INJURIES AROUND THE ELBOW

 1- SUPRACONDYLAR FRACTURE
 2- DISLOCATION ELBOW
 3- FRACTURE OLECRANON
 4- FRACTURE HEAD RADIUS
 5- FRACTURES OF HUMERAL CONDYLES
 6- EPICONDYLE FRACTURE
 7- PULLED ELBOW
 SUPRACONDYLAR FRACTURE
OF THE HUMERUS
 MECHANISM OF INJURY
AND TYPES OF SUPRACONDYLAR FRACTURES
supracondylar intercondylar
Extension type
Extension type 

 Flexion type

 The trauma is usually due to a fall on the outstretched hand, the distal
fragment is usually pushed backwards and displaced posteriorly and
tilted backwards; this is the most common type of injury
( the extension type of S.C.Fr.) and accounts for 85% of cases
 A much rarer type of injury is due to a direct trauma to the elbow or a
fall on the flexed elbow, where the distal fragment is displaced
anteriorly ( the flexion type of S.C.Fr.) and accounts for 5 % of cases
 Another rare type is the intercondylar T- or Y- type fracture which
occurs mainly in adults and accounts for 10 % of cases
 Diagnosis
A. Clinical picture

HISTORY
 History of trauma; a fall on the outstreched
hand or direct trauma to the flexed elbow
 Severe elbow pain
 Limited joint movements
 Elbow swelling
 May be symptoms of neuro-vascular injury
(hand pain, paraesthesia, or loss of
movements).
 O/E
INSPECTION:
. Elbow swelling with obliteration of the fossae
on the sides of the olecranon
. S-shaped deformity when looking to the elbow
from the sides
. there may be forearm and hand swelling
especially if presenting late, if the fracture was
manipulated by somebody, or if it is associated
with vascular injury.
PALPATION:
. local tenderness around the elbow maximally
over the distal end of the humerus.
. A step may be palpable between the proximal
and distal fragments.
. Crepitus may be palpated with movements.
The anatomical relation between bony landmarks
(the medial and lateral humeral epicondyles
and the tip of olecranon) is not disturbed ; i.e, they
fall on a straight line when the elbow is extended
and form a triangle in the flexed elbow.
MOVEMENTS:
. both active and passive elbow movements
are limited by severe pain and may be
associated with crepitus.
SPECIAL SIGNS:
. examine the forearm, wrist, and hand for evidence of
associated vascular or nerve injury (pallor, weak or
absent radial pulse, paraesthesia, pain with stretching
the fingers, paralysis of hand intrensic muscles or long
finger flexors).
B. X- Rays:
 EXT
FLEX

Plain X-ray of the elbow (AP

and Lateral views) may show
. In AP view the distal fragment
is shifted or tilted sideways and
rotated 
. In lateral view the fracture is
seen most clearly;
in the extension type the distal
fragment is displaced posteriorly and
  EXT
tilted backwards.
in the flexion type the distal
fragment is displaced and tilted
anteriorly FLEX
 TREATMENT
A- REDUCTION:
Undisplaced or minimally displaced fractures:
No need for reduction.
 Displaced fractures:
Must be reduced as soon as possible
Closed Reduction is done under
general anaesthesia (G.A) by traction and
manipulation to correct sideways and front
to back displacement, tilt, and
rotation.Reduction is performed under x-ray
control.

 Radial pulse must be palpated after reduction;

