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					                                                                                                                              CHAPTER 72




                                                                                                                                        The elbow




72.1 Introduction                                                  THE AGE INCIDENCE OF
                                                                   INJURIES ROUND THE ELBOW
Injuries of the elbow fall into two groups—those of children
and those of adults. A child seldom suffers from any of the          DISLOCATIONS
adult fractures and vice versa. But dislocations can occur at
any age. The penalty for mismanaging any of these injuries                                                      SUPRACONDYLAR FRACTURES

is likely to be a stiff painful elbow always.                                                                               the adult pattern is different
   The ligamentous injuries of the elbow include: (1) epi-
condylitis (tennis elbow) in adults, in which the attachment                      LATERAL CONDYLE                    MEDIAL CONDYLE
of the extensor muscles to the lateral condyle is strained, and
(2) pulled elbow in children in which the head of the radius
                                                                                                                                      CAPITULUM
jams inside the annular ligament. In pulled elbow there is                    NECK OF RADIUS
usually a history of a specific injury, but not in epicondyli-
tis.                                                                                                                           HEAD OF RADIUS
   The signs in the list which follows should enable you to
                                                                                       OLECRANON
diagnose most injured elbows, even if you do not have X–
rays. They are especially useful in children whose X–rays          1               2       3   4    5   6 7 8 9 10     20      30       40     50    60 70
are difficult to interpret. You cannot remember all these           Age in years

signs, so consult the following section with the patient in
                                                                   Fig. 72.1: INJURIES AROUND THE ELBOW have a characteristic age
front of you.                                                      incidence. You will see dislocations at all ages. Supracondylar fractures
                                                                   are the most common elbow injuries with a modal age of about 7. They
                                                                   are much less common in adults, and when they do occur are more often
EXAMINING THE ELBOW                                                T–shaped or comminuted. The medial epicondyle is injured in teenagers,
                                                                   and the lateral condyle in young children. Fracture of the capitulum is a
First, check the patient’s median, ulnar, and radial nerves        rare adult injury. The neck of the radius fractures in children, and its head
and his radial pulse, and record your findings (Fig. 75-3).         in adults.
   If his elbow is normal he can: (1) flex it by putting his hand
on his shoulder, (2) extend it by holding his arm out straight,
and (3) pronate and supinate it 90◦ in either direction, as in        If the 3 bony points are displaced in relation to one
Fig. 69-1. Limitation of any movement suggests disease.            another he may have a dislocation. If his olecranon is dis-
   Is the contour of the posterior of his arm abnormal?            placed, has it moved medially or laterally in relation to an
If so, he may have a supracondylar fracture or a dislocation.      imaginary line down the back of his arm? You will need to
If very little movement is possible, he has a dislocation, or      know this when you come to reduce a supracondylar frac-
supracondylar fracture, or a T–shaped fracture. If his elbow       ture or a dislocation.
is fixed in 45◦ of flexion with almost no movement, he almost           If his 3 bony points are their correct relation to one
certainly has a dislocation.                                       another but are displaced in relation to the lower end
   Does the head of his radius move normally? Bend his             of his humerus as in D, Fig. 72-2, he may have a supra-
elbow to 90◦ . If he can rotate his forearm, the head and          condylar fracture. This is a critically important sign in very
neck of his radius are probably normal. Place your middle          young children before much ossification has taken place in
finger on his lateral epicondyle, and your index beside it over     the lower end of the humerus so making the x–rays difficult
the head of his radius. Pronate and supinate his arm. If the       to interpret.
head of his radius is intact, you can feel it moving under your       Where is the greatest tenderness? Just above the pa-
index finger.                                                       tient’s elbow? (supracondylar fracture). On the medial side
   Can you feel the 3 bony points, as in A, in Fig. 72-2?          of his elbow? (fracture of the medial epicondyle). Over his
Are they in their normal position in relation to the tower end     lateral condyle and the outer part of his antecubital fossa?
of his humerus? If his elbow is severely swollen, you will not     (fracture of the lateral condyle, or epicondylitis). Over the
be able to feel them.                                              head of his radius? (fractured head of radius). If the tender-


                                                                                                                                                             1
72 The elbow


ness is over his olecranon, can you feel a gap in it, or move      SOME PHYSICAL
it in relation to the shaft of his ulna? These are signs that it   SIGNS IN THE ELBOW                              A
may be fractured.
    Can you move the end of his humerus or its condyles
on the shaft? Use your finger and thumb to feel the bony
ridges running up from his medial and lateral epicondyles.                           THE THREE                                              
Steady his arm with your other hand. Then very gently try                            BONY POINTS                                               
to move the lower end of his humerus sideways, and back-
wards and forwards on the shaft. If it moves, he has a supra-
condylar fracture. This is painful, so only do it if it is abso-
lutely necessary.
    If his elbow is obviously broadened, can you move one
condyle in relation to the other, perhaps with crepitus? (T–              NORMAL ARM                                        DISLOCATION
shaped fracture).
    Can he extend his elbow as in Fig. 72-23? If he can,                                      B                                             C
his extensor mechanism is intact.
    Is there an effusion? You can rarely diagnose an ef-                                                 almost no                              abnormal
                                                                                                         movement,                              hollows
fusion because of swelling of the soft tissues. Look at his                                              elbow fixed
                                                                                                         at 45°
elbow from the back. Are the normal hollows on either side
of his olecranon obliterated or bulging? If they are, he has
an effusion. You may be able to observe fluctuation be-
tween these swellings, or between them and the fullness on                                                                 45°
the anterior surface of his elbow. When compared with the
other side, does his ulnar nerve feel abnormally superficial in
its groove behind the medial epicondyle, or even displaced
                                                                           SUPRACONDYLAR                               DISLOCATION
from it by the effusion?                                                   FRACTURE
                                                                                                                                            E
                                                                                                   D
SUMMARY OF THF MAJOR FEATURES IN ELBOW
INJURIES
                                                                                                                                            epiphysea
Dislocated elbow Any age. Contour abnormal. Severe                                               fracture                                 line
                                                                                                                                    
swelling. Elbow fixed at 45◦ . The 3 bony points are not in                       
their normal relation to one another. Olecranon displaced                                                                  
posterior to the epicondyles. Lower end of humerus not ab-
normally mobile, no crepitus. Distance between lateral epi-        three                                         relation of
                                                                   bony points                                   three bony
condyle and radial styloid abnormal.                                                                             points disturbed
                                                                   correctly related
                                                                   to one another, but
                                                                   displaced posteriorly
                                                                   in relation to the shaft
Supracondylar fracture Common in children. Contour                 of the humerus
abnormal. Severe swelling. Some movement possible. Ole-
cranon not displaced above the epicondyles. The 3 bony             Fig. 72.2: SOME PHYSICAL SIGNS IN THE ELBOW. A, the 3 bony
points are in their correct places in relation to one another,     points on the back of the elbow. B, and C, the contour of a normal arm and
                                                                   a dislocation compared. D, in a supracondylar fracture the 3 bony points
but they lie posteriorly to the shaft of the humerus. Abnormal
                                                                   are correctly related to one another, but are posteriorly displaced in relation
mobility of the lower humeral fragment with crepitus. Dis-         to the shaft of the humerus. E, in a dislocation their normal relationship to
tance between lateral epicondyle and radial styloid normal.        one another is disturbed. Kindly contributed by John Stewart.


T–shaped fracture Adults. Severe swelling. Contour ab-             Fractured neck of radius Common. Children under 4
normal. Condyles move in relation to one another. Some             years. Contour normal. Flexion and extension less painful
movements of the elbow still possible. Crepitus. Swelling          than rotation. No rotation. The head of the radius may be
obscures the 3 bony points.                                        tender.


Fractured medial epicondyle Older children and youths.             Pulled elbow Young child. Contour normal. The child re-
Contour normal. Medial epicondyle tender and swollen.              fuses to use his arm. No rotation.
Some flexion and extension possible. Rotation normal.

                                                                   Fractured head of radius Adults. Contour normal. Mod-
Fractured lateral condyle Children. Contour normal. Lat-           erate swelling. Some flexion and extension possible but no
eral condyle tender and swollen.                                   rotation. The 3 bony points are normal. Head of the radius
                                                                   tender.
Fractured capitulum Rare. Adults. Very little flexion or
extension. Some rotation possible. The 3 bony points are           Fractured olecranon All ages. Contour normal. Moder-
normal. Tenderness difficult to localize.                           ate swelling. The olecranon is tender, and a gap may be


2
                                                                                                       72.3 Elevating and aspirating the elbow


palpable. There are two varieties of fracture depending on                       are mild subluxations. Try gently manipulating the elbow
whether active extension is possible or not (72.18).                             under anaesthesia. You may feel a sudden click after which
                                                                                 it moves normally.


                                                                                  IS THE MEDIAL EPICONDYLE OF AN INJURED ELBOW IN
72.2 X–rays of the elbow                                                                         ITS NORMAL PLACE?

Always X–ray an injured elbow. Ask for an AP and a lateral
view. Minor fractures such as small chips off the capitulum
are difficult to diagnose without an X–ray. In a severe elbow                     72.3 Elevating and aspirating the elbow
injury the medial epicondyle is easily detached, so it is the
first thing to look for. The films of a child’s injured elbow                      An injured elbow rapidly swells, and makes reduction of
are not easy to interpret, so X–ray his other elbow in the same                  a fracture difficult. As with the knee, aspirating the blood
position, and compare the two. Also consult the diagrams in-                     from a tensely distended elbow joint relieves pain, and al-
side the back cover, but remember that these apply to Cau-                       lows the patient to move his elbow much earlier. Some sur-
casians, and that African epiphyses unite later. If you are                      geons consider this an an important part of the active move-
still in doubt, X–ray the patient again in a week. The frac-                     ments treatment of comminuted supracondylar fractures in
ture, if there is one, will then be easier to see. Note that: (1)                adults (72.11), and especially of fractures of the head of the
in children a mildly oblique X–ray can both resemble and                         radius (72.15). Other surgeons never aspirate an injured el-
disguise a dislocation, and (2) that the head of the radius                      bow.
and the medial and lateral epicondyles can be displaced be-                         If an elbow is dislocated reduce it immediately. If it is
fore their centres of ossification appear. This makes diagno-                     fractured and too swollen to reduce immediately, put the
sis difficult.                                                                    patient’s arm up in forearm traction as in Fig. 72-11.
   If a child’s injured elbow looks normal on X–ray, the three
                                                                                    ASPIRATING THE ELBOW Clean the patient’s skin care-
bony points are in their normal places, and diagnosis is dif-
                                                                                 fully, paint it with iodine, and taking the most careful aseptic
ficult, consider pulled elbow (72.16). Some of these injuries
                                                                                 precautions, aspirate at the summit of the swelling between
                                                                                 the 3 bony points on the outer side of the elbow, as in Fig.
THE ELBOW OF                                                                     72-4.
A CHILD OF 10.                                                                      CAUTION! Don’t put anything into the joint except the tip
                                                                                 of a sterile aspirating needle.


