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Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e

Chapter 270: Elbow and Forearm Injuries Yvonne C. Chow

ANATOMY

Articulations of the distal humerus and proximal ulna and radius form the elbow joint (Figure 270-1).

FIGURE 270-1.

Elbow anatomy. A. Anterior view. B. Lateral view. C. Medial view.

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The epicondyles are nonarticulating surfaces that serve as sites of origin for forearm, wrist, and digit flexors and pronators(medial), and extensors and supinators (lateral). Medially, the trochlea articulates with the olecranon to form a uniaxial hingejoint. Laterally, the capitellum abuts the radial head to form a pivot joint. Between the condyles, the coronoid fossa is anterior,and the olecranon fossa is posterior. These allow for full flexion and extension of the ulna. The radial fossa lies proximal to thecapitellum anteriorly and permits full flexion of the radius.

The radius and ulna are joined together along their entire length by a fibrous interosseous membrane, and articulate only at theirends to form the complex proximal and distal radioulnar joints. The ulna is a comparatively straight bone, whereas the radius hasan important outward bowing. During the motions of supination and pronation, the radius rotates around the relatively fixedulna. Because these bones have such a close relationship to one another, injury to one will have a direct impact on the other. Adisplaced or angulated fracture of one bone typically disrupts the other or causes a dislocation at the proximal or distalradioulnar joint.

Several important neurovascular structures lie in close proximity to the distal humerus, and evaluation of their function isessential. These include the brachial artery, palpable just medial to the distal biceps tendon in the antecubital fossa, and theradial, median, and ulnar nerves (Table 270-1).

TABLE 270-1

Sensory and Motor Function Testing of the Radial, Median, and Ulnar Nerves

Radial Median Ulnar

Test for

sensory

function

Dorsum of the thumb index

web space

Two-point discrimination over the tip of the index

finger

Two-point discrimination

over the little finger

Test for motor

function

Extend both wrist and

fingers against resistance

"OK" sign with thumb and index finger; abduction

of the thumb (recurrent branch)

Abduct index finger against

resistance

The neuroanatomy is best understood by appreciating the neural control of basic wrist and finger movement (Figure 270-2). Theradial nerve travels over the lateral epicondyle and supplies the muscles of wrist extension before it branches o� into the

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posterior interosseous nerve. This deep branch travels around the proximal radius and through the supinator muscle andcontrols the muscles of finger and thumb extension. The remainder of the radial nerve lies adjacent to the radial artery. Thissuperficial branch is purely sensory and innervates the dorsal aspect of the hand from the thumb to the radial half of the ringfinger. Thus, the proximal portion of the radial nerve controls the more proximal function of wrist extension, the deep branch(posterior interosseous nerve) controls the more distal function of finger extension, and the superficial branch is purely sensory.Therefore, an isolated injury to the posterior interosseous branch a�ects finger extension but spares wrist extension andsensation to the dorsum of the hand.

FIGURE 270-2.

Neural innervation of the forearm, wrist, hand, and digits. A. Radial nerve innervation. B. Median nerve innervation. C. Ulnarnerve innervation.

The median nerve supplies the muscles of wrist and finger flexion and sensation over the volar surface of the hand from thethumb to the radial half of the ring finger, including the dorsal tips of the thumb and index and middle fingers. The proximalportion of the median nerve innervates the muscles that control wrist flexion and the flexor digitorum superficialis before it giveso� the anterior interosseous nerve. This branch controls portions of the remaining deep finger flexors. The remaining portion ofthe median nerve provides sensation to most of the volar surface of the hand in addition to controlling the thenar muscles of thethumb via a separate motor branch (recurrent branch of the median nerve).

The ulnar nerve provides innervation to forearm muscles and controls the intrinsic muscles of the hand while providing sensationto the little finger and the ulnar half of the ring finger. Proximal to the elbow, the ulnar nerve courses under a ligamentous bandcalled the arcade of Struthers prior to entering the cubital tunnel posterior to the medial epicondyle. These are two sites wherethe nerve can become entrapped, leading to ulnar neuropathy syndromes. The ulnar nerve is palpable as a cord in the cubitaltunnel and is vulnerable to injury with trauma over this area.

The biceps muscle has two proximal heads (Figure 270-3). The long head originates at both the supraglenoid tubercle of thescapula and the superior labrum of the glenohumeral joint, and then travels through the capsule of the shoulder and along theintertubercular (bicipital) groove of the humerus. The short head originates at the coracoid process of the scapula. The distalattachments are to the radial tuberosity by the distal biceps tendon and the forearm by the bicipital aponeurosis. A bicipitoradial

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bursa lies adjacent to the radial tuberosity. The biceps muscle is innervated by the musculocutaneous nerve (C5 and C6) andfunctions to flex the supinated forearm and supinate the flexed forearm.

FIGURE 270-3.

Biceps muscle anatomy.

The brachialis muscle lies deep to the biceps muscle. It originates on the distal anterior humerus and inserts on the ulnartuberosity of the proximal ulna. The brachialis muscle is innervated by both the musculocutaneous and radial nerves (C5, C6, C7,and C8) and is the primary flexor of the forearm.

The triceps muscle has three proximal heads (Figure 270-4): a long head originating from the infraglenoid tubercle of the scapula;a lateral head on the posterior surface of the humerus superior to the radial (spiral) groove; and a medial head inferior to theradial groove. The triceps inserts at the olecranon. A subtendinous bursa separates the triceps from the olecranon, and asubcutaneous bursa lies just distal to the tendinous insertion. The latter frequently becomes inflamed. The triceps muscle isinnervated by the radial nerve (C6, C7, and C8) and is the sole extensor of the forearm. Additionally, the triceps aids extension andadduction of the arm, and the long head stabilizes the head of the humerus in abduction.

FIGURE 270-4.

Triceps muscle anatomy.

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The intrinsic forearm muscles include the brachioradialis, pronator teres, pronator quadratus, anconeus, and supinator (Figure270-5). The brachioradialis muscle originates at the lateral condyle and assists with forearm flexion. The pronator teres musclehas two proximal heads that originate from the medial epicondyle and the proximal ulna; it pronates and flexes the forearm. Thepronator quadratus muscle originates from the distal ulna and is the primary pronator of the forearm. The anconeus muscleoriginates from the posterior lateral epicondyle and has trivial function in extending the forearm. Lastly, the supinator muscleoriginates from the posterior medial ulna and supinates the forearm with the biceps muscle. The deep branch of the radial nerve(posterior interosseous nerve) pierces the supinator muscle a�er branching o� of the proximal segment of the radial nerve. Thus,a compression neuropathy to the posterior interosseous nerve can occur at this level (Figure 270-6).

