1. Forearm Fractures
2. Forearm shaft fractures
3. Distal Radius Fractures
4. Distal Ulnar Fractures
5. Posterior Approach to Distal Humerus/Elbow/Proximal Ulnar
6. Proximal Olecranon Fracture Repair
   
7. Radial Head/Neck Fractures
8. Terrible Elbow Triad Injury
9. Capitulum Fractures
10. Epicondyle Elbow Fractures

Medial aspect of right forearm

Left Brachial plexus

Anterior view right distal humerus bone

The elbow joint is a hinge joint with axis of rotation around throchlear axis

Extensor muscles

Flexor muscles

Haversion bone system

Presentation:

• Pain
• Swelling and bruising
• Deformity

Clinical:

• Bone tenderness
• Deformity
• Palpable fracture

Investigation:

• X-rays: forearm fracture. Assess proximal and distal joints.

Management:

Nonsurgical:

• Brace/cast
• Analgesia

Surgery:

• Plate and screw fixation
• Open fractures: debridement and either initial plating and screw fixation or application of an external fixator

Plate and screw fixation

Superficial: Brachioradialis & flexor carpi radialis. Radial artery lies deep to brachioradialis in middle forearm and distally between brachioradialis and flexor carpi radialis. Superficial Radial nerve lies under brachioradialis.

Deep dissection: Middle third lateral border of pronator teres. Distal third lies flexor pollicis longus & pronator quadratus. Classic Henry approach is between brachioradialis and radial artery or modified Henry approach between radial artery and flexor carpi radialis. The radial artery is retracted laterally while flexor carpi radialis is retracted medially. With flexor pollicis longus also retracted medially pronator quadratus is exposed.

Skin incision follows subcutaneous ulna border from tip of olecranon process and ulnar styloid process.

Deep dissection: between flexor carpi ulnaris & extensor carpi ulnaris.

Anterior (Henry) approach to radius shaft

Plate & screw fixation radius

Direct approach to Ulnar with plate & screw fixation

• Distal radius fractures a common orthopaedic injury
• The mechanism usually a fall to the outstretch arm
• More common in females

Risk factors:

• Osteoporosis

Presentation:

• Pain
• Swelling
• Deformity

Clinically:

• Bone tenderness

Investigations:

• X-ray
• CT: for intra-articular fracture evaluation and surgical planning
• MRI: useful to evaluate soft tissue injuries that include the carpal ligaments (scapholunate, lunotriquetral or TFCC associated injuries)

Wrist/forearm position while falling producing either a Colles’ fracture or Smith fracture. When there is a partial dorsal or volar fragment extending to the wrist joint  in the sagittal plane then the fracture is termed a dorsal or volar Barton fracture respectively.

Radial styloid fracture. Assess and exclude potential scapholunate disruption

Management:

Non-surgical with immobilization in a splint/cast for closed fractures that are:

• Extra-articular
• < 5mm radial shortening
• Dorsal angulation < 5° or within 20° of contralateral side

Surgery:

• For fractures not compliant with conservative criteria
• Unstable fractures including (articular margin), dorsal and volar Bartons’ fractures
• Comminuted and displaced extra-articular fractures (Smiths’ fracture)
• Associated volar/dorsal comminution
• Associated ulnar fracture
• Articular incongruency > 2mm
• Die-punch fractures
• Open fractures

Options:

• Plate and screw fixation
• External fixator for open fractures, complex intraarticular fractures

Principles of fracture reduction and immobilization in cast/Plaster of Paris (POP).

Avoid extreme wrist flexion and ulnar deviation when positioning and molding a Colles’ fracture in POP, thereby preventing carpal tunnel syndrome (Cotton-Loder Position).

Factors associated with instability following closed reduction of distal radius fractures:

Injury factors:

• More than 5 mm shortening
• Dorsal tilt > 20°
• Articular displacement > 2mm
• Displacement > 2/3 shaft width in any direction
• Dorsal metaphyseal comminution
• Associated Ulnar fracture

Patient Factors:

• Osteoporosis

Plate and screw fixation

Closed distal complex radius fracture with wrist spanning external fixator

Superficial: Brachioradialis & flexor carpi radialis. Radial artery lies deep to brachioradialis in middle forearm and distally between brachioradialis and flexor carpi radialis. Superficial Radial nerve lies under brachioradialis.

