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Radial Head Fractures

Background

Fractures of the radial head are common and comprise nearly one-third of all fractures around the elbow.  Although the majority of these injuries can be treated conservatively, they occasionally require surgery.  A common complication of any injury around the elbow is stiffness and the goal of treatment of radial head fractures is to restore early range-of-motion.

Treatment

Radial head fractures are almost always diagnosed in the emergency department after an examination by the emergency room physician and appropriate imaging. Treatment is based on the severity of the injury.  The majority of radial head fractures are minimally displaced and can be treated without an operation.  Fractures that are comminuted (in multiple pieces), widely displaced, or are associated with other injuries (elbow dislocations, coronoid fractures, etc) require urgent orthopaedic consultation. Treatment generally takes one the following broad categories:

  1. Conservative: If you are in the majority of patients with a fracture that does not require surgery, you will require a short period of immobilization, most likely in a sling. Arrangements will be made for you to see an orthopaedic surgeon in fracture clinic within 7-14 days. At that time a repeat x-ray will be obtained to ensure the fracture hasn’t shifted. If the alignment of the fracture is still acceptable, you will be asked to begin working to regain your elbow range of motion.
  2. Surgery: If you are in the minority of patients that require an operation, there are three broad options for treatment. These are as follows:
    • Fragment Excision: If the fracture has caused a small piece of bone to become entrapped within the elbow joint, this will likely cause a mechanical restriction to normal range of motion. In order to restore range of motion, your surgeon may recommend an operation to remove that small piece of bone.
    • Open Reduction – Internal Fixation: If the fracture has resulted in two relatively large fragments, your surgeon may recommend an operation to put these back together with small plates and screws. This is generally done through a lateral incision on the elbow although this may change if there are other associated injuries.
    • Radial Head Replacement: If the injury has resulted in a fracture in many small pieces then your surgeon will likely recommend an operation to remove the small pieces and replace them with a metallic replacement.

Follow-Up and Rehabilitation

  1. 0-2 Weeks: The goal of this appointment will be to start working at gentle range of motion. A new x-ray will be obtained to ensure that the fracture hasn’t shifted. You will be cautioned to avoid any strengthening at this stage and should not be lifting anything heavier than a cup of coffee.
  2. 3-6 Weeks: Another x-ray will be obtained at this appointment to ensure healing is progressing. You will likely be permitted to start doing some gentle strengthening at this point. If your fracture was only minimally displaced and did not require surgery, this may be the last time you are asked to follow-up for this injury.
  3. 6-12 Weeks: Follow-up in this range is generally reserved for patients that required surgery or if there was a complication noted such as stiffness. A plan will be made based your injury pattern and you will likely be asked to attend formal physiotherapy to optimize your post-operative outcome.

Complications

The most frequent complication following this injury is elbow stiffness.  Even with relatively minor injuries it is not uncommon to lose the ability to fully straighten your arm. Fortunately, it is uncommon to have stiffness in the range of motion that we typically use for activities of daily living. To decrease the risk of significant elbow stiffness, it is important to start working at your range of motion as early as possible following your injury.

Other complications following this injury are rare. Any fracture that involves a joint does put you at increased risk of post-traumatic arthritis. Fortunately, symptomatic elbow joint arthritis is relatively rare. If you are immobilized for a prolonged period of time, this injury may also predispose you to a condition known as chronic regional pain syndrome. To decrease your risk of this complication it is imperative to begin working at your range of motion as early as possible following your injury.

Outcome

The outcome following a fracture of the radial head is generally very good. Most patients are left with a pain free elbow and have no restrictions once the fracture has healed. A good outcome is very dependent on re-establishing your elbow range of motion as soon as possible following your injury.

 

 

 

 

Distal Biceps Tendon Ruptures

Background

The biceps muscle is a collection of two muscular bodies (one termed ‘short’ and another ‘long’) which join at the elbow to form a single tendon. This tendon crosses the elbow and attaches to the radius bone in a region termed the radial tuberosity. Collectively, the biceps muscle works mainly as an elbow supinator (the motion involved in turning a screw driver or a door knob) and also an elbow flexor.

One of two components of a biceps tendon may rupture. The long head of the biceps tendon can rupture at the shoulder. This most commonly occurs in older individuals and requires no further treatment to achieve a good functional result. Conversely, the tendon may rupture at the elbow. This injury more commonly occurs in younger individuals and commonly requires surgical repair for optimal results. Rarely, the middle of the biceps tendon may rupture. This can occur in any age, and is commonly due to a direct blow to the arm or an object like a rope forcibly rubbing across the arm. No surgery is possible with this injury, and it is managed with splinting followed by gradual range of motion.

 

General Information

At the elbow, the biceps is responsible for 40% of elbow supination strength (i.e. turning a door knob or screw driver) and 20-30% of elbow flexion strength. Once injured, an individual frequently feels that they lose both strength and endurance when performing the above exercises. With time and therapy, we believe the arm can be strengthened to help compensate for the loss of the tendon. It nonetheless remains unclear how much strength deficit will remain if the tendon remains unattached by surgery.