FIGURE 270-5.

Intrinsic forearm muscles.

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FIGURE 270-6.

Posterior interosseous nerve.

CLINICAL FEATURES

HISTORY

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A thorough history is essential for determining the correct diagnosis in a patient with elbow or forearm pain. Onset of symptoms,mechanism of injury, exact location of pain, and associated symptoms such as numbness, weakness, or distal wrist and handcomplaints are important elements to obtain. Most acute traumatic injuries to the elbow and forearm occur due to a fall onto anoutstretched hand or a direct blow. Chronic overuse injuries should correlate with preceding activity involving a repetitivemotion. A history of arthritides may point to a systemic disorder such as lupus, rheumatoid arthritis, or gout.

PHYSICAL EXAMINATION

General examination of the elbow and forearm should include inspection for gross deformity, so� tissue swelling such as bursitis,or open wounds. Assess range of motion of the elbow in flexion, extension, pronation, and supination. Inability to fully extend the

elbow is correlated with the presence of a fracture.1 Strength testing against resistance should also include wrist flexion andextension. Carefully assess radial, median, and ulnar nerve function. The single best test of radial nerve motor function is to havethe patient extend both the wrist and fingers against resistance (Table 270-1). Test sensation with two-point discrimination overthe dorsum of the thumb index web space. Evaluate the median nerve by assessing its distal branches. A simple test of anteriorinterosseous nerve function is the ability to make a circle, or "OK" sign, with the thumb and index finger. Abduction of the thumbagainst resistance (recurrent branch of the median nerve) and sensory testing over the tip of the index finger complete theevaluation of the median nerve. The easiest way to test ulnar nerve function is to have the patient spread the fingers apartagainst resistance. Sensation is tested over the tip of the fi�h digit.

DIAGNOSIS

IMAGING

Initial imaging studies should include anteroposterior and lateral views of the elbow, and anteroposterior, lateral, and obliqueviews of the humerus and forearm. If a distal forearm injury is present, anteroposterior, lateral, and oblique views of the wristinstead of the humerus should be obtained. Attempts to derive a clinical decision rule to guide imaging decisions for the elbow,

similar to published ankle and knee imaging rules, have so far produced conflicting data.1,2,3

On lateral films of the elbow, a line drawn straight through the center of the radial sha� should bisect the radial head andcapitellum (radiocapitellar line) (Figure 270-7). Loss of this relationship should raise suspicion for an occult radius fracture ordislocation. A line drawn straight along the anterior border of the humerus should transect the posterior two thirds of thecapitellum (anterior humeral line) (Figure 270-8). Abnormal extension of the line through the anterior one third of the capitellumsuggests a distal humerus (in adults) or supracondylar fracture (in children). A small anterior fat pad may be a normal finding.Large anterior and any posterior fat pads are always abnormal and indicate the presence of a joint e�usion (Figure 270-9).

FIGURE 270-7.

The radiocapitellar line. On lateral views, a line drawn through the center of the radius transects the radial head and middle thirdof the capitellum. This relationship is lost even in subtle fractures.

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FIGURE 270-8.

The anterior humeral line. On lateral views, a line drawn along the anterior cortex of the humerus transects the posterior twothirds of the capitellum. Transection of the line through the anterior one third of the capitellum suggests a fracture.

FIGURE 270-9.

Anterior and posterior fat pad signs.

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CT imaging provides greater radiographic detail when evaluating certain elbow fractures, particularly coronoid and comminutedintra-articular fractures. MRI is useful in the evaluation of so� tissue injuries such as ligament or tendon ruptures but has limited

value in the acute setting. Bedside US can demonstrate e�usions and tendon injury but requires operator skill.4,5

TREATMENT

Consult an orthopedic surgeon immediately for open fractures, irreducible dislocations, injuries resulting in a grossly unsTableelbow joint, or vascular injury with signs of ischemia or uncontrolled hemorrhage. All other injuries may be referred for follow-upwithin 1 to 2 days for operative planning or up to a week for nonoperative treatment. Table 270-2 outlines guidelines for EDimmobilization and appropriate orthopedic consult time frames for the conditions discussed in this chapter.

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TABLE 270-2

Immobilization and Follow-Up Guidelines

Injury Splint Referral

So� tissue injuries

Biceps tendon rupture

Triceps tendon rupture

Lateral/medial epicondylitis

Sling immobilization

Sling immobilization

Forearm counterforce brace

1 wk

1 wk

2–4 wk

PRN

Elbow dislocation

Stable/postreduction

Unstable/postreduction

Irreducible

Long arm posterior splint, forearm in pronation

Long arm posterior splint (presurgical stabilization)

Long arm posterior splint (presurgical stabilization)

1 d

Immediate

Immediate

Elbow fractures

Distal humerus nondisplaced

Supracondylar

Intercondylar

Lateral condyle/epicondyle

Nondisplaced

Displaced

Medial condyle/epicondyle

Nondisplaced

Displaced

Articular surface

Coronoid

Nondisplaced or minimally

displaced

Markedly displaced or unstable

Olecranon

Radial head

Nondisplaced

Displaced or range of motion

block

Long arm posterior splint, forearm neutral

Long arm posterior splint (presurgical stabilization)

Long arm posterior splint, forearm neutral

Long arm posterior splint, forearm in supination, wrist extended

Long arm posterior splint (presurgical stabilization)

Long arm posterior splint, forearm in pronation, wrist flexed

Long arm posterior splint (presurgical stabilization)

Long arm posterior splint, forearm neutral

Long arm posterior splint, elbow past 90 degrees, forearm in supination

Long arm posterior splint (presurgical stabilization)

Long arm posterior splint, forearm neutral

Sling immobilization with early range of motion

Long arm posterior splint, forearm neutral

1 wk

Immediate

1–2 d

1–2 d

Immediate

1-2 d

Immediate

1–2 d

1–2 d

Immediate

<24 h

1 wk

<24 h

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Injury Splint Referral

Forearm fractures

Both bones

Pediatric

Greenstick

Displaced

Adult

Nondisplaced

Displaced

Isolated ulna sha�

Proximal two thirds of radius

Monteggia's

Galeazzi's

Long arm posterior splint

Long arm posterior splint (prereduction stabilization)