if absent the elbow is gradually extended till
the pulse returns

 X-Rays are taken to confirm reduction

 Indications for open reduction include:
 Open fractures
 Fractures which cannot be reduced by
closed manipulation
 Vascular injury not improving by
manipulation
 Vascular injury occurring after closed
reduction
 Intercondylar fractures
B- MAINTAINING REDUCTION (FIXATION) :
CAN BE DONE BY:
• above elbow back slab in the reduced position, with collar
en cuff sling for three weeks.
• percutaneous wires passed through the humeral
epicondyles fixing the distal fragment to the proximal
fragment, then applying a collar en cuff sling for three
weeks.
Indications for percutaneous wire fixation
(percutaneous pinning) include:
* unstable fractures which displace after closed reduction
* fractures associated with vascular injuries which improve
after closed reduction to avoid redisplacement and
vascular compression
* after open reduction for one of the previously mentioned
indications
C- CARE AFTER REDUCTION AND FIXATION:
* collar en cuff sling and back slab are kept for 3 weeks,
where they are removed to allow active movements of the
elbow joint.
* If percutaneous wires were applied, they are pulled out
after three weeks.
 COMPLICATIONS
A- Early complications:
1. Vascular injury (injury of the brachial artery):
- gangrene of the digits
- Volkmann’s ischaemic contracture
- ischaemic neurologic damage
2. Nerve injury:
*The median nerve
* The radial and ulnar


 B. Late complications:
 Deformity from malunion  cubitus varus
 Volkmann’s ischaemic contracture
 Myositis ossificans (Post-traumatic ossification)
4. Elbow stiffness
5. Nonunion: is very rare to occur in S.C.Fr



CUBITUS VARUS
 DISLOCATION OF THE
ELBOW JOINT

CAUSATIVE TRAUMA
 Usually caused by a fall on the
outstretched hand with the elbow in mild POSTERIOR 
flexion
Anterior
 The radio-ulnar complex is usually 
displaced posteriorly or postero-laterally
(POSTERIOR DISLOCATION)
 Rarely caused by fall on the back of the
elbow with the radio-ulnar complex
displaced anteriorly and olecranon broken
(Anterior dislocation)
MORE COMMON IN ADULTS THAN IN
CHILDREN POSTERIOR DISLOCATION
Clinical picture:

- prominent tip of the olecranon
on the posterior aspect of the
elbow
- the anatomical relation
between bony landmarks (the
medial and lateral humeral
epicondyles and the tip of
olecranon) is disturbed ; i.e,
they do not fall on a straight
line when the elbow is extended
with the olecranon pointing far
posteriorly

 Complete loss of passive and

active movements of the elbow
 Examination should include
forearm and hand examination
for associated vascular or
nerve injury
Clinical picture:

- prominent tip of the olecranon
on the posterior aspect of the
elbow
- the anatomical relation
between bony landmarks (the
medial and lateral humeral
epicondyles and the tip of
olecranon) is disturbed ; i.e,
they do not fall on a straight
line when the elbow is extended
with the olecranon pointing far
posteriorly

 Complete loss of passive and

active movements of the elbow
 Examination should include
forearm and hand examination
for associated vascular or
nerve injury
Clinical picture:
 The patient supports the forearm with the elbow in slight
flexion
 Local swelling may be severe with local bruises
 Severe local tenderness maximally around the joint
 Deformity:
- prominent tip of the olecranon on the posterior aspect of the elbow
- the anatomical relation between bony landmarks (the medial
and lateral humeral epicondyles and the tip of olecranon) is
disturbed ; i.e, they do not fall on a straight line when the elbow
is extended with the olecranon pointing far posteriorly
 Complete loss of passive and active movements of the
elbow
 Examination should include forearm and hand examination
for associated vascular or nerve injury
X- Rays:
 Radiographs of the elbow joint in AP and Lateral views will
show the type of displacement and excludes associated
fractures
 Treatment:
 The dislocation should be reduced as soon as
possible
 Reduction is done under GA and muscle relaxant
 Check movements after reduction and assess the joint
stability
 X- ray must be taken to confirm reduction and disclose
associated fractures
 Above elbow cast is applied for 3 weeks followed by
active exercises with collar en cuff sling in between for
another 3 weeks
 Anterior dislocation needs open reduction and internal
fixation of olecranon fracture
 COMPLICATIONS
A- Early complications:
1. Vascular injury (injury of the brachial artery):
- gangrene of the digits
- Volkmann’s ischaemic contracture
- ischaemic neurologic damage
2. Nerve injury:
*The median nerve
* The ulnar and radial
B. Late complications:
2. Volkmann’s ischaemic contracture
3. Myositis ossificans (Post-traumatic ossification)
4. Elbow stiffness