                                                              A line A−B
                                                                                 72.4 Dislocation of the elbow
                                                                 meets
lateral
epicondyle
                                  medial                         epiphysis       A patient of any age can dislocate his elbow if he falls on his
                                  epicondyle                     in the middle
(12)                              (4−6)                                          outstretched hand. In this common injury a force travels up
                                                              head of            his forearm and pushes his radius and ulna posteriorly, or
                                                              radius             his humerus posteriorly and laterally. He cannot move his
                                                              (4−5)
                                   trochlea (9)
                                                                                 elbow, and holds it at about 45◦ . The posterior outline of his
                                                                                 arm, instead of being normally rounded, or showing a slight
                                                                                 prominence over his olecranon, bends abruptly backwards
                                                                                 as in C, Fig. 72-2. The three bony points of the elbow are
 capitulum (1)
                                                                                 not in their normal places. There may be other injuries also:
                                        olecranon (9)                            (1) A child may fracture his medial epicondyle which may
                 A normal epiphysis lies                45°
                                                                                 become trapped inside his dislocated elbow. (2) His lateral
                 in front of line A−B!
                                                                                 condyle may also fracture.
                                                  B


                                                                                 ASPIRATING
Fig. 72.3: AN X–RAY OF THE ELBOW OF A CHILD OF 10 YEARS.                         THE ELBOW
Six centres of ossification can be seen in an AP view, but they are not
always present at the same time. A large centre for the capitulum appears
in the first year. A smaller one for the medial part of the trochka appears
at about 9 years. A centre for the medial epicondyle appears about the
fifth year. It is entirely outside the capsule and unites with the shaft at
20. The lateral epicondyle starts to ossify at about 12. The centres for the
capitulum, the trochlea and the lateral condyle join one another and the                                           these are
                                                                                                                   your three
shaft at puberty. A centre for the head of the radius appears in the fourth                                        bony
or fifth year, and unites with the shaft at puberty. There is also a centre                                         landmarks
of ossification for the olecranon, and another centre for the trochlea (not
shown). These appear at about 9 years and unite at puberty.
In a lateral view, the shaft of the humerus and its lower epiphysis overlap
one another and obscure most of the epiphyseal space, which is wider be-                          the syringe and needle must be absolutely sterile!
hind than it is in front. A normal epiphysis lies in front of the lower end
of the shaft, so that a line AB drawn down the anterior border of the shaft,
meets the epiphysis at its middle. A supracondylar fracture disturbs these       Fig. 72.4: ASPIRATING AN ELBOW JOINT. Use an absolutely sterile
relationships. After Perkins with kind permission.                               needle and feel for the bony landmarks.



                                                                                                                                                       3
72 The elbow


DISLOCATION                                                                       Ask an assistant to exert traction on the patient’s wrist,
OF THE ELBOW                                                                   while at the same time you press on the back of his olecra-
                                                                               non. Using the same movements described above, you may
                                                                               be able to coax his olecranon back into place.
                                                                                  Alternatively, and with experience, you may be able to ca-
                                                                               ress his elbow and then suddeny flick it into place before
                                                                               he knows what has happened, and without using an anaes-
                                                                               thetic.
                                                                                  X–RAYS Check: (1) that reduction is satisfactory, and (2)
                                                                               that there is no bony fragment trapped in the joint. If there
                                                                               is, it will have to be removed by opening the joint. If you are
                                                                               not able to do this, refer the patient.
                                                                                  CAUTION! if you neglect to X–ray a patient after trying to
                                                                               reduce his dislocated elbow, you may fail to diagnose that
                                                                               reduction is incomplete, until after the swelling has gone.
Fig. 72.5: AN X–RAY OF A DISLOCATED ELBOW The sooner you                       Reduction will then be possible only at open operation.
reduce a dislocated elbow the easier this wilt be, and the fewer the compli-
cations.
                                                                               POSTOPERATIVE CARE FOR A DISLOCATED ELBOW

  A patient may also have severe soft tissue injuries, and oc-                 As soon as a patient recovers from the anaesthetic, reexam-
casionally the circulation of his forearm is obstructed, with                  ine his radial pulse, and his median, ulnar, and radial nerves
the danger of Volkmann’s ischaemic contracture (70.4).                         to make sure that you have not injured them during reduc-
                                                                               tion.
                                                                                  If reduction is stable, rest his arm in a sling for 3 weeks
       REDUCE A DISLOCATED ELBOW IMMEDIATELY                                   in the hope of avoiding post– traumatic ossification. While it
                                                                               is in the sling he should move it as much as possible. Start
                                                                               shoulder, finger, and wrist exercises within the sling immedi-
                                                                               ately. Don’t let him take the sling off for 3 weeks. If there are
REDUCING A DISLOCATED ELBOW                                                    no complications, his elbow will recover slowly, but he may
                                                                               always have some limitation of full extension.
The sooner you do this, the easier it will be, and the fewer                      CAUTION! Never perform passive stretching exercises.
the complications. If it is very recent, the alternative method                These encourage post–traumatic ossification.
described below may work.                                                         If reduction is unstable, flex his elbow as far as it will go
   Check the patient’s radial pulse, and his median, ulnar,                    in a collar and cuff sling, or with a posterior slab, for 3 weeks.
and radial nerves (Fig. 75-3).                                                 Then start active movements.
   ANAESTHESIA Good relaxation is essential in adults, but                        If reduction is very unstable in all directions: (1) there
is less necessary in children. (1) General anaesthesia. (2)                    is a fracture, or (2) his medial epicondyle is trapped inside
Give a child ketamine (A 8.2) or a general anaesthetic. (3)                    his elbow (see below), or (3) his ligaments are torn. Apply a
Axillary (A 6.18) or brachial plexus blocks are satisfactory if                temporary plaster backslab and refer him.
you do them well.
   REDUCTION lie the patient on his back with his upper
                                                                               DIFFICULTIES WITH A DISLOCATED ELBOW
arm vertical, and his forearm flexed across his chest, as in
A, Fig. 72-6.                                                                  If the patient’s dislocation occurred MORE THAN TWO
   Find an assistant and ask him to exert traction on the pa-                  WEEKS AGO, every day’s delay will have made the progno-
tient’s hand from the other side of the table (1), and at the                  sis worse. If the dislocation occurred less than 6 weeks ago,
same time, to flex the elbow gradually (2). While he does                       try to reduce it by manipulation. If it is already 2 weeks old,
this, grasp the patient’s elbow in both hands, with your fin-                   this will be difficult. If you fail, refer him for open reduction.
gers round the front of his humerus, and your thumbs behind                    An arthrodesis or elbow excision may be necessary.
his olecranon, then push it forwards (3).                                         If his dislocated elbow has been INCOMPLETELY RE-
   The patient’s olecranon should lie in the centre of his arm                 DUCED: (1) A child’s medial epicondyle may have broken off
midway between his two epicondyles as in A, Fig. 72-2.                         and be inside the joint. If you are in doubt, X–ray his other
If it is shifted sideways, first move it into the midline with                  elbow, and look for a small centre of ossification in an abnor-
your thumbs as you reduce it, then push it forwards over the                   mal position. (2) There may still be a sideways displacement
lower end of the humerus. The dislocation will reduce with a                   after the backward displacement has been corrected. If so,
scrunch.                                                                       try to reduce the dislocation again. If you fail, refer him with-
   When you think that you have succeeded, move the pa-                        out delay because there is probably soft tissue between the
tient’s elbow through its normal range. Unless you can get                     joint surfaces.
full flexion, you have not reduced it. If it feels stable, treat it                If the patient’s elbow REDISLOCATES EASILY and is
as described below.                                                            very unstable, make sure there are no fractures. Apply a
   ALTERNATIVE METHOD If the dislocation is very recent,                       collar and cuff to maintain the stable position for 2 weeks. If
method B, in Fig. 72-6 may work without an anaesthetic.                        it still redislocates, refer him.
   Sit the patient sideways on a chair. Put a pillow over the                     If his MEDIAL EPICONDYLE IS TRAPPED inside his
top of the chair’s back, and let his forearm hang over it.                     elbow, he is likely to present as failure to reduce a disloca-


4
                                                                            72.5 Posteriorly displaced supracondylar fractures in children


REDUCING A                                                                      SUPRACONDYLAR
                                       B                                                                                         ANTERIOR
DISLOCATED                                                                      FRACTURES                                        DISPLACEMENT
                                                                                                                lower fragment
ELBOW                                                                                                           lies in front
                                                                                                                of a line
                            use the palm                                                                        down the                  B
                            of your hand                                           POSTERIOR DISPLACEMENT       humerus


                                                                                      A


                  A


                                                  Assistant
                  You
                                           1

                                2
                  3




                                                                                Fig. 72.7: SUPRACONDYLAR FRACTURES. A, posterior displace-
                                                                                ment is much more common. B, in an anterior displacement a line down
                                                                                the front of the humerus passes behind the distal fragment.


                                                                                and exercises. The only safe movements are those that are
Fig. 72.6: TWO WAYS OF REDUCING A DISLOCATED ELBOW. If                          possible using the injured elbow’s own muscles, without the
a dislocation is very recent, method B may work without an anaesthetic.         help of his normal hand. X–ray his elbow and look for soft
Sit the patient sideways on a chair. Put a pillow over the top of the chair’s   tissue calcification, usually anteriorly in brachialis. See also
back, and let his forearm hang over it. Kindly contributed by John Stewart.     Section 72.10.
                                                                                   Don’t try to remove any bony lumps or refer him for their
                                                                                removal until at least a year after the injury. Sometimes, in
tion and a very unstable elbow. A trapped medial epicondyle                     spite of the best care, a patient’s elbow becomes stiff per-
is easy to find because the flexor muscles are attached to it.                    manently. If this starts to happen, keep it in its most useful
If it really is in his elbow joint and his elbow is unstable in all             position, according to his needs. This is usually flexed to
directions, apply a temporary posterior slab, and refer him.                    about 90◦ , with his forearm in mid–pronation (Fig. 73-1).
    If he has OTHER FRACTURES, he may have a flake off
his capitulum, or a fracture of his coronoid, or a fracture of
the head of his radius. First reduce the dislocation, and then                             AVOID FORCED ELBOW MOVEMENTS
treat the fracture as if the dislocation had never existed. If it
is a major flake, refer him immediately to have it removed.
    If a NERVE HAS BEEN INJURED, particularly his ulnar
nerve, it may need to be explored by an expert if it does                       72.5 Posteriorly displaced supracondylar
not recover spontaneously in a month. Any of the nerves                              fractures in children
crossing the elbow may be injured, especially the ulnar.
    If 2 or 3 weeks after an injury the MOVEMENT OF A                           This a particularly important children’s fracture—the wrong
PATIENT’S ELBOW BECOME LESS, a firm mass forms                                   treatment can easily make it worse. Supracondylar fractures
near the joint, and his soft tissue starts to calcify, he is                    are common between the ages of 3 and 11, and are rare after
suffering from POST TRAUMATIC OSSIFICATION (myosi-                              the age of 20.
tis ossificans). When an elbow dislocates the periosteum                            A child falls on his outstretched arm, and breaks the lower
is torn off the back of the humerus and brachialis is torn                      end of the shaft of his humerus just above the epiphyseal
from the front. These injured tissues may calcify and os-                       line in one of four ways: (1) In a third of cases there is no
sify, particularly in children. The same complication can fol-                  displacement, or the fracture is incomplete, so that the child
low a supracondylar fracture, and is made worse by: (1) re-                     needs no treatment except for a collar and cuff. (2) In the re-
peated manipulations in an attempt to reduce the injury, and                    maining two thirds of cases the distal fragment is displaced
(2) forceful movements subsequently.                                            posteriorly. The child is tender just above his elbow, which
    Watch the patient carefully for the first few weeks after                    swells rapidly and obscures the bones round the fracture.
reduction. If at any time movement of his elbow becomes                         (3) Occasionally, the lower fragment is displaced anteriorly
less, stop him moving it for a few days. Continue to immo-                      (72.7). (4) Occasionally, separation takes place at the epi-
bilize it, until unrestricted use of it no longer diminishes its                physeal line and displaces the epiphysis. Treat these epi-
range. Allow him full activity, but avoid forced movements                      physeal displacements exactly as if they were supracondy-


