72. Elbow
From Primary Surgery
72.1 Introduction
Injuries of the elbow fall into two groups-those of children and those of adults. A child seldom suffers from any of the adult fractures and vice versa. But dislocations can occur at any age. The penalty for mismanaging any of these injuries is likely to be a stiff painful elbow always.
The ligamentous injuries of the elbow include: (1) epicondylitis (tennis elbow) in adults, in which the attachment of the extensor muscles to the lateral condyle is strained, and (2) pulled elbow in children in which the head of the radius jams inside the annular ligament. In pulled elbow there is usually a history of a specific injury, but not in epicondylitis.
The signs in the list which follows should enable you to diagnose most injured elbows, even if you do not have X-rays. They are especially useful in children whose X-rays are difficult to interpret. You cannot remember all these signs, so consult the following section with the patient in front of you.
EXAMINING THE ELBOW
First, check the patient's median, ulnar, and radial nerves and his radial pulse, and record your findings (Fig. 75-3).
If his elbow is normal he can: (1) flex it by putting his hand on his shoulder, (2) extend it by holding his arm out straight, and (3) pronate and supinate it 90° in either direction, as in Fig. 69-1. Limitation of any movement suggests disease.
Is the contour of the posterior of his arm abnormal? if so, he may have a supracondylar fracture or a dislocation. if very little movement is possible, he has a dislocation, or supracon dylar fracture, or a T-shaped fracture. if his elbow is fixed in 45° of flexion with almost no movement, he almost certainly has a dislocation.
Does the head of his radius move normally? Bend his elbow to 90°. if he can rotate his forearm, the head and neck of his radius are probably normal. Place your middle finger on his lateral epicondyle, and your index beside it over the head of his radius. Pronate and supinate his arm. i f the head of his radius is intact, you can feel it moving under your index finger.
Can you feel the 3 bony points, as in A, in Fig. 72-2 Are they in their normal position in relation to the tower end of his humerus? if his elbow is severely swollen, you will not be able to feel them.
If the 3 bony points are displaced in relation tc one another he may have a dislocation. if his olecranon is displaced, has it moved medially or laterally in relation to an imaginary line down the back of his arm? You will need to know this when you come to reduce a supracondylar fracture or a dislocation.
If his 3 bony points are r theirrelation to one another but are displaced in relation to the lower end of his humerus as in D, Fig. 72-2, he may have a supracondylar fracture. This is a critically important sign in very young children before much ossification has taken place in the lower end of the humerus so making the x-rays difficult to interpret.
Where is the greatest tenderness? Just above the patient's elbow? (supracondylar fracture). On the medial side of his elbow? (fracture of the medial epicondyle). Over his lateral condyle and the outer part of his antecubital fossa? (fracture of the lateral condyle, or epicondylitis). Over the head of his radius? (fractured head of radius). if the tenderness is over his olecranon, can you feel a gap in it, or move it in relation to the shaft of his ulna? These are signs that it may be fractured.
Can you move the end of his humerus or its condyles onthe shaft? Use your finger and thumb to feel the bony ridges running up from his medial and lateral epicondyles. Steady his arm with your other hand. Then very gently try to move the lower end of his humerus sideways, and backwards and forwards on the shaft. if it moves, he has a supracondylar fracture. This is painful, so only do it if it is absolutely necessary. I f his elbow is obviously broadened, can you move one condyle in relation to the other, perhaps with crepitus? (T-shaped fracture).
Can he extend his elbow as in Fig. 72-23? If he can, his extensor mechanism is intact.
Is there an effusion? You can rarely diagnose an effusion because of swelling of the soft tissues. Look at his elbow from the back. Are the normal hollows on either side of his olecranon obliterated or bulging? if they are, he has an effusion. You may be able to observe fluctuation between these swellings, or between them and the fullness on the anterior surface of his elbow. When compared with the other side, does his ulnar nerve feel abnormally superficial in its groove behind the medial epicondyle, or even displaced from it by the effusion? SUMMARY
SUMMARY OF THF MAJOR FEATURES IN ELBOW INJURIES
Dislocated elbow Any age. Contour abnormal. Severe swelling. Elbow fixed at 45°. The 3 bony points are not in their normal relation to one another. Olecranon displaced posterior to the epicondyles. Lower end of humerus not abnormally mobile, no crepitus. Distance between lateral epicondyle and radial styloid abnormal.
Supracondylar fracture Common in children. Contour abnormal. Severe swelling. Some movement possible. Olecranon not displaced above the epicondyles. The 3 bony points are in their correct places in relation to one another, but they lie posteriorly to the shaft of the humerus. Abnormal mobility of the lower humeral fragment with crepitus. Distance between lateral epicondyle and radial styloid normal.
T-shaped fracture Adults. Severe swelling. Contour abnormal. Condyles move in relation to one another. Some movements of the elbow still possible. Crepitus. Swelling obscures the 3 bony points.
Fractured medial epicondyle Older children and youths. Contour normal. Medial epicondyle tender and swollen. Some flexion and extension possible. Rotation normal.
Fractured lateral condyle Children. Contour normal. Lateral condyle tender and swollen.
Fractured capitulum Rare. Adults. Very little flexion or extension. Some rotation possible. The 3 bony points are normal. Tenderness difficult to localize.
Fractured neck of radius Common. Children under 4 years. Contour normal. Flexion and extension less painful than rotation. No rotation. The head of the radius may be tender.
Pulled elbow Young child. Contour normal. The child refuses to use his arm. No rotation.
Fractured head of radius Adults. Contour normal. Moderate swelling. Some flexion and extension possible but no rotation. The 3 bony points are normal. Head of the radius tender.
Fractured olecranon All ages. Contour normal. Moderate swelling. The olecranon is tender, and a gap may be palpable. There are two varieties of fracture depending on whether active extension is possible or not (72.18).
72.2 X-rays of the elbow
Always X-ray an injured elbow. Ask for an AP and a lateral view. Minor fractures such as small chips off the capitulum are difficult to diagnose without an X-ray. In a severe elbow injury the medial epicondyle is easily detached, so it is the first thing to look for. The films of a child's injured elbow are not easy to interpret, so X-ray his other elbow in the same position, and compare the two. Also consult the diagrams inside the back cover, but remember that these apply to Caucasians, and that African epiphyses unite later. If you are still in doubt, X-ray the patient again in a week. The fracture, if there is one, will then be easier to see. Note that: (1) in children a mildly oblique X-ray can both resemble and disguise a dislocation, and (2) that the head of the radius and the medial and lateral epicondyles can be displaced before their centres of ossification appear. This makes diagnosis difficult.
If a child's injured elbow looks normal on X-ray, the three bony points are in their normal places, and diagnosis is difficult, consider pulled elbow (72.16). Some of these injuries are mild subluxations. Try gently manipulating the elbow under anaesthesia. You may feel a sudden click after which it moves normally.
72.3 Elevating and aspirating the elbow
An injured elbow rapidly swells, and makes reduction of a fracture difficult. As with the knee, aspirating the blood from a tensely distended elbow joint relieves pain, and allows the patient to move his elbow much earlier. Some surgeons consider this an an important part of the active movements treatment of comminuted supracondylar fractures in adults (72.11), and especially of fractures of the head of the radius (72.15). Other surgeons never aspirate an injured elbow.
If an elbow is dislocated reduce it immediately. If it is fractured and too swollen to reduce immediately, put the patient's arm up in forearm traction as in Fig. 72-11.
ASPIRATING THE ELBOW Clean the patient's skin carefully,
paint it with iodine, and taking the most careful aseptic precautions, aspirate at the summit of the swelling between
the 3 bony points on the outer side of the elbow, as in Fig. 72-4.
CAUTION ! Don't put anything into the joint except the tip of a sterile aspirating needle.
