[MUSIC] [MUSIC] [MUSIC] In order to gain a better understanding of injuries to the elbow, it makes sense to take a look at human anatomy once again. The elbow joint is a very special joint as it combines two movements. On the one hand, hinge joint movements and on the other hand pro- and supination movements. This also accounts for there being a total of three joints. Namely the humeroulnar, the humeroradial and the radioulnar. The complication which is most feared among elbow joint fractures is joint stiffness. This particular mobility of the elbow joint results from a special arrangement of ligaments. A distinction is made here between the ulnar collateral ligament, the radial collateral and the anular ligament. In the direct vicinity of the elbow joint a series of essential neurovascular structures can be found: the brachial artery and also the radial, median and ulnar nerves. This slide once again makes clear the close anatomical relationship between the corresponding structures and the elbow. It can be seen clearly that, for example, the ulnar nerve runs directly behind the articular capsule. This then naturally means that a wide variety of different types of fracture can also result from the wide variety of osseous structures to be found. The distal humerus can fracture, the olecranon, the head of the radius or combination injuries with dislocation mechanisms can also occur. >> Dr. Kirchhoff, we have another ‘Blade Night’ victim. A young lady having experienced a fall. >> She is in Room 2: >> I’ll come with you: Hello. >> Hello. >> Kirchhoff from the Trauma Surgery Department So what have you been up to? >> Well, I went skating at Blade Night and I saw this really sexy guy there. >> A really sexy guy... >> Yes, and I was desperate to impress him and wanted to overtake him but then… somehow or other I fell over. >> Okay. And did you just fall onto your arm or did you hit your head as well? >> No, no, I just fell onto my arm. >> Were you wearing a helmet? >> No, wearing one doesn’t match my outfit. >> Sorry. I imagine you were not wearing any protectors either? >> No. >> Knee, wrists - do they hurt? >> No, it is just my arm which hurts. >> OK, then let's have a look at it, shall we? Just place your arm in my hand like this. >> But.... >> I’ll be very careful. I’ve done this lots of times. Excellent. Is that OK? >> Mhm. >> Good. Can you just lift your fingers for me, please? Excellent. Spread them out. >> Very good. And the thumbs as well. Can you feel everything here? Good. And here between the fingers as well? No feeling of numbness, of having gone to sleep? Down here on the hand either? >> No. >> Pulses are also good. Blood flow is also good. Excellent. Does it hurt if I press down here at the wrist? >> Not so much. But not badly? >> Up here? If I press your forearm together like this, does that hurt? Okay. And if I press down here? >> Yes! >> Excuse me, I’m sorry. You also have a really large graze there, don’t you? >> Mhm. >> Have you received tetanus protection? >> Yes. >> When was that done? >> Four years ago. >> OK, good. Can you stretch out your arm against the force I am applying? >> No, no. >> Because it hurts down here again as well? >> Mhm. >> OK, good. We’ll stop doing much else entirely for the moment. Just place your arm in your hand. Exactly, that's just right. With regard to the x-ray: Are you pregnant? >> No. >> Are you otherwise completely healthy? >> Yes. >> Are you taking any medication? >> No. >> Have you drunk anything this evening? >> No. >> Are you taking any drugs? >> No. >> Good. I would now like to ask you to go for an x-ray by walking just ten meters to the right here. Your name will be called out. Once the x-ray has been taken, please come back to this room again straight away. >> Okay. >> See you soon. >> For number 21 of the proximal forearm, the AO classification of elbow fractures assigns A1 >> to fractures of the ulna, with the radius intact, A2 to fractures of the radial head with the ulna intact, and A3 to both bones being broken. The AO classification of the olecranon covers articular fractures of Type B, Type B1, ulnar fractures with the radius being intact, B2, a radial head fracture with joint involvement and the ulna being intact and B3, a bone with one fracture on the articular side and the other extra-articular. If complex articular fractures occur in both bones, then we talk about 21 Type C fractures. C1 are simple fractures, C2 cover a range of multi-fragment ones and C3 multi-fragment ones as a whole. Olecranon fractures affect the proximal ulna. The proximal ulna articulates on one side with the humeral trochlea and is bordered on the other side by the coronoid process. Analysis of the epidemiology of olecranon fractures reveals that approx. 7% of all fractures incurred by human beings involve fractures of the elbow. Of these, approx. 