 FRACTURE OLECRANON
It can be caused by :
 - A fall on the elbow or by a direct trauma ;
usually  comminuted fracture
 - By a fall on the hand with sudden powerful
contraction of triceps muscle usually 
avulsion of the olecranon as a large single
fragment
 - Sometimes associated with dislocation elbow
especially the anterior type
Clinically:
- local pain, bruises, and tenderness
- a gap may be palpable at the fracture site due
to separation of the fracture fragments by
triceps pull
- inability to extend the elbow against resistance
 FRACTURE OLECRANON
Treatment:
usually surgical and aims at:
- restoring extensor mechanism if interrupted
- restoring the articular surface of the olecranon
- start early active movements
Complications:
 stiffness due to long immobilization
 non-union due to inadequate reduction and fixation
 osteoarthritis due to improper reduction of the
articular surface
 FRACTURE HEAD RADIUS
It is common in adults ,rare in
children
It is caused by a fall on the
outstretched hand
•It causes local pain and tenderness
on the lateral side of the elbow
maximal over the dimple overlying
the radial head.
•There is limitation of rotation of the
forearm and elbow extension
•X-Rays show the fracture which
may be a split fracture, a single
sector fracture, or a comminuted
fracture
 FRACTURE HEAD RADIUS
Treatment depends on the type of fracture:
- undisplaced fracture is treated in collar en cuff sling
and encouraging gradual active movements
- a single large fragment can be openly reduced and
fixed with a screw
- a comminuted fracture is treated by excision of the
radial head
Complications :
- Joint stiffness
- Myositis ossificans
- Degenerative arthrosis of the radio-humeral joint
 FRACTURES OF THE HUMERAL
CONDYLES
 Condylar fractures are relatively uncommon,
they occur mainly in children
 The lateral condyle is fractured much more
common than the medial condyle
 The usual cause is a fall, muscle pull is
involved in the mechanism of injury;
- common extensor origin avulsion  lateral
lateral condyle fracture
- common flexor origin avulsion 
medial condyle fracture
 In children the greater part of the detached
fragment is cartilagenous, so the fragment
appears much smaller on X-ray than it is in fact
 It is essential to reduce the displacement
because the fracture involves the joint surface
as well as the growth plate in most cases medial
Treatment :
- a simple crack without displacement is
treated in above elbow splint or cast for 3 weeks
followed by a course of mobilizing exercises for
the elbow
- displaced fractures should be well reduced
to avoid permanent disability;
. an attempt to reduce the fragment by
closed manipulation under G.A and x-ray control, if
successful a plaster is applied and kept till healing
of the fracture followed by physiotherapy
. open reduction is indicated if closed
reduction fails to give perfect reduction or if the
fracture redisplaces after reduction.
The fracture is then fixed in position by wire pins
(K-wires)
 Complications:
1. Non-union:  cubitus valgus
2. deformity
3. delayed ulnar nerve palsy
4. Osteoarthritis
 FRACTURES OF THE HUMERAL
EPICONDYLES
a. It occurs more often in children than in adults
 the fracture usually affects the medial epicondyle
 it is usually caused by avulsion injury, the
epicondyle being pulled off by the attached medial
common flexor origin during a fall
TREATMENT
- undisplaced cases; symptomatic treatment
- severe displacement requires open reduction
and K-wire fixation followed by physiotherapy
COMPLICATIONS
 1. Injury to the ulnar nerve
lateral
 2. inclusion of the medial epicondyle fragment in
the joint
 3. non-union due to muscle pull on the fragment

 PULLED ELBOW
(SUBLUXATION OF THE HEAD OF THE RADIUS )
 The radial head is pulled partly out
of the annular ligament
 It is caused by sudden lifting of a
child by the wrist
 There is local pain and the elbow is
held in pronation with restricted
extension and supination
 Treatment by closed reduction by
pushing the forearm upwards and
rotating it alternatively into
supination and pronation
The Wrist and Hand
 Articulations

The wrist comprises three movable joints:

• Distal radio-ulnar joint.
• Radio-carpal joint (between the radius and the proximal row of carpal bones).
• Mid-carpal joint (between the proximal and distal rows of carpal bones).
 Movement

