Download 14- Fractures/Injuries to Forearm and Elbow Core Principle: The

14- Fractures/Injuries to Forearm and Elbow
Core Principle: The Anterior Bundle of the Medial Collateral ligament is the strongest of the Medial
Collateral Ligaments.
Core Principle: Injury to the MCL can lead to Valgus Instability of the Elbow.
CORE PRINCIPLE: Nerve Injury ranks highest among all complications assoc. with Supracondyar
Fractures of the Elbow
Extention type: affects anterior interosseous n
Flexion: ulnar n.
Core Principle: RADIAL NERVE: At the level of the lateral epicondyle of the humerus the radial nerve
divides into the posterior interosseous nerve and the superficial sensory branch which continues distally
in the flexor compartment of the forearm undercover of the brachioradialis.
Superficial Sensory Branch Radial Nerve; From proximal to distal it lies on the supinator, the tendon of
pronator teres, FDS, and FPL. The Radial Artery is medial to it. Occassionally gives a motor branch to
the ECRL, before continuing as a purely sensory nerve.
RADIAL NERVE: Lies deep to the brachioradialis which it supplies, anterior to the humerus, and lateral to
the brachialis.
Core Principle: MEDIAN NERVE AND ANTERIOR INTEROSSEOUS NERVE: MEDIAN nerve is isolated
proximal to pronator teres and traced distally as it passes between the humeral and ulnar heads of the
P. Teres. It sends branches to the Pronator Teres.
MEDIAL INTERMUSCULAR SEPTUM: Is identified in proximal part of the wound. ULNAR NERVE with the
SUPERIOR ULNAR COLLATERAL ARTERY is found by careful dissection posterior to the intermuscular
septum.
ULNAR NERVE: Gives branches to the elbow joint and more distally to the FCU. The UN then passes
more distally and posterior to the medial epicondyle in the CUBITAL tunnel, before entering between
the two heads of the FCU.
Pt comes in and cannot perform heavy pinch then ADductor
General Principles of Evaluation
C/C, History of Present IIlness
Clinical Examination
Inspection, Palpation
Circulatory Evaluation
MRS if possible (motor, reflex, sensory)
14- Fractures/Injuries to Forearm and Elbow
Core principle:
Motor Evaluation (Quick)
o EPL(extensor palusus longus) – Radial Nerve (motor= hitchhike, sensory=thumb
webspace)
o APB (abductor polusis brevis) – Median Nerve (motor= palmar abduction sensory=index
finger
o 1st Dorsal Interosseous – Ulnar Nerve (pinky finger
Sensory Evaluation (Quick)
o 1st Dorsal Webb Space – Radial Nerve
o Palmar aspect Index Finger – Median Nerve
o Palmar aspect Small Finger – Ulnar Nerve
Imaging Studies
o X-Ray injured joint and the joint above and the Joint below
o CT scan, MRI, Arteriogram (?)
REMEMBER: The Radial Nerve Motor: Innervates the Thumb, wrist and finger extensors, and supinator
primarily, and the Median nerve motor innervates the thumb / thenar muscles, the Wrist Flexors, and
the and the radial two lumbricals to the index and middle fingers. The Ulnar Nerve motor innervates the
intrinsics, and the the adductor pollicus, and the ulnar two lumbricals to the ring and small finger and
the flexor carpi ulnaris.
Elbow pain video:
Tennis Elbow
Radial Tunnel Syndrome
Biceps Tendon Rupture
Elbow arthritis
Golfers elbow
Cubital tunnel syndrome
MCL Injury
Posterior Elbow pain
Nursemaids Elbow:
Fix by flexion and supination
14- Fractures/Injuries to Forearm and Elbow
Little Leaguers Elbow:
o Symptoms
o Elbow Pain
o Restricted Range of Motion
o Locking of the Elbow Joint
o Valgus Overload Stress Injury Med. Elbow
o Result of Repetitive Throwing motions
o Results in Tension – Med Epicondyle, Medial Epicondylar apophysis, and MCL Complex
o Results in Compression Lateral Structures – Radial Head and Capitellum.