Anteroposterior long arm splint

Long arm posterior splint (presurgical stabilization)

Long arm posterior splint, forearm neutral or sugar tong splint if stable and

nondisplaced

Long arm posterior splint, forearm neutral

Long arm posterior splint (presurgical stabilization)

Long arm posterior splint (presurgical stabilization)

1 wk

Immediate

1 wk

<24 h

1 wk

1 wk

Immediate

Immediate

SOFT TISSUE INJURIES

BICEPS TENDON RUPTURE

Of all injuries to the biceps, the vast majority are proximal, and nearly all involve the proximal long head. Injuries are usually theresult of repetitive microtrauma and overuse. Steroids, whether injected locally or used systemically, can accelerate thebreakdown of tendons. Biceps tendon rupture usually occurs when there is sudden or prolonged contraction against resistance inmiddle-aged and older individuals with a history of chronic bicipital tenosynovitis. A snap or pop is usually described, and pain ispresent in the anterior shoulder. Examination of the anterior shoulder will reveal swelling, tenderness, and o�en crepitus over thebicipital groove. Ecchymosis may extend the entire length of the biceps. Flexion of the elbow will elicit pain and may produce amidarm "ball," which represents the distally retracted biceps muscle. Comparing arms for symmetry helps. Loss of strength isminimal due to the function of the brachialis and supinator. Avulsion fractures occasionally occur, so radiographs of the shouldershould be obtained.

ED treatment includes sling, ice, analgesics, and referral to an orthopedic surgeon for definitive care. Surgical repair is usuallyrecommended for young, active patients. A conservative approach with immobilization may be adequate for elderly patientswhose activities of daily living are not significantly compromised by the injury.

Distal biceps injuries are less common than proximal injuries.6,7 Complete ruptures of the tendon are most common in middle-aged men and usually involve the dominant extremity. Partial tears are seen in men and women. Mechanism of injury is typicallya sudden eccentric (extension) load applied to a flexed elbow. In ruptures of the distal biceps, pain is felt in the antecubital fossa,with swelling, ecchymosis, and tenderness to palpation noted on examination. A distal rupture is indicated by a palpable defect inthe antecubital fossa and a midarm "ball." Strength loss, especially supination, is usually greater than with proximal ruptures.

The biceps squeeze test, similar to the Thompson test for assessing Achilles tendon rupture, can detect biceps rupture.8 With thepatient seated and the forearm at 60 to 80 degrees of flexion, place one hand on the muscle belly of the biceps brachii and theother hand on the myotendinous junction, and squeeze with both hands. The squeeze should result in forearm supination,indicating an intact biceps. Lack of supination is considered a positive test, indicating rupture of the distal biceps brachii. To

perform the hook test,9 flex the patient's elbow to 90 degrees, and during active supination, if the biceps tendon is intact, theexaminer can "hook" the index finger under the distal biceps tendon in the antecubital fossa. Obtain elbow radiographs to searchfor an associated avulsion fracture. Although most complete distal ruptures are diagnosed clinically, MRI and US can aid in

confirming the diagnosis of partial tears.10,11

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ED treatment includes sling, ice, analgesics, and referral to an orthopedic surgeon for definitive care. Without surgical repair of

complete ruptures, supination strength is decreased by approximately 50% and flexion strength by almost 30%.12,13

TRICEPS TENDON RUPTURE

Injury to the triceps is rare and almost always occurs distally.14 Ruptures result from either a fall on an outstretched hand causinga forceful flexion of an extended elbow or a direct blow to the olecranon. Spontaneous ruptures from systemic illnesses,

particularly hyperparathyroidism and chronic renal failure requiring hemodialysis, have also been reported.15,16 Triceps ruptureusually causes pain in the posterior elbow. Examination of the elbow reveals swelling and tenderness posteriorly just proximal tothe olecranon. A sulcus with a more proximal mass, representing the retracted triceps muscle, may be palpated. With partialtears, some degree of function remains; however, with complete ruptures, the ability to extend the elbow is lost. A modifiedThompson test can be used to evaluate triceps function. The upper extremity is positioned such that the arm is supported andthe forearm is hanging in a relaxed position with 90 degrees of flexion. Squeezing the triceps muscle should produce extension ofthe forearm unless a complete rupture is present. Radiographs of the elbow are needed because avulsion fractures of theolecranon are common. US and MRI may aid in diagnosis, especially of partial tears.

ED treatment includes sling, ice, analgesics, and referral to an orthopedic surgeon for definitive care. Complete ruptures requiresurgical repair, whereas most partial tears can be treated conservatively with immobilization.

LATERAL EPICONDYLITIS

The lateral epicondyle serves as the origin for wrist and digit extensors and forearm supinators. Lateral epicondylitis, or "tenniselbow," is an overuse syndrome a�ecting these so� tissues. Although the condition is o�en seen in tennis players, it can arise as aresult of any repetitive movement involving these muscle groups. The diagnosis is made clinically by tenderness over the lateralepicondyle and pain with resisted wrist and digit extension and forearm supination. Treatment is usually conservative, with rest,ice, anti-inflammatory medications, and immobilization, o�en via a counterforce brace. Physical therapy consisting of forearm

stretching and strengthening exercises has been proven to be a useful adjunct in addition to the above.17,18 Corticosteroidinjections can provide short-term relief of symptoms but have been shown to result in higher recurrence rates at 1 year compared

to conservative measures.17,18 Surgery may be indicated for refractory cases.

MEDIAL EPICONDYLITIS

The less common counterpart to lateral epicondylitis is medial epicondylitis ("golfer's elbow"). As with lateral epicondylitis, thediagnosis is made clinically, with tenderness over the medial epicondyle and pain with resisted wrist and digit flexion andforearm pronation, as these are the muscle groups a�ected. In addition, patients may develop an ulnar neuropathy, given theproximity of the ulnar nerve to the medial epicondyle. Treatment is similar to that of lateral epicondylitis, with rest, ice, anti-inflammatory medications, bracing, and physical therapy.

ELBOW DISLOCATION

The elbow is one of the more sTable joints. The muscular attachments, lateral collateral ligament, and medial ulnar collateralligament augment its inherent stability in the flexion-extension plane. Despite this, dislocations of the elbow are commonly seenand rank third in large-joint dislocations, a�er glenohumeral and patellofemoral dislocations. Possible fractures of the coronoidprocess, radial head, medial epicondyle, and olecranon complicate the treatment of elbow dislocations. The "terrible triad"injury describes an unsTable joint consisting of an elbow dislocation coupled with fractures of the radial head and coronoid. Thisinjury creates an unsTable joint and requires surgical repair a�er initial reduction.

