Topic B/8

Dislocations of the elbow. Monteggia and Galeazzi fractures.

Elbow dislocation
The cause of most elbow dislocations is usually a fall, most
commonly with the arm all the way out.

Classification:
A simple dislocation does not have any major bone injury.
A complex dislocation can have severe bone and ligament injuries.
Severe dislocations, the blood vessels and nerves that travel across the elbow may be injured. If
this happens, there is a risk of losing the arm.

Symptoms: Complete
Loss of feeling in the hand
No longer pulse
Severe pain, swelling, and inability to bend your arm
Partial
Treatment:
Non-surgical
Reduction of the elbow by pulling down on the wrist and levering the elbow back into
place. This is very painful. Complex
A splint will make an "L" around the back of the elbow. It will be make of plaster or
fiberglass. It prevents the movement of the arm at the elbow. Usually, the arm will be
After alignment,
placed in a sling to help hold up the splint and arm.
normal
Surgical
In case of complex injury. After surgery, the elbow may be protected with an external
hinge. This device protects the elbow from dislocating again. If blood vessel or nerve
injuries are associated with the elbow dislocation, additional surgery may be needed to
repair the blood vessels and nerves and repair bone and ligament injuries.

Complications that may occur are:

Fractures
Injuries to the arteries, nerves that run through the elbow area, impairing movement and
feeling in the arm/hand.

Monteggia and Galeazzi fractures

Whenever one of the two bones of the forearm fractures with considerable shortening (usually through
angulation), then something has to happen to shorten the other bone
The other bone can also fracture
The other bone can dislocate
Ligaments are torn
Galeazzi and Monteggia fractures are both fractures in which there is a fracture with shortening of one
of the two bones of the forearm with dislocation of the other bone

Galeazzi Fracture
Mechanism: Fall on outstretched hand with elbow flexed
Fracture of the radius with shortening and dislocation of the distal ulna
Dorsal angulation
Complications
High incidence of
Nonunion
Delayed union
Malunion (unstable fracture)
Limitation of pronation or supination
 Monteggia Fracture
Mechanism: direct blow to the forearm
Ant dislocation of the radial head with a fracture of the ulna, usually angulated dorsally
May have associated wrist injury
Complications
Nonunion
Limitation of motion at elbow
Nerve abnormalities
Reverse Monteggia Fracture
Dorsally angulated proximal ulnar fracture and posterior dislocation of radial head
Topic B/9
Forearm fractures in children and adults.

Classification:
A1 Simple fracture, of the ulna, radius intact (subgroup 3: with dislocation of the radial head
(Monteggia)
A2 Simple fracture, of the radius, ulna intact (subgroup 3: with dislocation of the distal
radio-ulnar joint (Galeazzi)
A3 Simple fracture of both bones
B1 Wedge fracture, of the ulna, radius intact(subgroup 3: with dislocation of the radial head
(Monteggia)
B2 Wedge fracture, of the radius, ulna intact (subgr 3: with dislocation of the distal
radio-ulnar joint (Galeazzi)
B3 Wedge fracture, of the one bone, simple or wedge fracture of the other.
C1 Complex fracture, of the ulna
C2 Complex fracture, of the radius
C3 Complex fracture, of both bones

It is important to establish whether the patient is multiply injured or has an isolated forearm
injury and try to ascertain some idea of the mechanism of injury. The physical examination should
stress recognition of the degree of soft tissue injury. The neurovascular status of the limb must be
carefully assessed and constant vigilance for compartment syndrome of the forearm is in order.
Radiologic evaluation of these injuries should always include the elbow and the wrist.

Treatment
The treatment goals are to restore the anatomy so that normal function can follow. It is important to
restore the radial bow with the radius.

Nonoperative treatment is relatively rare.

Surgical treatment
The treatment options are open reduction with internal fixation with plates, intramedullary
nailing, and external fixation.
ORIF (open reduction and internal fixation) with plating predominates.

Intramedullary nailing certainly does have role with certain soft tissue injuries. Rush rods
have been used. Interlocking and flanged nails are available on the market today. An
acceptable closed reduction must be obtainable.

External fixation is often used as temporary stabilization for a patient with a severe soft tissue injury.