72. 4 Dislocation of the elbow
A patient of any age can dislocate his elbow if he falls on his outstretched hand. In this common injury a force travels up his forearm and pushes his radius and ulna posteriorly, or his humerus posteriorly and laterally. He cannot move his elbow, and holds it at about 45°. The posterior outline of his arm, instead of being normally rounded, or showing a slight prominence over his olecranon, bends abruptly backwards as in C, Fig. 72-2. The three bony points of the elbow are not in their normal places. There may be other injuries also: (1) A child may fracture his medial epicondyle which may become trapped inside his dislocated elbow. (2) His lateral condyle may also fracture.
A patient may also have severe soft tissue injuries, and occasionally the circulation of his forearm is obstructed, with the danger of Volkmann's ischaemic contracture (70.4).
| REDUCE A DISLOCATED ELBOW IMMEDIATELY |
REDUCING A DISLOCATED ELBOW
The sooner you do this, the easier it will be, and the fewer the complications. if it is very recent, the alternative method described below may work.
Check the patient's radial pulse, and his median, ulnar, and radial nerves (Fig. 75-3).
ANAESTHESIA Good relaxation is essential in adults, but is
less necessary in children. (1) General anaesthesia. (2) Give
a child ketamine (A 8.2) or a general anaesthetic. (3) Axillary
(A 6.18) or brachial plexus blocks are satisfactory if you do
them well.
REDUCTION lie the patient on his back with his upper arm
vertical, and his forearm flexed across his chest, as in A, Fig.
72-6.
Find an assistant and ask him to exert traction on the patient's hand from the other side of the table (1), and at the same time, to flex the elbow gradually (2). While he does this, grasp the patient's elbow in both hands, with your fingers round the front of his humerus, and your thumbs behind his olecranon, then push it forwards (3).
The patient's olecranon should lie in the centre of his arm midway between his two epicondyles as in A, Fig. 72-2. if it i s shifted sideways, first move it into the midline with your thumbs as you reduce it, then push it forwards over the lower end of the humerus. The dislocation will reduce with a scrunch.
When you think that you have succeeded, move the patient's elbow through its normal range. Unless you can get full flexion, you have not reduced it. if it feels stable, treat it as described below.
ALTERNATIVE METHOD if the dislocation is very recent,
method B, in Fig. 72-6 may work without an anaesthetic.
Sit the patient sideways on a chair. Put a pillow over the top of the chair's back, and let his forearm hang over it.
Ask an assistant to exert traction on the patient's wrist, while at the same time you press on the back of his olecranon. Using the same movements described above, you may be able to coax his olecranon back into place.
Alternatively, and with experience, you may be able to caress his elbow and then suddeny flick it into place before he knows what has happened, and without using an anaesthetic.
X-RAYS Check: (1) that reduction is satisfactory, and (2) that
there is no bony fragment trapped in the joint. if there is, it will have to be removed by opening the joint. if you are not able to do this, refer the patient.
CAUTION ! if you neglect to X-ray a patient after trying to reduce his dislocated elbow, you may fail to diagnose that reduction is incomplete, until after the swelling has gone. Reduction will then be possible only at open operation.
POSTOPERATIVE CARE FOR A DISLOCATED ELBOW
As soon as a patient recovers from the anaesthetic, reexamine his radial pulse, and his median, ulnar, and radial nerves to make sure that you have not injured them during reduction.
If reduction is stable, rest his arm in a sling for 3 weeks
in the hope of avoiding post traumatic ossification. While it
is in the sling he should move it as much as possible. Start
shoulder, finger, and wrist exercises within the sling
immediately. Don't let him take the sling off for 3 weeks. if
there are no complications, his elbow will recover slowly, but
he may always have some limitation of full extension.
CAUTION ! Never perform passive stretching exercises. These encourage post traumatic ossification.
If reduction is unstable, flex his elbow as far as it will go
in a collar and cuff sling, or with a posterior slab, for 3 weeks.
Then start active movements.
If reduction is very unstable in all directions: (1) there is
a fracture, or (2) his medial epicondyle is trapped inside his
elbow (see below), or (3) his ligaments are torn. Apply a temporary
plaster backslab and refer him.
DIFFICULTIES WITH A DISLOCATED ELBOW
If the patient's dislocation occurred MORE THAN TWO WEEKS AGO, every day's delay will have made the prognosis worse. if the dislocation occurred less than 6 weeks ago, try to reduce it by manipulation. if it is already 2 weeks old, this will be difficult. if you fail, refer him for open reduction. An arthrodesis or elbow excision may be necessary.
If his dislocated elbow has been INCOMPLETELY REDUCED: (1) A child's medial epicondyle may have broken off and be inside the joint. if you are in doubt, X-ray his other elbow, and look for a small centre of ossification in an abnormal position. (2) There may still be a sideways displacement after the backward displacement has been corrected. if so, try to reduce the dislocation again. if you fail, refer him without delay because there is probably soft tissue between the joint surfaces.
If the patient's elbow REDISLOCATES EASILY and is very unstable, make sure there are no fractures. Apply a collar and cuff to maintain the stable position for 2 weeks. if it still redislocates, refer him.
If his MEDIAL EPICONDYLE IS TRAPPED inside his elbow, he is likely to present as failure to reduce a dislocation and a very unstable elbow. A trapped medial epicondyle is easy to find because the flexor muscles are attached to it. if it really is in his elbow joint and his elbow is unstable in all directions, apply a temporary posterior slab, and refer him.
If he has OTHER FRACTURES, he may have a flake off his capitulum, or a fracture of his coronoid, or a fracture of the head of his radius. First reduce the dislocation, and then treat the fracture as if the dislocation had never existed. if it is a major flake, refer him immediately to have it removed.
If a NERVE HAS BEEN INJURED; particularly his ulnar nerve, i t may need to be explored by an expert if it does not recover spontaneously in a month. Any of the nerves crossing the elbow may be injured, especially the ulnar.
If 2 or 3 weeks after an injury the MOVEMENT OF A PATIENT'S ELBOW BECOME LESS, a firm mass forms near the joint, and his soft tissue starts to calcify, he is suffering from POST TRAUMATIC OSSIFICATION (myositis ossificans). When an elbow dislocates the periosteum is torn off the back of the humerus and brachialis is torn from the front. These injured tissues may calcify and ossify, particularly in children. The same complication can follow a supracondylar fracture, and is made worse by: (1) repeated manipulations in an attempt to reduce the injury, and (2) forceful movements subsequently.
Watch the patient carefully for the first few weeks after reduction. if at any time movement of his elbow becomes less, stop him moving it for a few days. Continue to immobilize it, until unrestricted use of it no longer dmlnishes its range. Allow him full activity, but avoid forced movements and exercises. The only safe movements are those that are possible using the injured X-ray his elbow and look for soft tissue calcification, usually anteriorly in brachialis. See also Section 72.10. Don't try to remove any bony lumps or refer him for their removal until at least a year after the injury. Sometimes, in spite of the best care, a patient's elbow becomes stiff permanently. if this starts to happen, keep it in its most useful position, according to his needs. This is usually flexed to about 90°, with his forearm in mid-pronation (Fig. 73-1).
| AVOID FORCED ELBOW MOVEMENTS |
72.6 Posteriorly displaced supracondylar fractures in children
This a particularly important children's fracture-the wrong treatment can easily make it worse. Supracondylar fractures are common between the ages of 3 and 11, and are rare after the age of 20.
A child falls on his outstretched arm, and breaks the lower end of the shaft of his humerus just above the epiphyseal line in one of four ways: (1) In a third of cases there is no displacement, or the fracture is incomplete, so that the child needs no treatment except for a collar and cuff. (2) In the remaining two thirds of cases the distal fragment is displaced posteriorly. The child is tender just above his elbow, which swells rapidly and obscures the bones round the fracture. (3) Occasionally, the lower fragment is displaced anteriorly (72.7). (4) Occasionally, separation takes place at the epiphyseal line and displaces the epiphysis. Treat these epiphyseal displacements exactly as if they were supracondylar fractures. Reduce them immediately. Like all epiphyseal injuries, they unite rapidly.
