grasping the patient's hand with the examiner's hand, placing the examiner's elbow in the patient's antecubital fossa. Pushing downward on the patient's distal humerus and pulling posteriorly helps return the dislocated elbow to its normal position.
Rehabilitation Considerations
- Extensive casting and prolonged immobilization are detrimental, so avoidance is crucial.
- Initial splinting for 5-7 days is important for soft tissue rest.
- Compressive dressings and ice help control swelling.
- At 5-7 days post-injury, a hinged brace is used (30-90 degrees). Active range of motion (ROM) begins.
- Active ROM requires muscle activation to assist with stability and compression across the joint.
- Increased ROM of 10-15 degrees per week in the brace is recommended.
Physical therapy considerations
- Avoid passive ROM, valgus stress, abduction and external rotation for 2 weeks after injury:
- Avoid strengthening exercises for 2 to 4 weeks
- Elbow flexion returning first, followed by full flexion obtained by 6-12 weeks
- Further improvements in extension can take place over 3-5 months
- Early active ROM and prevention of stiffness is key to a favorable result, so early intervention is important for simple elbow dislocations.
Radial Head Fracture
- Radial head fractures result from indirect trauma, typically a fall on an outstretched arm with minimal or moderate elbow flexion (0-80 degrees).
- A direct blow to the elbow can also cause a radial head fracture but is uncommon.
- Symptoms often include lateral elbow swelling, limited ROM, and maximal tenderness over the radial head.
- Complication: 10° to 15° limitation in ROM is common.
Treatment of Radial Head Fracture
- Type I: Immobilization in plaster cast for 3 weeks
- Type II: ORIF and immobilization in plaster cast for 2 weeks
- Type III: ORIF or excision of radial head, followed by immobilization in plaster cast for 2 weeks.
- Type IV: Radial head resection or replacement.
Forearm Bone Shaft Fracture (Monteggia and Galeazzi)
- Monteggia fracture dislocation: Fracture of the upper third of the ulna with anterior displacement of the upper ulna fragment and anterior dislocation of the radius. Requires ORIF (open reduction and internal fixation) to avoid redisplacement.
- Galeazzi fracture-dislocation: Fracture of the distal third of the radius, often associated with dislocation/subluxation of the distal radioulnar joint, caused by rotational forces. Conservative treatment may result in redisplacement.
Both Bone Forearm Fracture Rehabilitation
- Phase I (0-2 weeks): Immobilization in a splint to protect surgical incisions. Sutures/staples removed. Extremity elevation. Edema control and finger exercises.
- Phase II (2-6 weeks): Splint/brace removal, progression to Active and Active-Assisted AROM of elbow, forearm, and wrist, no repetitive forearm twisting.
- Phase III (6+ weeks): Lifting/twist limitations lifted after union has been confirmed (with treatment surgeon), focus on regaining preoperative motions, and weight lifting restrictions if needed.
Distal Radial Fractures (Colles', Smith's, Barton's, Radial styloid)
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Colle's fracture: Extra-articular fracture across the distal radius, commonly occurring in falls on an outstretched hand with extended wrist. Characterized by a dinner fork deformity.
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Smith's fracture: Similar to a Colle's fracture but results from a fall on a flexed wrist. This injury is characterized by a garden spade deformity.
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Barton's fracture: An intra-articular fracture of the distal radius with volar/palmar or dorsal displacement. Requires ORIF.
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Radial Styloid Fracture: Caused by scaphoid impaction against the styloid. Treated: Non-displaced Fractures: cast immobilization, Displaced Fractures: Surgical Fixation.
Carpal Bone Fractures (Scaphoid)
- Caused by falls on the outstretched hand, resulting in extreme wrist dorsiflexion and radial side compression. Characterized by a dull ache in the radial wrist area, often mild, aggravated by pinching/gripping. Potentially swollen/bruised wrist, possible fullness in anatomical snuffbox—indicating wrist effusion.
- The radial artery supplies blood to the scaphoid. The proximal scaphoid portion has no direct blood supply.
- Fracture of the distal scaphoid pole heals in 2-3 weeks, fracture of distal scaphoid waist or proximal scaphoid pole needs 8-12 weeks of immobilization. Avoid active movement of the thumb until the fracture is radiographically healed after 6-8 weeks.
- Complications include delayed union, avascular necrosis, and osteoarthritis.
Lunate Fracture
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Result of FOOSH mechanism, with highest incidence of avascular necrosis.
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Tenderness occurs in the lunate fossa when palpated, and worsens with wrist flexion (because the lunate moves against examiner's finger in the fossa)
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Suspect lunate fracture with tenderness in lunate fossa, whether or not confirmed by radiograph.
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Treatment for the undisplaced fracture: Immobilized in a short arm cast for 4-6 weeks. Displaced requires surgical fixation.
Metacarpal Fractures (Bennett's, Boxer's Fracture)
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Bennett's fracture: Oblique base fracture of the first metacarpal, often associated with dislocation of the carpometacarpal joint.
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Management: Stable fracture = thumb spica splint; Unstable fracture = surgical fixation with percutaneous pinning.
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Boxer's fracture: Fracture of the neck of the fourth or fifth metacarpal resulting from hitting an object with a closed fist.
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Treatment: Immobilization using buddy taping to the ring finger, cast or splint. Surgery considered for significant angulation or misalignment.
Treatment Considerations for all fractures
- Reduction: Fracture reduction is maintained during splinting or casting.
- Contracture Prevention: Proper positioning to avoid contractures is important.
- Immobilization Duration: Don't immobilize longer than 3 weeks unless specific circumstances dictate.
- Uninvolved Joint Splinting: Uninvolved joints should not be immobilized in stable fractures.
- Skin Obstructions: Casts and splints should not obstruct skin creases.
- Early Active Tendon Gliding: Early active tendon gliding should be part of the treatment protocol.
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Description
Test your knowledge on upper limb fractures and elbow dislocations. Explore the differences between simple and complex dislocations and the implications of associated injuries. This quiz will cover essential classifications and treatment considerations.