Deep dissection: Middle third lateral border of pronator teres. Distal third lies flexor pollicis longus & pronator quadratus. Classic Henry approach is between brachioradialis and radial artery or modified Henry approach between radial artery and flexor carpi radialis. The radial artery is retracted laterally while flexor carpi radialis is retracted medially. With flexor pollicis longus also retracted medially pronator quadratus is exposed.

Anterior (Henry) approach to distal radius shaft. Release Brachioradialis at radius styloid process and make radial incision over pronator quadratus.

Plate & screw fixation radius

Open distal radius complex fracture

Open distal radius fracture with external wrist spanning external fixator with wound vacuum suction dressing

Open wound debridement and curettage

Apply vacuum suction dressing after debridement

Application of external fixator: 2 Doral distal radius pin insertion with 2 pins inserted to the dorsal aspect of 2nd metatarsal

Arm sling

Hand grip exercises with arm in splint

Forearm strength exercise

Distal radioulnar joint:

The distal ulnar joint primary function is a weight-bearing joint. Radioulnar ligaments attachment to the ulnar fovea and base of ulnar styloid process.

Arm sling

Hand grip exercises with arm in splint

Forearm strength exercise

Olecranon fractures are fractures of the proximal Ulnar bone that forms the elbow joint. This area is superficial and can easily fracture when falling onto it or with a direct blow to the area (comminuted fracture type) or it can be fractured indirectly by falling with an outstretched arm (transverse/oblique fracture type).

Presentation:

• Pain swelling
• Deformity
• Inability to extend the arm

Clinically:

• Bone tenderness
• Loss of extensor arm mechanism

Investigations:

• X-ray will confirm the fracture and severity

Simple olecranon fracture

Complex olecranon fracture

Based on the fracture pattern

Transverse:

• Apex of sigmoid notch and usually represents an avulsion fracture

Transverse impacted:

• Direct force causing depression and comminution

Oblique

• From hyper extension injury and begins at midpoint of sigmoid notch and runs distally

Oblique distal

• Extend distal to the coronoid and compromise elbow stability

Comminuted with associated injuries

• Direct high energy trauma with fractures of the coronoid process that may cause elbow instability

Fracture dislocation

• Usually high energy with severe trauma

Schatzker classification of olecranon fractures

Non-surgical:

Nondisplaced fractures can be managed nonoperatively in a splint or in a Plaster of Paris cast. There is however a risk of elbow stiffness with prolonged rehabilitation to restore elbow range of motion. Start mobilization after 1 week. Conservative management is a consideration for low demand, elderly individuals.

Surgery:

Surgical fixation include either tension band wiring for simple fractures or plate and screw fixation for complex oblique fractures. Plate and screw fixation has lower rate of revision surgery rates for removal of symptomatic metalware.
Other options include intramedullary nail and screw fixation, fragment excision with triceps advancement and elbow joint replacement.

Tension band wiring for transverse fracture with no comminution. The K-wire and 18-gauge tension band wire fixation converts the triceps force into a compressive force with elbow flexion.

Screw fixation with tension band wiring for transverse fracture with no comminution. The 6.5mm cancellous screw and 18-gauge tension band wire fixation converts the triceps force into a compressive force with elbow flexion.

Plate and screw fixation

Nail with screw fixation

Posterior approach to right distal humerus, Radial nerve at risk

Radial nerve is responsible for motor elbow and wrist extension. Sensory distribution shown on pic.

Distal humerus to curving around the lateral olecranon to 2-4cm along ulnar crest

Ulnar nerve exploration along medial intermuscular septum and followed to the cubital tunnel, isolate and retract with latex loop

Retract triceps laterally

Medial attachment of triceps along olecranon is partially released

Free triceps on lateral side

Split triceps fascia & mobilize from lateral intermuscular septum &

partially release triceps tendon on lateral side of olecranon with 1mm sliver of cartilage

Retract triceps medially

Distally partially release anconeus

Split triceps tendon in midline to to upper limit of olecranon fossa to proximal triceps muscle area with caution to Radial nerve for more proximal muscle splitting

Medial incision along medial ulnar border ± cartilage/periosteum sleeve

Retract the split triceps

Osteotomy

Final bone incision with osteotome

Olecranon fixation options: plate & screws/tension band wire

Skin incision: Direct incision over proximal Ulnar.

2 K-wire inserted and engage anterior ulnar cortex but avoid overpenetration to prevent injury to the anterior interosseous nerve or limit forearm ROM.

Skin incision: Direct incision over proximal Ulnar.

Screw length must engage distal intramedullary canal.

Skin incision: Direct incision over proximal Ulnar entry point.