There is one rare immediate danger and two common later ones.
The rare immediate danger, both with this fracture and with posterior dislocations of the elbow, is that they can impair the blood supply to a child's lower arm, and so cause the compartment syndrome followed by ischaemic fibrosis of his forearm muscles (Volkmann's ischaemic contracture), or gangrene requiring amputation (70.4). Contracture from a supracondylar fracture is much rarer than Contracture as the result of failing to split a circular cast on a fracture of the forearm.
The force causing the injury pushes the distal fragment posteriorly and proximally, and the proximal fragment anteriorly and distally. The sharp proximal fragment pierces the periosteum, and comes to lie under brachialis. If the force continues the proximal fragment goes straight through brachialis into the child's antecubital fossa, and may even penetrate his skin. As it moves forwards it may tear his brachial artery, or make the artery go into spasm, or it may injure his median or occasionally his radial nerve. The artery and the nerve may also come to lie between the proximal and distal fragments, and so prevent reduction. Worse, the antecubital fossa fills with blood. This: (1) obstructs the collateral vessels which might otherwise bypass the injured artery, and (2) impairs the venous return from his arm. The ischaemic forearm muscles swell and the compartment syndrome develops (73.7). Bending such an acutely swollen elbow is like trying to bend a balloon.
The most common later disability is a very stiff, or fixed elbow. This is caused by the post traumatic ossification that may follow repeated manipulation. So try to reduce the fracture with the minimum of manipulation. One attempt at manipulation followed by one more is the most you should try. Your first attempt is the most likely to succeed, and later ones will become more and more difficult.
The other common late disability is a deformed elbow. Some displacements remodel and others do not.
The displacements which remodel are: (1) Moderate angulation of the lower fragment in the plane of the elbow. (2) Posterior displacement of the lower fragment; growth of the epiphysis corrects this. The displacements which do not remodel are: (1) Severe angulation of the lower fragment in the plane of the elbow. If you leave this unreduced, or reduce it badly, the child will be left with permanent hyperextension and severe loss of flexion. (2) Valgus or varus angulation. This does does not remodel, however mild it is or however young the child. Varus angulation is common and is usually accompanied by internal rotation and medial displacement. The result is a loss of the normal carrying angle in mild cases, or an ugly varus deformity in more severe ones, like the child in Fig. 72-8. This is common, and although it does not affect flexion or extension, so that disability is mild, it does not look good, and makes it difficult for the patient to carry a basket.
The principles of reduction are: (1) To exert traction on the child's elbow, and while doing this to correct the sideways displacement of the distal fragment. Then, (2) to flex his arm while still exerting traction, so as to use his triceps tendon to hold the lower fragment in place. A common error is to try to correct sideways displacement after you have flexed his arm.
Never treat these fractures with a circular cast. The risk of Volkmann's ischaemic Contracture is great. If you do apply plaster, it must be a backslab.
| NEVER PUT A CIRCULAR CAST ON A SUPRACONDYLAR FRACTURE |
A CHILD'S SUPRACONDYLAR FRACTURE POSTERIORLY DISPLACED
The following description assumes that the child's fracture is on the right side, and follows Fig. 72-9.
If possible, reduce the fracture immediately. If there am signs of ischaemia this is urgent.
If immediate reduction is impossible because his arm is swollen like a balloon, apply forearm traction as in Fig. 72- 11, and reduce the fracture as soon as the swelling has subsided sufficiently for you to feel the fragments. if the skin of his forearm is blistered, so that you cannot apply traction to it, elevate it in a stockinette sleeve or towel pinned together and suspended from a drip stand, as in Fig. 75-1. Reduction is possible up to a week later, but not more.
If the fracture is more than a week old, it will be difficult to manipulate, so leave it. Six months later, if there is a severe deformity, refer him for a corrective osteotomy.
Check his median, ulna, and radial nerves (Fig. 75-3).
ANAESTHETIC (1) intravenous ketamine (A 8.3).(2) General
anaesthesia.
REDUCTION OF A SUPRACONDYLAR FRACTURE
Flex the child's normal elbow, feel its bony anatomy carefully, and compare it with his injured elbow. Feeling the bony parts of the injured elbow may be impossible if it is very swollen. Note especially the position of his olecranon in relation to the axis of his humerus. This is a useful guide to satisfactory reduction.
Feel how much external rotation of his flexed elbow is possible on the normal side. Later, when you come to reduce a medially displaced fragment, you will need to rotate his injured forearm externally to the limit of what is possible on the normal side, and a bit more. This external rotation may be critical. Sideways displacement either corrects itself, or is easily corrected.
What happens to his pulse if you flex and exert gentle traction on his arm? if his pulse disappears when you do this and only reappears when his arm is nearly straight, it may merely be due to the swelling round his elbow, or he may have a brachial artery lesion.
DIAGRAM A
Steady the child's shoulder. Ask your assistant to hold it by passing a towel round it (1).
Pull to disimpact the fracture and correct angulation Extend the child's elbow gently. Grip his wrist and distal forearm. Pull hard in a longitudinal direction for at least 1 minute by the clock (2). You will feel the fragments disimpact and release the soft tissues trapped between them. Check that you have disimpacted them by feeling that the lower fragment is free.
DIAGRAM B, REDUCING A SUPRA CONDYLAR FRACTURE
Correcting medial and lateral displacement. The distal fragment is usually displaced medially. TractIon usually corrects this. if it does not, now is the time to try to correct it. Feel the distal fragment, although the child's elbow may be so swollen that this is impossible. if necessary, move the distal fragment towards the midline of his arm (2a).
DIAGRAM C
Correct the posterior displacement. While still exerting longitudinal traction with your right hand (3), press the olecranon with your thumb (4).
Begin flexing (5) with your thumb pressing on his olecranon. Do this while your assistant maintains traction in the child's axilla. Keep pressing his olecranon with your left thumb as you do so. Externally rotate his forearm a little more than was possible on the normal side. This will help to restore the normal carrying angle.
Continue flexing. As the child's arm reaches 90°, pull posteriorly on his humerus, and anteriorly on his forearm. CAUTION ! Use only moderate tension as his arm reaches 90°. if you pull too hard at this stage, it is possible to pull the distal fragment in front of the end of the humerus. Fortunately this is rare.
DIAGRAM D, REDUCING A SUPRACONDYLAR FRACTURE
Complete flexing. Beyond 90° further flexion does not improve reduction, but it does stabilize reduction by wrappi ng the child's triceps tendon round the distal fragment and fixing it. This also impacts the fragments. Lateral displacement of the distal fragment cannot now be corrected.
The position of the point of the olecranon is the best guide to satisfactory reduction. It should be in line with the axis of the humerus or perhaps little anterior to it (8). You should also be able to feel both epicondyles forming, with the tip of the olecranon, the 3 bony points of the elbow in A, Fig. 72-2.
DIAGRAMS E, F and G, REDUCING A SUPRACONDYLAR FRACTURE
Check the child's pulse (7). This may be difficult because of oedema. if his pulse disappears when you flex his arm, extend it until his pulse reappears.
If he has a good radial pulse, put his arm in a collar and cuff in as much flexion as his pulse will allow. His hand should be able to reach his mouth. if you cannot feel his pulse, extend his elbow until you can free it. Make a cuff out of two lengths of stockinette filled with cotton wool (8).
If you cannot get his arm beyond 70° without his pulse disappearing put him in forearm traction (Fig. 72-11), as described below.
If you are not sure if you can feel his pulse or not, don't worry for the moment. But immediately he wakes from the anaesthetic, ask him if he can flex his fingers. if he cannot do this, proceed as in Section 72.8.