                                                                                                                                                  5
72 The elbow


lar fractures. Reduce them immediately. Like all epiphyseal                             The other common late disability is a deformed elbow.
injuries, they unite rapidly.                                                        Some displacements remodel and others do not.
   There is one rare immediate danger and two common                                    The displacements which remodel are: (1) Moderate angula-
later ones.                                                                          tion of the lower fragment in the plane of the elbow. (2)
   The rare immediate danger, both with this fracture and                            Posterior displacement of the lower fragment; growth of the
with posterior dislocations of the elbow, is that they can im-                       epiphysis corrects this.
pair the blood supply to a child’s lower arm, and so cause                              The displacements which do not remodel are: (1) Severe angu-
the compartment syndrome followed by ischaemic fibrosis                               lation of the lower fragment in the plane of the elbow. If you
of his forearm muscles (Volkmann’s ischaemic contracture),                           leave this unreduced, or reduce it badly, the child will be left
or gangrene requiring amputation (70.4). Contracture from                            with permanent hyperextension and severe loss of flexion.
a supracondylar fracture is much rarer than Contracture as                           (2) Valgus or varus angulation. This does does not remodel,
the result of failing to split a circular cast on a fracture of the                  however mild it is or however young the child. Varus an-
forearm.                                                                             gulation is common and is usually accompanied by internal
   The force causing the injury pushes the distal fragment                           rotation and medial displacement. The result is a loss of the
posteriorly and proximally, and the proximal fragment an-                            normal carrying angle in mild cases, or an ugly varus defor-
teriorly and distally. The sharp proximal fragment pierces                           mity in more severe ones, like the child in Fig. 72-8. This
the periosteum, and comes to lie under brachialis. If the                            is common, and although it does not affect flexion or exten-
force continues the proximal fragment goes straight through                          sion, so that disability is mild, it does not look good, and
brachialis into the child’s antecubital fossa, and may even                          makes it difficult for the patient to carry a basket.
penetrate his skin. As it moves forwards it may tear his                                The principles of reduction are: (1) To exert traction on
brachial artery, or make the artery go into spasm, or it may                         the child’s elbow, and while doing this to correct the side-
injure his median or occasionally his radial nerve. The                              ways displacement of the distal fragment. Then, (2) to flex
artery and the nerve may also come to lie between the prox-                          his arm while still exerting traction, so as to use his triceps
imal and distal fragments, and so prevent reduction. Worse,                          tendon to hold the lower fragment in place. A common er-
the antecubital fossa fills with blood. This: (1) obstructs the                       ror is to try to correct sideways displacement after you have
collateral vessels which might otherwise bypass the injured                          flexed his arm.
artery, and (2) impairs the venous return from his arm. The                             Never treat these fractures with a circular cast. The risk of
ischaemic forearm muscles swell and the compartment syn-                             Volkmann’s ischaemic Contracture is great. If you do apply
drome develops (73.7). Bending such an acutely swollen el-                           plaster, it must be a backslab.
bow is like trying to bend a balloon.
   The most common later disability is a very stiff, or fixed
elbow. This is caused by the post– traumatic ossification that                         NEVER PUT A CIRCULAR CAST ON A SUPRACONDYLAR
may follow repeated manipulation. So try to reduce the frac-                                            FRACTURE
ture with the minimum of manipulation. One attempt at ma-
nipulation followed by one more is the most you should try.
Your first attempt is the most likely to succeed, and later
ones will become more and more difficult.                                             A CHILD’S SUPRACONDYLAR FRACTURE
                                                                                     POSTERIORLY DISPLACED

UNCORRECTED ANGULATION IN                                                            The following description assumes that the child’s fracture is
A SUPRACONDYLAR FRACTURE                                                             on the right side, and follows Fig. 72-9.
                                                                                        If possible, reduce the fracture immediately. If there
                                                                                     am signs of ischaemia this is urgent.
                                                                                        If immediate reduction is impossible because his arm
                                                                                     is swollen like a balloon, apply forearm traction as in Fig.
                                                                                     72-11, and reduce the fracture as soon as the swelling has
                                                                                     subsided sufficiently for you to feel the fragments. If the skin
                                                      normal                 varus   of his forearm is blistered, so that you cannot apply trac-
                                                                                     tion to it, elevate it in a stockinette sleeve or towel pinned
                                                                                     together and suspended from a drip stand, as in Fig. 75-1.
                                                                                     Reduction is possible up to a week later, but not more.
                                                                                        If the fracture is more than a week old, it will be difficult
                                                                                     to manipulate, so leave it. Six months later, if there is a
                                                                                     severe deformity, refer him for a corrective osteotomy.
                                                                                        Check his median, ulna, and radial nerves (Fig. 75-3).
                                                                                        ANAESTHETIC (1) intravenous ketamine (A 8.3).(2) Gen-
          at the time of the injury   X−ray 4 years       4 years later there is a   eral anaesthesia.
          with angulation not         later               severe varus deformity
          corrected

                                                                                     REDUCTION OF A SUPRACONDYLAR FRACTURE
Fig. 72.8: UNCORRECTED ANGULATION IN A SUPRACONDY-
LAR FRACTURE. Varus angulation is common and results in a loss of                    Flex the child’s normal elbow, feel its bony anatomy carefully,
carrying angle in mild cases, or in an ugly varus deformity is more se-              and compare it with his injured elbow. Feeling the bony parts
vere ones, like this child. It does not affect flexion and extension, so that         of the injured elbow may be impossible if it is very swollen.
disability is mild, but it does not look good. After perkins with kind permission.   Note especially the position of his olecranon in relation to


6
                                                                            72.5 Posteriorly displaced supracondylar fractures in children


REDUCING A                                                                      this and only reappears when his arm is nearly straight, it
SUPRACONDYLAR FRACTURE                                                          may merely be due to the swelling round his elbow, or he
                                                                                may have a brachial artery lesion.
  A
                                                                                DIAGRAM A, REDUCING A SUPRACONDYLAR
                                                                                FRACTURE
                          1                     2
                                                                                Steady the child’s shoulder. Ask your assistant to hold
                                                                                it by passing a towel round it (1). Pull to disimpact the
                                                                                fracture and correct angulation Extend the child’s elbow
                                                                                gently. Grip his wrist and distal forearm. Pull hard in a lon-
                                                                                gitudinal direction for at least 1 minute by the clock (2). You
 B                                         2a                                   will feel the fragments disimpact and release the soft tissues
                                                                                trapped between them. Check that you have disimpacted
                                                                                them by feeling that the lower fragment is free.


                                           2a
                                                                                DIAGRAM B, REDUCING A SUPRACONDYLAR
                                                                                FRACTURE

  C                                             D                               Correcting medial and lateral displacement. The distal
                                                                                fragment is usually displaced medially. Traction usually cor-
                               5                                                rects this. If it does not, now is the time to try to correct it.
                                                                5
                                                                                Feel the distal fragment, although the child’s elbow may be
                                   3                             3              so swollen that this is impossible. If necessary, move the
                1
                                                                                distal fragment towards the midline of his arm (2a).
                                       4

                                                                                DIAGRAM C, REDUCING A SUPRACONDYLAR
                                                                                FRACTURE
 E                  Feel his pulse!        F
                                                                                Correct the posterior displacement. While still exerting
                                                    7
                                                                                longitudinal traction with your right hand (3), press the ole-
                                                                                cranon with your thumb (4).
                                                            6
                                                                                  Begin flexing (5) with your thumb pressing on his ole-
                                                                                cranon. Do this while your assistant maintains traction in
                                                                                the child’s axilla. Keep pressing his olecranon with your left
                                                                                thumb as you do so. Externally rotate his forearm a little
           8                                                                    more than was possible on the normal side. This will help to
 G
                                                                                restore the normal carrying angle.
                                                                                  Continue flexing. As the child’s arm reaches 90◦ , pull
                                                                                posteriorly on his humerus, and anteriorly on his forearm.
                                                                                  CAUTION! Use only moderate tension as his arm reaches
                                                                                90◦ . If you pull too hard at this stage, it is possible to pull the
                                                                                distal fragment in front of the end of the humerus. Fortu-
                                                                                nately this is rare.

                                                                                DIAGRAM D, REDUCING A SUPRACONDYLAR
Fig. 72.9: REDUCING A SUPRACONDYLAR FRACTURE. The prin-                         FRACTURE
ciples of reduction are to exert traction on a child’s elbow and while doing
so to correct the sideways displacement of the diatal fragment. Then, flex       Complete flexing. Beyond 90◦ further flexion does not im-
his arm while still exerting traction, so as to use his biceps tendon to bold   prove reduction, but it does stabilize reduction by wrapping
the lower fragment in place. Kindly contributed by Peter Bewes.                 the child’s triceps tendon round the distal fragment and fix-
                                                                                ing it. This also impacts the fragments. Lateral displacement
                                                                                of the distal fragment cannot now be corrected.
the axis of his humerus. This is a useful guide to satisfactory                    The position of the point of the olecranon is the best guide
reduction.                                                                      to satisfactory reduction. It should be in line with the axis of
   Feel how much external rotation of his flexed elbow is pos-                   the humerus or perhaps little anterior to it (8). You should
sible on the normal side. Later, when you come to reduce                        also be able to feel both epicondyles forming, with the tip of
a medially displaced fragment, you will need to rotate his                      the olecranon, the 3 bony points of the elbow in A, Fig. 72-2.
injured forearm externally to the limit of what is possible on
the normal side, and a bit more. This external rotation may
                                                                                DIAGRAMS E, F and G, REDUCING A
be critical. Sideways displacement either corrects itself, or
                                                                                SUPRACONDYLAR FRACTURE
is easily corrected.
   What happens to his pulse if you flex and exert gentle                        Check the child’s pulse (7). This may be difficult because
traction on his arm? If his pulse disappears when you do                        of oedema. If his pulse disappears when you flex his arm,


