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WRIST AND ELBOW INJURIES (Fractures and dislocations around the elbow in…

- - - - Colles
        
        A Colles' fracture is a type of fracture of the distal forearm in which the broken end of the radius is bent backwards.[2] Symptoms may include pain, swelling, deformity, and bruising.[2] Complications may include damage to the median nerve.[1]
        
        It typically occurs as a result of a fall on an outstretched hand.[2] Risk factors include osteoporosis.[2] The diagnosis may be confirmed with X-rays.[2] The tip of the ulna may also be broken.[4]
        
        Treatment may include casting or surgery.[3] Surgical reduction and casting is possible in the majority of cases in people over the age of 50.[5] Pain management can be achieved during the reduction with procedural sedation and analgesia or a hematoma block.[5] A year or two may be required for healing to occur
      - Smith's
        
        A Smith's fracture, also sometimes known as a reverse Colles' fracture or Goyrand-Smith's, is a fracture of the distal radius.[1] It is caused by a direct blow to the dorsal forearm[2] or falling onto flexed wrists, as opposed to a Colles' fracture which occurs as a result of falling onto wrists in extension. Smith's fractures are less common than Colles' fractures.
        The distal fracture fragment is displaced volarly (ventrally), as opposed to a Colles' fracture which the fragment is displaced dorsally. Depending on the severity of the impact, there may be one or many fragments and it may or may not involve the articular surface of the wrist joint.
    - - Conveniently the Salter-Harris types can be remembered by the mnemonic SALTR
        
        III
        
        7-10%
        
        fracture plane passes some distance along the growth plate and down through the epiphysis
        
        lower
        
        poorer prognosis as the proliferative and reserve zones are interrupted
        
        IV
        
        intra-articular
        
        10%
        
        fracture plane passes directly through the metaphysis, growth plate and down through the epiphysis
        
        poor prognosis as the proliferative and reserve zones are interrupted
        
        through or transverse or together
        
        II
        
        ~75% (by far the most common)
        
        fracture passes across most of the growth plate and up through the metaphysis
        
        above
        
        good prognosis
        
        V
        
        uncommon <1%
        
        crushing type injury does not displace the growth plate but damages it by direct compression
        
        ruined or rammed
        
        worst prognosis
        
        I
        
        slipped
        
        5-7%
        
        fracture plane passes all the way through the growth plate, not involving bone
        
        cannot occur if the growth plate is fused
        
        good prognosis
        
        Physeal fractures (also called Salter-Harris fractures) are important childhood fractures that involve the physeal plate. They are relatively common and important to differentiate from other injuries because the involvement of the physis (growth plate) may cause premature closure resulting in limb shortening and abnormal growth.
  - - - • Fractures of the distal radius. Usually treated by closed reduction (manipulation) and the application of a well moulded plaster.
        • If very unstable in theatre (radial and ulnar complete fractures, displaced) or if the fracture has slipped position in plaster after manipulation, then internal fixation with percutaneous K wires or more rarely, open fixation with plates and screws may be used.
    - - Fractures with dorsal displacement/angulation
        
        • Undisplaced + stable. Below elbow plaster immobilization for 6 weeks.
        
        • Displaced + stable. Closed reduction and plaster immobilization for 6 weeks.
        
        • Displaced + unstable. Closed reduction and either percutaneous K wire fixation (two wires), external fixation, or ORIF with plates and screws.
        
        • Complex intra-articular fractures or highly unstable patterns can now be successfully treated with modern anatomic pre-contoured distal radius locking plates.
      - Fractures with volar displacement (‘Smith's fracture’)
        
        Unstable and are treated by a volar buttress plate (supports a fracture like a shelf, propping up or supporting the distal fragment).
        
        Intra-articular fractures with volar displacement (‘Barton's fracture’)
        
        Internal fixation is mandatory as it is a highly unstable fracture.
        