CAUTION ! (1) Make the knot of the collar and cuff so secure that neither the child, nor his parents, nor his grandparents can remove it. A good way to secure it is to cover it with plaster. Provided there are no complications, it will need to stay on for 3 weeks. In whatever way the child twists and turns, he must not be able to extend his elbow more than 90° or reduction will be lost. (2) Don't fit a plaster backslab, it is unnecessary and make it difficult to flex his elbow sufficiently.
As soon as he awakes, make sure he can flex and extend his fingers. Check the function of his median and ulnar nerves. They may be injured, but they usually recover eventually.
CHECK REDUCTION The post reduction X-rays are of less
help than they might be in seeing if angulation has been successfully
reduced or not, because: (1) the child's arm must
be kept flexed after reduction, and (2) the centres of ossification
in the lower fragment may still be small. However, do your
best by the the X-ray criteria in Fig. 72-10. if they are not met,
have one further attempt at reduction, not more, or you will damage
the child's elbow, and increase the chances of post-traumatic
ossification.
PREVENT ISCHAEMIC PARALYSIS Don't send the child home
because he may return with an irreversible Volkmann's contracture!
Admit him to the ward and monitor the circulation
i n his hand carefully for 36 hours. Watch him for early signs
of ischaemia. Check his pulse, and then press on his nail beds
and see how quickly his capillaries refill. The first signs of ischaemic paralysis are: (1) pain on passive extension of his fingers, (2) paraesthesiae (3) pallor, and (4) paralysis as shown by the inability to use his fingers.
Make sure the ward staff know why they are monitoring the child's circulation and what signs they should watch for. if they don't know this, they may be quite content to feel the pulse in his normal arm!
CAUTION ! Don't give him morphine or any analgesic until you are sure that ischaemia is no longer a danger.
POSTOPERATIVE CARE AFTER REDUCING A SUPRACONDYLAR FRACTURE
If you have to reduce the flexion of a child's elbow, because of his impaired circulation, flex it again as his swollen elbow recovers. Then, X-ray him again.
Keep his collar and cuff on for 3 weeks. Don't let him take it off during this period. Make sure his parents understand this.
At 3 weeks his fracture will have united, so remove his collar and cuff, and replace it by a sling for 3 more weeks.
If, when you remove his collar and cuff, he ceases to be able to touch his mouth, replace it, and gradually tighten it until he can.
His elbow will be stiff for a long time. Encourage him to use it, but let movement return on its own, using its own active movements. Even when movement is slow to return, you can assure his mother that it will be better at the end of a year.
CAUTION ! (1) Forceful passive movements will make the stiffness worse. (2) Don't try to straighten his elbow by making him carry weights.
| DON'T SEND HIM HOME FOR 36 HOURS AFTER REDUCTION |
72.7 Supracondylar fracture of the humerus in children with anterior displacement of the distal fragment
Anterior displacement of the distal fragment of a supracondylar fracture is rare, and the signs are milder than with posterior displacement. Make the diagnosis from the lateral X-ray, as shown in & Fig. 72-7. This may be difficult to interpret because the lower end of the diaphysis overlaps the epiphysis, especially in a young child, so that the epiphysis may appear to be displaced when it is not. The best test is to look at a lateral X-ray and to see where a line drawn down the front of the humerus cuts the curved lower border of the epiphysis, this is the line A-B in Fig. 72-3. It should bisect it as in Fig. 72-3. The epiphysis should not lie in front of this line.
A CHILD'S SUPRACONDYLAR FRACTURE ANTERIORLY DISPLACED
Anaesthetize the child as for forward displacement (72.8). Extend his forearm. Ask an assistant to exert steady traction in the line of his arm with his forearm supinated.
While your assistant is doing this, steady the lower end of his humerus with one hand, and correct the sideways displacement of the lower fragment with your other hand.
Either, put his arm up in traction as in Fig. 72-11, or apply a 10 cm plaster slab along the back of his arm and forearm with his elbow extended. Keep it in place with a crepe bandage.
Confirm reduction with an X-ray. Remove the slab in 3 weeks in a child and put his arm in a sling.
Alternatively, flex his elbow to 90°, and push his forearm posteriorly on his upper arm so as to convert the anterior displacement to a posterior one. Then, treat it as you would a posterior displacement (72.6 ).
72.8 Ischaemia following a supracondylar fracture
This is a child who cannot move his fingers after the reduction of a supracondylar fracture. His arm shows some or all of these signs: (1) He has severe, deep, poorly localized, pain in the flexor muscles of his forearm. Pain when you extend his fingers passively is a serious late sign. So is flexion of his fingers. Occasionally, the syndrome is subacute and painless. (2) Paraesthesiae develop. First he feels 'pins and needles', then his arm becomes numb with anaesthesia of glove distribution. (3) The skin of his arm (if his is conscious) becomes white or blue (if he is Caucasian). There is no circulation in his nail beds. (4) His arm is weak, and he cannot use his fingers. (5) Palpable induration of his forearm muscles is a diagnostic sign, but it occurs late. (6) His radial pulse may be weak or absent. An absent pulse is an unreliable sign, because the pulse is sometimes present even when there is severe ischaemia. Teach your staff the importance of the four ' Ps'- pain, paraesthesia, pallor (if they are caring for Caucasians) and paralysis, in that order.
Be vigilant, quick, and decisive. Recognize these signs early. If they are getting worse decompression is urgent. This is a very rare acute emergency, and there is no time to refer him. It is one of the few occasions where doing something is always better than doing nothing. If you are lucky, extending his forearm in traction, as in Fig. 72-11, will be enough to restore his circulation. If this fails, you will have to explore his antecubital fossa, and decompress the muscles of his arm. The penalty for not doing this will be Volkmann's ischaemic contracture (70.4).
EARLY SIGNS OF IMPENDING ISCHAEMIC CONTRACTURE
Temporarily ignore the child's fracture. Take off all bandages. if a plaster cast has been applied, remove it.
FOREARM TRACTION Apply longitudinal traction to the skin
of the child's forearm. Use adhesive strapping and pass the
cord over a pulley, so that if he moves about, traction will still
be maintained. Suspend his arm as in Fig. 72-11.
Slope his bed slightly to stop him falling out, by putting a pillow under one side of the mattress. Monitor the circulation in his arm.
If the pain goes, his circulation improves, and he is able to move his fingers, continue traction. When most of the swelling has gone, usually in about a week, reduce the fracture as described above, and put his arm in a collar and cuff. You should now have no trouble with his pulse. Usually, by this ti me the fracture is so firmly fixed that you will have to accept the malposition.
CAUTION I if pain, paraesthesiae, pallor, and paralysis persist, for more than an hour, make preparations to take him to the theatre, explore his antecubital fossa and, if necessary, the volar aspect of his forearm, as described below. Don't be put off by a full stomach (16.1).
72.9 Forearm traction fails to restore the pulse of a child with a supracondylar fracture
This is the child whose supracondylar fracture is complicated by ischaemia of his forearm. He is unlucky in that signs of ischaemia persist, even with his arm extended in forearm traction and any tight cast or bandage removed. Take him to the theatre. There are two things you can do: (1) You can release the tension in his antecubital fossa and relieve the pressure on his vessels. (2) You can decompress his forearm muscles to relieve the compartment syndrome (73.7)., Opinions vary as to which of these is the most important. Releasing the tension in his antecubital fossa is easier and may be all that is necessary. Don't delay; a wait of 3 or 4 hours may make all the difference between a normal and a totally useless arm. If you act promptly his prognosis is likely to be good. Don't try to inspect or repair his brachial artery-this is a highly skilled task, it is rarely necessary, and, because the collateral circulation round the elbow is so good, a blocked brachial artery does not necessarily cause Volkmann's ischaemic contracture.
| WATCH FOR PAIN, PARAESTHESIA, PALLOR, AND PARALYSIS |
OPERATING FOR ISCHAEMIA
Don't explore the child's antecubital fossa until you have tried to reduce the fracture, because this may itself be enough to improve the circulation his arm.