                                                                                                                                                  7
72 The elbow


extend it until his pulse reappears.                              CHECKING
    If he has a good radial pulse, put his arm in a collar
                                                                                                               A
                                                                  REDUCTION
and cuff in as much flexion as his pulse will allow. His hand
should be able to reach his mouth. If you cannot feel his
pulse, extend his elbow until you can free it. Make a cuff out
of two lengths of stockinette filled with cotton wool (8).
    If you cannot get his arm beyond 70◦ without his pulse                   B
disappearing put him in forearm traction (Fig. 72-11), as
described below.
    If you are not sure if you can feel his pulse or not, don’t
worry for the moment. But immediately he wakes from the
anaesthetic, ask him if he can flex his fingers. If he cannot
do this, proceed as in Section 72.8.
    CAUTION! (1) Make the knot of the collar and cuff so se-
cure that neither the child, nor his parents, nor his grandpar-
ents can remove it. A good way to secure it is to cover it with
plaster. Provided there are no complications, it will need to
stay on for 3 weeks. In whatever way the child twists and
turns, he must not be able to extend his elbow more than
90◦ or reduction will be lost. (2) Don’t fit a plaster backslab,
it is unnecessary and make it difficult to flex his elbow suffi-
ciently.                                                          Fig. 72.10: CHECKING THE REDUCTION OF A SUPRACONDY-
    As soon as he awakes, make sure he can flex and ex-            LAR FRACTURE. A, the post reduction X–ray; This is schematic only
tend his fingers. Check the function of his median and ulnar       and is from an older patient. B, positioning the arm and the film to take
nerves. They may be injured, but they usually recover even-       the X–ray. Don’t let the X–ray assistant remove the child’s collar and cuff
                                                                  to X–ray his arm. Take a lateral X-ray, and an AP view through the point
tually.                                                           of his elbow as shown: (1) There should be no angulation of the lower frag-
    CHECK REDUCTION The post reduction X–rays are of              ment in the AP view, (2) There should be no significant forward bowing
less help than they might be in seeing if angulation has been     in the lateral view. (3) The fragments must be in contact. If these criteria
successfully reduced or not, because: (1) the child’s arm         are met, reduction is satisfactory. Sideways and posterior displacement are
                                                                  not important.
must be kept flexed after reduction, and (2) the centres of
ossification in the lower fragment may still be small. How-
ever, do your best by the the X–ray criteria in Fig. 72-10. If       If, when you remove his collar and cuff, he ceases
they are not met, have one further attempt at reduction, not      to be able to touch his mouth, replace it, and gradually
more, or you will damage the child’s elbow, and increase the      tighten it until he can.
chances of post–traumatic ossification.                               His elbow will be stiff for a long time. Encourage him to
    PREVENT ISCHAEMIC PARALYSIS Don’t send the child              use it, but let movement return on its own, using its own
home because he may return with an irreversible Volk-             active movements. Even when movement is slow to return,
mann’s contracture! Admit him to the ward and monitor the         you can assure his mother that it will be better at the end of
circulation in his hand carefully for 36 hours. Watch him for     a year.
early signs of ischaemia. Check his pulse, and then press on         CAUTION! (1) Forceful passive movements will make the
his nail beds and see how quickly his capillaries refill. The      stiffness worse. (2) Don’t try to straighten his elbow by mak-
first signs of ischaemic paralysis are: (1) pain on passive        ing him carry weights.
extension of his fingers, (2) paraesthesiae (3) pallor, and (4)
paralysis as shown by the inability to use his fingers.
                                                                         DON’T SEND HIM HOME FOR 36 HOURS AFTER
    Make sure the ward staff know why they are monitoring
                                                                                       REDUCTION
the child’s circulation and what signs they should watch for.
If they don’t know this, they may be quite content to feel the
pulse in his normal arm!
    CAUTION! Don’t give him morphine or any analgesic until
you are sure that ischaemia is no longer a danger.                72.6 Supracondylar fracture of the humerus
                                                                       in children with anterior displacement of
                                                                       the distal fragment
POSTOPERATIVE CARE AFTER REDUCING A
SUPRACONDYLAR FRACTURE                                            Anterior displacement of the distal fragment of a supra-
                                                                  condylar fracture is rare, and the signs are milder than with
If you have to reduce the flexion of a child’s elbow, because      posterior displacement. Make the diagnosis from the lateral
of his impaired circulation, flex it again as his swollen elbow    Xray, as shown in B, Fig. 72-7. This may be difficult to in-
recovers. Then, X–ray him again.                                  terpret because the lower end of the diaphysis overlaps the
   Keep his collar and cuff on for 3 weeks. Don’t let him take    epiphysis, especially in a young child, so that the epiphysis
it off during this period. Make sure his parents understand       may appear to be displaced when it is not. The best test is to
this.                                                             look at a lateral X–ray and to see where a line drawn down
   At 3 weeks his fracture will have united, so remove his        the front of the humerus cuts the curved lower border of the
collar and cuff, and replace it by a sling for 3 more weeks.      epiphysis, this is the line A–B in Fig. 72-3. It should bisect it


8
                                                                                 72.7 Ischaemia following a supracondylar fracture


as in Fig. 72-3. The epiphysis should not lie in front of this        FOREARM TRACTION
line.
                                                                         A Extension traction
A CHILD’S SUPRACONDYLAR FRACTURE
ANTERIORLY DISPLACED

Anaesthetize the child as for forward displacement (72.8).                         This is NOT a method
Extend his forearm. Ask an assistant to exert steady traction                      of reduction!

in the line of his arm with his forearm supinated.
   While your assistant is doing this, steady the lower end of
his humerus with one hand, and correct the sideways dis-                                                                    impaired
placement of the lower fragment with your other hand.                                                                       circulation

   Either, put his arm up in traction as in Fig. 72-11, or apply
a 10 cm plaster slab along the back of his arm and fore-
                                                                                    nothing
arm with his elbow extended. Keep it in place with a crepe                          encircling
bandage.                                                                            the arm

   Confirm reduction with an X–ray. Remove the slab in 3
weeks in a child and put his arm in a sling.                                                                               supracondylar
                                                                                                                           fracture
   Alternatively, flex his elbow to 90◦ , and push his forearm
posteriorly on his upper arm so as to convert the anterior
displacement to a posterior one. Then, treat it as you would
a posterior displacement (72.6 ).


72.7 Ischaemia following a supracondylar
     fracture
This is a child who cannot move his fingers after the reduc-
tion of a supracondylar fracture. His arm shows some or
all of these signs: (1) He has severe, deep, poorly localized,
                                                                         B Dunlop traction
pain in the flexor muscles of his forearm. Pain when you
extend his fingers passively is a serious late sign. So is flex-
ion of his fingers. Occasionally, the syndrome is subacute
and painless. (2) Paraesthesiae develop. First he feels ’pins
and needles’, then his arm becomes numb with anaesthesia
of glove distribution. (3) The skin of his arm (if his is con-
scious) becomes white or blue (if he is Caucasian). There is
no circulation in his nail beds. (4) His arm is weak, and he
cannot use his fingers. (5) Palpable induration of his fore-
arm muscles is a diagnostic sign, but it occurs late. (6) His
radial pulse may be weak or absent. An absent pulse is an
unreliable sign, because the pulse is sometimes present even
when there is severe ischaemia. Teach your staff the impor-
tance of the four ’Ps’—pain, paraesthesia, pallor (if they are
caring for Caucasians) and paralysis, in that order.
   Be vigilant, quick, and decisive. Recognize these signs
early. If they are getting worse decompression is urgent.
This is a very rare acute emergency, and there is no time
to refer him. It is one of the few occasions where doing
something is always better than doing nothing. If you are
lucky, extending his forearm in traction, as in Fig. 72-11, will be
enough to restore his circulation. If this fails, you will have to    Fig. 72.11: FOREARM TRACTION is useful first treatment for is-
explore his antecubital fossa, and decompress the muscles of          chaemia following a supracondylar fracture. Only if this fails to restore
                                                                      a child’s circulation need you explore his arm. A, traction in extension. B,
his arm. The penalty for not doing this will be Volkmann’s
                                                                      Dunlop traction. B, is more widely recognized, A is easier and adequate.
ischaemic contracture (70.4).                                         After Mercer Rang with kind permission.


EARLY SIGNS OF IMPENDING ISCHAEMIC
                                                                      the cord over a pulley, so that if he moves about, traction will
CONTRACTURE
                                                                      still be maintained. Suspend his arm as in Fig. 72-11.
Temporarily ignore the child’s fracture. Take off all ban-               Slope his bed slightly to stop him falling out, by putting a
dages. If a plaster cast has been applied, remove it.                 pillow under one side of the mattress.
  FOREARM TRACTION Apply longitudinal traction to the                    Monitor the circulation in his arm.
skin of the child’s forearm. Use adhesive strapping and pass             If the pain goes, his circulation improves, and he is able


                                                                                                                                                9
72 The elbow


to move his fingers, continue traction. When most of the            EXPLORING THE
swelling has gone, usually in about a week, reduce the frac-       ANTECUBAL FOSSA                                           A
ture as described above, and put his arm in a collar and cuff.
You should now have no trouble with his pulse. Usually, by
this time the fracture is so firmly fixed that you will have to
accept the malposition.
   CAUTION! If pain, paraesthesiae, pallor, and paralysis
persist, for more than an hour, make preparations to take
                                                                        cephalic             basilic
him to the theatre, explore his antecubital fossa and, if nec-          vein          B      vein
essary, the volar aspect of his forearm, as described below.
Don’t be put off by a full stomach (16.1).


72.8 Forearm traction fails to restore the
     pulse of a child with a supracondylar                                                                               C
     fracture
This is the child whose supracondylar fracture is compli-
cated by ischaemia of his forearm. He is unlucky in that
signs of ischaemia persist, even with his arm extended in
forearm traction and any tight cast or bandage removed.
Take him to the theatre. There are two things you can do:
(1) You can release the tension in his antecubital fossa and
relieve the pressure on his vessels. (2) You can decompress                                                   brachial
                                                                                                              artery         median
his forearm muscles to relieve the compartment syndrome
                                                                                                                             nerve
(73.7)., Opinions vary as to which of these is the most impor-
tant. Releasing the tension in his antecubital fossa is easier                     this shows the anatomy of the veins
and may be all that is necessary. Don’t delay; a wait of 3 or                      and is not part of the dissection!