        Ulnar styloid fractures
        
        Do not often require fixation unless the fragment is large in which case, it may represent a TFCC injury (see Orthopaedic surgery) treated by internal fixation.
- - - - • Usually transverse fractures of the radius and ulna.
      - • May be angulated only with one of the cortices still intact (‘greenstick fracture’).
      - • Be aware of plastic deformation (no obvious fracture, but bowing of one or both bones).
      - • May sustain a fracture dislocation as in adults.
    - - • Usually either a transverse or oblique fracture of the radius and ulna.
      - • Isolated ulna shaft fractures (‘nightstick fractures’ named after mechanism of defending direct blow from a policeman's nightstick or truncheon).
      - • Displacement and significant angulation are indications for fixation.
      - • Remember, the forearm is a ‘force parallelogram’ and that a fracture of only one bone will usually result in a dislocation of the other bone at the proximal or distal joints. These fracture dislocations are:
        
        • Monteggia fracture. Proximal ulnar fracture with dislocation of the proximal radial head.
        • Galeazzi fracture. Distal radial fracture with dislocation of the DRUJ.
  - - - Greenstick fractures. Closed reduction and cast immobilization from wrist to above the elbow.
        
        • In-line traction is always the key to any initial reduction and often all that is required to realign, given patience.
        • Use minimal force. If the periosteal hinge is broken during reduction, the fracture may displace completely and become unstable.
      - • Plastic deformation needs to be corrected.
      - • Displaced fractures are often unstable and can be treated by ORIF with plates and screws, or flexible intramedullary nail fixation.
      - • Fracture dislocations (Monteggia and Galeazzi). Closed manipulation and cast immobilization (failed reduction may require open reduction).
        
        GRIMUS helps to remember which forearm bone is fractured and whether the distal ("inferior") or proximal ("superior") part of the bone is involved.
        
        G: Galeazzi
        R: radius
        I: inferior
        M: Monteggia
        U: ulna
        S: superior
        
        MUGR
        
        Monteggia involves fracture of the ulna with proximal radial dislocation
        
        Galeazzi involves fracture of the radius with distal radioulnar dislocation
- - - - • Based on the mechanism of injury, extension type (approximately 95%) and flexion type (5%).
      - • Classified using the modified Gartland system:
        
        • Type I. Undisplaced.
        
        • Type II. Angulated/displaced, but posterior cortex is intact, acting as a hinge.
        
        • Type III. Complete displacement.
        
        • Type IV. Completely displaced and unstable in flexion and extension.
  - - - • Assess neurovascular status and document beforehand.
      - • Reduce under GA by straight arm traction (up to 5min may be required).
      - • Then manipulate to correct rotation, varus/valgus tilt, and finally any extension deformity.
      - • Try to flex the elbow up past 90° with the forearm pronated (may be difficult due to anterior soft tissue swelling; the reduction technique itself can cause loss of the pulse in the flexed position).
      - • Displaced (type III/IV) fractures should be reduced and stabilized with K wires. Some advocate the same for type II injuries.
      - • Common configuration is two crossed condylar K wires, one medial (beware of ulnar nerve), and one lateral used to fix the fracture.
      - • An above elbow cast is then used to supplement fixations and wires are removed at 4 weeks.
      - • Long arm traction may be used as definitive treatment, but involves a long inpatient stay until the bone has united (usually 3 weeks).
      - Undisplaced fractures (type I) can be treated with a collar and cuff with or without plaster backslab.
  - - - • Injury to the brachial artery is rare as the pulse usually returns after fracture reduction.
      - • Examination is the key. An absent pulse with a well perfused hand does not require any immediate vascular management; however, a pulseless cold hand or a pulse that is lost post-reduction and pinning does!
      - • True loss of the radial pulse may be due to:
        
        • Vascular spasm. Typified by good capillary refill after reduction, but slow return of the pulse. Failure of pulse return may be due to other injuries and requires a vascular surgical opinion. partial injury (endothelial flap) is treated by direct repair.
        • Complete transection or disruption. May be treated by direct repair or more often, interposition vein graft.
      - • Contracture. Untreated vascular injury will result in fibrosis and contracture of the forearm (‘Volkman's ischaemic contracture’). This is a devastating and debilitating condition and should be avoidable with early (<12h) exploration and/or repair or vascular damage.
    - - • Neuropraxia is commonest with gradual recovery. May involve the:
        
        • Radial nerve.
        