o Recurrent Micro Trauma Elbow Joint
o Delayed or Accelerated Growth Medial Epicondyle (Medial Epicondylar Apophysitis)
o Medial Epicondylar Fragmentation(Traction Apophysitis)
o Medial Epicondylitis
Arthritis
o Treatment
o Stop Throwing
o Rest & Ice packs
o Refine Throwing techniques
o Occasional Surgery ( Girls > 12, Boys > 14)
o Arthroscopic removal loose bone or loose bodies
o Bone grafting defects
o Ligament repair or Reconstruction
o Valgus Stress Left Elbow: Tremendous Stress on MCL Left Elbow
UCL Surgery (Tommy John)
Biceps Tendon Rupture: repair back to radial tuberosity
Flexion, supination (if lose, lose 40% supination)
Arcade of Froshse: point of compression that helps produce radial tunnel syndrome
14- Fractures/Injuries to Forearm and Elbow
o
Cubital Tunnel Syndrome
o Early Signs
o Pain & Numbness Elbow
o Tingling Ring & Small Finger (ulnar n)
o Late Signs
o Weakness Ring Finger & Small Finger
o Decreased Pinch Thumb – Index
o Decreased Hand Grip
o Muscle Wasting
o Claw Like Deformity of Hand
o Clinical Examination
o (+) Passive Elbow Flexion Test
o (+) FDP (flexor digitor profundus) Small Finger Weakness
o (+) Intrinsic Weakness (ulnar nerve innervates intrinsic)
o Altered sensation or 2 Point discrimination RF,SF
14- Fractures/Injuries to Forearm and Elbow
Pronator syndrome: Compression of Median n. by forearm muscles
SYMPTOMS: Similar to Carpal Tunnel Syndrome
MEDIAN NERVE: Courses via Two Heads of Pronator Teres innervating the same.
MEDIAN NERVE: Then courses inferior to the FDS giving rise to the Anterior Interosseous Nerve
(AIN)
AIN provides motor innervations to FPL, FDP- index medial and pronator guadratus (make a 6
with your hand)
Posterior Elbow dislocation
Most common elbow fracture in children is supracondylar fracture
When Child falls onto an out stretched arm with the elbow in hyperextension, the force of the
fall is transmitted through the olecranon to the weak supracondylar region causing a
supracondylar fracture.
Median Nerve and Brachial Artery is frequently impinged in supracondylar fractures, and
Compartment Syndrome is a risk.
Radial head must align with capitellum
14- Fractures/Injuries to Forearm and Elbow
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Complications
o Vascular Injury – Brachial Artery
o Compartment Syndrome
o Neurapraxia, Axonotmesis, Neurotmesis
o Median Nerve
o Radial Nerve
o Ulnar Nerve
BRACHIAL ARTERY: Scraping by bony fragment may result in intimal damage to the vessel, with
subsequent thrombosis and vascular insufficiency.
COMPARTMENT SYNDROME: Excessive swelling and ecchymosis at the elbow, Increased
forearm pain, Increased pain with passive extension of fingers
Cold hand with poor perfusion, pallor, and diminished or absent pulse ( late finding). Comp.
measurement > 25 -30 mmHg.
MEDIAN NERVE INJURY: MN crosses Elbow Joint with the Brachial Artery. Injury results in
weakness of the flexor muscles of the hand, and loss of 2PDiscrimination palmar surface thumb,
index, and middle fingers.
ANTERIOR INTEROSSEOUS NERVE: Branch of the median Nerve. Lacks a sensory component.
Exam: Weak “ Ok sign”, and lack of DIPJ flexion when making the Ok sign.
RADIAL NERVE: Runs between the brachialis and brachioradialis muscles before crossing the
elbow and penetrating the supinator muscle. Injury results in weakness of wrist extension, hand
supination, and thumb extension. Additionally altered sensation is found in the 1st dorsal web
space between the thumb and index finger.
ULNAR NERVE: Crosses elbow posterior to medial epicondyle, and is typically not affected by
extension type supracondylar fractures. Prone to Injury – Flexion type supracondylar fractures.
Injury – causes Weakness of Wrist Flexion, and Adduction and Abduction of the fingers. These
Motor findings are accompanied by altered sensation of the ulnar ½ of the ring finger and all of
the small finger.
Nerve Injury ( EMG – NCS Helpful)
o Neuropraxia ( Mildest grade periph. Nv. Injury)
o Reduction or complete block of conduction across a segment of nerve with
axonal continuity preserved.
o Axonotmesis (More severe grade peripheral nerve injury compared to neuropraxia)
o Result of damage to axons with preservation of the neural connective tissue
sheath (Endoneurium), Epineurium, Schwann Cell tubes and other supporting
structures
o Neurotmesis ( Most severe grade peripheral nerve injury)
o Occurs when the axon, myelin and connective tissue components are damaged
and disrupted or transected
14- Fractures/Injuries to Forearm and Elbow