37% are isolated olecranon fractures. There are two frequency peaks, on the one hand around the age of 20, which predominantly affect men, and, on the other hand, at around the age of 65. The latter tend to affect women more. Children tend more to suffer from supracondylar humerus fractures due to the differing speed at which the ossification centres turn to bone. The AO system of classification is not the only one covering elbow fractures. The Schatzker system of classification is also found in the international literature on a wide-spread basis. Type A fractures are simple transverse fractures. Type B is used to describe transverse fractures with impaction of the articular surface occurring at the same time. Type C indicates oblique fractures with a fracture line commencing at the distal part of the articular surface. If a comminuted fracture has occurred with avulsion of the coronoid process, then reference is made to a Type D injury. Simple distal oblique fractures are classified as Type E and dislocation fractures are designated as Type F. The typical accident mechanism for olecranon fractures is falling directly with an inflected elbow joint onto a firmly fixed obstacle such as the edge of a pavement. This is why the patient's history is often indicative in terms of the path to be followed. Patients often hold their arm in a typical relieving posture in a slightly extended position. When conducting the examination, please also take note of any supplementary soft tissue injuries or palpable steps. In terms of the basic examination, an isosceles triangle should be present, consisting of both epicondyles and the tip of the olecranon. As always, it is important to examine and record the peripheral blood flow, motor function and sensitivity. The standard imaging procedure includes an x-ray examination of the elbow in two planes. When doing this, pay particular attention to indirect signs of fractures such as fat-pad signs. As soon as more complex injuries are present, an indication for extensive MRI examination is to be given. The first decision to be made is whether treatment is required on a non-operative or surgical basis. The basic treatment objective can be formulated as achieving a painstaking repair of the articular surface, restoring stability with the highest degree of mobility and muscular strength of the forearm. The indication for non-operative treatment is given for all non-dislocated fractures or small avulsions at the tip of the olecranon. But only in the event of active extension being possible. Non-operative treatment consists of an upper arm plaster cast for approx. one week. Early functional physiotherapy should then be administered after this. Regular x-ray check-ups are important in order to check for any secondary dislocation of the fragments which may have occurred. Please note: If the elbow joint is immobilised for a longer period of time, then there is the danger of stiffening occurring rapidly. [MUSIC] Come in, Ms. Wagner. Unfortunately, I have to report That you have broken your elbow. >> Aha. So... does that mean I will have to undergo an operation? >> It is unfortunately the case >> that in cases involving a fracture such as yours, there really is no alternative to operating when a young person like you is involved. I can take you through the procedure slowly by making use of the x-ray image. You can see your elbow here, firstly x-rayed from the front and then from the side. Here is the bone in your upper arm, the humerus, >> Aha. >> and these are the ulna and radial bones. The radial bone is located at the side where your thumb is, while the ulna is where your small finger is. >> Aha. >> OK. And if you look from the side, then you can see the ulna, with the ulna ending in the direction of the elbow >> in this extension, which is what is called the olecranon. >> Aha. Ok. >> That is what is broken in your case at precisely this spot here and with the joint being involved. The problem with the olecranon is that this triceps muscle is attached here. You are perhaps aware of that from your visits to the gym. Triceps exercises consist of exercises involving pulling ropes, >> Mhm. >> in which >> the end result is that the rope pulls downwards. In exactly the same way, the triceps muscle always pulls on this olecranon and pulls the fracture apart, meaning it will never heal properly. >> Ok. Does that therefore mean... I will need to stay here today? >> No, you don’t have to stay here. The swelling means we could actually already operate tomorrow. We would make all the preparations for the operation now, fit a plaster splint on you and you could then go home and would pay us a visit on the ward tomorrow morning at seven o’clock. [NO_AUDIO] The indication for surgical treatment is made in cases of a dislocation of the fragments measuring more than 2 mm or of non-dislocated fractures in younger patients, so as to allow for functional exercising to be conducted as soon as possible. The advantage of surgical treatment is to be found in the neutralisation of the tractive force of the triceps muscle, the repair of the axis and the early functional exercising resulting from this which helps to avoid movement disorders occurring. The simplest surgical treatment employed with olecranon fractures is tension band wiring. This