Elbow dislocations include five types: posterior, anterior, medial, lateral, and divergent (Figure 270-10). Some dislocations mayinvolve a combination of the above based on the direction of force applied during the injury. Approximately 90% of all elbow

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dislocations are posterolateral.19 The mechanism of injury is usually due to a fall on an outstretched hand.

FIGURE 270-10.

Elbow dislocations. [Reproduced with permission from Browner BD, Levine AM, Jupiter JB, et al: Skeletal Trauma: Basic Science,Management, and Reconstruction, 4th ed. Vol 1. © 2009, Saunders, an imprint of Elsevier Inc., Philadelphia, PA. Figure 42-40, p.1533.]

Clinically, the patient presents with the elbow in 45 degrees of flexion. The olecranon is prominent posteriorly, and the deformityresembles a displaced supracondylar fracture. If the patient is seen immediately a�er the injury, the bony landmarks can beidentified. Later, however, the swelling may be quite severe, with no possibility of evaluating the injury topographically. The firstpriority of care is to assess the neurovascular status of structures most vulnerable to entrapment, namely the brachial artery andthe ulnar, radial, and median nerves. Perform neurovascular examination before and a�er manipulation, because neurovascularcomplications (most frequently the ulnar nerve) occur in 8% to 21% of patients. Vascular complications (most frequently the

brachial artery) occur in 5% to 13% of elbow dislocations.20 Absence of a radial pulse before reduction, an open dislocation, and

systemic injuries (such as those of the head, chest, and abdomen) are associated with arterial injury.21,22 If vascular injury issuspected, then angiography may be required to assess the extent of injury and need for repair.

On the lateral radiograph, both the ulna and radius are displaced posteriorly (Figure 270-11). In the anteroposterior view, theremay be lateral or medial displacement, with the ulna and radius in their normal relationship to each other. Assess for associatedfractures, particularly of the coronoid process and radial head. In a child, an associated fracture of the medial epicondyle iscommon.

FIGURE 270-11.

Posterior elbow dislocation.

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Due to the amount of force that is necessary to reduce a dislocated elbow, success is o�en dependent on adequate analgesia andmuscular relaxation. This may require the use of intravenous analgesics or procedural sedation, particularly in children. As analternative to procedural sedation or intravenous analgesia, anecdotal success has been reported using intra-articular lidocaineto provide regional anesthesia for closed reduction of dislocated elbows, similar to the well-described use of intra-articular

blocks for reduction of anterior glenohumeral shoulder dislocations.23,24 In the elbow, intra-articular lidocaine is e�ective for

postoperative pain control following arthroscopic procedures in adults and supracondylar fracture repairs in children.25,26

Regardless of the type of analgesia used, ensure appropriate patient comfort prior to attempting closed reduction.

Closed reduction can be accomplished by several methods. In the first two-person reduction technique, position the patientsupine and apply gentle longitudinal traction on the wrist and forearm with one hand while an assistant applies a stabilizingcountertraction force on the upper arm (Figure 270-12). First, correct any medial or lateral displacement with the other hand.Then apply downward pressure to the proximal forearm with the other hand to help disengage the coronoid process from theolecranon fossa. Continue distal traction, and flex the elbow. In the second two-person technique, position the patient prone withthe arm abducted and the elbow slightly flexed. The patient may also be positioned supine with the a�ected arm adductedacross the torso and the elbow slightly flexed (Figure 270-13). Have an assistant apply longitudinal traction on the wrist andforearm. Then, grasp the elbow, positioning both thumbs on the olecranon, and apply firm pressure against the olecranon topush it up and over the trochlea and back into anatomic position. Apply countertraction with the fingers against the distalhumerus. The last technique is a modification of the Stimson hanging technique used in shoulder reductions (Figure 270-14). Onebenefit of this technique is that it can be performed by a single provider. Place the patient prone with the elbow flexed over theedge of the stretcher. Support the humerus proximal to the elbow with a folded blanket or pillow. Suspend 5-lb weights from thewrist. The patient's elbow should reduce over a period of several minutes. Gentle manipulation may be applied to the olecranonto aid reduction.

FIGURE 270-12.

A and B. Traction and flexion method of reducing a posterior elbow dislocation. Side-to-side manipulation is used to correctmedial or lateral displacement (A). The elbow is then flexed while maintaining longitudinal traction (B).

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FIGURE 270-13.

A and B. Olecranon manipulation method of reducing a posterior elbow dislocation with the patient positioned prone (A) orsupine (B).

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FIGURE 270-14.

A. Hanging arm method of reducing a posterior elbow dislocation. B. Gentle manipulation can be applied to the olecranon ifnecessary.

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With reduction, a palpable "clunk" is felt as the olecranon is seated in the humeral articular surface (trochlea). Then move theelbow through its full range of motion to assess stability. Inability to maintain reduction through full range of motion necessitatesorthopedic consultation for surgical repair. If full and smooth passive range of motion is not possible, examine the postreductionradiograph for entrapment of the medial epicondyle, especially common in children, or other intra-articular fragments. If theelbow remains reduced through full range-of-motion testing, assess medial and lateral stability with gentle valgus and varusstress on the elbow in full extension. Valgus (medial) laxity is more common and suggests disruption of the medial (ulnar)collateral ligament complex, which is the primary stabilizing structure of the elbow joint against valgus forces. Medial instabilitythat stabilizes with 90 degrees of flexion and maximal pronation of the forearm should be splinted in this position and referred for

follow-up.27 Instability that cannot be stabilized with flexion and pronation suggests associated fractures or more significantdisruption of the capsule and ligaments. In this case orthopedic consultation for surgical repair is necessary.

A�er reduction, immobilize sTable dislocations in a long arm posterior splint with the elbow in slightly less than 90 degrees offlexion and the forearm in mild pronation. Obtain a neurovascular follow-up examination the following day. Treatment with anearly range-of-motion program a�er 1 week of splinting generally leads to favorable results.