Galeazzi fractures are fractures of the distal third of the radius associated with distal radial ulnar joint
injury. The twin sister of the Galeazzi fracture is the Monteggia fracture which occurs at the other end
of the forearm. These are usually simple proximal ulnar fractures associated with radial head
dislocations. The management of these injuries involves fixing the long bone and reducing the
dislocation. A failure to reduce the radioulnar joint can signify a malalignment of the long bone open
reduction and internal fixation. Temporary pin transfixation of the radioulnar joint may be required if
the joint is unstable after long bone fixation

Complications
Complications that are common to most fractures treated with ORIF (e.g. infection) are relatively rare -
except in the case of open fractures. Neurovascular injury is most likely due to the injury itself.
Posterior interosseous nerve palsies occur and luckily most recover. Nonunion and failure of fixation
are uncommon. Refractures can occur above and below the plates.
Infection
Neurovascular injury
Nonunion
Failure of fixation
Topic B/14
Possibilities of treatment for injuries of the radial, ulnar and median nerves.

Relieve pressure on compressing situation. Ex: fasciotomy in carpal tunnel syndrome.

Reconnect the nerves by surgery. Primary repair is direct reconnection of the nerve immediately after
injury. In an epineurial repair, the epineuriums of the separated nerve endings are sutured together
using a microsuture.
Secondary repairs are delayed repairs that may entail different strategies. Bones can be shortened to
add length to a nerve. Nerve transposition across a flexed joint (eg, the ulnar nerve in the elbow) is
another strategy for gauging nerve length in secondary repairs.
Neurolysis is performed on intraneural and extraneural scar tissue to release regenerating nerve fibers
in the hope of improving functional recovery.

Extensive physiotherapy
Topic C/1
Fractures of the pelvis and accompanying injuries.
Topic C/4
Complication of femur neck fractures

Redisplacement Tilting of the fracture to various directions

Local displacement of the implant (slipping out, perforation
Pseudarthrosis rare with screw fixation
Non-union
Migrant pseudarthrosis. Regeneration of the necrotic head begins from the site of fracture in direction to the
head. The fracture heals, the border of living and necrotic bone is displaced in central direction.
Necrosis of the femoral head
Partial: collapse of the weightbearing surface is typical. Fracture healing occurs, but the femoral head
with its damaged blood supply collapses.
Total: necrosis of the complete femoral head, resorption of the neck. Solution: prosthetic replacement.

Non-union
Failure of union of this fracture still occurs due to improper reduction of imperfect internal fixation. When this
occurs, the patient complains of pain and develops instability on walking. The condition is treated by
intertrochanteric osteotomy in the younger age group and replacement arthroplasty in the elderly.

Avascular Necrosis
Avascular necrosis of the head of the femur is an unpredictable complication met with after any type of
internal fixation. The patient presents with pain in the hip and limping. There is limitation of all
movements of the hip with muscle spasm. Radiography shows patchy areas of increased density in the
head of the femur. Treatment in the early stages is by rest, traction and weight relieving caliper. When
indicated, osteotomy or replacement arthroplasty is done.

Classification:
Stage 0 has no radiographic findings. This preclinical stage is diagnosed by means of magnetic
resonance imaging (MRI) or bone scanning.

Stage 1 manifests as slight osteoporosis on plain images. Clinical symptoms may be present, but
sclerosis is not.

Stage 2 involves diffuse osteoporosis and sclerosis at the region of the infarction. The infarcted
area is well delineated due to a reactive shell of bone. The spherical shape of the femoral
head is maintained.

Stage 3 results in the crescent sign, or a radiolucency under the subchondral bone, which
represents a fracture. The contour of the femoral head is abnormal. The joint space is
preserved.

Stage 4 is char by femoral head collapse, joint-space narrowing, and subchondral sclerosis.

The Ficat-Arlet classification is especially pertinent in Garden III and IV fractures in which there is a
significant incidence of AVN.
Topic C/7
Fractures of the patella. Stable and unstable fractures of the tibial condyles. Fractures of the
intercondylar eminence.
Topic C/12
Injuries of the ankle ligaments. Injuries of the Achilles tendon.

An ankle sprain is an injury to the ligaments in the ankle.