is indicated in the case of oblique and simple transverse fractures. This slide illustrates the principle of effectiveness underlying tension band wiring. With tension band wiring, the muscular forces of a muscle are antagonised by means of wire cerclage. This can be seen clearly on the right-hand side diagram. This principle of tension band wiring is also employed in a series of other injuries, as shown in this diagram. These diagrams once again make clear - on the left-hand side - the principle of tension band wiring in theory and on the right the postoperative checks conducted on a patient. It can be clearly seen how both of the Kirschner wires which have just been inserted stabilise the fracture and the tension exerted by the triceps muscle is antagonised by means of the wire cerclage. [NO_AUDIO] [NO_AUDIO] It can clearly be seen from this that tension band wiring can only be employed if the bone fragments provide support to each other. As soon as multifragment fractures are present, plate osteosynthesis must therefore be employed. Both these images show typical plate osteosynthesis procedures. On the left side a hook plate and on the right side a fixed-angle olecranon plate. With all compound fractures or complex polytrauma situations, a fixateur can always be fitted. This is pulled by the humerus onto the ulna in a way which crosses the joint. In order to avoid movement disorders occurring here, a movement segment can be inserted between the humeral and the ulnar components. [MUSIC] >> : I will be able to practise sport again, though, won’t I? >> Perhaps I should quietly first tell you a little bit about what the operation involves and then what will happen afterwards. Well, if you transfer this x-ray image onto this paper version, wires will be inserted into the bone from behind here. These wires will then be rotated using such an 8-er cerclage. These wires can cause discomfort at the elbow precisely in thin women, such as you, after a certain time has elapsed, meaning they then have to be removed again in a second operation. >> OK and will I then have to wear a plaster cast? >> You will be fitted with a plaster cast now, simply just to treat the pain up to the time of the operation, but the aim is for you not to require any immobilisation any more following the operation, as the elbow is a very sensitive joint which can become stiff incredibly quickly and lose its freedom of movement. For that reason, we have to be able to move the arm completely freely after the operation. >> What type of scars will be left? >> That depends a little on... >> I love dressing up in sexy clothing and you should know that. Will the scars therefore be large or small? >> Well, >> scars vary a bit from one case to another. Do scars usually heal well for you or do they become broad and thick? >> I don’t know. >> Oka good. Well, purely in principle we will try and make as small an incision with you as possible, 5 or 6 cm, and then time alone can tell. >> Ok. Ok. >> Ok? >> Mhm. Mhm. >> OK, now we’ll send you off to see the anaesthetist and he will discuss the anaesthetic procedure with you. >> Okay. >> And then we just need to fit the plaster cast for you. OK? >> Okay, good. >> If there are no further questions, then I wish you all the best and see you tomorrow. Goodbye. >> Okay. It fits. Goodbye. [MUSIC] [NOISE] [NO_AUDIO] >> These diagrams on the left side show the typical positioning for treating olecranon fractures, either in a supine position or in a lateral position, as shown bottom left. The diagram on the right shows an olecranon fracture being treated in a prone position. These intraoperative images show, - on the left side - the incision marked with radial incision around the tip of the olecranon. The skin has already been opened on the right and the olecranon has been repositioned provisionally by means of a Kirschner wire. You can see the corresponding operating schemes here. On the left, it can clearly be seen how the olecranon is repositioned by means of bone hooks and is then provisionally transfixed using the 2.0 Kirschner wire. Threading of the cerclage can be seen in the middle and on the right the final treatment. [NO_AUDIO] As a clinical example, you can see here a simple Type A Schatzker fracture, on the left side in the lateral and on the right side in the anterior-posterior ray path. The dislocation of the fragment by the tension exerted by the triceps can be seen clearly. This x-ray image shows the lateral image of the elbow joint following surgical treatment by means of tension band wiring. What can be very easily recognised is how the dislocation is cancelled out by the tension band and the forces exerted by the triceps are antagonised. Let me summarise: Elbow fractures occur frequently and can range from very simple to highly complex. The types of complication which are most feared are stiffening of the joint or injury to neurovascular structures. Simple fractures can be treated by means of tension band wiring. Many thanks for your attention and I wish you every continued success! [MUSIC] [MUSIC] [MUSIC]