Nail with screw fixation proximally and distally.

Skin incision: Direct incision over proximal Ulnar.

Plate and screw fixation.

Surgery approach: directly over ulnar. Reattach triceps tendon close to the articular surface thereby improving stability as triceps acts as a sling for the trochlea.

2 Tunnels are drilled using a 2mm bit, drilling from proximal to distal:

• Dorsal superficial
• Volar deep
• Start at the volar corners of footprint & drill the deep tunnels in a crossing pattern so that the tunnels exit 1.5 to 2.5 cm distal to olecranon tip and 8 to 10mm to the side of dorsal ulnar ridge
• The superficial (dorsal) tunnels drilled similarly crossing corners of the footprint starting from dorsal ulnar ridge 10 to 12mm proximal to deep tunnels
• Triceps sutured with Krackow technique with 4 exiting strands exiting deep surface of triceps
• Unattached free sutures are passed, crossing retrograde through superficial tunnels exiting the dorsal corners of footprint. These sutures are passed through the triceps using a free needle from deep to superficial and tied across four corners after the Krakow sutures are tied
• Modified technique used with excision of proximal olecranon

Arm sling

Hand grip exercises with arm in splint

Forearm strength exercise

The mechanism usually fall to the outstretched arm

More common in females

Risk factors:

• Osteoporosis

Presentation:

• Pain
• Swelling
• Deformity

Clinically:

• Bone tenderness

Investigations:

• X-ray
• CT: for intra-articular fracture evaluation and surgical planning

Type Ⅰ: < 30° displacement

Type Ⅱ: 30°-60° displacement

Type Ⅲ: > 60° displacement

Posterolateral elbow dislocation with radial neck and coronoid fractures

Non operative:

• Stable nondisplaced fractures
• Sling for comfort but immediate range of elbow motion

Operative treatment:

• Displaced intraarticular fractures
• Elbow dislocation with associated displaced fracture
• Ligamentous disruption with elbow instability with associated fracture
• Loose intraarticular bodies
• Fracture dislocation
• Inability to maintain anatomical fracture reduction
• Open fracture
• Fracture with neurovascular compromise

Radial Head Plate and Screw Fixation

Radial Head Plate and Screw Fixation

Arm sling

Hand grip exercises with arm in splint

The terrible triad elbow injury is a traumatic elbow injury characterized by elbow dislocation, radial head/neck fracture and a coronoid fracture.

Mechanism: fall on extended arm with an axial, valgus and posterolateral complex disruption producing a posterolateral elbow dislocation.

Posterolateral elbow dislocation with radial neck and coronoid fractures

Presentation:

• Pain
• Swelling
• Deformity
• Clicking and locking

Clinically:

• Bone tenderness
• Varus/valgus instability
• Exclude Essex-Lopresti injury

Investigations:

• X-ray: X-ray elbow and include wrist joint when clinically indicated. Assess joint congruency.
• CT: for intra-articular fracture evaluation and surgical planning

Type Ⅰ: avulsion tip

Type Ⅱ: single or comminuted fracture involving < 50% of coronoid

Type Ⅲ: single or comminuted fracture involving > 50% of coronoid

Non surgical management is seldom done with immobilization in a splint/cast for closed fractures provided :

• Reduced elbow
• Radial head fracture doesn’t meet surgery recommendations for fixation
• Insignificantly small coronoid fracture

Options:

• Splint for one week with progressive increasing elbow range of motion while limiting full extension until after 4-6 weeks

Surgery:

• Fixation options: radial head replacement or radial head fixation with repair of collateral ligament and coronoid fracture fixation for fractures >10% of the coronoid

Surgery considerations for radial head/neck injury associated with Terrible Triad. ORIF coronoid and lateral elbow ligament complex.

Hinged elbow external fixator

Jones et al treatment algorithm for surgical treatment of terrible triad elbow injuries (2017)

Lateral approach (Kocher/Kaplan)

Surgery considerations for radial head/neck injury associated with Terrible Triad. ORIF coronoid and lateral elbow ligament complex.

• LCL repaired and sutured to lateral epicondyle through bone tunnels or anchor fixation
• With elbow at 90° flexion the LCL is repaired with forearm in pronation if MCL is intact or forearm in supination if torn MCL

Fracture reduction and screw fixation for large fracture fragments. Type fractures may require a Lasso technique by suture fixation of Brachialis muscle/tendon complex and securing it by tie fixation after passing it to through olecranon bone tunnels.