4 hours may make all the difference between a normal and
a totally useless arm. If you act promptly his prognosis is        Fig. 72.12: EXPLORING THE ANTECUBITAL FOSSA. Don’t explore
                                                                   the child’s antecubital fossa until you have tried to reduce the fracture,
likely to be good. Don’t try to inspect or repair his brachial     because this may itself be enough to improve the circulation his arm. After
artery—this is a highly skilled task, it is rarely necessary,      Campbell permission requested.
and, because the collateral circulation round the elbow is so
good, a blocked brachial artery does not necessarily cause
Volkmann’s ischaemic contracture.                                  not reasonably reduced, apply forearm traction. If it is re-
                                                                   duced, apply a collar and cuff.
                                                                     Skin graft the wound after 4 days. If a contracture devel-
     WATCH FOR PAIN, PARAESTHESIA, PALLOR, AND                     ops, see Section 72.10.
                     PARALYSIS

                                                                    TREAT THE EARLIEST SIGNS OF ISCHAEMIC PARALYSIS
                                                                                     IMMEDIATELY
OPERATING FOR ISCHAEMIA
Don’t explore the child’s antecubital fossa until you have tried
to reduce the fracture, because this may itself be enough to       72.9 Other difficulties with supracondylar
improve the circulation his arm.                                        fractures in children
   Make the lazy ’S’ incision as in A, Fig. 72-12, beginning
above the flexor crease on the inner border of his biceps           These include nerve injuries, post-traumatic ossification, a
tendon.                                                            persistent varus deformity, and severe malunion. Most of
   Pull back the flaps, incise his tight deep fascia and his        these complications are difficult to treat. The principle is to
bicipital aponeurosis (B). Pale or blue–black muscle will          prevent them by the methods described above if you possi-
bulge from the wound. There may be a tight haematoma.              bly can.
Remove it. This may be enough to relieve the obstruction
and restore his circulation.
                                                                   OTHER DIFFICULTIES WITH A SUPRACONDYLAR
   CAUTION! Don’t meddle with his brachial artery, or try to
                                                                   FRACTURE
resect the spastic section.
   DECOMPRESSING A CHILD’S FOREARM MUSCLES if                      If a child has NERVE INJURIES after a supracondylar
the above methods fail, and his forearm is swollen, carry the      fracture, they probably recover. They are more common
Incision down through it, as in Fig. 73-11. Slit his deep fascia   than injuries to the brachial artery, but are less serious.
in the length of the incision. Pale oedematous muscles will        Nerve injuries alone are not an indication for an immediate
burst through the slit fascia. Decompress the superficial and       operation. If there is no recovery in a month, refer the child
deep volar compartments of his arm, as in Section 73.7.            to have his elbow explored.
   POSTOPERATIVE CARE Leave the flaps open, and                        If the child’s ELBOW WiLL NOT MOVE after a supra-
dress the child’s wound. Don’t sew it up. If the fracture is       condylar fracture, he is suffering from POST TRAUMATIC


10
                                                                                    72.10 Supracondylar fractures of the humerus in adults


OSSIFICATION. After 3 weeks, when the collar and cuff are                      72.10 Supracondylar fractures of the
removed, his elbow will not move, or perhaps there is some                           humerus in adults
movement which gradually becomes less. The front of his
elbow is tender, there is muscle spasm and the tendon of                       Supracondylar fractures in adults differ from those in chil-
his biceps stands out as a taut band. X–rays may show a                        dren, and are caused in a different way: (1) An old per-
vague shadow like callus in front of the joint, or it may be so                son falls and strikes his elbow on the ground. The force of
dense that it looks like bone. Sometimes a stiff painful elbow                 the blow drives his ulna up against his humerus and either
with new bone around it is his presenting symptom.                             breaks off its lower end, as in a child, or, more often, splits
   Encourage his parents to put his injured elbow through                      it into two or more pieces which may separate widely and
several 15 minute periods of gentle active movements each                      displace backwards or forwards. Or, (2) the patient rests
day, both flexion and rotation. His parents must be patient,                    his arm on the window of his car, and has it crushed by a
persistent and gentle. Forced movements and even too vig-                      passing vehicle (sidewipe fracture). In either case he cannot
orous passive movements will make his elbow worse. Make                        move his swollen and deformed elbow. Swelling obscures
this clear to them. If the movements of a child’s arm are di-                  the bony landmarks and if you examine it carefully, you may
minishing, put his arm in a collar and cuff until muscle spasm                 be able to feel crepitus.
has disappeared, which may take months. If he cannot flex                          These fractures are usually T–shaped or comminuted.
his elbow enough to get his hand to his mouth, put it in a                     Rarely, they are transverse as in children; if so, you can
loose collar and cuff and gradually tighten it until he can.                   manage them in the same way. If the fracture is T–shaped
After prolonged rest the spasm disappears and movement                         or comminuted, you cannot reduce the fragments by closed
returns, but there is usually some permanent loss of move-                     manipulation, and they are difficult to fix at open operation.
ment. Unfortunately, post–traumatic ossification is common,                     Even when the fragments are fixed internally, the late results
and is a major disability, especially when pronation is lost.                  are often disappointing, so it is fortunate that the results of
Osteotomy followed by an arthrodesis in the position of func-
tion (about 90◦ , see Fig. 7-16) may be necessary.
   If SEVERE VARUS DEFORMITY PERSISTS, refer the                               OLECRANON
child for corrective osteotomy not earlier than a year after                   TRACTION
the injury.
   If the fracture was never property reduced, and he
now has MALUNION with only 30◦ of movement or less,
management depends on where the movement is. If it is
around the position of function (90◦ ) an osteotomy is un-                                                      1
likely to improve him. But if it is around full extension, an
osteotomy may bring it into a more useful range.


  NEVER MOVE AN ELBOW CONTRACTURE FORCEFULLY


                                                                                                                        2


A COMMINUTED SUPRACONDYLAR
FRACTURE IN AN ADULT



                                                                                                                                              7
                                                                                             3
                                                                                                                    4




                                                                                                                                         6
                                                                                         5

             X−ray after                    range of movement
             the injury                     a year later


Fig. 72.13: A COMMINUTED SUPRACONDYLAR FRACTURE                                Fig. 72.14: TRACTION THROUGH THE OLECRANON FOR A T–
treated by active movements showing the range of movement possible 18          SHAPED SUPRACONDYLAR FRACTURE. If a patient’s olecranon is
months later. Note that the range of active movement is around the posi-       intact, pass a Kirschner wire through it (70.10), and tension the wire with
tion of function (about 90◦ ). This patient is right handed, to this enables   a Gissane stirrup (1), or, less satisfactorily, use a thin (less than 4 mm)
his right hand to reach his mouth. Kindly contributed by Peter Bewes.          Steinmann pin. After de Palma with kind permission.



                                                                                                                                                       11
72 The elbow


early active movement are usually better as shown in Fig.                Apply 0.5 to 1 kg of backward traction on his upper arm
72-13, and that patients have much less osteoarthritis than           (5). This is not essential.
you might expect. But the results will only be better, if the pa-        Feel the bony prominences on the back of his elbow (6)
tient really does start moving his elbow early. The function he       and adjust the direction of traction so that the position of the
will ultimately get depends on the relationship of his two            prominences matches that on the normal side, and corrects
condyles. If they are widely apart and shifted on one an-             any sideways shift. You may have to tie the traction cord to
other, movement will be poor. If they are parallel and not            one of the outer holes in the stirrup (7).
shifted, movement will be better. Displacement of the frag-              CAUTION! Check his radial pulse often. Don’t apply too
ments at the transverse fracture is less important. You can           much traction, or you may obstruct the circulation to his arm,
combine active movements with traction, as in Fig. 72-14.             injure his nerves, or distract the fragments and so prevent
                                                                      union.
                                                                         X–ray him. Slight backward displacement is acceptable,
SUPRACONDYLAR FRACTURES OF THE
                                                                      but there should be no angulation or lateral displacement.
HUMERUS IN ADULTS                                                        While he is in traction, encourage him to move his elbow
INDICATIONS FOR REFERRAL (1) If the lower end of the                  as much as he can. Let him take hold of the traction cord
patient’s humerus is in one or two fragments only, and you            and assist his elbow movements himself.
can refer him to a superb technician, he may benefit from                 Remove the traction at 2 to 3 weeks, put his arm in a sling
internal fixation, especially if he is young. (2) Injuries to his      with his elbow at 90◦ and his forearm in 45◦ of pronation.
median or ulnar nerves.                                               Start carefully graded active movements without using force.
                                                                      Recovery will take several months.

TRANSVERSE SUPRACONDYLAR FRACTURES
                                                                      DIFFICULTIES WITH SUPRACONDYLAR FRACTURES
If the lower fragment is in one piece, treat it as for a child’s      IN ADULTS
supracondylar fracture (72.6).
                                                                      If a patient’s HUMERUS IS BADLY COMMINUTED AND

T–SHAPED, Y–SHAPED, OR COMMINUTED
SUPRACONDYLAR FRACTURES                                               INJURIES OF THE DISTAL
                                                                      HUMERAL EPIPHYSIS
EARLY ACTIVE MOVEMENTS if necessary, anaesthetize
the patient and try to get the fragments into a better posi-                       LATERAL CONDYLE

tion. Try to start active movements as soon as possible. If              A         (younger child)

                                                                      common
his arm is very swollen keep it raised for a few days. Put his        extensor
arm in a collar and cuff for not more than a week. During             origin
                                                                                                      line of
this time take it out several times a day and encourage him                                           attachement
to move it.                                                                        piece of           of joint
                                                                                   shaft              capsule
    CAUTION! (1) FlexIon and extension are subsequently
likely to be limited, so make sure they are in the most useful
range, as in Fig. 72-13. (2) For the same reason his forearm
should be in mid–pronation.
                                                                      centre for
    Start pendulum exercises for his shoulder (Fig 71-7), and         capitulum     fracture line
exercises for his wrist and fingers immediately after the in-                        enters joint
jury.                                                                              MEDIAL EPICONDYLE
    After a week, provided he continues to be able to put his            B         (older child or youth)
hand to his mouth, put his arm in a sling. Keep him in the
sling for 5 weeks. Encourage him to use his hand and move
his elbow as much as he can. Tell him that he will not regain
any movement in his elbow unless he tries very hard to use                                              common
it.                                                                                                     flexor
                                                                                                        origin
    OLECRANON TRACTION If the patient’s olecranon is in-
tact, pass a Kirschner wire through it (70.10), and tension
the wire with a Gissane stirrup (1), or, less satisfactorily, use
a thin (less than 4 mm) Steinmann pin. The danger with a
pin is that it is more likely to get in the way of his ulnar nerve.          centre for trochlea
                                                                                                    fracture line outside joint
If the fragments are displaced, ask an assistant to exert trac-
tion on the stirrup while you press the fragments back into           Fig. 72.15: INJURIES OF THE DISTAL HUMERAL EPIPHYSES. The
place (2).                                                            medial epicondyle and lateral condyle differ considerably. A, The lateral
    Apply enough traction to keep his upper arm under ten-            condyle is a pressure epiphysis to which the common extensor origin is
sion (3) but not enough to lift his shoulder off the mattress.        attached. It is fractured in young children. The fracture line enters the
                                                                      joint displacing the centre for the capitulum and sometimes part of the
You may need to apply 2 to 5 kg.                                      shaft. The displaced fragment must be accurately replaced. B, the medial
    Apply a sling (4) to keep his elbow at 90◦ and his wrist          epicondyle is a traction epiphysis outside the elbow joint to which the com-
half–way between pronation and supinaton, with his hand               mon flexor origin is attached. It is displaced in teenagers, and unless it
over his opposite shoulder.                                           happens to go inside the elbow joint it need not be removed or reattached.