Make the lazy 'S' incision as in A, Fig. 72-12, beginning above the flexor crease on the inner border of his biceps tendon.
Pull back the flaps, incise his tight deep fascia and his bicipital aponeurosis (B). Pale or blue-black muscle will bulge from the wound. There may be a tight haematoma. Remove it. This may be enough to relieve the obstruction and restore his circulation.
CAUTION! Don't meddle with his brachial artery, or try to resect the spastic section.
DECOMPRESSING A CHILD'S FOREARM MUSCLES if the above methods fail, and his forearm is swollen, carry the Incision down through it, as in Fig. 73-11. Slit his deep fascia in the length of the incision. Pale oedematous muscles will burst through the slit fascia. Decompress the superficial and deep volar compartments of his arm, as in Section 73.7.
POSTOPERATIVE CARE Leave the flaps open, and dress the
child's wound. Don't sew it up. if the fracture is not reasonably
reduced, apply forearm traction. If it is reduced, apply a collar and cuff.
Skin graft the wound after 4 days. if a contracture develops, see Section 72.10.
| TREAT THE EARLIEST SIGNS OF ISCHAEMIC PARALYSIS IMMEDIATELY |
72.10 Other difficulties with supracondylar fractures in children
These include nerve injuries, post-traumatic ossification, a persistent varus deformity, and severe malunion. Most of these complications are difficult to treat. The principle is to prevent them by the methods described above if you possibly can.
OTHER DIFFICULTIES WITH A SUPRACONDYLAR FRACTURE
If a child has NERVE INJURIES after a supracondylar fracture, they will probably recover. They are more common than injuries to the brachial artery, but are less serious. Nerve injuries alone are not an indication for an immediate operation. if there is no recovery in a month, refer the child to have his elbow explored.
If the child's ELBOW WiLL NOT MOVE after a supracondylar fracture, he is suffering from POST TRAUMATIC OSSIFICATION. After 3 weeks, when the collar and cuff are removed, his elbow will not move, or perhaps there is some movement which gradually becomes less. The front of his elbow is tender, there is muscle spasm and the tendon of his biceps stands out as a taut band. X-rays may show a vague shadow like callus in front of the joint, or it may be so dense that it looks like bone. Sometimes a stiff painful elbow with new bone around it is his presenting symptom.
Encourage his parents to put his injured elbow through several 15 minute periods of gentle active movements each day, both flexion and rotation. His parents must be patient, persistent and gentle. Foxed movements and even too vigorous passive movements will make his elbow worse Make this clear to them. if the movements of a child's arm are diminishing, put his arm in a collar and cuff until muscle spasm has disappeared, which may take months. If he cannot flex his elbow enough to get his hand to his mouth, put it in a loose collar and cuff and gradually tighten it until he can. After prolonged rest the spasm disappears and movement returns, but there is usually some permanent loss of movement. Unfortunately, post-traumatic ossification is common, and is a major disability, especially when pronation is lost. Osteotomy followed by an arthrodesis in the position of function (about 90°, see Fig. 7-16) may be necessary.
If SEVERE VARUS DEFORMiTY PERSISTS, refer the child for corrective osteotomy not earlier than a year after the injury.
If the fracture was never property reduced, and he now has MALUNION with only 30° of movement or less, management depends on where the movement is. if it is around the position of function (90°) an osteotomy is unlikely to improve him. But if it is around full extension, an osteotomy may bring it into a more useful range.
| NEVER MOVE AN ELBOW CONTRACTURE FORCEFULLY |
72.11 Supracondylar fractures of the humerus in adults
Supracondylar fractures in adults differ from those in children, and are caused in a different way: (1) An old person falls and strikes his elbow on the ground. The force of the blow drives his ulna up against his humerus and either breaks off its lower end, as in a child, or, more often, splits it into two or more pieces which may separate widely and displace backwards or forwards. Or, (2) the patient rests his arm on the window of his car, and has it crushed by a passing vehicle (sidewipe fracture). In either case he cannot move his swollen and deformed elbow. Swelling obscures the bony landmarks and if you examine it carefully, you may be able to feel crepitus.
These fractures are usually T-shaped or comminuted. Rarely, they are transverse as in children; if so, you can manage them in the same way. If the fracture is T-shaped or comminuted, you cannot reduce the fragments by closed manipulation, and they are difficult to fix at open operation. Even when the fragments are fixed internally, the late results are often disappointing, so it is fortunate that the results of early active movement are usually better as shown in Fig. 72-13, and that patients have much less osteoarthritis than you might expect. But the results will only be better, if the patient really does start moving his elbow early. The function he will ultimate' y get depends on the relationship of his two condyles. If they are widely apart and shifted on one another, movement will be poor. If they are parallel and not shifted, movement will be better. Displacement of the fragments at the transverse fracture is less important. You can combine active movements with traction, as in Fig. 72-14.
SUPRACONDYLAR FRACTURES OF THE HUMERUS IN ADULTS
INDICATIONS FOR REFERRAL (1) If the lower end of the patient's humerus !s in one or two fragments only, and you can refer him to a superb technician, he may benefit from internal fixation, especially if he !s young. (2) Injuries to his median or ulnar nerves.
TRANSVERSE SUPRACONDYLAR FRACTURES
If the lower fragment is in one piece, treat it as for a child's supracondylar fracture (72.6).
T-SHAPED, Y-SHAPED, OR COMMINUTED SUPRACONDYLAR FRACTURES
EARLY ACTIVE MOVEMENTS if necessary, anaesthetize the patient and try to get the fragments into a better position. Try to start active movements as soon as possible. If his arm is very swollen keep it raised for a few days. Put his arm in a collar and cuff for not more than a week. During this time take it out several times a day and encourage him to move it.
CAUTION ! (1) FlexIon and extension are subsequently likely to be limited, so make sure they are !n the most useful range, as in Fig. 72-13. (2) For the same reason his forearm should be in mid-pronation.
Start pendulum exercises for his shoulder (Fig 71-7), and exercises for his wrist and fingers immediately after the injury.
After a week, provided he continues to be able to put his hand to his mouth, put his arm in a sling. Keep him in the sling for 5 weeks. Encourage him to use his hand and move his elbow as much as he can. Tell him that he will not regain any movement in his elbow unless he tries very hard to use it.
OLECRANON TRACTION if the patient's olecranon is intact, pass a Kirschner wire through it (70.10), and tension the wire with a Gissane stirrup (1), or, less satisfactorily, use a thin (less than 4 mm) Steinmann pin. The danger with a pin is that i t is more likely to get in the way of his ulnar nerve. if the fragments are displaced, ask an assistant to exert traction on the stirrup while you press the fragments back into place (2).
Apply enough traction to keep his upper arm under tension (3) but not enough to lift his shoulder off the mattress. You may need to apply 2 to 5 kg.
Apply a sling (4) to keep his elbow at 90° and his wrist half-way between pronation and supinaton, with his hand over his opposite shoulder.
Apply 0.5 to 1 kg of backward traction on his upper arm (5). This is not essential.
Feel the bony prominences on the back of his elbow (6) and adjust the direction of traction so that the position of the prominences matches that on the normal side, and corrects any sideways shift. You may have to tie the traction cord to one of the outer holes in the stirrup (7).
CAUTION ! Check his radial pulse often. Don't apply too much traction, or you may obstruct the circulation to his arm, injure his nerves, or distract the fragments and so prevent union.
X-ray him. Slight backward displacement is acceptable, but there should be no angulation or lateral displacement.
While he is in traction, encourage him to move his elbow as much as he can. Let him take hold of the traction cord and assist his elbow movements himself.
Remove the traction at 2 to 3 weeks, put his arm in a sling with his elbow at 90° and his forearm in 45° of pronation. Start carefully graded active movements without using force. Recovery will take several months.