Appropriate treatment of elbow dislocations requires adequate reduction and recognition of neurovascular complications,associated fractures, and postreduction instability. If there is any question of neurovascular compromise, then consider admittingthe patient for observation. Obtain emergency orthopedic consultation for irreducible dislocations, neurovascular compromise,postreduction instability, associated fractures, and open dislocations. Potential late complications include posttraumaticsti�ness, posterolateral joint instability, ectopic ossification, and occult distal radioulnar joint disruption.

FRACTURES ABOUT THE ELBOW

Elbow fractures can be divided into those of the distal humerus, proximal ulna, and proximal radius. The distal humerus includesthe condylar structures and the articular surface (trochlea and capitellum). The proximal ulna includes the coronoid process andolecranon, and the proximal radius is essentially the radial head.

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Radiographs of fractures about the elbow may reveal abnormal fat pads (Figure 270-9).28 Normally, a posterior fat pad is notvisible, and an anterior fat pad may be visible as a thin lucent stripe. With injury, fat from the olecranon fossa is displacedposteriorly (posterior fat pad), and the anterior fat pad may become quite prominent ("sail sign") due to hemarthrosis. Abnormalfat pads may also be seen with nontraumatic joint e�usions. Furthermore, they may be absent in severe trauma that disrupts thejoint capsule and allows intra-articular fluid extravasation. In some nondisplaced fractures, the fracture line may not be seen,with the fat pad sign being the only evidence of injury. Treatment is initiated as though a fracture were identified, with splintimmobilization and orthopedic consultation.

DISTAL HUMERUS FRACTURES

Routine ED care of nondisplaced distal humerus fractures with normal neurovascular function includes immobilization, ice,elevation, analgesics, and orthopedic referral. Displaced fractures or those with neurovascular compromise require immediateorthopedic consultation. See chapter 271, "Shoulder and Humerus Injuries," for a detailed discussion of shoulder and humerusinjuries.

SUPRACONDYLAR FRACTURES

Supracondylar fractures are the most common fracture about the elbow in children between 5 and 10 years of age, but can occurin adults, especially as a result of high-velocity injuries. Fractures can be either extension type (>95%), which are displacedposteriorly, or flexion type (<5%), which are displaced anteriorly. Treatment largely depends on the degree of displacement of thedistal fragment.

EXTENSION-TYPE SUPRACONDYLAR FRACTURES

Injuries most o�en occur with a fall on an outstretched hand with the elbow in full extension. The patient will have significantedema and tenderness at the elbow, a prominent olecranon, and a depression proximal to the elbow. The appearance may beeasily mistaken for a posterior elbow dislocation. Nondisplaced fractures may be subtle and diagnosed only by the presence of aposterior fat pad, anterior "sail sign," or disruption to the normal path of the anterior humeral line. Initially treat withimmobilization using a long arm posterior splint, keeping the elbow at 90 degrees of flexion and the forearm in neutral rotation,followed by outpatient referral for casting. The presence of >20 degrees of angulation necessitates orthopedic consultation for

reduction under anesthesia and possible pin fixation.29 In displaced fractures, the anteroposterior radiograph usually reveals atransverse fracture line. More severely displaced fractures may show medial or lateral displacement or rotation along the axis ofthe humerus (Figure 270-15). The lateral radiograph will reveal the fracture line extending obliquely from posterior proximal toanterior distal. The distal fragment will be displaced proximally and posteriorly. Displaced fractures must be reduced and requireorthopedic consultation. Indications for open reduction are vascular insu�iciency with a probable entrapped brachial artery inthe fracture site or an irreducible fracture. Admit patients with displaced fractures or significant so� tissue swelling forobservation of neurovascular function.

FIGURE 270-15.

Extension-type, displaced supracondylar fracture.

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FLEXION-TYPE SUPRACONDYLAR FRACTURES

Flexion-type fractures are rare. The mechanism of injury is a direct anterior force against a flexed elbow, resulting in anteriordisplacement of the distal fragment. Because the mechanism is direct force, these fractures are o�en open. Radiographs revealan oblique fracture from anterior proximal to posterior distal. The distal fragment is anterior to the humerus. Displaced fracturesmust be reduced and require immediate orthopedic consultation. Indications for open reduction are vascular insu�iciency with aprobable entrapped brachial artery in the fracture site or an irreducible fracture. Admit patients with displaced fractures orsignificant so� tissue swelling for observation of neurovascular function.

COMPLICATIONS OF SUPRACONDYLAR FRACTURES

There are numerous potential complications of supracondylar fractures (Table 270-3). Neurologic complications—resulting fromtraction, direct trauma, or nerve ischemia—have an incidence of 7%. Posteromedial displacement may involve the radial nerve,and posterolateral displacement usually a�ects the median nerve. Ulnar nerve injuries are uncommon, with the highestincidence reported from pin placement. However, a high incidence has been noted of anterior interosseous nerve injuries withsupracondylar fractures. This nerve arises from the median nerve. The mechanism of injury is usually traction or contusion.Complete transection is rare, and entrapment within the fracture occurs only occasionally. Because there is no sensorycomponent to the anterior interosseous nerve, identification of the injury can be made only by motor testing, which consists offlexion at the index finger distal interphalangeal and thumb interphalangeal joints (making the "OK" sign). Patients usually regain

full flexion and strength a�er 4 to 17 weeks.30

TABLE 270-3

Complications of Supracondylar Fractures

Early complications Neurologic

Radial nerve

Median nerve (anterior interosseous branch)

Ulnar

Vascular

Volkmann's ischemic contracture (compartment syndrome of the forearm)

Late complications Nonunion

Malunion

Myositis ossificans

Loss of motion

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Acute vascular injuries must always be suspected in patients with supracondylar fractures. Absence of a radial pulse is common inchildren and, in the majority of published cases, is an indicator of brachial artery injury, even if the hand appears warm, pink, and

well perfused.31 Injury can be due to a partial or complete transection, an intimal tear and thrombosis, or entrapment within thefracture fragment of the brachial artery. Treatment of supracondylar fractures with absent radial pulse begins with closedreduction and percutaneous pinning. Extremities still without a pulse despite adequate reduction warrant more aggressivevascular exploration and repair.