Extension (dorsiflexion), Flexion (palmarflexion),

Ulnar deviation, radial deviation, also pronation and
supination (an arc of motion about 120 at radio-
ulnar joint .
 Deformities

Congenital:
• Carpal fusions: Coalition of two or more carpal bones.
• Transverse absence: Failure of formation most common.
at the junction o the middle and upper third of the forearm.
• Longitudinal deficiencies:
•Radial deficiency or radial club hand: The wrist is
in marked radial deviation. There is absence of the
whole or part of the radius, also often the thumb,
scaphoid and trapezium fail to develop normally.
•Treatment consist of manipulation and splintage.
Surgical treatment is intended to improve appearance
and function. Treatment aims at centralization of the
carpus on the ulna. In bilateral cases, elbow stiffness
is a contraindication to corrective surgery because
radial deviation of the wrist is the only position in
which the hand can reach the mouth or perineum.
 •Ulnar deficiency: The wrist is in ulnar deviation due
to partial or complete absence of the ulna. Treatment
consist of stretching and splintage soon after birth.
Surgical correction is reserved for marked deformity.

• Madelung’s deformity: (congenital or acquired)Deformed

distal radius with volar (anterior) and radial (lateral)
displacement of the carpus with the distal ulna being
prominent as a hump on the back of the wrist. Surgical
treatment is needed if there is severe deformity or wrist
pain.
 Arthrogryposis multiplex congenita:
Multiple, non progressive joint contractures
are noted at birth. The limbs appears atrophic
with waxy skin lacking normal joint creases.
Treatment is in the form of serial
manipulation and casting. Surgical correction
in severe, resistant or reccurent cases.

Acquired deformities:
• Physeal injuries: Fracture separation of the distal radial
epiphysis may result in partial fusion of the physis (bony
bar is formed between the metaphysis and epiphysis) with
asymmetrical growth deformity of the wrist. Treatment is
by excision of the formed bony bar if it is small. Correction
of the deformity by suitable osteotmy is also done.
• Forearm fractures: Malunion of distal radial fractures
results in Madelung’s deformity.
• Rheumatoid Deformities: This is commonly in the form
of radial deviation at the wrist and ulnar deviation of the
fingers also forward subluxation of the carpus and radio
ulnar subluxation may occur.
• Drop wrist: result from radial nerve injury with inability
to extend the wrist which drop into flexion.
Acquired Finger deformities:
• Skin contracture: Cuts and burns of the palmar skin are
liable to heal with contracture.
• Dupuytren’s contracture: The superficial palmar fascia
(palmar aponeurosis) fans out from the wrist towards the
fingers, sending extensions across the metacarpophalangeal
joints to the fingers. Hypertrophy and contracture of the
palmar fascia lead to puckering of the palmar skin and
fixed flexion of the fingers.
Muscle contracture
Volkmann’s ischemic contracture:
Contracture of the forearm muscles that
may follow circulation insufficiency due
to injuries at or below elbow Shortening
of the long flexors cause fingers to be
held in flexion deformity. They can only
be extended when flexing the wrist to
relax the long flexors.
Shortening of the intrinsic muscles:
This lead to a characteristic deformity
with flexion at the metacarpophalangeal
joints with extension o the
interphalangeal joints and thumb
adduction. This is the intrinsic plus
hand.
•Tendon lesions:
Mallet finger: The distal interphalangeal joint is held in
flexion due to injury of the extensor tendon of the
terminal phalanx. Passive extension is normal. It may
be associated with a small bony fragment from the
tendon insertion into the distal phalanx. Treatment is by
splintage in full extension for 8 weeks.
Boutonniere deformity: Flexion deformity of the
proximal interphalangeal joint this is due to
interruption or stretching of the central slip of the
extensor tendon where it inserts into the base of the
middle phalanx. The lateral slips separate and the head
of the proximal phalanx thrusts through the gap like a
button through a buttonhole.
•Tendon lesions:
Swan neck deformity: This is the reverse
of boutonniere deformity, the proximal
interphalangeal joint is hyper-extended
and the distal interphlangeal joint flexed.
This usually results from imbalance
between flexor versus extensor action at
the proximal interphalangeal joint.
•Joint disorders:
Rheumatoid arthritis, juvenile chronic
arthritis,psoriatic arthritis, systemic lupus
erythematosus,scleroderma, gout and trauma
to the joint can lead to a variety of deformities
like mallet finger,boutonniere and swan neck
deformity.
•Neuromuscular disorders:
Spastic disorders like cerebral palsy
may result in Intrinsic plus
deformity also thumb in palm
deformity.
Flaccid disorders like
poliomyelitis, peripheral nerve
lesions also lead to a variety of
deformities among which is the
intrinsic minus (claw hand) hand
that shows wasting of the small
muscles of the hand and clawing
with extension of the
metacarpophalangeal joints and
flexion of the interphalangeal
joint.
 Tenosynovitis
The extensor retinaculum contains six compartments which
transmit tendons lined with synovium. Tenosynovitis can be
caused by overuse, repetitive minor trauma or spontaneously.
The resulting synovial inflammation causes secondary
thickening of the sheath and stenosis of the compartment.

