Arm and elbow injuries

Adult – Humeral neck fracture

The surgical neck fractures occur more than the anatomical neck of the humerus. It may be associated with a greater tuberosity fracture.

A fracture in this area may cause damage to the axillary nerve (didn’t recover despite early surgery).

_{^{Case courtesy of Frank Gaillard, Radiopaedia.org. From the case rID: 18281}}

Neer Classification of Humeral Head Fractures

Classification	Description	Notes
1 part	Surgical neck, anatomic neck, lesser tuberosity or greater tuberosity	Any fracture pattern with less than 1 cm displacement
2 parts	Surgical neck, anatomic neck, lesser tuberosity or greater tuberosity	Fragments must be displaced by 1 cm
3 parts	Surgical neck and greater tuberosity or surgical neck and lesser tuberosity	Fragments must be displaced by 1 cm
4 parts	Surgical neck, lesser and greater tuberosities	Fragments must be displaced by 1 cm

Treatment: – Fractures in the elderly without associated joint dislocation and gross rotational deformity can be managed with collar & cuff and be seen in fracture-clinic.

Child – Slipped upper humeral epiphysis

Treatment in children less than 5 years of age is generally conservative.

Treatment in children from 5 to 12 years closed reduction may be required for significantly displaced or angulated fractures in children near the end of growth.

Shaft of humerus fracture

Results from a fall onto an outstretched hand or onto the elbow.

Treatment:

Check distal pulses, radial nerve and elbow joint.
Provide analgesia and support the fracture in a POP U-slab or hanging cast POP.
If displaced, comminuted, angulated or associated with neurovascular complications, then refer for manipulation under anaesthesia (MUA) & internal fixation.

_{^{Case courtesy of Piotr Gołofit, Radiopaedia.org. From the case rID: 46128}}

Biceps tendon ruptures

Rupture of the long head of the biceps tendon (Proximal): bunching of the muscle lower in the arm the so-called Popeye sign. In the majority of cases surgical repair is not indicated.
Distal biceps ruptures: – the tendon avulses from its insertion on the radial tuberosity usually after a strong contraction. It’s more common in those who have taken anabolic steroids. It needs Repair ASAP. If repair is not carried out patients tend to notice poor supination.

Elbow Injuries

Anterior Humeral Line

If a line is drawn along the anterior part of the humerus on the lateral radiograph, then it should intersect the middle third of the capitulum.
Failure to do this indicates that the capitulum has been displaced. There is often posterior displacement in association with supracondylar fractures.

^{_{Case courtesy of Samir Benoudina, Radiopaedia.org. From the case rID: 41167}}

The Radio-Capitellar Line

A line drawn through the middle of the radius should always bisect the capitulum. This should occur in every direction, no matter which x-ray view is taken.
Failure to do this suspect dislocation of the radial head and remember that this can sometimes be associated with ulna fractures (Monteggia fracture-dislocation).

_{^{Case courtesy of Samir Benoudina, Radiopaedia.org. From the case rID: 41196}}

Fat Pads

It is never normal to see a posterior fat pad.
“The sail sign” due to displaced anterior fat pad in association with a posterior fat pad.
In the setting of acute trauma, it represents blood in the joint due subtle fracture of head radius. In the non-trauma setting effusion may be due to an inflammatory cause.

Ossification Centres

A well-known helpful pneumonic for this is CRITOL or CRITOE:

Capitulum	1 year
Radial head	3 years
Internal (medial) epicondyle	5 years
Trochlear	7 years
Olecranon	9 years
Lateral (External) epicondyle	11 years

Supracondylar fractures

Typically follow a fall onto an outstretched hand. The peak incidence between 5 – 8 years.

X-rays include presence of fat pads & loss of normal anterior humeral alignment.

These injuries have been classified by Gartland into 3 types.

Type 1 is an un-displaced fracture (accounts for 25% of injuries).
Type 2 represents a fracture with posterior displacement but with an intact posterior cortex.
Type 3 injury has posterior displacement with complete cortical disruption.

^{_{Case courtesy of Andrew Murphy, Radiopaedia.org. From the case rID: 97447}}

Treatment

Analgesia and neurovascular assessment.
Un-displaced fractures may be treated with a collar and cuff and can be followed up in fracture clinic. If there is significant pain, a back slab may be a better option.
Displaced fractures should all be referred for manipulation, urgently if circulation is compromised.

Complications include:

Cubitus varus (gun stock deformity)
Malunion and stiffness
Myositis ossificans
Nerve injury (most commonly median nerve)
Brachial artery (due to stretch and posterior displacement)
Volkmann’s ischaemic contracture (due to compartment swelling)

Lateral epicondyle epiphyseal injury

This is the 2^nd most common elbow fracture seen in children, usually between age of 4 – 10 years.

It results from a varus force applied through the extended elbow, normally due to a fall on an outstretched hand.

It is commonly displaced by the action of the forearm extensors.

Displaced fractures often need reduction whereas un-displaced fractures can be managed in a back-slab with orthopaedic follow up.