The most serious complication is a compartment syndrome of the forearm, also known as Volkmann's ischemic contracture. Thisclassically occurs following a supracondylar fracture. Postischemic swelling, producing increased pressure within the enclosedosteofascial forearm compartment, reduces capillary blood perfusion below the level necessary for tissue viability. If unrelieved,the end result is muscle and nerve necrosis and eventual replacement by fibrotic tissue, producing a contracture. Refusal to openthe hand in children, pain with passive extension of the fingers, and forearm tenderness are signs of impending Volkmann'sischemia. It is now well understood that the mere lack of a radial pulse does not indicate ischemia unless accompanied by thesesigns. Extremities with signs of ischemia are taken emergently to the operating room for fasciotomy and brachial arteryexploration.

INTERCONDYLAR FRACTURES

Intercondylar fractures, in which the condylar fragments are separated, are much more common in adults than in children.Assume any distal humerus fracture in an adult to be intercondylar rather than supracondylar. The mechanism of injury is a forcedirected against the posterior elbow, driving the olecranon against the humeral articular surface, separating the condyles andproducing the typical fracture. Carefully search for a fracture line separating the condyles from each other and from the humerus.By definition, all intercondylar fractures involve the articular surface. CT imaging is useful for identifying comminuted fracturesand for planning operative therapy for displaced fractures. Treatment is dependent on the amount of displacement of thefracture fragments.

Nondisplaced intercondylar fractures are sTable and can be treated initially with immobilization in a long arm posterior splintwith the elbow flexed at 90 degrees and the forearm in neutral position. Treatment of displaced, rotated, or comminuted fracturesis o�en directed at reestablishing articular surface congruity. If this cannot be achieved by closed methods, then the integrity ofthe articular surface is restored by an open reduction and fixation. In older patients with severely comminuted injuries, elbow

replacement may be considered.32 As in supracondylar fractures, admit patients with severe edema or displaced fractures.

EPICONDYLE FRACTURES

Lateral epicondyle fractures almost never occur, because the anatomic position of the condyle reduces its exposure to directblows, resulting instead in fractures of the lateral condyle. When they do occur, lateral epicondyle fractures are usually avulsionfractures and may be treated by long arm posterior mold, with the elbow flexed to 90 degrees and the forearm in supination, andorthopedic referral.

Isolated medial epicondyle fractures are considered extra-articular injuries and usually occur in children and adolescents.Mechanisms include a posterior elbow dislocation, repeated valgus stress, such as throwing a baseball (Little League elbow), or adirect blow. If there is an associated tear of the medial (ulnar) collateral ligament, the epicondyle itself may become entrapped inthe joint space. Patients present with pain over the medial elbow that is exacerbated by supination of the forearm and flexion ofthe forearm, wrist, and digits. Edema and tenderness are noted in the same area. Standard radiographs are obtained with specialattention to any intra-articular fragment. Carefully test ulnar nerve function. Nondisplaced or minimally displaced medialepicondyle fractures can be treated nonoperatively, with early range of motion. There is an increasing trend toward operative

treatment for these fractures due to significantly increased odds of bony union with fixation.33 Open fractures, unsTable joints,fragment displacement >5 mm, and an intra-articular fragment are well-described indications for surgical treatment with internal

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fixation. ED treatment consists of long arm posterior splint immobilization, with the forearm in flexion and pronation, andorthopedic referral.

Complications of lateral and medial epicondyle fractures are frequent and include nonunion, cubitus valgus or varus deformity,

ulnar nerve palsy, and avascular necrosis.34 Careful neurovascular assessment is required for these injuries. Because surgicaltreatment is generally preferred, orthopedic consultation is recommended for both lateral and medial epicondyle fractures.

CONDYLE FRACTURES

Lateral condyle fractures occur in children and are more common than their medial counterpart.35 Lateral condyle fracturesresult from a direct blow to the lateral elbow or from varus stress with the forearm extended, as in a fall on an outstretched hand.Patients complain of pain in the lateral elbow, and swelling is noted in the same area.

Medial condyle fractures are uncommon and are mostly limited to children. Mechanism of injury is from either a transmitted forcefrom the ulna, such as a fall on an outstretched hand, or excessive valgus stress. Pain and swelling medially are prominentfindings. The injury is o�en confused with the more common medial epicondyle fracture for two reasons. First, the mechanismand examination findings are similar. Second, because the trochlea ossification center does not appear until age 9 to 10 years old,it is o�en missed on radiographs.

ED care of nondisplaced lateral and medial condyle fractures with normal neurovascular function includes long arm posteriorsplint immobilization, ice, elevation, analgesics, and orthopedic referral. Follow-up imaging every 2 weeks is recommended dueto the risk of late displacement, which is treated with surgical fixation. Displaced fractures or those with neurovascularcompromise require immediate orthopedic consultation. Complications include malunion with resultant cubital valgus or varusdeformity, delayed ulnar nerve injury, and arthritis.

ARTICULAR SURFACE FRACTURES

TROCHLEA FRACTURES

Isolated trochlea fractures are rare, and they are more o�en associated with other elbow injuries, such as posterior elbowdislocations. Physical findings usually include swelling, tenderness, and limited movement of the elbow joint. Radiographicfindings can be subtle, and CT or MRI may be required for diagnosis. ED treatment includes long arm posterior splintimmobilization and orthopedic consultation because this is an articular surface injury and surgical repair is usually indicated.Complications are common and include limited flexion and extension, elbow joint instability, avascular necrosis, nonunion, andarthritis.

CAPITELLUM FRACTURES

Isolated capitellum fractures are rare. They are usually associated with radial head fractures. Pain and tenderness are presentover the lateral elbow, and examination reveals swelling, lateral tenderness, and limitation of flexion and extension. If pain andtenderness are present medially, then suspect injury to the medial collateral ligament. Radiographic findings may be subtle andare best seen on a lateral view. The capitellum has no tendinous or ligamentous attachments, so many fractures arenondisplaced. A radial head–capitellum view can be helpful in addition to standard anteroposterior and lateral views. CT imagingis useful for diagnosis. ED treatment is similar to that of trochlea fractures. Definitive care is surgical, and complications aresimilar to those of trochlea fractures.

PROXIMAL ULNA FRACTURES

The distal humerus articulates with the proximal ulna to form a uniaxial hinge joint, which allows flexion and extension of theforearm and provides some intrinsic stability. The trochlea of the humerus rests in the greater sigmoid (semilunar) notch of the

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ulna. The anterior projection of the notch is the coronoid, and the posterior prominence, which is easily palpable, is theolecranon. The brachialis muscle inserts at the coronoid, and the triceps muscle inserts at the olecranon. Nearly all proximal ulnafractures are considered intra-articular, with the exception of a proximal olecranon chip fracture.