DIFFICULTIES WITH SUPRACONDYLAR FRACTURES IN ADULTS
If a patient's HUMERUS IS BADLY COMMINUTED AND OPEN, AND HIS RADIUS AND ULNA ARE INJURED TOO, this is likely to be the result of a car accident in which he had his elbow over the edge of the window. Toilet his wound. if his elbow is dislocated, reduce it. Suspend his arm in the position of function, and get it moving. Dress it, but do not close it by primary suture. Look at it in 4 or 5 days, and either close it or graft it. (1) Hang it up with metacarpal Kirschner wire (70.12), or (2) use skin traction on his fingers while watching their circulation carefully. Hang his hand up in the same position as for forearm traction.
72.12 Fracture of the medial epicondyle of the humerus
Between the ages of 5 and 20 the centre of ossification of the medial epicondyle is a separate piece of bone. The flexor muscles of the forearm are attached to it, and if these are pulled on hard enough by a fall on an outstretched hand, they can pull it away from a patient's humerus. His detached medial epicondyle may remain outside his elbow joint or go inside the joint and lock it. Closed methods may succeed in removing it, but if they fail, an open operation is necessary Removing the detached medial epicondyle would not be a difficult operation, if his ulnar nerve were not so close. Sometimes, his elbow is dislocated also (72.4).
After a fall an older child or youth complains of a painful elbow. The contour of his arm is normal, but his medial epicondyle is tender and swollen. Rotation is normal and some flexion and extension is usually possible. Compare the X-rays of both his elbows.
FRACTURE OF THE MEDIAL EPICONDYLE
IF THE PATIENT CAN MOVE HIS ELBOW ADEQUATELY, put his arm in a collar and cuff for a week. Then give him a sling and encourage active movements. Full movements may not return for a year.
IF HE CANNOT MOVE HIS ELBOW ADEQUATELY,
anaesthetize him. Extend his wrist to tension his flexor
muscles. Flex, abduct, and supinate his elbow, then suddenly
extend it. The fragment may reduce with a sudden clunk. Xray
his elbow, and repeat the manoeuvre twice if necessary.
If you can move his elbow through its full range of movement and it is stable, apply a collar and cuff as above.
If you cannot move his elbow through most of its full range, refer him for open reduction.
OPERATION if you cannot refer him, and are familiar with the
procedures, consider operating. This is not an operation for
the beginner, because the child's ulnar nerve will not be in its
normal position and may be kinked into the joint with his
medial epicondyle. Make all incisions in the line of the nerve,
not across it.
Make a 5 cm longitudinal incision 1 cm anterior to his
medial epicondyle. Find his ulnar nerve and take care not to
injure it. You will see the fibres of the common flexor origin
emerging from the joint cavity. Pull on these fibres with a hook
or forceps, and pull the epicondyle out of the joint.
Find the rough place on the medial side of his elbow from which the epicondyle broke off. Either suture it in place by drilling a small hole in it and In the neighbouring bone, or, anchor It in place with two short pieces of Kirschner wire with their ends bent over subcutaneously. Remove them 4 to 6 weeks later. If fixing the epicondyle is difficult, and the fragment is small, excise it. His flexor muscles will quickly find new attachments.
DIFFICULTIES WITH FRACTURES of THE MEDIAL EPICONDYLE
If the patient's ULNAR NERVE IS INJURED paralysis maybe due to stretching and only be temporary. If recovery is delayed more than 6 weeks, refer him for transfer of the nerve to the front of his elbow.
If the FRAGMENT HAS BEEN LEFT INSIDE THE JOINT, and you discover It some time later, refer the child. if you cannot refer him, warn him that full movement may not return.
72.13 Fracture of the lateral condyle of the humerus (children)
A young child aged 4 to 15 falls on his outstretched hand. His wrist extensors, which are attached to his lateral condyle, pull it away from his humerus. His elbow is swollen and will not move. You can rotate his forearm, showing that his radius is intact. The posteromedial side of his arm is not tender, showing that he has probably not got a supracondylar fracture. Sometimes his elbow is dislocated also.
This is a serious Type IV epiphyseal injury (69.6). It occurs at a younger age than an injury to the medial epicondyle, and the displaced fragment is larger. The fracture line runs from the middle of the articular surface of the child's elbow upwards and laterally, isolating part of his trochlea, the whole of his capitulum, and often a small part of the shaft of his humerus, as in Fig. 72-15. Sometimes, there is only a little lateral shift which need not be reduced. More often, the lower fragment turns over completely inside the joint. If it is not reduced, it unites to the shaft with fibrous tissue, and growth in the lateral half of his epiphysis stops. The result is a severe valgus deformity of his elbow which increases until growth ceases. Distortion of the path of his ulnar nerve round his severely deformed elbow causes a late ulnar paralysis with wasting of the small muscles of his hand.
The X-rays of his elbow are difficult to interpret, because a large part of the fragment is cartilage and casts no shadow. An AP view shows that the epiphysis of his capitulum is missing; instead, there is an abnormal mass of bone on the outer side of his elbow. In a lateral view this may be hidden behind his humerus, but it is usually displaced anteriorly. If he is under 12, you will not see the centre of ossification for his displaced lateral epicondyle, because it will not yet have appeared. If in doubt compare the X-ray of the injured side with that of the normal one. Don't mistake this injury for a supracondylar fracture!
FRACTURE OF THE LATERAL CONDYLE OF THE HUMERUS
IF THERE IS NO DISPLACEMENT relieve the child's pain, if necessary, by aspirating his elbow joint (Fig. 72-4) using careful sterile precautions. Apply a backslab from his axilla to his knuckles with his elbow in 60° of flexion and his wrist dorsiflexed. Mould the backslab closely round his elbow, and hold it in a sling.
At 4 weeks replace the slab by a sling.
IF THERE IS DISPLACEMENT, suspend his arm in extension
traction, as in Fig. 72-11, until the swelling is less. Find two
assistants. Anaesthetize the patient.
Ask one assistant to apply traction to the child's partly flexed forearm. Ask the other assistant to apply counter traction to his upper arm. Ask them to slightly adduct his arm at the same time, so as to widen the space on the lateral aspect of his elbow joint.
While they are applying traction and adduction, try to manipulate the fragment back into place in contact with his humerus.
If closed reduction is successful, immobilize his elbow in a plaster backslab as above. Mould the backslab round the lateral side of his elbow to keep the fragment in place.
If closed reduction fails, do all you possibly can to refer the child for open reduction immediately. This involves fixing the lateral fragment with two fine Kirschner wires. The penalty for not doing so is likely to be a fixed elbow always. if the fragment is not replaced, warn his parents that a progressive valgus deformity and ulnar paralysis may occur, and that he must return early, so that an ulnar nerve transposition can be done.
DIFFICULTIES WITH FRACTURES of THE LATERAL CONDYLE
If 10 to 30 years later the patient complains of NUMBNESS AND TINGLING in the distribution of his ulnar nerve, followed by wasting of the small muscles of his hand, he has an ulnar nerve paralysis. Warn his parents that this may follow the progressive valgus deformity of his elbow many years later, because he may not connect it with his injury. His ulnar nerve should be moved anteriorly in his elbow before the small muscles of his hand start to waste.
72.14 Fracture of the capitulum (adults)
In this rare fracture a piece of the patient's capitulum breaks off, tilts, and moves anteriorly. Unless it is reduced, he will have very little use in his elbow. The fragment varies in size from a small piece of cartilage, to the whole of the front of the patient's capitulum and part of his trochlea. The head of his radius may be fractured at the same time.
The patient holds his slightly swollen elbow at 90°, the contour of his arm is normal, and tenderness is difficult to locate. Rotation is fair, but very little flexion is possible. Small fragments consisting only of cartilage are difficult to see on the X-ray, so diagnose them from the history of locking and the signs of a loose body in the joint.