 

Work-Up

Patients are often seen first in either the emergency room or their family physician’s office. For any patient with elbow pain where a fracture has been ruled out, clinical exam will dictate how quickly additional imaging should be considered. If a clinical exam is very highly suggestive of an distal biceps injury, an ultrasound can be quickly arranged to assess for the possibility of a tendon tear. Depending on the results of ultrasound and clinical exam, an MRI may be obtained to confirm the diagnosis. The diagnosis of a distal biceps tendon rupture should prompt an immediate referral to an Orthopaedic surgeon, as any surgery undertaken is best performed within 3-4 weeks of injury.

 

Treatment

Surgery

Your surgeon will present you with the treatment options they feel are relevant to your situation. Many people sustaining distal biceps tendon ruptures are active males that require strength to perform their job or sport. If seen before 3 weeks, surgery remains an option in most individuals. Unfortunately, those presenting after 4 weeks are not eligible for surgical repair, as the biceps has retracted and scarred in too much to allow for it to be repaired.

The purpose of surgery is to reattach the torn tendon back to its insertion on the radial tuberosity. Although there are several techniques, our surgeons utilize a one incision technique with a metallic button. For those interested, the product we use can be found here.

The benefit of surgery is the reattachment of the tendon, and thus the greatest chance at strength recovery. The drawback of surgery relates to the risks of the operation. Your surgeon should detail these risks to you, although a few ones are unique to this surgery.

  1. Several nerves are very close in the surgical site. Many people are left with a patch of numbness over the back of the wrist on the thumb side. Rarely, patients may have a significant motor nerve injury that compromises hand function.
  2. Operations around the elbow may cause heterotopic ossification. In this condition, abnormal bone forms around the elbow leading to stiffness. We prescribe an anti-inflammatory medication to decrease the risk of this complication.
  3. Stiffness: any operation around the elbow has the potential to lead to stiffness and motion loss.
  4. Weakness: re-attachment of the tendon does not guarantee perfect use and strength of the arm. Post-operative physical therapy is key in maximizing function following surgery.

Surgery also requires a brief period of immobilization (2 weeks) and avoiding strengthening exercises for 6 weeks following surgery. This period of time allows the tendon to heal. Following this, gradual strengthening may occur.

Return to work is variable and depends largely on the type of job a person performs.

Non-Surgical Treatment

Therapy alone may be recommended to some patients, while others may chose this treatment over surgery. The benefit of non-surgical treatment is that a person can begin to move and use the arm immediately, with no true restrictions. Pain and arm cramping associated with the tendon tear will gradually improve. With time and therapy, strength will continue to improve. It remains unlikely, however, that someone will regain full strength with therapy alone. This may not be an issue in some circumstances (such as an injury to a non-dominant hand) but should be factored into the decision making.

Patients for whom surgery is not an option, or for those who decide surgery is not for them, can return to work within 1-4 weeks of injury with progressive hours and duties.

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. The following guidelines are for non-operatively treated shoulders. Therapy should be initiated, conducted and monitored by trained professionals.

  • Stage 1 – Motion: The first goal is to achieve and maintain the maximal amount of range of motion possible, ideally back to pre-injury state. Active and active assisted range of motion of the elbow, shoulder, wrist and fingers is started.
  • Stage 2 – Light Strengthening: To start when 80% of expected range of motion is achieved. Recommend starting with light bands and progress to cables and finally free weights. Focus is on low weight with higher repetition.
  • Stage 3 – Strengthening and Conditioning: This stage involves increasing weight to regain pre-injury strength. Exercises are tailored towards job-specific or sport-specific tasks. Care should be taken to maintain proper form and avoid re-injury.
  • Stage 4 – Maintenance: An often forgotten or neglected component of the rehabilitation program. Exercises from Stage 3 should be incorporated into a weekly fitness regimen with the goal of avoiding re-injury.

 

Notable Challenges

  • Post-Operative Pain: Shoulder surgery is painful, especially in the first two weeks following an operation. We utilize a multi-modal pain management strategy to keep a patient comfortable while also decreasing narcotic medication consumption.
  • Shoulder Stiffness and Weakness: Stiffness around the shoulder is to be expected, especially in operatively managed shoulders requiring post-operative immobilization in a sling. It can take upwards of a year to maximize gains in shoulder range of motion and strength. Physical therapy and ongoing exercises are critical for recovery during this time.
  • Complex Regional Pain Syndrome: a challenging adverse pain response associated with some fractures. Requires time, physical therapy and occasionally medications to treat.