De Quervain’s disease:
Tenosynovitis of the first extensor compartment containing
the abductor pollicis longus and extensor pollicis brevis.
Clinically the patient complain of pain on the redial side of
the wrist, sometimes there is swelling over the distal end of
the radius and the tendon sheath feels thick and hard.
Tenderness is most severe at the tip of the styloid radius.
De Quervain’s disease:

The pathognomonic sign is elicited by Finkelstein’s test

where the examiner places the patient’s thumb across the
palm in full flexion, then turning the wrist sharply into
adduction. In a positive test this is acutely painful.
Differential diagnosis includes arthritis of the base of the
thumb, scaphoid non union.
Treatment in early cases is in the form of splintage, NSAID,
local corticosteroids injection. Resistant cases need surgical
release of the compartment slitting the thickened tendon
sheath.
Other sites of extensor tenosynovitis:
Tenosynovitis of the extensor carpi radialis brevis (the most
powerful extensor of the wrist) or extensor carpi ulnaris cause
pain directly over its relative compartment. Usually rest and
corticosteroid injection are effective.

Flexor Tendinitis:
Except for specific inflammatory disorders such as
rheumatoid arthritis flexor tendons are rarely affected.
Flexor carpi radialis tendinitis causes pain alongside the
scaphoid tubercle, symptoms are reproduced by resisted wrist
flexion. Flexor
carpi ulnaris can become inflamed near its insertion in to the
pisiform. Treatment
consist of rest, NSAID or local steroid injection.
 Stenosing
tenovaginitis
(trigger finger)
A flexor tendon may become entrapped at its
entrance to the fibrous flexor sheath, on forced
extension it passes the constriction with a snap
(triggering). The cause is thickening of the
fibrous flexor sheath following trauma or
unaccustomed activity, also it can occur in
rheumatoid patients, diabetics and in gout. When
the finger is flexed it remains bent at the
proximal interphalangeal joint, it extends with a
snap. A tender nodule can be felt in front of the
metacarpophalangeal joint.
Treatment: early cases may be cured by local
injection of corticosteroids in the tendon sheath.
Late cases need surgical release of the fibrous
sheath till the tendon moves freely.
Swellings around the wrist

Ganglion cysts:
The ganglion cyst is the most common
swelling around the wrist. It arises from
leakage of synovial fluid from a joint or tendon
sheath and contain a viscous fluid. Most
common on the dorsal surface of the wrist.
Clinically the swelling is usually painless. It is
well defined, cystic, not tender.
Treatment is usually not necessary, it may
disappears spontaneously. Surgical excision is
indicated if the swelling is painful or pressing
a nearby nerve.
 Compound palmar Ganglion