CORONOID FRACTURES

Coronoid fractures are usually associated with posterior elbow dislocations as the trochlea is driven into the coronoid. A coronoid

fracture can rarely occur as an isolated injury secondary to elbow hyperextension.36 There is pain, swelling, and tenderness overthe antecubital fossa. Radiographic visualization is best with lateral and oblique films. O�en CT is needed to make the diagnosis.

ED treatment should include long arm posterior splint immobilization with the elbow in flexion and the forearm in supination,ice, elevation, analgesics, and referral to an orthopedic surgeon within 24 hours. Conservative treatment of nondisplacedcoronoid fractures remains controversial, and early orthopedic referral is indicated. Displaced fractures or those associated withjoint instability require open reduction and internal fixation and frequently have poor outcomes.

OLECRANON FRACTURES

The olecranon is usually fractured by direct trauma or by a fall with forced hyperextension of the elbow. Olecranon fractures are

quite common and represent up to 10% of upper extremity fractures.37 Associated injuries are common, including open fractures,dislocations, other fractures (especially of the radial head), and ulnar nerve injury. Pain is present over the posterior elbow, andexamination reveals swelling, tenderness, and occasionally crepitus. Because the triceps muscle inserts at the olecranon, tricepsfunction is usually compromised. It is important to test forearm extension against resistance, as the patient may falsely appear tohave intact forearm extension by using gravity to draw the forearm down. Ulnar nerve injury is common; therefore, a carefulneurologic examination is required. Lateral radiographs o�er the best view of the olecranon. In adolescents, the epiphysis ossifiesby age 11 years old and fuses by age 16 years old, so comparison films and the appearance of an abnormal fat pad can aid in thediagnosis. ED treatment includes long arm posterior splint immobilization with the elbow in flexion and forearm neutral, ice,elevation, analgesics, and referral to an orthopedist within 24 hours. Stable, nondisplaced fractures with intact extensor functioncan be treated conservatively with immobilization. Nonoperative treatment may also be considered for poorly functioning elderly

patients who would not tolerate surgery. All other olecranon fractures require surgical repair.38

RADIAL HEAD FRACTURES

The radial head is located just distal to the lateral epicondyle. Pronating and supinating the forearm with the elbow flexed allowsthe examiner to palpate the radial head. It articulates with the capitellum and the lesser sigmoid notch of the ulna to form a pivotjoint. The radial head serves as a stabilizer of the elbow against valgus stress, along with the medial collateral ligament, andagainst longitudinal forces.

Radial head fractures are the most common fractures of the elbow. They result from a fall on an outstretched hand causing theradial head to be driven into the capitellum. Associated injuries are common and may include capitellum, olecranon, andcoronoid fractures, medial collateral ligament injury, medial epicondyle avulsion fracture secondary to valgus stress, and elbowdislocation. A specific associated injury, the Essex-Lopresti lesion, occurs when there is disruption of the triangular fibrocartilageof the wrist and the interosseous membrane between the radius and ulna, causing pain in the wrist and forearm. The result is adistal radioulnar joint dissociation, which can cause migration of the radius proximally if radial head excision is performed. Openreduction and internal fixation of the proximal radius fracture is indicated for this injury.

Radial head fractures cause pain in the lateral elbow, especially with pronation and supination of the forearm. On examination,there may be swelling laterally and tenderness with palpation of the radial head. On standard elbow radiographs, radial headfractures may be subtle (Figure 270-16). Additional images, including obliques and a radial head–capitellum view, may be helpful.Furthermore, two radiographic clues can aid in the diagnosis. The first is abnormal displacement of the radiocapitellar line away

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from the center of the capitellum (Figure 270-7). This is especially helpful in children whose epiphysis has not fused. The otherclue is the appearance of an abnormal fat pad (Figure 270-9).

FIGURE 270-16.

Subtle radial head fracture and anterior fat pad sign (arrow).

Nondisplaced fractures with no mobility restrictions can be treated conservatively with immobilization. For these, ED treatmentconsists of sling immobilization with the elbow in flexion, ice, elevation, analgesics, and referral to an orthopedic surgeon within

1 week. Consider aspiration of the joint hematoma in the ED to improve pain and facilitate early mobilization.39 Additional paincontrol may be obtained with intra-articular injection of lidocaine or bupivacaine following aspiration, but this does not o�er any

long-term benefit over aspiration alone.40 For displaced fractures or those with restricted range of motion, surgical repair isgenerally indicated, and orthopedic referral within 24 hours is needed. Complications of radial head fracture include chronic painand restricted range of motion at the elbow.

FOREARM FRACTURES

In adults, solitary fractures of the forearm are uncommon due to the close relationship of the radius and ulna. The fibrousinterconnection between the radius and ulna transmits traumatic energy above and below the injury. So, fractures usually occurat two or more sites or involve a fracture of one bone with a ligamentous injury, with or without an associated joint dislocation.Because distant structures are commonly injured, examine joints above and below the involved bones both clinically andradiologically. Be especially observant for associated injuries if there is significant angulation of the fracture.

The radius and ulna are under the influence of numerous muscle groups, such as those that supinate and pronate (Figure 270-5).The biceps brachii and the supinator insert on the proximal radius and are the powerful supinators of the forearm. The pronator

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teres inserts on the radial sha� and exerts a pronating force. Radius fractures that are located between these muscle groups willresult in marked displacement of the radius, with supination of the proximal segment and pronation of the distal portion.However, if the fracture is distal to the insertion of the pronator teres, these forces tend to neutralize one another and result inless rotational deformity. When considering treatment of these fractures, careful attention must be paid to the maintenance oflength, alignment, and angulation. Also, the lateral bow of the radius must be preserved to allow full pronation and supinationa�er healing.

FRACTURES OF BOTH RADIUS AND ULNA

A great amount of force is necessary to fracture both the radius and the ulna. This injury occurs most o�en from vehicular trauma,falls from a height, or a direct blow. Force magnitude determines injury type. Moderate forces produce transverse or mildlyoblique fractures. High-impact forces produce comminuted and segmental fractures (o�en displaced).

Nondisplaced fractures of both bones are exceedingly rare because the force necessary to produce the injury is also su�icient todisplace the bones. Examination of the forearm reveals swelling, deformity, and tenderness. Carefully assess the neurovascularstatus. Nerve injuries can be seen with severe open fractures but are uncommon with most closed injuries. Because of theexcellent collateral circulation of the forearm, vascular compromise is generally not a major problem if either the radial or ulnarcirculation is intact.