Inversion Ankle Sprains

The foot is inverted, falling inward. When this type of ankle sprain happens, the outer, or lateral,
ligaments are stretched too far. There are three ligaments that attach to the outer side of the ankle. 90%
of sprains are inversion. Pain is always on the outside of the ankle, and there is usually no pain on the
inside of the ankle joint.

Eversion Ankle Sprains

The foot is twisted outwards. When this occurs, the inner ligament, called the deltoid ligament, is
stretched too far. Patients will have pain on the inner side of the ankle.

Grade I Ankle Sprain:

Grade I ankle sprains cause stretching of the ligament. The symptoms tend to be limited to
pain and swelling. Most patients can walk without crutches, but may not be able to jog or
jump.
Grade II Ankle Sprain:
A grade II ankle sprain is more severe partial tearing of the ligament. There is usually more
significant swelling and bruising caused by bleeding under the skin. Patients usually have pain
with walking, but can take a few steps.
Grade III Ankle Sprain:
Grade III ankle sprains are complete tears of the ligaments. The ankle is usually quite painful,
and walking can be difficult. Patients may complain of instability, or a giving-way sensation
in the ankle joint.

As said before, pain and swelling are the most common symptoms of an ankle sprain. Patients often
notice bruising over the area of injury. This bruising will move down the foot towards the toes in the
days after the ankle sprain--the reason for this is gravity pulling the blood downwards in the foot.

A high ankle sprain is a particular type of injury to the ligaments around the ankle. In a high ankle
sprain, the ligaments above the joint are also injured. These ligaments, called the syndesmosis
ligaments, can also be injured, and may necessitate a longer course of rehabilitation.

Treatment:
RICE: rest, ice, compress, elevate
Achilles Tendon Injuries
The Achilles tendon is the tendon of the gastronemius and soleus muscles of the posterior leg and
connects these muscles to the heel bone (calcaneus). It is located along the lower back portion of the
calf and runs to the heel. This muscle tendon group is responsible for plantar flexion of the ankle and is
the primary motor for standing and walking on the toes as powers push off when a person runs or
jumps.

Injury usually results when the tendon is stressed by short quick movements, or sudden starts and stops
such as in Racquetball, tennis, football, or dance

Inflammation of this tendon is known as Achilles Tendonitis. It occurs when the overstressed tendon
becomes inflamed and causes pain, swelling and restricted flexibility. If untreated, it could grow
progressively worse and a small tear may lead to tendon rupture, separating the calf muscle from the
heel bone. When this occurs, normal movement of the ankle is impossible.

If Achilles Tendonitis is treated before tendon rupture, there are a number of non-operative ways to
recover strength to the area. They include stretching, ice, shoe modifications, nutritional supplements,
and alterations in an individual's training schedule. Still, the best treatment is prevention. Tendonitis
can be avoided with the proper strengthening of all muscle groups in the leg, along with adequate
stretching and warm-ups before demanding activities or sports.

A complete rupture often occurs spontaneously during sports, without a pre-existing tendonitis. The
complete rupture requires surgery to reconstruct the torn edges of the tendon, or more uncommonly
repair the tendon back to the bone. After surgery, a Cryo/Cuff is applied followed by a very short
period of casting.
Intracerebral hemorrhage is more likely to result in death or major disability than ischemic stroke or
subarachnoid hemorrhage. Intracerebral hemorrhage and accompanying edema may disrupt or
compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain
parenchyma may cause elevation of intracranial pressure (ICP) and potentially fatal herniation
syndromes.

Treatment
Perform endotracheal intubation if decreased level of consciousness and poor airway protection
Lower blood pressure to a mean arterial pressure (MAP) less than 130 mm Hg, avoid excessive hypotension.
Rapidly stabilize vital signs, and simultaneously acquire emergent CT scan
Intubate and hyperventilate if IC pressure is increased; administration of mannitol for further control
Maintain euvolemia, using normotonic rather than hypotonic fluids, to maintain brain perfusion
without exacerbating brain edema
Avoid hyperthermia
Correct any identifiable coagulopathy with fresh frozen plasma, vit K, protamine or platelet transfusions.
Initiate fosphenytoin (anticonvulsant) for seizure activity or lobar hemorrhage
Transfer to the operating room or ICU