FRACTURE OF THE CAPITULUM
Ask an assistant to exert traction on the patient's extended forearm. While he does this, press the fragment down firmly with your thumbs. Then when the fragment is in place, flex the patient's elbow to more than 90°.
If closed reduction is successful, apply a collar and cuff for a few weeks and start shoulder and finger exercises immediately.
If X-rays show that reduction has failed, refer him for external fixation of the fragment.
72.15 Fractures of the head of the radius (adults)
In this common injury a force travelling up the patient's arm drives the head of his radius against his capitulum. What happens depends on his age: (1) In a child the neck of the radius bends so that its head is displaced anteriorly and laterally, but the head itself almost never fractures. (2) In an adult the head may crack, a piece may chip off, it may break into many pieces, or the whole head may displace elsewhere in the joint. Treatment must be prompt and adequate.
Typically, the contour of the patient's arm is normal, and not greatly swollen. He is able to flex and extend his elbow a little, but he cannot rotate his wrist. The head of his radius is tender. His elbow and his X-ray may look so normal that the fracture is easily missed. If you think that he might have fractured the head of his radius, but his X-ray looks normal, treat him conservatively and X-ray him again in a week; the fracture will then be more obvious.
In the instructions below we advise you treat a patient conservatively if you possibly can. Although the operation itself is not difficult, you can easily cut the deep branch of his radial nerve (posterior interosseous nerve); so refer him if possible.
| ROLF (37 years) fell on the ice, and broke the head of his radius, sustaining Fracture B, in Fig. 72-19. Instead of treating him with active movements, an 'expert' orthopaedic surgeon immobilized his arm, quite unnecessarily, in a cpst for several weeks. When this was removed his arm was stiff for several more weeks. LESSONS there are many fractures for which a cast is NOT indicated! |
| DON'T OPERATE WITHOUT A TOURNIQUET |
FRACTURES OF THE HEAD OF THE RADIUS
CONSERVATIVE TREATMENT
INDICATIONS Start by treating all fractures of the head of the radius this way.
METHOD Make sure that the patient's elbow is not also dislocated. if it is, reduce it first.
Aspirate the blood in his elbow joint (Fig. 72-4), inject 2 ml of local anaesthetic solution. You will now be able to flex, extend, and supinate his elbow. Start active movements (69.10) and encourage easy movements, especially rotation. Don't apply plaster. Observe him carefully.
If he improves, over the next few days, good. if not, refer him for operation as early as possible. By the time 5 days have elapsed you should know if conservative treatment is going to succeed or mot. It i s more likely to succeed in fractures A, and B, in Fig. 72-19 than it is in C, and D. Most skilled surgeons would operate immedIately on C, or D, without attempting conservative treatment; you would probably be wise to try conservative treatment first. if the fragment in fracture E, is not much dIsplaced, it may have to be removed at open operation. But if it is widely displaced, it may be not be restricting elbow movement, so conservative treatment may succeed.
If the patient improves under conservative treatment, so much the better, but warn him that full recovery will be slow.
OPEN OPERATION ON THE HEAD OF THE RADIUS
If possible refer the patient. This is not an operation for the beginner, or one to do if you have not seen it done. It you decide to operate, the sooner you do so the better. Try to operate within 5 days before dense scar tissue forms.
INDICATIONS Failure of conservative treatment. There is no
need to remove a loose fragment (E) unless it is interfering
with the movement of the elbow joint. Don't remove the head of the radius in a child, because this will interfere with the growth of the bone, and cause a severe valgus deformity.
TOURNIQUET Exsanguinate the patient's arm with an
Esmarch bandage, and place a tourniquet (3.8) round his upper
arm. Operating without a tourniquet will place the deep
branch of his radial nerve in greater danger.
POSITION Lie him on his back and bring his arm over the front
of his chest, so that the posterior surface of his elbow is
uppermost. Leave his hand free so that you can rotate his
wrist, and so turn the head of the radius. if necessary, attach
a weight to his wrist, or tie it.
INCISION Make a 5 cm incision (A, in Fig. 72-20) over the
posterolateral surface of the patient's elbow, extending
downwards from his lateral epicondyle to his ulna over the
interval between his extensor carpl ulnaris and his anconeus
muscles.
Deepen the incision through the fascIa between anconeus and extensor carpi ulnaris (B), to expose the joint capsule. if there is much bruising, and you cannot define these muscles, incise them between his lateral epicondyle and his olecranon.
CAUTION I The deep branch of the radial nerve (posterior interosseus nerve) arises from the radial nerve 2 or 3 cm below the elbow. It winds round the lateral side of the neck of the radius, 1 cm below its head, between the two planes of the fibres of supinator. Don't dissect deeply in front of the radius, or distal to the annular ligament posteriorly. Unfortunately, its course may vary considerably.
Make a longitudinal incision in the capsule (C) to expose the head of the patient's radius and his capitulum (D). Syringe away the blood clot from the joint.
Find his annular ligament and divide the periosteum immediately proximal to it. Don't strip any of the perlosteum from the bone.
Cut away the head of his radius with nibblers immediately proximal to the annular ligament (E). Don't cut this ligament.
Remove all loose pieces of bone (F). Reassemble the head of his radius to make sure that no pieces are still missing inside the joint.
If possible, close the soft tissues over the broken neck of his radius with a purse string suture (G). This is not easy, and is not essential.
If his elbow has been dislocated, redislocate it to remove any loose fragments of the radial head that may be lying in other parts of the joint. Fragments are sometimes driven through the capsule and lie outside it. inspect his capitulum for injury.
Rinse the wound forcibly with Ringer's lactate, or saline, and if possible insert a suction drain. Close the capsule and the muscle with one layer of interrupted sutures. Release the tourniquet and control bleeding.
POSTOPERATIVE CARE Flex the patient's elbow to 90°. Apply
a pressure dressing to the wound and give him a collar and
cuff.
Next day, encourage him to start exercising his fingers and shoulders. After a week encourage him to move his elbow. Avoid vigorous exercise or forced passive movement.
If he is in much pain or spasm, immobilize his elbow again for a few weeks, and then try again to mobilize It.
DIFFICULTIES WITH FRACTURES OF THE HEAD OF THE RADIUS
If a patient PRESENTS LATE with a fracture like that in D Fig. 72-19, refer him. There is however little to be done.
If he has a STIFF ELBOW, watch the progress of his movements carefully. An Injured elbow takes a long time to recover. The tissues round it sometimes ossify. if movements become fewer, stop them completely for a few days, then start them again cautiously. Don't push exercises If recovery is slow, because it increases the risk of post-traumatic ossification. X-ray his elbow and look for this.
| MAKE SURE YOU REMOVE ALL THE FRAGMENTS |
72.16 Pulled elbow (young children)
This common injury is the result of lifting up a child by one arm, or swinging him around on it. Many minor and otherwise undiagnosed injuries are probably pulled elbows. The head of a child's radius has no well defined neck, so that if it is pulled distally, it can be gripped by the annular ligament.
A child with a pulled elbow holds his hand in neutral, he refuses to use his arm, and he cannot rotate his wrist. Sometimes, the head of his radius is tender. His X-rays are normal. The differential diagnosis of a fracture of the neck of his radius.
Treatment is usually easy. Hold his hand in one of your hands as if you were shaking hands, and cup his elbow in the palm of your other hand. Suddenly supinate his arm and at the same ti me quickly push his hand towards his elbow, while pushing on the head of his radius with your thumb. This will usually free the head of his radius from the annular ligament. Sometimes, even extending his elbow to take an X-ray does the same. He will cry loudly, but he will usually be able to move his arm. If this fails, do nothing. He will usually recover completely in a few weeks; if he does not, refer him.
72.17 Fracture of the neck of the radius (children)
A child falls on his outstretched hand and breaks the neck of his radius just distal to the epiphyseal plate, proximal to the attachment of his biceps. The head of his radius angulates anteriorly and laterally on its broken neck, and usually remains attached to the shaft. The same injury may fracture his medial epicondyle, strain or rupture the medial ligament of his elbow, or fracture the upper third of his ulna.