The fractures are clearly visible on the radiographs. Note the degree of angulation, displacement, and shortening. Changes inrotational alignment may be subtle. Noting the normal orientation of various bony prominences of these bones can make a roughestimate of rotational alignment. On the anteroposterior view, the radial styloid and radial (bicipital) tuberosity normally point inopposite directions, whereas the ulnar styloid and coronoid process do so on the lateral view. A change in this arrangementsuggests rotation malalignment. Because these bones are also oblong rather than circular in their cross-sectional appearance, asudden change in the bone's width at the fracture site is another clue to a rotational deformity. Obtain radiographs of the wristand elbow because of the likelihood of an associated dislocation or articular fracture.

Treatment depends on the type of fracture. Torus or greenstick fractures with minimal angulation in children can be treated withimmobilization in a long arm splint. Angulation >15 degrees warrants referral for closed reduction. In younger children, treatdisplaced fractures with closed reduction and cast immobilization due to the continued remodeling that occurs a�er fracturehealing. Perform closed reduction urgently in the ED by an orthopedic consultant to ensure appropriate alignment. Surgicalintervention is becoming increasingly popular, although there is a lack of evidence showing improved outcomes from surgery

over conservative management.41,42 Nondisplaced fractures in adults can be immobilized with a long arm splint and referred forurgent follow up. All other fractures in adults require operative reduction and internal or external fixation, ideally within 24 to 48hours.

Complications include reduced ability to supinate and pronate, osteomyelitis, nonunion, malunion, neurovascular injury, andcompartment syndrome. Recognizing the development of a compartment syndrome is particularly important to preventdebilitating ischemic or Volkmann's contractures of the forearm. The diagnostic findings are palpable induration of the area, painwith passive movement of the fingers, and pain disproportionate to the physical findings. Loss of radial pulse is o�en a latefinding, and presence of a radial pulse does not exclude compartment syndrome. Direct measurements of elevated compartmentpressures confirm the diagnosis. Urgent fasciotomy is required, ideally within 8 hours of the onset of symptoms.

ULNA FRACTURES

ISOLATED ULNA FRACTURE (NIGHTSTICK FRACTURE)

Isolated fractures of the ulna most o�en result from direct blows to the forearm. A fracture resulting from the natural response toraise the forearm in defense of a blow from a club is referred to as a nightstick fracture. Nondisplaced fractures are immobilized ina splint and closely followed for subsequent displacement. A short arm cast is preferable to a long arm cast for treatment.

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Fractures with >50% displacement, with >10% angulation, or that involve the proximal third of the ulna are considered

unstable.43 Obtain orthopedic consultation for unsTable fractures. Open reduction and internal fixation with a compression plateand screws are necessary to prevent angulation, loss of length, and rotational deformity. Assess injuries for any possible radiusfracture or dislocation.

MONTEGGIA'S FRACTURE-DISLOCATION

Fracture of the proximal third of the ulna with a radial head dislocation is o�en referred to as Monteggia's fracture-dislocation

(Figure 270-17). The associated radial head dislocation may be easily missed.44 Missing the radial head dislocation can lead tochronic pain, limited range of motion, and, possibly, radial head excision as treatment. Monteggia's fractures can occur followinga fall onto an outstretched hand or a direct blow. The most typical injury pattern seen is a diaphyseal fracture in the proximalthird of the ulna with an anterior dislocation of the radial head (60% of cases). Clinically, there is considerable pain and swellingat the elbow. The radial head may be palpable in an anterolateral or posterolateral location. The forearm may appear shortenedand angulated. The ulnar fracture is clearly visible and may overshadow the less obvious radial head dislocation. As a rule, theradial head normally points to the capitellum in all radiographic views of the elbow. In a Monteggia's fracture, the apex of theulna fracture points in the direction of the radial head dislocation.

FIGURE 270-17.

Monteggia's fracture-dislocation. The angulation of the comminuted fracture of the proximal ulna points in the direction of theradial head dislocation.

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Obtain consultation with an orthopedic surgeon. Monteggia's fracture-dislocations are generally treated with open reduction andinternal fixation of the ulna and closed reduction of the radial head dislocation. In children, the injury may be treated with closedreduction and long arm splinting. Complications include nonunion, recurrent dislocation, chronic pain, infection, and paralysis ofthe posterior interosseous nerve, a deep branch of the radial nerve.

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1. 

2. 

3. 

4. 

5. 

RADIUS FRACTURES

FRACTURES OF THE PROXIMAL TWO THIRDS OF THE RADIUS

Radius fractures can be divided into those that are proximal and those that are distal to the junction of the middle and distalthirds of the bone. Excluding radial head fractures, isolated fractures of the proximal two thirds of the radius are uncommonbecause the radius is relatively well protected from direct blows by the ulna and surrounding forearm musculature. Nondisplacedfractures are rare and treated with cast immobilization. Fractures of the proximal two thirds of the radius are o�en displaced byboth the force of the injury and the action of the supinators and pronators on the radius. They require internal fixation to preventrotational deformity. Compartment syndrome is rare with these fractures. Most complications involve malunion or nonunionbecause of inadequate or lost reduction.

GALEAZZI'S FRACTURE-DISLOCATION

Fractures of the distal third of the radial sha� are produced by falls on the outstretched hand in forced pronation or by a directblow. The radius, generally the distal third, is fractured along with a dislocation of the distal radioulnar joint. Galeazzi's fracture iso�en referred to as the reverse Monteggia's fracture. There is localized tenderness and swelling over the distal radius and wrist.The radius fracture is usually short oblique or transverse with dorsal lateral angulation. The distal radioulnar joint injury can besubtle. Radiographs may show only a slightly increased distal radioulnar joint space on the anteroposterior view. On the lateralview, the ulna is displaced dorsally. This injury is treated surgically by open reduction and internal fixation of the radius fracture.Complications include infection, nonunion, and malunion. Injuries to the ulnar nerve and anterior interosseous branch of themedian nerve have been reported but usually heal spontaneously. If the radius heals with a rotational deformity, there may bepain at the distal radioulnar joint with extreme pronation and supination.

Acknowledgments: The authors wish to recognize the contributions of Harold Chin, MD, and Arthur F. Proust, MD, in previouseditions of this chapter, and of Christopher Sullivan for his research and editorial assistance.

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