12
                                                                               72.12 Fracture of the lateral condyle of the humerus (children)


OPEN, AND HIS RADIUS AND ULNA ARE INJURED TOO,                                     FRACTURE OF THE MEDIAL EPICONDYLE
this is likely to be the result of a car accident in which he had
his elbow over the edge of the window. Toilet his wound.                           IF THE PATIENT CAN MOVE HIS ELBOW ADEQUATELY,
If his elbow is dislocated, reduce it. Suspend his arm in                          put his arm in a collar and cuff for a week. Then give him
the position of function, and get it moving. Dress it, but do                      a sling and encourage active movements. Full movements
not close it by primary suture. Look at it in 4 or 5 days,                         may not return for a year.
and either close it or graft it. (1) Hang it up with metacarpal                       IF HE CANNOT MOVE HiS ELBOW ADEQUATELY,
Kirschner wire (70.12), or (2) use skin traction on his fingers                     anaesthetize him. Extend his wrist to tension his flexor mu-
while watching their circulation carefully. Hang his hand up                       cles. Flex, abduct, and supinate his elbow, then suddenly
in the same position as for forearm traction.                                      extend it. The fragment may reduce with a sudden clunk.
                                                                                   X–ray his elbow, and repeat the manoeuvre twice if neces-
                                                                                   sary.
                                                                                      If you can move his elbow through its full range of
                                                                                   movement and it is stable, apply a collar and cuff as
72.11 Fracture of the medial epicondyle of                                         above.
      the humerus                                                                     If you cannot move his elbow through most of its full
                                                                                   range, refer him for open reduction.
                                                                                      OPERATION If you cannot refer him, and are familiar with
Between the ages of 5 and 20 the centre of ossification of the                      the procedures, consider operating. This is not an operation
medial epicondyle is a separate piece of bone. The flexor                           for the beginner, because the child’s ulnar nerve will not be
muscles of the forearm are attached to it, and if these are                        in its normal position and may be kinked into the joint with
pulled on hard enough by a fall on an outstretched hand,                           his medial epicondyle. Make all incisions in the line of the
they can pull it away from a patient’s humerus. His de-                            nerve, not across it.
tached medial epicondyle may remain outside his elbow                                 Make a 5 cm longitudinal incision 1 cm anterior to his me-
joint or go inside the joint and lock it. Closed methods may                       dial epicondyle. Find his ulnar nerve and take care not to
succeed in removing it, but if they fail, an open operation is                     injure it. You will see the fibres of the common flexor origin
necessary Removing the detached medial epicondyle would                            emerging from the joint cavity. Pull on these fibres with a
not be a difficult operation, if his ulnar nerve were not so                        hook or forceps, and pull the epicondyle out of the joint.
close. Sometimes, his elbow is dislocated also (72.4).                                Find the rough place on the medial side of his elbow from
  After a fall an older child or youth complains of a painful                      which the epicondyle broke off. Either suture it in place by
elbow. The contour of his arm is normal, but his medial                            drilling a small hole in it and in the neighbouring bone, or,
epicondyle is tender and swollen. Rotation is normal and                           anchor it in place with two short pieces of Kirschner wire
some flexion and extension is usually possible. Compare                             with their ends bent over subcutaneously. Remove them 4
the X–rays of both his elbows.                                                     to 6 weeks later. If fixing the epicondyle is difficult, and the
                                                                                   fragment is small, excise it. His flexor muscles will quickly
                                                                                   find new attachments.

FRACTURES OF THE
MEDIAL EPICONDYLE                                                                  DIFFICULTIES WITH FRACTURES OF THE MEDIAL
                                                                                   EPICONDYLE

                                                                                   If the patient’s ULNAR NERVE IS INJURED, paralysis may
                                                                                   be due to stretching and only be temporary. If recovery is de-
                                                                                   layed more than 6 weeks, refer him for transfer of the nerve
                                                                                   to the front of his elbow.
                                                                                       If the FRAGMENT HAS BEEN LEFT INSIDE THE JOINT,
                                                                                   and you discover It some time later, refer the child. If you
                                                                                   cannot refer him, warn him that full movement may not re-
                                                                                   turn.
                                A
                                B
                                                                                   72.12 Fracture of the lateral condyle of the
                            C                                                            humerus (children)
                                                                                   A young child aged 4 to 15 falls on his outstretched
                                                                                   hand. His wrist extensors, which are attached to his lat-
                                                                                   eral condyle, pull it away from his humerus. His elbow
                                                                                   is swollen and will not move. You can rotate his forearm,
                                                                                   showing that his radius is intact. The posteromedial side of
      AP view                                                  Lateral view
                                                                                   his arm is not tender, showing that he has probably not got
                                                                                   a supracondylar fracture. Sometimes his elbow is dislocated
Fig. 72.16: FRACTURE OF THE MEDIAL EPICONDYLE. If the child
is over 5, the age at which the centre of ossification appears, you will be
                                                                                   also.
able to see if it is in its normal position A or not. If it is displaced, it may      This is a serious Type IV epiphyseal injury (69.6). It occurs
not prevent his elbow moving (B), or it may be inside his elbow and locking        at a younger age than an injury to the medial epicondyle,
it (C). From Perkins with kind permission.                                         and the displaced fragment is larger. The fracture line runs


                                                                                                                                                13
72 The elbow


FRACTURE OF THE LATERAL CONDYLE                                                  THE LATERAL CONDYLE
 NORMAL                               DISPLACED




                                                                                                           centres of
                                                                                                           ossification




                                                                                 Fig. 72.18: FRACTURE OF THE LATERAL CONDYLE. If this injury
                                                                                 is not treated correctly, it will be followed by a severe valgus deformity
                                                                                 which increases until growth ceases. After Watson Jones with kind permission.

      in this case the lateral
      condyle did not carry
      away a piece of the shaft
                                                                                 he is under 12, you will not see the centre of ossification for
                                                        LATE RESULT
      with it, compare Fig. 72−15                       OF DISPLACEMENT
                                                                                 his displaced lateral epicondyle, because it will not yet have
                                                                                 appeared. If in doubt compare the X–ray of the injured side
                                                                                 with that of the normal one. Don’t mistake this injury for a
                                                                                 supracondylar fracture!
                                                               this patient
                                                               can expect
                                                               a late ulnar
                                                               nerve paralysis   FRACTURE OF THE LATERAL CONDYLE OF THE
                                                                                 HUMERUS

                                                                                 IF THERE IS NO DISPLACEMENT relieve the child’s pain,
                                                                                 if necessary, by aspirating his elbow joint (Fig. 72-4) using
                                                   Severe valgus deformity       careful sterile precautions. Apply a backslab from his axIlla
                                                                                 to his kunckles with his elbow in 60◦ of flexion and his wrist
                                                                                 dorsiflexed. Mould the backslab closely round his elbow, and
Fig. 72.17: FRACTURE OF THE LATERAL CONDYLE is a serious                         hold it in a sling.
Salter Harris Type IV epiphyseal injury; it occurs at a younger age than
injuries of the medial condyle, and the fragment is larger. Kindly contributed      At 4 weeks replace the slab by a sling.
by John Stewart.                                                                    IF THERE IS DISPLACEMENT, suspend his arm in exten-
                                                                                 sion traction, as in Fig. 72-11, until the swelling is less. Find
                                                                                 two assistants. Anaesthetize the patient.
from the middle of the articular surface of the child’s el-                         Ask one assistant to apply traction to the child’s partly
bow upwards and laterally, isolating part of his trochlea, the                   flexed forearm. Ask the other assistant to apply counter trac-
whole of his capitulum, and often a small part of the shaft                      tion to his upper arm. Ask them to slightly adduct his arm
of his humerus, as in Fig. 72-15. Sometimes, there is only                       at the same time, so as to widen the space on the lateral
a little lateral shift which need not be reduced. More often,                    aspect of his elbow joint.
the lower fragment turns over completely inside the joint.                          While they are applying traction and adduction, try to ma-
If it is not reduced, it unites to the shaft with fibrous tissue,                 nipulate the fragment back into place in contact with his
and growth in the lateral half of his epiphysis stops. The                       humerus.
result is a severe valgus deformity of his elbow which in-                          If closed reduction is successful, immobilize his elbow in
creases until growth ceases. Distortion of the path of his                       a plaster backslab as above. Mould the backslab round the
ulnar nerve round his severely deformed elbow causes a                           lateral side of his elbow to keep the fragment in place.
late ulnar paralysis with wasting of the small muscles of his                       If closed reduction fails, do all you possibly can to refer the
hand.                                                                            child for open reduction immediately. This involves fixing the
   The X–rays of his elbow are difficult to interpret, because                    lateral fragment with two fine Kirschner wires. The penalty
a large part of the fragment is cartilage and casts no shadow.                   for not doing so is likely to be a fixed elbow always. If the
An AP view shows that the epiphysis of his capitulum is                          fragment is not replaced, warn his parents that a progressive
missing; instead, there is an abnormal mass of bone on the                       valgus deformity and ulnar paralysis may occur, and that he
outer side of his elbow. In a lateral view this may be hidden                    must return early, so that an ulnar nerve transposition can
behind his humerus, but it is usually displaced anteriorly. If                   be done.


14
                                                                                      72.14 Fractures of the head of the radius (adults)


DIFFICULTIES WITH FRACTURES OF THE LATERAL                               If X–rays show that reduction has failed, refer him for
CONDYLE                                                                external fixation of the fragment.

If 10 to 30 years later the patient complains of NUMB-
NESS AND TINGLING in the distribution of his ulnar                     72.14 Fractures of the head of the radius
nerve, followed by wasting of the small muscles of his                       (adults)
hand, he has an ulnar nerve paralysis. Warn his parents
that this may follow the progressive valgus deformity of his           In this common injury a force travelling up the patient’s arm
elbow many years later, because he may not connect it with             drives the head of his radius against his capitulum. What
his injury. His ulnar nerve should be moved anteriorly in his          happens depends on his age: (1) In a child the neck of the
elbow before the small muscles of his hand start to waste.             radius bends so that its head is displaced anteriorly and lat-
                                                                       erally, but the head itself almost never fractures. (2) In an
                                                                       adult the head may crack, a piece may chip off, it may break
72.13 Fracture of the capitulum (adults)                               into many pieces, or the whole head may displace elsewhere
                                                                       in the joint. Treatment must be prompt and adequate.
In this rare fracture a piece of the patient’s capitulum breaks           Typically, the contour of the patient’s arm is normal, and
off, tilts, and moves anteriorly. Unless it is reduced, he will        not greatly swollen. He is able to flex and extend his elbow
have very little use in his elbow. The fragment varies in size         a little, but he cannot rotate his wrist. The head of his radius
from a small piece of cartilage, to the whole of the front of          is tender. His elbow and his X–ray may look so normal that
the patient’s capitulum and part of his trochlea. The head of          the fracture is easily missed. If you think that he might have
his radius may be fractured at the same time.                          fractured the head of his radius, but his X–ray looks normal,
   The patient holds his slightly swollen elbow at 90◦ , the           treat him conservatively and X–ray him again in a week; the
contour of his arm is normal, and tenderness is difficult to            fracture will then be more obvious.
locate. Rotation is fair, but very little flexion is possible.             In the instructions below we advise you treat a patient
Small fragments consisting only of cartilage are difficult to           conservatively if you possibly can. Although the operation
see on the X–ray, so diagnose them from the history of lock-           itself is not difficult, you can easily cut the deep branch of
ing and the signs of a loose body in the joint.                        his radial nerve (posterior interosseous nerve); so refer him
                                                                       if possible.

