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Traumatic elbow injuries are commonly

encountered in the emergency department


setting ~ complexity & clinical significance
often go unrecognized at the initial evaluation
15% of emergency department visits for upperextremity musculoskeletal injuries annually
Orthopedic surgeons frequently use a
classification system different from those used
by their colleagues in radiology :
miscommunication or delay in communication
of the most clinically relevant findings
Awareness and detection of these injuries may
be improved by a better-developed and more
intuitive understanding of the mechanisms that
underlie the most common injury patterns

Elbow : 3 primary articulations that provide


two degrees of freedom of motion
Flexion and extension movements are centered at
the ulnotrochlear articulation
pronation and supination are centered at the
radiocapitellar and radioulnar articulations

The elbow articulations are stabilized by the

Medial Collateral Ligament (MCL) complex


anterior, posterior, and transverse bundles

Lateral Collateral Ligament complexes


radial collateral ligament (RCL)
lateral ulnar collateral ligament (LUCL)
annular ligament

CT 3D lateral view LCL Complex

CT 3D oblique view MCL


Bundles
LUCL (red)
Anterior (red)
RCL (blue)
Posterior (blue)
Annular ligament (yellow)
Transverse (yellow)

ELBOW
INSTABILITY
VALGUS INSTABILITY MOST COMMONLY RESULTS FROM
INJURIES TO THE ANTERIOR BUNDLE OF THE MCL
WHEN THE ANTERIOR MCL IS INJURED, SECONDARY
STABILIZATION IS PROVIDED BY THE FLEXOR-PRONATOR
MUSCLES AND RADIOCAPITELLAR ARTICULATION
NORMAL FUNCTIONAL STRESSES ON THE ANTERIOR MCL
ARE THOUGHT TO BE HIGHEST WHEN VALGUS LOADING
OCCURS WHILE THE FOREARM IS SUPINATED AND
EXTENDED OR FLEXED AT AN ANGLE BETWEEN 0 AND
90

Injury mechanism
involves valgus and pronation stresses
after a fall onto an outstretched hand (FOOSH)

Ligament damage is best depicted at computed


tomographic (CT) arthrography, magnetic resonance
(MR) arthrography, or MR imaging

Elbow trauma
Early identification of injuries that can lead to elbow
instability is critical to guide decision making about
appropriate treatment
An understanding of the most common injury
mechanisms will help direct attention toward the
most critical injuries

RADIAL HEAD & NECK INJURY


ESSEX LOPRESTI FRACTURE
DISLOCATION
DISTAL HUMERUS FRACTURE
CORONOID PROCESS FRACTURE
OLECRANON FRACTURE
ELBOW DISLOCATION
TERRIBLE TRIAD
MONTEGGIA FRACTURE &
DISLOCATION

Most common elbow fractures in adults

approximately 33%50% of elbow fractures


20% of elbow trauma cases

Most often associated with a FOOSH-type injury


mechanism
results from axial loading during forearm pronation with
extension or relative flexion of 080
causes the radial head to forcefully impact the
capitellum of the humerus

Mason-Johnston system, radial head and neck


fractures

morphologic characteristics of the fracture


presence or absence of associated dislocation

Mason - Johnston type I injury

Mason-Johnston type II fracture

Uncommonly seen but clinically important involves a

comminuted fracture of the radial head with


dislocation of the distal radioulnar joint and
disruption of the interosseous membrane,
producing the oft-cited floating radius

The mechanism is most likely a variation of that present in a


FOOSH-type injury
The radiographic features of distal radioulnar joint dislocation
can be subtle

but a radioulnar distance discrepancy of >5 mm


on lateral radiographs of the injured wrist relative
to the contralateral uninjured wrist

dorsal subluxation of the distal


ulna with widening of the
axial loading along the forearm
radioulnar distance

comminuted radial head fracture

distraction forces at the


distal radioulnar joint

medial and lateral structural columns that


provide primary axial load-bearing stability to
the humerus
Potential injury mechanisms include a direct
impact on the elbow with resultant axial loading
of the humerus during flexion of various degrees,
as well as a FOOSH
distal humerus fractures, it is most critical to
report the salient radiographic findings that
guide treatment: column involvement, the
direction and degree of displacement of
epicondylar avulsion fractures and single-column
fractures, and the presence of comminution or
two-column injury