Chronic inflammation distends the common flexor

tendon sheath both above and below the flexor
retinaculum.
Rheumatoid arthritis and tuberculosis are the
commonest causes. The synovial membrane
becomes thick and villous. The amout of fluid
increases and may contain fibrin particles. The
tendons may fray and rupture.
Clinically it is painless but pressure over the median
nerve may elicit paraethesia. The swelling is hour
glass in shape bulging above and below the flexor
retinaculum, fluid can be pushed from one part to
the other. Treatment: If the
condition is tuberculous, general treatment is begun,
the content of the sac is evacuated, streptomycin is
instilled and wrist splint applied. Flexor sheath is
excised if these measures fails, also it is excised in
RA.
 Carpal Tunnel Syndrome
Median nerve compression under the flexor retinaculum.
It is more common in females, between 40 and 50 years. In
younger patient other factors are commonly present such
as pregnancy, rheumatoid arthritis, gout.
Clinically: Pain and paraethesia occur in the distribution
of the median nerve in the hand. Patient usually wake up
with burning pain, tingling and numbness. Sensory
symptoms can often be reproduced by percussion over the
median nerve (Tinel’s sign) or by holding the wrist fully
flexed for a minute or two (Phalen’s test). In late cases
there is wasting of the thenar muscles, weakness of thumb
abduction and sensory dulling in median nerve
distribution.
INABILITY TO ABDUCT THE
THUMB
 Carpal Tunnel Syndrome
Treatment:
Light splint that prevent wrist flexion help those
with night pain or with pregnancy. Local corticosteroid
injection in the carpal canal provides temporary relief.
Surgical division of the transverse carpal ligament
(the flexor retinaculum) provides cure.
 Injuries of the wrist
Colles’ fracture:
It is the most common of all fractures in older people. The
patient is usually a post menopausal woman.

Mechanism of injury: Fall on the out stretched hand. It occurs

within 2 cm of the articular surface and may extend into the
distal radio-carpal joint or the distal radio-ulnar joint. The
distal fragment shows: Dorsal angulation (Dinner fork
deformity), dorsal displacement, radial angulation, radial
displacement, impaction (shortening) and There is often an
accompanying fracture of the ulnar styloid, which may signify
avulsion of the TFC insertion.
Clinical features: There is a
dinner fork deformity, with
prominence on the back of the
wrist and a depression in front
with local tenderness and pain
on wrist movements.

X-ray: There is a transverse

fracture of the radius at the
corticocancellous junction, and
often the ulnar styloid process
is broken off. The distal
fragment is impacted into radial
and backwards tilt. Sometimes
it is comminuted or severely
crushed..
Treatment:
Undisplaced fractures (or only very slightly displaced), cast
is applied below elbow (if ulnar styloid is intact) or above
elbow if there is fracture ulnar styloid. If the patient’s
wrist is markedly swollen a splint is first applied till the
sweling has resolved, then cast is applied.
Displaced fractures must be reduced under anaesthesia
then cast is applied either below or above elbow according
to the presence of ulnar styloid fracture. X-rays are taken
after one week, redisplacement is not uncommon to which
re-reduction is done. The fracture usually unites in about 6
weeks.
Comminuted Colles’ fractures can not be treated
sufficiently with cast immobilization, this is supplemented
by K-wire fixation. Cast and wires are removed after 6
weeks.
Severely comminuted fractures external fixator is needed.
Complications:
Early
Circulation in the fingers should be checked; cast may need
to be split.
Nerve injury is rare, but compression of the median nerve
in the carpal tunnel is fairly common. Mild symptoms may
resolve by elevation and release of cast. Persistent and
severe symptoms require carpal tunnel release.
Reflex sympathetic dystrophy is common but usually it does
not progress to full picture of Sudek’s atrophy. This is
avoided by finger exercises.
Triangular fibrocartilage complex (TFCC) injury: As the
distal radius displaces dorsally, the TFCC is damaged.
Late
Malunion is common either because reduction was not
complete or because displacement within the plaster was
overlooked. Osteotomy to correct the deformity is needed
if there is painful movement.
Delayed union and non union of the distal radius are rare,
but the ulnar styloid process often joins by fibrous tissue
only and remains painful for several months.
Stiffness of the shoulder, elbow and fingers from patient
neglect is a common complication that can be avoided by
exercises.
Tendon rupture of extensor pollicis longus occasionally
occurs a few weeks after an apparently trivial undisplaced
fracture of the lower radius.
SMITH FR
 ENCHONDROMA
WITH PATHOLOGICAL FRACTURE
MULTIPLE ENCHONDROMATA
The hand is the commonest site