 

Summary of Common Treatment/Rehabilitation Pathway

 

Olecranon Fractures

Introduction

The olecranon process is a part of your ulna and is important to normal elbow and forearm function.  Fractures of the olecranon process are typically separated into low and high energy mechanisms of injury.  Relatively young patients typically sustain high energy injuries and examples would include motor-vehicle accidents, falls from height and injuries sustained during contact sport. Relatively older patients are more at risk for low energy injuries as typically sustained in falls from standing height.

Treatment

After sustaining an injury to their elbow patients are typically seen by a physician in the emergency room.  An olecranon fracture is diagnosed following a physical examination and x-rays of the injured arm. It is important for the entire elbow to be examined in the emergency department as olecranon fractures are sometimes found in association with other injuries. “Open” olecranon fractures (where the broken bone has come through the skin) are also not uncommon, especially in older patients with poor skin. Open injuries require early administration of antibiotics and potentially updating your tetanus prophylaxis to decrease the risk of developing an infection.

Following your initial assessment and diagnosis in the emergency department, an orthopaedic surgeon will be consulted to manage your definitive care. There are two broad categories for the treatment of olecranon fractures:

  1. Non-Operative Treatment: There are several types of olecranon fractures which may not be treated with an operation:
    • Non-Displaced Fractures: If your fracture is not shifted (displaced) and you are able to move your elbow through a range of motion without any displacement, then your fracture likely does not require surgery.
    • Avulsion Fractures: Occasionally a forceful eccentric contraction of your triceps can cause a small flake of bone to come free from the olecranon. This may represent a complete separation of your triceps muscle from the olecranon and you would require a different surgical procedure to address this. If your ability to straighten your elbow against resistance is not impaired, however, these injuries can be treated without surgery.
    • Elderly Patients: There is increasing evidence in the medical literature that elderly patients with relatively low functional demands with even displaced olecranon fractures can be treated without surgery and expect a good functional result.  Given that this is somewhat controversial at present, you will have to speak with your surgeon surrounding the risks and benefits of pursuing this treatment approach.
  2. Operative Treatment: The majority of patients with displaced olecranon fractures will be treated with an operation.  Surgery will be performed after you have been assessed by an orthopaedic surgeon had the chance to discuss the risks, benefits and potential alternatives to surgery. Surgery is usually performed within 7 – 10 days of your injury. Depending on factors including the fracture location, the number of fracture fragments and the quality of your bone your surgeon will choose the most appropriate implant to address your injury.

Expected Follow-Up:

  1. 0 – 2 Weeks: For the first 7 – 14 days following your injury and subsequent operation, you may be asked to wear a splint to protect your elbow. The purpose of this splint is not so much to help in bone healing but rather to decrease the stress on the skin and soft tissue around your elbow and avoid issues with your surgical incision. You will be re-assessed in fracture clinic at 7 – 14 days from your injury for an examination of your incision, removal of skin clips or sutures and a repeat x-ray.
  2. 2 – 6 Weeks: If no complications are identified at your first follow-up appointment, you will be asked to start working on regaining the normal range of motion in your injured elbow. Your elbow is very sensitive to prolonged periods of immobility so it is important to begin working at your range of motion as soon as possible to avoid developing painful elbow stiffness. At this early stage following your injury you will likely be asked to avoid any strengthening to decrease the risk of fracture displacement. A good general guide for the amount of weight you should be limiting yourself to in your injured arm is a cup of coffee. A follow-up appointment will be arranged at around six weeks from your initial injury.
  3. 6 – 12 Weeks: After your 6 week post-operative assessment you will continue to work on your range of motion and may now begin working at gentle strengthening of your injured arm. You will likely be referred to a physiotherapist at this point in your rehabilitation. As your strength improves and you are able to use your injured arm for more activities you will be transitioned back to work (if you have been away). If your recovery has been straight forward then the follow-up assessment at 12 weeks from your injury may be the final one. Additional follow-up may be indicated for more severe injuries of if there have been any complications.

Complications

An operation to fix an olecranon fracture is subject to standard surgical risks such as infection, injury to nerves and blood vessels, and risks associated with your anaesthetic.  Additionally, there are some risks that are unique to this particular operation:

  1. Stiffness: Any injury to the elbow is at risk for the subsequent development of post-traumatic elbow stiffness and arthritis and this includes olecranon fractures. Your active participation in rehabilitation following your injury is extremely important in maximizing your range-of-motion post-operatively.
  2. Hardware Irritation: Your olecranon is almost immediately under the skin and this places it at increased risk of hardware prominence and irritation post-operatively. The risk of hardware irritation is roughly the same regardless of the type of implant your surgeon chooses to address your particular fracture. If that hardware is particularly bothersome, it may be removed once the fracture is solidly healed.

Outcome

Patients with olecranon fractures can generally expect good to excellent outcomes once their fracture has gone on to heal. As with other elbow injuries, patients must be particularly engaged in their post-injury rehabilitation in order to maximize their range-of-motion and outcome. Hardware removal relatively common following successful fracture healing.