FRACTURE OF THE CAPITULUM                                                 ROLF (37 years) fell on the ice, and broke the head of his radius,
                                                                       sustaining Fracture B, in Fig. 72-20. Instead of treating him with
If the fragment is small, refer the patient for open removal.          active movements, an ’expert’ orthopaedic surgeon immobilized his
   If the fragment is large, try to reduce it.                         arm, quite unnecessarily, in a cast for several weeks. When this was
   Ask an assistant to exert traction on the patient’s extended        removed his arm was stiff for several more weeks. LESSONS there
forearm. While he does this, press the fragment down firmly             are many fractures for which a cast is NOT indicated!
with your thumbs. Then when the fragment is in place, flex
the patient’s elbow to more than 90◦ .
   If closed reduction is successful, apply a collar and cuff                    DON’T OPERATE WITHOUT A TOURNIQUET
for a few weeks and start shoulder and finger exercises im-
mediately.

                                                                       FRACTURES OF THE HEAD
FRACTURE OF THE CAPITULUM                                              AND THE NECK OF THE RADIUS
                                                                                                                               If the fragment is
                                                                                                                               widely displaced,
                                                                        ADULTS                                                 you may be able
                                                                                                                               to leave it
                                                                        A                B                 C                 D                         E




                                                                        conservative treatment                                             open operation more
                                                                        more likely to succeed                                             likely to be needed


                                                                        CHILDREN        These injuries can usually be treated by closed methods

                                                                                                                                                    never excise
                                                                                                                                                    the head of
                                                                                                                                                    the radius




          Lateral view                        A−P view
                                                                       Fig. 72.20: FRACTURES OF THE HEAD AND NECK OF THE RA-
                                                                       DIUS are common injuries and can usually be treated conservatively. The
Fig. 72.19: FRACTURE OF THE CAPITULUM is a rare adult injury.          patient’s elbow and his X–ray may look so normal that the frac-ture is
The arrow shows a large piece of the capitulum displaced anteriorly.   easily missed. Kindly contributed by Peter Bewes.



                                                                                                                                                                   15
72 The elbow


FRACTURES OF THE HEAD OF THE RADIUS                               EXCISING THE HEAD
                                                                  OF THE RADIUS                                                   A
CONSERVATIVE TREATMENT

INDICATIONS Start by treating all fractures of the head of
the radius this way.
   METHOD Make sure that the patient’s elbow is not also
dislocated. If it is, reduce it first.
   Aspirate the blood in his elbow joint (Fig. 72-4), inject
                                                                                                                     B
2 ml of local anaesthetic solution. You will now be able to                                                                              deep branch
                                                                                                       anconeus                          of radial nerve
flex, extend, and supinate his elbow. Start active move-
ments (69.10) and encourage easy movements, especially
rotation. Don’t apply plaster. Observe him carefully.                 C
   If he improves, over the next few days, good. If not, refer
him for operation as early as possible. By the time 5 days
have elapsed you should know if conservative treatment is                                          joint                                   extensor
                                                                                                   capsule                                 carpi
going to succeed or mot. It is more likely to succeed in frac-                                                                             ulnaris
tures A, and B, in Fig. 72-20 than it is in C, and D. Most
skilled surgeons would operate immedIately on C, or D, with-                                                              D
out attempting conservative treatment; you would probably
be wise to try conservative treatment first. If the fragment in
fracture E, is not much dIsplaced, it may have to be removed
                                                                               E
at open operation. But if it is widely displaced, it may be not
be restricting elbow movement, so conservative treatment
may succeed.
   If the patient improves under conservative treatment, so
                                                                                                                              annular
much the better, but warn him that full recovery will be slow.                                                                ligament


                                                                                              head
                                                                                                                              F
OPEN OPERATION ON THE HEAD OF THE RADIUS                                                      reassembled

If possible refer the patient. This is not an operation for the
beginner, or one to do if you have not seen it done. It you                    G
decide to operate, the sooner you do so the better. Try to
operate within 5 days before dense scar tissue forms.
    INDICATIONS Failure of conservative treatment. There is
no need to remove a loose fragment (E) unless it is interfer-
ing with the movement of the elbow joint. Don’t remove the
head of the radius in a child, because this will interfere with                                      close soft tissues
                                                                                                     over the stump
the growth of the bone, and cause a severe valgus deformity.
    TOURNIQUET Exsanguinate the patient’s arm with an
Esmarch bandage, and place a tourniquet (3.8) round his
upper arm. Operating without a tourniquet will place the          Fig. 72.21: EXCISING THE HEAD OF THE RADIUS. If possible refer
deep branch of his radial nerve in greater danger.                the patient. This is not an operation for the beginner, or one to do if you
                                                                  have not seen it done before. If you decide to operate, the sooner you do so
    POSITION Lie him on his back and bring his arm over the       the better. Try to operate within 5 days before dense scar issue forms. After
front of his chest, so that the posterior surface of his elbow    de Palma with kind permission.
is uppermost. Leave his hand free so that you can rotate
his wrist, and so turn the head of the radius. If necessary,
attach a weight to his wrist, or tie it.                          radius, or distal to the annular ligament posteriorly. Unfortu-
    INCISION Make a 5 cm incision (A, in Fig. 72-20) over         nately, its course may vary considerably.
the posterolateral surface of the patient’s elbow, extend-           Make a longitudinal incision in the capsule (C) to expose
ing downwards from his lateral epicondyle to his ulna over        the head of the patient’s radius and his capitulum (D). Sy-
the interval between his extensor carpi–ulnaris and his an-       ringe away the blood clot from the joint.
coneus muscles.                                                      Find his annular ligament and divide the periosteum im-
    Deepen the incision through the fascia between anconeus       mediately proximal to it. Don’t strip any of the perlosteum
and extensor carpi ulnaris (B), to expose the joint capsule.      from the bone.
If there is much bruising, and you cannot define these mus-           Cut away the head of his radius with nibblers immediately
cles, incise them between his lateral epicondyle and his ole-     proximal to the annular ligament (E). Don’t cut this ligament.
cranon.                                                              Remove all loose pieces of bone (F). Reassemble the
    CAUTION! The deep branch of the radial nerve (posterior       head of his radius to make sure that no pieces are still miss-
interosseus nerve) arises from the radial nerve 2 or 3 cm         ing inside the joint.
below the elbow. It winds round the lateral side of the neck         If possible, close the soft tissues over the broken neck of
of the radius, 1 cm below its head, between the two planes        his radius with a purse string suture (G). This is not easy,
of the fibres of supinator. Don’t dissect deeply in front of the   and is not essential.


16
                                                                            72.16 Fracture of the neck of the radius (children)


   If his elbow has been dislocated, redislocate it to re-        PULLED ELBOW
move any loose fragments of the radial head that may be                                                A
lying in other parts of the joint. Fragments are sometimes
driven through the capsule and lie outside it. Inspect his
capitulum for injury.
   Rinse the wound forcibly with Ringer’s lactate, or saline,                 How it happens
and if possible insert a suction drain. Close the capsule and
the muscle with one layer of interrupted sutures. Release
the tourniquet and control bleeding.                               B
   POSTOPERATIVE CARE Flex the patient’s elbow to 90◦ .
Apply a pressure dressing to the wound and give him a collar
and cuff.
   Next day, encourage him to start exercising his fingers and
shoulders. After a week encourage him to move his elbow.
Avoid vigorous exercise or forced passive movement.
   If he is in much pain or spasm, immobilize his elbow again
for a few weeks, and then try again to mobilize it.



DIFFICULTIES WITH FRACTURES OF THF HEAD OF
THF RADIUS
                                                                                               1
If a patient PRESENTS LATE with a fracture like that in D                                             2
Fig. 72-20, refer him. There is however little to be done.                                                             3
   If he has a STIFF ELBOW, watch the progress of his
movements carefully. An Injured elbow takes a long time
to recover. The tissues round it sometimes ossify. If move-
ments become fewer, stop them completely for a few days,
then start them again cautiously. Don’t push exercises if
recovery is slow, because it increases the risk of post–
traumatic ossification. X–ray his elbow and look for this.



    MAKE SURE YOU REMOVE ALL THE FRAGMENTS


                                                                  Fig. 72.22: PULLED ELBOW. A, shows the mechanism of pulled elbow,
                                                                  and B, the method of manipulating it.


72.15 Pulled elbow (young children)                               72.16 Fracture of the neck of the radius
                                                                        (children)
This common injury is the result of lifting up a child by one
arm, or swinging him around on it. Many minor and other-          A child falls on his outstretched hand and breaks the neck
wise undiagnosed injuries are probably pulled elbows. The         of his radius just distal to the epiphyseal plate, proximal to
head of a child’s radius has no well defined neck, so that if it   the attachment of his biceps. The head of his radius angu-
is pulled distally, it can be gripped by the annular ligament.    lates anteriorly and laterally on its broken neck, and usually
   A child with a pulled elbow holds his hand in neutral,         remains attached to the shaft. The same injury may fracture
he refuses to use his arm, and he cannot rotate his wrist.        his medial epicondyle, strain or rupture the medial ligament
Sometimes, the head of his radius is tender. His X–rays are       of his elbow, or fracture the upper third of his ulna.
normal. The differential diagnosis of a fracture of the neck         The contour of his elbow is normal, and flexion and ex-
of his radius.                                                    tension are less painful than rotation.
   Treatment is usually easy. Hold his hand in one of your           This injury can occur before the centre of ossification ap-
hands as if you were shaking hands, and cup his elbow in          pears in the head of his radius at the age of 10. If it does, the
the palm of your other hand. Suddenly supinate his arm            only X–ray sign of a complete displacement of the head of
and at the same time quickly push his hand towards his            his radius is this: the proximal end of his radius is closer to
elbow, while pushing on the head of his radius with your          the lower end of his humerus on the injured side than it is
thumb. This will usually free the head of his radius from         on the normal one. If so, refer him.
the annular ligament. Sometimes, even extending his elbow            Treatment depends on the degree of angulation and on
to take an X–ray does the same. He will cry loudly, but he        the child’s age. Mild angulation needs no treatment. Mod-
will usually be able to move his arm. If this fails, do noth-     erate and severe angulation must be corrected, because the
ing. He will usually recover completely in a few weeks; if        head may grow abnormally and ultimately dislocate, par-
he does not, refer him.                                           ticularly after severe displacement in an older child. In very