The contour of his elbow is normal, and flexion and extension are less painful than rotation.
This injury can occur before the centre of ossification appears in the head of his radius at the age of 10. If it does, the only X-ray sign of a complete displacement of the head of his radius is this: the proximal end of his radius is closer to the lower end of his humerus on the injured side than it is on the normal one. If so, refer him.
Treatment depends on the degree of angulation and on the child's age. Mild angulation needs no treatment. Moderate and severe angulation must be corrected, because the head may grow abnormally and ultimately dislocate, particularly after severe displacement in an older child. In very young children the head may grow almost normally, even after severe displacement. Never excise the head, because this is sure to cause a severe growth deformity.
FRACTURE OF THE NECK OF THE RADIUS
CHOICE OF PROCEDURE The following indications refer to angulation in the AP or the lateral view. If the head is angulated less than 15°, put the child's arm in a sling for 10 days. Recovery will be complete.
If the angulation is more than 15°, t ry closed reduction, as described below. This may succeed even if the head is severely displaced.
If the child's elbow Is also dislocated, reduce it and then treat the head of his radius.
If the head of the radius is completely separated (see above), refer him for open reduction.
CLOSED REDUCTION If the child's elbow is very swollen, suspend his arm in extension traction (Fig. 72-11), until the swelling his reduced.
Anaesthetize him, and ask an assistant to steady his upper arm. Extend his arm, grasp his wrist with one hand, and his elbow with the other, as in Fig. 72-22. Adduct his forearm at his elbow (1), so as to open the joint between his capitulum and the head of his radius a little.
Rotate his forearm (2) into the position In which the most prominent part of the displaced head lies laterally and superficially.
Put your thumb over the displaced head of his radius. While you adduct his forearm, press the head of his radius proximally and medially (3). Now flex his forearm and supinate it sharply (4).
If closed reduction falls to reduce the angulation to 15° or less, refer him for open reduction. if this is not possible, the head of his radius may remodel if he is young, so proceed with active movements only.
POST REDUCTION X RAYS in the lateral view the forward
angulation of the head should be corrected, and in the AP
view the lateral angulation should also be corrected. In both
views the surface of the head of the child's radius should be
parallel to his capitulum.
POSTOPERATIVE CARE Bandage on a plaster backslab
extending two thirds of the way around his arm. After 3 weeks
replace it by a collar and cuff for another 3 weeks.
72.18 Fractures of the olecranon
A patient can fracture his olecranon in two ways: (1) He can receive a direct blow to the point of his elbow which fractures it directly. (2) He can fall on his outstretched hand at the same time as his triceps is contracting, and thus break his olecranon indirectly. In both cases his elbow is acutely tender and swollen. Sometimes the head of his radius is also injured.
Examine him. Can he extend his forearm against gravity, as in A, Fig. 72-23?
If he can extend his arm against gravity, the extensor mechanism of his s elbow is intact, and active movements alone are enough, whatever his X-ray may show.
If he cannot extend his forearm against gravity, his extensor mechanism needs repair. Look at his lateral X-ray. If more than half his olecranon fossa is intact, excise the proximal fragments and suture his triceps to his ulna, as in Fig. 72-24. If less than half his olecranon fossa is intact, fix the two fragments of his olecranon by tension band wiring (Fig. 72-26). In this method two stiff Kirschner wires go obliquely through his olecranon and are anchored in the cortical bone of the anterior surface of his ulna to give the fragment longitudinal stability. They are kept together by a band of flexible steel wire, wound in a figure of eight. If you don't have the equipment for tension band wiring, or if a patient's olecranon is in many fragments, you can excise the fragments and suture his triceps to his ulna.
If his elbow needs repair, but this is not possible, treat him with active movements, and warn him to expect some permanent loss of extension.
Olecranon injuries in children, A child may have several centres of ossification in his olecranon, so you may have difficulty deciding if he has a fracture or not. If in doubt, X-ray his other elbow. The epiphysis of the olecranon occasionally separates from the shaft of the ulna between the ages of 10 and 16. If it does, treat it in the same way as you would a fracture.
FRACTURES OF THE OLECRANON
ACTIVE MOVEMENTS TREATMENT
INDICATIONS (1) All patients in whom the triceps mechanism is intact, as described above, even if the fragments have separated slightly. (2) A patient who Is too oId to notice that active extension is lost, for example, he will never need to reach to lift a jam jar from a high shelf. METHOD Put the patient's arm in a sling for a few days, and give him analgesics. Encourage him to use his arm, and to take it out of the sling from time to time and let it dangle. Encourage him to return early to light work.
CAUTION! Don't splint his elbow, especially not In extension.
His elbow will heal rapidly. if there was less than 5 mm displacement, there will be bony union. Otherwise, there will be a slightly unstable fibrous union with an excellent range of movement.
EXCISING FRAGMENT(S) IN OLECRANON FRACTURES
INDICATIONS (1) Loss of the extensor mechanism of a patient's elbow caused by a fracture involving half or less of his olecranon fossa. More than half of his olecranon fossa remains intact on the shaft. (2) Any fracture of his olecranon in which the extensor mechanism is lost and the equipment for tension band wiring is not available. If possible, refer him. However, if you cannot refer him, proceed as follows.
INCISION Exsanguinate the patient's arm with an Esmarch
bandage (3.8). Place a blood pressure cuff around his arm as
high as possible. Lie him on his back and fold his arm over
his chest so that his elbow lies uppermost.
Incise and expose his olecranon, as described below for tension band wiring. Remove the bone fragments, and cut them away from the tendon of his triceps. Drill two holes in the shaft of his ulna. If you don't have a drill, you can make holes at the edge of his ulna with a strong towel clip. Pass strong sutures through these holes, and then through his triceps tendon, as in A, Fig. 72-24.
CAUTION ! Watch his ulnar nerve. Find and gently retract it.
TENSION BAND WIRING FOR OLECRANON FRACTURES
INDICATIONS Loss of the extension mechanism of the elbow, due to a fracture involving more that half the patient's olecranon fossa, with a single proximal fragment suitable for wiring. If possible refer the patient. If you cannot refer him, proceed as follows.
EQUIPMENT Kirschner wire, 0.35 mm stainless steel wire, Faraboef's rougine, pliers, wire cutters, scoop, bone hooks or towel clips.
INCISION Make an 8 cm longitudinal incision just lateral to
the point of the patient's elbow (A, in Fig. 72-26). incise the
periosteum and scrape it away from the fracture site with a
rougine. Expose the smaller fragment. It may be in smaller
pieces than the X-rays suggest. Open the joint and clear away
any blood clot (B).
Hold the fragments together with a bone hook or towel clip so as to close up the joint line. Hold the hook so that it presses in the long axis of the ulna. Try to obtain hair-line reduction. The fracture line will be easier to see if you have previously stripped away the periosteum from around it. Drill in two Kirschner wires (C). Drill the olecranon transversely for the insertion of the tension band (D).
Thread the wire in a figure of eight through the hole in the ulna and round the Kirschner wires (E). Twist the ends of the wire loosely together. Bend the ends of a Kirschner wire upwards at 90° with pliers (F).
Cut the first Kirschner wire, leaving a few millimetres of its bent end projecting (G). Do the same thing for the other Kirschner wire. Turn the bent cut ends of both of them back against the bone. Twist the ends of the tension band together and cut them off (H).
POSTOPERATIVE CARE (bath methods) Put the patient's arm
in a collar and cuff and start active movements early.
CAUTION ! Don't let him try to extend his arm actively against resistance for at least a month.
DIFFICULTIES WITH OLECRANON FRACTURES
If the patient is a CHILD (rare), immobilize his elbow in extension for 5 weeks. Stiffness is unlikely to be a problem.