        • Anterior interosseous (branch of medial nerve).
        
        • Median and rarely, ulnar nerves.
    - - • Incorrectly reduced fractures will not remodel and can lead to cubitus valgus and a ‘gunstock deformity’. Much less common with K wire fixation.
        • Recurvatum common following cast management of type II/III; remodels poorly.
  - - - Classified according to Milch, depending on how much of the intra-articular surface is involved:
        
        • Type I. Fracture through growth centre of capitellum (Salter–Harris type IV).
        
        • Type II. Fracture medial to growth centre and can involve trochlea (Salter–Harris type II).
    - - • Displaced fracture. ORIF with either two cannulated screws or two K wires.
      - • The fragment is always considerably larger than expected from the X-ray due to the condyle being not fully ossified.
      - • If not reduced and fixed, the fragment will displace. This is due to the pull of the wrist extensors, arising from the lateral epicondyle. This will lead to a cubitus valgus deformity and can present in later life with an ulnar nerve palsy as it has been chronically stretched (‘tardy’ ulnar nerve palsy).
  - - - Avulsion type injuries of the apophysis. High association with elbow dislocations. The fragment can remain undisplaced, displaced, or become trapped in elbow joint. Treatment is usually conservative in a long arm cast. Surgery is indicated for trapped fragments.
    - - Essentially the same as medial; treated with a long arm cast unless fragment entrapped in joint.
  - - - • <30°. Angulation acceptable; sling is provided and early mobilization.
      - • 30–60°. Reduction should be attempted, but ongoing debate.
      - • >60°. Reduction is required under GA, usually stable; once reduced, do not require any further fixation.
      - • Occasionally open reduction is required.
      - • Intra-articular fractures that are displaced may require fixation with K wires or screws.
  - - - • Undisplaced fractures require a cast in extension (removes pull of triceps) for 4 weeks.
        • Displaced fractures require ORIF with tension band wiring.
- - - - • Usually as a result of a fall with direct blow or torsional forces.
      - • Can be low energy (osteoporotic) or high energy (younger age group).
      - • X-rays of joints (above and below) important to rule out intra-articular extension. High energy injuries, especially to rule out floating elbow or shoulder.
      - • Remember to evaluate neurovascular status (radial nerve at risk).
    - - • Transverse, oblique, spiral, multifragmentary.
        • Distal third fractures associated with radial nerve palsy, known as Holstein–Lewis fracture.
    - - Conservative management
        
        Is the mainstay.
        
        • Can accept 20° anterior/posterior angulation, 30° varus/valgus angulation, 15° rotations, and 1–3cm of shortening.
        
        • Remember to mobilize elbow and shoulder or will stiffen!
        
        • Initial sugar tongue cast or hanging cast for 1–2 weeks, then convert to functional brace until union (usually by 3 months); requires regular clinic evaluation.
      - Surgical treatment
        
        Indicated if there is an open fracture, vascular injury, associated intra-articular fracture, floating joint (proximally or distally), pathological fracture.
        
        • Relative indications include multiple injuries, inability to maintain reduction closed, segmental fractures, or transverse fractures in young athletes.
        
        • ORIF with plate and screws is commonly used. Locking plates can be utilized if poor bone quality.
        