2 bone columns that


provide primary loadbearing support to
the arm

AO-ASIF type A1 fracture


comminuted
intraarticular fracture
of the
distal humerus
transverse metaphyseal
fracture

mildly displaced
medial epicondylar
fracture

AO-ASIF type C1 injury


AO-ASIF type C3 fracture

Makes up the anterior margin of the ulnohumeral articulation and


serves to resist varus stress and prevent posterior elbow subluxation
serves as the site of anterior attachment of the joint capsule,
insertion of the MCL, and insertion of the brachialis muscle at its
anterior aspect
The mechanism of fracture is thought to relate to axial loading
translating to shear stress on the coronoid process ~ commonly
seen in FOOSH-type injuries
Fractures of the anteromedial facet are a commonly seen coronoid
process fracture pattern, often with associated injuries of the MCL
(which inserts on the sublime tubercle of the medial coronoid base)
that lead to the development of varus and posteromedial rotatory
instability or PLRI (

ODriscoll fracture classification system,


which comprises three fracture types (I,
II, and III) defined on the basis of their
location in the 3D anatomy

comminuted fracture (arrow) extending through the


anteromedial facet of the coronoid process, a finding of an
ODriscoll type II fracture

fracture of the anteromedial facet of the ulnar coronoid process

Olecranon, which forms the posteroinferior margin of


the ulnohumeral articulation, functions as a buttress
preventing anterior dislocation of the elbow
Mechanism :

Axial loading of the humerus by an impact on the elbow during


flexion of 90 >>>>
Complex forced hyperextension injuries
Simultaneously opposing contraction of the brachialis and
triceps, or a fall onto a partially flexed elbow, can cause
olecranon fractures and triceps avulsion injuries
Patients with nondisplaced fractures that are les than 2 mm
wide, with no increase in displacement over 90 of flexion or
during active extension, can usually undergo a trial of
conservative therapy
Displacement of fracture fragments (with a gap of >2 mm),
increased displacement during elbow flexion or extension, and
the presence of comminution are surgical indications.

avulsion fracture of the olecranon at the site of triceps


comminuted
tendon
insertionfracture of the olecranon

Second most common type of joint dislocation


in adults, after shoulder dislocation
Classified according to the direction of
movement and described as either simple or
complex, depending on the absence or
presence of an associated fracture
Adult elbow dislocations are most commonly
posterior in direction
Anterior dislocations of the elbow are rare
and are most often seen in children, in whom
they are usually the result of rebound after
posterior dislocation

simple posterior elbow


dislocations
complex posterior elbow dislocations

Computer-generated images of the elbow show


the stages of posterior elbow subluxation and
instability

MR arthrography demonstrates
disruption of the RCL
and
LUCL
after
reduction
for posterior dislocation

lateral capitellum and lateral


epicondyle, an injury produced
by impact of the radial head.

Full-thickness tears of the MCL


and LUCL complex

combination of

posterior elbow dislocation with


radial head fracture
coronoid process fractures

associated with extensive ligament


damage

chronic instability and severe arthritis

TERRIBLE TRIAD
comminuted radial
head
fracture (arrow)

coronoid process
fracture fragment
(arrowhead).

fracture of any
the proximal
in association with
ulnar ulna
fracture
anterior
dislocation at the
radial head
with
radiocapitellar
dislocation

Monteggia injuries are classified within the


Bado system
Direction of dislocation
Angulation of the ulnar fracture fragment
Presence or absence of an associated fracture of
the radius

transverse fracture of the ulnar diaphysis


(arrowhead) with anterior angulation of the
apex and predominantly anterior dislocation
of the radial head (arrow),

Bado type I
Monteggia fracture

Evaluation of traumatic elbow injuries


Radiographic detection of bone abnormalities
Inference of potential associated secondary occult bone and softtissue injuries

Understanding
of the
most common
injury
direct the early imaging
evaluation
as appropriate
mechanisms
to facilitate detection of the most clinically
relevant associated injuries

adopting the clinically most relevant classification


Radiologists
systems
used by their colleagues in orthopedic surgery,
radiologists can minimize the potential for
inappropriate or delayed treatment