_{^{emd_16_013_20_01_zoom.jpg (700×520) (rcemlearning.co.uk) – The x-ray shows a displaced lateral condyle fracture.}}

Medial epicondyle avulsion injury

These injuries tend to occur in adolescents due to valgus stress during a fall on an outstretched hand.

There may be associated ulna nerve damage & elbow dislocation.

Un-displaced avulsions can be managed conservatively while displaced fragments should be referred for reduction.

^{_{emd_16_013_20_02_zoom.jpg (600×929) (rcemlearning.co.uk)}}

Elbow dislocation

Caused by a fall onto the outstretched hand.

Clinical examination: –

The triangular relationship of the epicondyles and olecranon will be disrupted.
Posterior dislocation is more common.
Risk of damage to the brachial artery or median and ulnar nerves.
Associated epicondylar fractures and fractures of the lateral condyle may occur in children.

Treatment

Analgesia, Procedural sedation (with full monitoring) is likely to be required.
Reduction should be immediately followed by a further neurovascular assessment.
Immobilise in a back-slab in 90 of flexion. Confirm the reduction by repeat x-ray.
Outpatient orthopaedic review should subsequently be arranged.

_{^{emd_16_013_17_01_zoom.jpg (600×660) (rcemlearning.co.uk)}}

Radial head fractures

Caused by a fall onto an outstretched wrist or direct trauma.

Clinical examination: pain may only be evident with palpation of the radial head during passive forearm pronation. Elbow extension is usually restricted.

Radiography may reveal the fracture or merely the presence of a joint effusion.

Treatment

Greater than 20 of angulation in the adult requires reduction.
Un-displaced fractures can be managed with a collar & cuff sling and fracture clinic follow-up.
Comminuted or displaced fractures may require MAU or internal fixation.

_{^{Case courtesy of Frank Gaillard, Radiopaedia.org. From the case rID: 18045}}

Radial neck fractures are seen more commonly in children and are managed similar to radial head fractures. Greater than 20 degrees of angulation in the adult requires reduction.

Olecranon fractures

Caused by a fall onto the point of the elbow or onto a semi-flexed outstretched forearm.

Examination will reveal swelling and tenderness over the posterior aspect of the elbow. Radiography will confirm the diagnosis and also reveal any displacement due to the pull of the triceps tendon.

Un-displaced fractures – treat with a back-slab in 90° flexion of elbow and fracture clinic follow-up.

Displaced fractures (> 2mm) or comminuted fractures may require operative fixation.

_{^{Case courtesy of David Cuete, Radiopaedia.org. From the case rID: 27347}}

Monteggia fracture-dislocation

Defined as: ulnar fracture associated with dislocation of the radial head. (Manchester United Discharged Ronaldo)

Caused by: a direct blow to the ulna or forced pronation.

Suspect in X-ray: if there is fracture ulna with disruption of the Radio-Capitellar Line

Treatment: open reduction & internal fixation in adult. Children can be treated with Closed reduction.

_{^{Case courtesy of Frank Gaillard, Radiopaedia.org. From the case rID: 8012}}

Galeazzi fracture-dislocation

Defined as a fracture of the radius associated with dislocation of the distal radio-ulnar joint at the wrist

Treatment: analgesia & immobilization in a temporary POP back-slab. Refer for ORIF.

^{_{emd_16_013_18_04_zoom.jpg (700×702) (rcemlearning.co.uk)}}

Pulled elbow

Caused by: traction on the arm of a child between 1 – 5 years, although this is not always the case.

Results from: subluxation of the radial head from its position encircled by the annular ligament.

Elbow x-ray is normal, and it is not necessary prior to attempted manipulation.

Reduction method: achieved by applying pressure over the radial head then fully pronating the forearm followed by flexing the elbow to 90° (Click will be heard & the child will begin using the arm a short time later).

Other soft tissue injuries

Olecranon bursitis	# It may be acute from direct trauma or chronic and can be associated with crystal arthropathy or inflammatory arthritis. Septic bursitis is most commonly due to Staphylococcus aureus infection. # Examination: localised swelling & tenderness +/- erythema over the posterior aspect of the elbow. # Patients with septic bursitis may be systemically unwell with fever, cellulitis & axillary lymphadenopathy. # Blood tests: may reveal an elevated ESR, CRP and white cell count. Septic or crystal-induced bursitis can be confirmed with bursal aspiration and subsequent microscopy and Gram stain. # Management: Rest in broad arm sling & analgesia. Septic bursitis requires antibiotics as per local policy.
Lateral epicondylitis (Tennis elbow)	* An overuse of the forearm extensor tendons. * The patient complains of a diffuse ache located over the lateral aspect of the elbow. * Management: relative rest, ice therapy and analgesia. Steroids injection & physiotherapy may help.
Medial epicondylitis (Golfers’ elbow)	– An overuse injury of the forearm flexor tendons – pain over the medial aspect of the elbow. – In 20% of cases ulnar nerve symptoms may be present, specifically paraesthesia in an ulnar nerve distribution. – Management: relative rest, ice therapy and analgesia. Steroids injection & physiotherapy may help.