        • Intramedullary nailing is an alternative, good for pathological or segmental fractures, or medically labile patients due to small exposure. It is associated with shoulder pain and rotator cuff dysfunction.
  - - - Usually due to impaction injury (the olecranon driven into the humerus via a direct fall and the condyle usually splits into a ‘T’- or ‘Y’-shaped pattern). Pattern depends upon bone quality and angle of flexion at time of injury. Careful neurovascular evaluation required.
    - - • Intercondylar fracture (most common). The fracture line extends from the articular surface to the supracondylar region in a ‘T’- or ‘Y’-shaped pattern.
      - • Supracondylar.
      - • Isolated medial or lateral condyle fracture.
      - • Isolated capitellum fracture.
    - - Intercondylar
        
        • Intra-articular fractures. Thus principles are open anatomical reduction with absolute stability, providing stability to allow early mobilization.
        
        • Posterior approach with either a triceps spilt or if more complex, a trans-olecranon osteotomy to visualize the articular surface.
        
        • Fixation by plate and screw constructs (reconstruction plates). Compression across the intra-articular segments may be required. Newer pre-contoured distal humerus locking plates more commonly used.
        
        • Can be difficult to treat if heavily comminuted and the bone quality is poor.
        
        • An option is conservative management in cast, but early mobilization to try to maintain as much function as possible (‘bag of bones’ technique).
        
        • Non-union is not uncommon following these fractures and sometimes salvage surgery in the form of elbow replacement may be considered.
        
        • In the elderly with a low fracture pattern, primary elbow replacement is sometimes used.
      - Supracondylar
        
        • Conservative management in a cast if undisplaced or highly comminuted in elderly. Mobilize at 2 weeks in hinged brace. Cast. Discontinue when healed (6–8 weeks).
        • ORIF if displaced. 90/90 plating was the classical method (medial and posterolateral), but now utilize pre-contoured, bicolumnar locking plates. Again stable fixation with early mobilization is the goal.
      - Transcondylar
        
        • A very distal fracture and within the joint capsule.
        • Management follows same principles as of supracondylar type.
      - Capitellum
        
        • Radiographs. The capitellum aligns with radial head on AP and lateral views. Classification dependent on size of fragment (best seen on lateral).
        
        • Type I is a large osseous fragment, often involving the trochlea.
        
        • Type II is a thin articular fragment with little osseous composition.
        
        • Type III is multifragmentary.
        
        Treatment
        
        Type I requires ORIF. A common technique is headless compression screws from a posterior to anterior direction.
        
        Type II is usually not amenable to fixation and is excised, as are the loose components of type II injuries.
        
        Kocher's approach (interval between anconeus and extensor carpi ulnaris) often used.
  - - - A fall on to the point of the elbow, but can occur as a fall on to the outstretched hand where the triceps avulses the olecranon process.
    - - • Type I. Undisplaced (<2mm separation, able to extend elbow against gravity).
      - • Type II. Displaced (subtypes—IIA, avulsion; IIB, oblique/transverse; IIC, comminuted; IID, fracture-dislocation)
    - - • Undisplaced. Place in a cast at 90°. At 4 weeks, begin mobilization.
      - • Displaced. ORIF with tension band wire technique.
      - • Comminuted. Plate and screw ± bone graft. Newer pre-contoured locking plate available.
  - - - Fall on to the outstretched hand, forearm in pronation
    - - • Type 1. Minimally displaced.
      - • Type 2. Displaced.
      - • Type 3. Comminuted and displaced.
    - - • Type 1 (<3mm displacement). Sling or half cast for 1–2 weeks, then mobilization (aspiration of the joint haematoma acutely can give pain relief and injection of local anaesthetic can rule out any mechanical block).
      - • Type 2 (displaced, mechanical block to motion or part of more complex injury pattern). ORIF with compression screw and/or mini-plate.
      - • Type 3 (too comminuted to allow ORIF). Radial head replacement indicated. Excision considered at a later stage and contraindicated if other destabilizing ligamentous injuries.
- - - - • Type 1, tip fractured (consider anterior capsule injury).
      - • Type 2, <50% of the process.
      - • Type 3, >50% of the process.