                                                                                                                                17
72 The elbow


young children the head may grow almost normally, even                          Rotate his forearm (2) into the position in which the most
after severe displacement. Never excise the head, because                    prominent part of the displaced head lies laterally and su-
this is sure to cause a severe growth deformity.                             perficially.
                                                                                Put your thumb over the displaced head of his radius.
FRACTURE OF THE NECK OF THE RADIUS                                           While you adduct his forearm, press the head of his ra-
                                                                             dius proximally and medially (3). Now flex his forearm and
CHOICE OF PROCEDURE The following indications refer                          supinate it sharply (4).
to angulation in the AP or the lateral view.                                    If closed reduction fails to reduce the angulation to
   If the head is angulated less than 15◦ , put the child’s                  15◦ or less, refer him for open reduction. If this is not pos-
arm in a sling for 10 days. Recovery will be complete.                       sible, the head of his radius may remodel if he is young, so
   If the angulation is more than 15◦ , try closed reduction,                proceed with active movements only.
as described below. This may succeed even if the head is
                                                                                POST REDUCTION X–RAYS in the lateral view the for-
severely displaced.
                                                                             ward angulation of the head should be corrected, and in
   If the child’s elbow is also dislocated, reduce it and
                                                                             the AP view the lateral angulatIon should also be corrected.
then treat the head of his radius.
                                                                             In both views the surface of the head of the child’s radius
   If the head of the radius is completely separated (see
                                                                             should be parallel to his capitulum.
above), refer him for open reduction.
   CLOSED REDUCTION If the child’s elbow is very swollen,                       POSTOPERATIVE CARE Bandage on a plaster backslab
suspend his arm in extension traction (Fig. 72-11), until the                extending two thirds of the way around his arm. After 3
swelling his reduced.                                                        weeks replace it by a collar and cuff for another 3 weeks.
   Anaesthetize him, and ask an assistant to steady his up-
per arm. Extend his arm, grasp his wrist with one hand, and
his elbow with the other, as in Fig. 72-23. Adduct his fore-                 72.17 Fractures of the olecranon
arm at his elbow (1), so as to open the joint between his
capitulum and the head of his radius a little.
                                                                             A patient can fracture his olecranon in two ways: (1) He
                                                                             can receive a direct blow to the point of his elbow which
REDUCING A DISPLACEMENT                                                      fractures it directly. (2) He can fall on his outstretched hand
OF THE NECK OF THE RADIUS                                                    at the same time as his triceps is contracting, and thus break
                                                                             his olecranon indirectly. In both cases his elbow is acutely
                                                                             tender and swollen. Sometimes the head of his radius is
                                                                             also injured.
                                                                                Examine him. Can he extend his forearm against gravity,
                                                                             as in A, Fig. 72-24?
                                                                                If he can extend his arm against gravity, the extensor mech-
                                                                             anism of his s elbow is intact, and active movements alone
                                                                             are enough, whatever his X–ray may show.
                                                                                If he cannot extend his forearm against gravity, his extensor
                                                                             mechanism needs repair. Look at his lateral X–ray. If more
                                                                             than half his olecranon fossa is intact, excise the proximal
                                                                             fragments and suture his triceps to his ulna, as in Fig. 72-
                                                                             24. If less than half his olecranon fossa is intact, fix the two
        AP before reduction                   lateral before reduction
                                                                             fragments of his olecranon by tension band wiring (Fig. 72-
            A                       B
                                                                             27). In this method two stiff Kirschner wires go obliquely
                                                                             through his olecranon and are anchored in the cortical bone
                                                                             of the anterior surface of his ulna to give the fragment longi-
                                                                             tudinal stability. They are kept together by a band of flexible
                                                                             steel wire, wound in a figure of eight. If you don’t have the
        3                                         4                          equipment for tension band wiring, or if a patient’s olecra-
                                                                             non is in many fragments, you can excise the fragments and
                              3                                              suture his triceps to his ulna.
                                                                                If his elbow needs repair, but this is not possible, treat him
                                                                             with active movements, and warn him to expect some per-
                                                        4                    manent loss of extension.
                     1


                                                                             Olecranon injuries in children. A child may have several
        2                                                                    centres of ossification in his olecranon, so you may have dif-
                                                                             ficulty deciding if he has a fracture or not. If in doubt, X–ray
Fig. 72.23: REDUCING A DISPLACEMENT OF THE NECK OF THE                       his other elbow. The epiphysis of the olecranon occasionally
RADIUS. Treatment depends on the degree of angulation and on the             separates from the shaft of the ulna between the ages of 10
child’s age. Mild angulation needs no treatment, but moderate and severe     and 16. If it does, treat it in the same way as you would a
angulation must be corrected. Closed reduction like this usually succeeds.   fracture.


18
                                                                                                                                72.17 Fractures of the olecranon


OLECRANON                                    Testing the                                 EXCISING COMMINUTED FRAGMENTS
                                             extensor          A                         OF THE OLECRANON
FRACTURES                                    mechanism



                                                                                                                                          fragments removed
                           B
                                                                                                  A



   This patient has a
   comminuted fracture
   (C below), but his
   extensor mechanism
   was intact. After
   treatment he can lift
                                                                                                                                                holes drilled
   a heavy weight.                                                                                                                              through bone




                                                                                                  B
   loss of
   extension     20°


  C


                                      comminuted
                                                           D   more than half
                                                                                excise
                                      fracture without
                                      destruction of the
                                      triceps mechanism
                                                                                                                                      triceps tendon sutured
                                                                                                                                      to surrounding fascia


  If a patient’s extensor mechanism is not intact,                                       Fig. 72.25: EXCISING THE FRAGMENTS OF THE OLECRANON.
  but more than half his olecranon fossa remains,                                        This is only necessary if a patient has lost the use of the extensor mecha-
  you can excise the fragment.
                                                                                         nism of his elbow and if more than half his olecranon fossa is intact. After
                                                                                         Robb and Smith with kind permission.
Fig. 72.24: CONSERV       ATIVE TREATMENT FOR AN OLECRANON
FRACTURE. A, testing a patient’s triceps mechanism by seeing if he can
extend his elbow against gravity. B, early active movements with his arm                 EXCISING FRAGMENT(S) IN OLECRANON FRACTURES
in a sling gave this patient enough power to lift this heavy book, with
only a little loss of extension. C, shows the extensive comminution of his               INDICATIONS (1) Loss of the extensor mechanism of a pa-
olecranon. D, If a patient has lost his triceps mechanism and has move
than half his olecranon fossa intact, excise the proximal fragment and sew               tient’s elbow caused by a fracture involving half or less of
his triceps tendon to his ulna. If less than half is intact use tension band             his olecranon fossa. More than half of his olecranon fossa
wiring. Kindly contributed by Peter Bewes and John Stewart.                              remains intact on the shaft. (2) Any fracture of his olecranon
                                                                                         in which the extensor mechanism is lost and the equipment
                                                                                         for tension band wiring is not available.
                                                                                             If possible, refer him. However, if you cannot refer him,
FRACTURES OF THE OLECRANON                                                               proceed as follows.
                                                                                             INCISION Exsanguinate the patient’s arm with an Es-
ACTIVE MOVEMENTS TREATMENT                                                               march bandage (3.8). Place a blood pressure cuff around
                                                                                         his arm as high as possible. Lie him on his back and fold his
                                                                                         arm over his chest so that his elbow lies uppermost.
INDICATIONS (1) All patients in whom the triceps mecha-                                      Incise and expose his olecranon, as described below for
nism is intact, as described above, even if the fragments                                tension band wiring. Remove the bone fragments, and cut
have separated slightly. (2) A patient who is too oId to notice                          them away from the tendon of his triceps. Drill two holes
that active extension is lost, for example, he will never need                           in the shaft of his ulna. If you don’t have a drill, you can
to reach to lift a jam jar from a high shelf.                                            make holes at the edge of his ulna with a strong towel clip.
   METHOD Put the patient’s arm in a sling for a few days,                               Pass strong sutures through these holes, and then through
and give him analgesics. Encourage him to use his arm, and                               his triceps tendon, as in A, Fig. 72-24.
to take it out of the sling from time to time and let it dangle.                             CAUTION! Watch his ulnar nerve. Find and gently retract
Encourage him to return early to light work.                                             it.

   CAUTION! Don’t splint his elbow, especially not in exten-
sion.                                                                                    TENSION BAND WIRING FOR OLECRANON
                                                                                         FRACTURES
   His elbow will heal rapidly. if there was less than 5 mm
displacement, there will be bony union. Otherwise, there will                            INDICATIONS Loss of the extension mechanism of the el-
be a slightly unstable fibrous union with an excellent range                              bow, due to a fracture involving more that half the patient’s
of movement.                                                                             olecranon fossa, with a single proximal fragment suitable for


                                                                                                                                                                  19
72 The elbow


THE MECHANICS OF                                                                                                                            TENSION BAND
TENSION BAND WIRING                                                                                                                         WIRING


               ends of Kirschner wire                Kirschner wires                                       A
               anchored in cortex                    align the fragments                                          incise the periosteum
                                                                                                                  and scrape the fracture
                                                                                                                  site with a rougine



                                                                                                                                                          clear
                                                                                                                                                B         blood
                                                                                                                                                          from
                                                                                                                                                          the
                                                                                                                                                          joint

                  figure of eight tension band           ends turned over                      hold the fragments
                  holds the fragments together
                                                                                           C   with a hook and
                                                                                               drill in two
                                                                                               Kirschner wires




                                                                                                                                                drill his olecranon
                                                                                                                                            D   transversely




                    ends of tension band twisted
                    together and turnded down


Fig. 72.26: THE MECHANICS OF TENSION BAND WIRING. The
stiff Kirschner wires maintain alignment, while the figure of eight of soft                E       thread the wire in a
                                                                                                  figure of eight
wire holds the fragments together. From the AO handbook.



wiring. If possible refer the patient. If you cannot refer him,                                                                       F
proceed as follows.                                                                                                                             bend the Kirschner
                                                                                                                                                wire
   EQUIPMENT Kirschner wire, 0.35 mm stainless steel
wire, Faraboef’s rougine, pliers, wire cutters, scoop, bone
hooks or towel clips.
   INCISION Make an 8 cm longitudinal incision just lateral to
the point of the patient’s elbow (A, in Fig. 72-27). incise the
periosteum and scrape it away from the fracture site with a
rougine. Expose the smaller fragment. It may be in smaller
pieces than the X–rays suggest. Open the joint and clear
away any blood clot (B).                                                                      G       cut the
                                                                                                      Kirschner
   Hold the fragments together with a bone hook or towel                                              wire                                      H    the completed
                                                                                                                                                     tension band
clip so as to close up the joint line. Hold the hook so that it
presses in the long axis of the ulna. Try to obtain hair–line
reduction. The fracture line will be easier to see if you have
previously stripped away the periosteum from around it. Drill
in two Kirschner wires (C). Drill the olecranon transversely
for the insertion of the tension band (D).
   Thread the wire in a figure of eight through the hole in the
ulna and round the Kirschner wires (E). Twist the ends of
the wire loosely together. Bend the ends of a Kirschner wire
upwards at 90◦ with pliers (F).
   Cut the first Kirschner wire, leaving a few millimetres of                 Fig. 72.27: TENSION BAND WIRING. If less than half the patient’s
its bent end projecting (G). Do the same thing for the other                 olecranon fossa is intact, fix the two fragments of his olecranon by tension
Kirschner wire. Turn the bent cut ends of both of them back                  band wiring like this. From the AO handbook.
against the bone. Twist the ends of the tension band to-
gether and cut them off (H).                                                 DIFFICULTIES WITH OLECRANON FRACTURES
   POSTOPERATIVE CARE (bath methods) Put the pa-
tient’s arm in a collar and cuff and start active movements                  If the patient is a CHILD (rare), immobilize his elbow in
early.                                                                       extension for 5 weeks. Stiffness is unlikely to be a problem.
   CAUTION! Don’t let him try to extend his arm actively
against resistance for at least a month.


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