Fractures & Dislocations Of The Upper Limb (2) PDF

Fractures & Dislocations Of The Upper Limb (2) By Dina Othman Shokri  Elbow dislocation Elbow dislocations constitute 10% to 25% of all injuries to the elbow. Among injuries to the upper extremity, dislocation of...

Fractures & Dislocations Of The Upper Limb (2) By Dina Othman Shokri  Elbow dislocation Elbow dislocations constitute 10% to 25% of all injuries to the elbow. Among injuries to the upper extremity, dislocation of the elbow is second only to dislocation of the shoulder in adults. Elbow dislocations can be broken up into simple and complex patterns. Simple dislocations of the elbow are those in which the injury is only ligamentous without any associated fractures. It can be classified as anterior or posterior. Posterior dislocation is by far the most common and is further subdivided by the direction of the dislocated ulna (posterior, posteromedial, posterolateral, direct lateral). X-ray of right elbow dislocated and clinical appearance  Posterior elbow dislocation (PED) Anterior elbow dislocation ,radius occurs when the radius and ulna are and ulna are driven anterior to forcefully driven posterior to the humerus. humerus Complex elbow dislocations are elbow dislocations that include associated fractures. The most common associated fractures include the radial head, coronoid process of the ulna, and the olecranon. The “terrible triad” elbow dislocation commonly mentioned is an elbow dislocation with injuries to the coronoid process, radial head, and posterior lateral dislocation of the elbow joint. It may be associated with nerveovascular injury as ulnar/median neuropraxia, possible brachial artery Injury. Sometimes elbow dislocation are accompanied by ulnar collateral ligament tear.  Mechanism of injury In children under 10 years, PEDs are the most common type of joint dislocation. Most commonly due to fall on outstretched hand or elbow resulting in force to unlock the olecranon from the trochlea. Posterior dislocation following axial compression, valgus stress, arm abduction, and forearm supination. Anterior dislocation ensuing from direct force to the posterior forearm with elbow flexed, it is rarely occurred.  TREATMENT Simple posterior dislocation: Closed reduction under sedation, fixation in plaster cast or posterior splint with the elbow at 90 degrees for 2-3 weeks. Active range of motion exercise should be start early as much as possible. Complex or unstable elbow dislocation, severe soft tissue injuries or bony entrapment need open reduction with or without internal fixation and usually require ulnar collateral repair.  Reduction of Posterior Elbow Dislocation Palm-palm technique: Grasp pt’s hand with palm to palm and fingers interlocked. Place examiner’s elbow in patient’s ante cubital fossa, Distract dislocation by pushing downward on patient’s distal humerus with examiner’s elbow Pull posteriorly dislocated elbow back into anatomic position.  Rehabilitation considerations Most agree that extended casting and prolonged immobilization lead to elbow post-traumatic stiffness and should be avoided. For simple elbow dislocations, early active ROM is the key to preventing post-traumatic stiffness and obtaining a favorable result. The elbow is splinted for 5 to 7 days to allow soft tissue rest. Soft tissue swelling can be controlled with compressive dressings and application of ice. Beginning at day 5 to 7, a hinged elbow brace from 30 to 90 degrees is applied and active ROM is initiated. Active ROM requires muscle activation and assists with elbow stability and compression across the joint. ROM is increased in the hinged elbow brace 10 to 15 degrees per week. Up to 2 week the following should be avoided (Passive ROM should be avoided because it increases swelling and inflammation, Valgus stress to the elbow should be avoided because it may disrupt healing of the MCL and lead to instability or recurrent dislocation, avoid abduction and external rotation). Forced terminal extension should be avoided. During this time, no strengthening or resistive exercises should be prescribed because this may place tension on the healing ligamentous structures. At 6 to 8 weeks, strengthening can begin Elbow flexion returns first, with full flexion obtained by 6 to 12 weeks. Extension returns more slowly and may continue to improve for 3 to 5 months.  Radial Head Fracture Radial head fractures usually occur as a result of indirect trauma, with most resulting from a fall on an abducted arm with minimal or moderate flexion of the elbow joint (0-80 degrees). This results in valgus pronation stress with the radial head forcibly pushed against the capitalism of the humerus. In practice, the history is often a fall onto an outstretched arm. A direct blow to the elbow can cause a radial head fracture but is uncommon. May occur in elbow dislocation, Swelling at lateral aspect. Limited ROM, maximal tenderness over radial head. Most common complication: 10º to 15º limit to ROM. X ray for stable radius head fr FIGURE 14.12 The Mason classification of radial head fractures. Type I—minimally displaced fractures (2mm of displacement. Type III—complete articular fractures with severe comminution. Type IV—radial head fracture associated with an elbow dislocation. (Reproduced with permission from Morrey BF. The Elbow and its Disorders. Philadelphia: W.B. Saunders Company; 1993.)  Treatment 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, immobilization in plaster cast for 2 weeks Type IV: radial head resection or replacement. Physical therapy guide No passive movement should be given to the elbow or radio ulnar joint for 14 to 21 days at least to decrease liability for myositis osificans. active and active-assisted ROM exercises start early.  Forearm bone shaft fracture Monteggia fracture and Galeazzi fracture-dislocation  MoNtegia fracture dislocation It is a fracture of the upper third of the ulna with anterior displacement of the upper fragment of the ulna and anterior dislocation of the radius. In short, Monteggia’s fracture is the proximal ulnar fracture with superior radio-ulnar joint dislocation It requires ORIF or it will redisplace  Galeazzi fracture-dislocation It is a fracture of the distal 1/3rd of the radius with dislocation or subluxation of the inferior radioulnar joint. It is due to rotational force causing swelling of the lower forearm; prominent head of ulna; and ulnar nerve injury. Like Montegia fracture if treated conservatively it will redisplaye This fracture appeared in acceptable Fracture redisplaced in POP. This required position after reduction and POP ORIF Galeazzi Fracture