Arc for safe zone for application of external fixator pins of right arm

Risk factors:

• Increased carrying angle hence more common in females
• Exclude elbow dislocation and instability due to posterolateral subluxation

Presentation:

• Pain with supination and pronation
• Swelling
• Deformity
• Block to elbow range of motion

Clinically:

• Bone tenderness
• Haemarthrosis
• Flexion/extension block
• Exclude elbow instability

Investigations:

• X-ray: AP & Lateral & capitellar views. The double arc sign is pathognomonic of a Type Ⅳ capitellar fracture.
• CT: for intra-articular fracture evaluation and surgical planning.

Type Ⅰ (Hahn-Steinthal): complete capitellar fracture with no/little extension into lateral trochlear

Type Ⅱ (Kocher-Lorenz):   anterior osteochondral fracture with minimal subchondral bone

Type Ⅲ: comminuted or compression capitellar fractures

Type Ⅳ: capitellar fractures with extension medially into the trochlea

Variations in the types of elbow dislocation

Non-operative:

• Stable and nondisplaced fractures
• Displaced: Reserved for ill, low demand patients whose co-morbidities preclude surgical intervention
• Arm sling with 90° elbow flexion for 4-6 weeks

Operative Treatment:

• Displaced intraarticular fractures
• Elbow dislocation with associated displaced fracture
• Ligamentous disruption with elbow instability with associated fracture
• Loose intraarticular bodies
• Fracture dislocation
• Open fracture

Capitellar screw fixation

• Lateral approach to elbow and distal humerus
• Keep forearm pronated to move posterior interosseous nerve away from surgical field
• Dissect subcutaneous tissue and identify lateral column
• The common origin of forearm extensor tendon together with anterior capsule is mobilized as full thickness flap anteriorly
• Deep dissection: Kaplan- between extensor digitorum communis & extensor carpi ulnaris interval. Alernate Hotchkiss interval between flexor pronator mass & carpi ulnaris muscle.
• Expose fracture & reduce
• Maintain position with K-wire fixation
• Screw fixation anterior to posterior e.g. Herbert screws or fully threaded mini-Acutrak screws
• Screws directed in divergent pattern
• Osteochondral fragment (TypeⅡfracture ) can be removed if purely cartilaginous and irrepairable or fixed if possible with bioabsorbale implants

Arm sling

Hand grip exercises with arm in splint

Forearm strength exercise

Posterolateral elbow dislocation with radial neck and coronoid fractures with ligamentous disruption

Distal humerus segment (13)

Type A-extraarticular

A1- avulsion fracture

A2- simple fracture

A3-multifragmentary fracture

Non-operative:

• Indicated for nondisplaced or minimally displaced fracture
• Immobilization in arm split for 3-4 weeks

Ensure that there is no concomitant elbow ligamentous instability

Disadvantage:

• Elbow stiffness
• Close fracture monitoring

Surgery:

• For displaced fragment
• Large fragment
• Associated elbow instability requiring repair
• Surgery fixation options include K-wires, screw/s, staples, sutures and tension bands

Lateral epicondyle fragment reduction:

• Manual traction to arm with one hand while palpating the lateral epicondyle fragment and manipulating it into its anatomical position
• Confirm reduction with X-ray imaging
• Maintain elbow at 90° and apply splint

Surgery: fragment reduction & screw fixation

Arm sling

Hand grip exercises with arm in splint

Strength exercises only performed after union

Fracture complication: Medial epicondyle intraarticular fragment require reduction and fixation

Non-operative:

• Indicated for nondisplaced or minimally displaced fracture (<5mm)
• Immobilization in arm splint

Ensure that there is no concomitant elbow ligamentous instability

Disadvantage:

• Elbow stiffness
• Close fracture monitoring
• Fibrous nonunion
• Note: assess Ulnar nerve function

Surgery:

• For displaced fragment
• Large fragment
• Intraarticular fragment entrapment in elbow joint
• Associated elbow instability
• Open fracture

Surgery: fragment reduction & screw fixation

• Skin incision: center over over medial supracondylar ridge, the medial epicondyle and in line with flexor/pronator mass
• Identify Ulnar nerve between the intermuscular septum and triceps, posterior medial epicondyle groove and in between the 2 heads of flexor carpi ulnaris
• Incise capsule

At the proximal end elevate muscles & joint capsule from medial supracondylar ridge. Distally open the capsule and reflect anterior to the medial collateral ligament

Pendulum shoulder range of motion

Pendulum shoulder strength exercise

Shoulder strengthening with resistance band

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