Upper Extremity Trauma: page 1 of 15 Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Topics Giving Credit to Famous Authors Charles Monroe “Sparky” Schultz (1922-2000) Anatomy Thanks to Carrie Bartels Anatomy Creator of… Radiographs and Shana Jatczak for Radiographs Charlie Brown FOPH the 3D processing and FOPH BBFF segmentation! BBFF 1947: Li’l Folks Monteggia Monteggia 1950: Peanuts 2600 newspapers Galeazzi Galeazzi 21 languages Essex-Lop. Essex-Lop. 355 million readers in Fat Pads Fat Pads 75 countries Published a total of Peds Elbow Peds Elbow 17,897 strips Supracond. Supracond. “arguably the longest Lat.condyle Lat.condyle story ever told by one human being”* Med.epicon. Med.epicon. 4 4 March 1964… www.schreibman.info www.schreibman.info wikipedia.org © 2013 Ken L Schreibman, PhD/MD Slide 1 of 90 © 2013 Ken L Schreibman, PhD/MD *Professor Robert Thompson, Syracuse University Slide 2 of 90 Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm What’s wrong with Charlie Brown’s arm? Elbow: [OE] el “forearm” + bow “bend” Anatomy Anatomy 3 Bones Radiographs Radiographs Humerus FOPH FOPH BBFF BBFF Monteggia Monteggia Galeazzi Galeazzi Essex-Lop. Essex-Lop. Fat Pads Fat Pads Radius Peds Elbow Peds Elbow Supracond. Supracond. Lat.condyle Lat.condyle Med.epicon. Med.epicon. 4 4 Ulna www.schreibman.info www.gocomics.com 3/6/1964 www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 3 of 90 © 2013 Ken L Schreibman, PhD/MD Slide 4 of 90 Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Parts of the Humerus Parts of the Ulna Anatomy Anatomy Radiographs Humerus Radiographs Humerus Coracoid Radius FOPH FOPH Scapula BBFF BBFF Monteggia Monteggia [Gr] ōlenē “elbow” Galeazzi Medial Galeazzi + krānion “head/skull” Trochlea Essex-Lop. Epicondyle Lateral Essex-Lop. “Head of the Elbow”* Coronoid Fat Pads Epicondyle Fat Pads Olecranon Peds Elbow Peds Elbow Supracond. Capitellum Supracond. Coronoid Lat.condyle [L] “small head” Lat.condyle Trochlea [Gr] “crow’s beak” Mandible Med.epicon. [Gr] “pulley” round like a ball Med.epicon. 4 round like a spool 4 www.schreibman.info Ulna www.schreibman.info Ulna © 2013 Ken L Schreibman, PhD/MD Slide 5 of 90 © 2013 Ken L Schreibman, PhD/MD *dartmouth.edu Slide 6 of 90 ©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info Upper Extremity Trauma: page 2 of 15 Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Olecranon-Trochlea Joint “Joint Mice” Anatomy Hinge Joint Anatomy Loose bodies Radiographs Radiographs Small fragment off the FOPH Extension FOPH in joint capsule tip of the coronoid… BBFF Flexion BBFF Bone fragment Monteggia Monteggia Cartilage piece Galeazzi Olecranon Galeazzi Essex-Lop. Fossa Essex-Lop. Can limit range Fat Pads (deep) Fat Pads of motion (ROM) Peds Elbow Peds Elbow Supracond. Anterior view Supracond. In coronoid fossa Lat.condyle Coronoid Lat.condyle Limits flexion … limiting flexion Med.epicon. Fossa Med.epicon.In olecranon fossa 4 Posterior view (shallow) 4 Limits extension www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 7 of 90 © 2013 Ken L Schreibman, PhD/MD Slide 8 of 90 Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Parts of the Radius Radiocapitellar Joint Anatomy 3 Bones Anatomy Ball & Socket Joint Radiographs Humerus Radiographs FOPH FOPH Flex & Extend BBFF BBFF Rotate Monteggia Radial Neck Monteggia Pronation & Galeazzi Radial Head Outside the Galeazzi Supination Essex-Lop. joint capsule Essex-Lop. Fat Pads Round & flat Radius Fat Pads #1: Peds Elbow Like a disk Peds Elbow Supracond. Inside the Supracond. Radial head ALWAYS Lat.condyle joint capsule Radial Tuberosity Lat.condyle points to the Capitellum Med.epicon. (Biceps Tuberosity) Med.epicon. Regardless of how the elbow is bent 4 UlnaInsertion of Biceps Brachii Tendon 4 Regardless of how the x-ray beam is oriented www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 9 of 90 © 2013 Ken L Schreibman, PhD/MD Slide 10 of 90 Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Elbow Radiographs AP View Anatomy Anatomy Radiographs Radiographs FOPH FOPH BBFF BBFF X-ray Monteggia Monteggia beam Galeazzi Galeazzi Vertical Essex-Lop. Essex-Lop. Capitellum Elbow C Fat Pads Fat Pads raised to aligned Peds Elbow Peds Elbow shoulder with R Supracond. Supracond. height Lat.condyle Lat.condyle Radial head Med.epicon. Med.epicon. 4 4 Elbow straight www.schreibman.info www.gocomics.com 3/5/1964 Marty Brown www.schreibman.info C,A 34yoF © 2013 Ken L Schreibman, PhD/MD age 15½ Slide 11 of 90 © 2013 Ken L Schreibman, PhD/MD Slide 12 of 90 ©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info Upper Extremity Trauma: page 3 of 15 Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Lateral View Radial Head View Anatomy Anatomy Capitellum Radiographs Capitellum Radiographs FOPH X-ray aligned FOPH X-ray aligned BBFF beam with BBFF beam with Vertical angled Monteggia Radial head Monteggia Radial head Galeazzi Galeazzi 45° Essex-Lop. Essex-Lop. C R Elbow C R Elbow Fat Pads flexed Fat Pads flexed Peds Elbow 90° Peds Elbow 90° Supracond. Supracond. Lat.condyle Lat.condyle Med.epicon. Med.epicon. 4 Coronoid overlaps Radial Head 4 Eliminates Radial Head Overlap www.schreibman.info K,C 33yoF www.schreibman.info Greenspan. AJR 1982; 138: 1186 H,E 22yoF © 2013 Ken L Schreibman, PhD/MD Slide 13 of 90 © 2013 Ken L Schreibman, PhD/MD Slide 14 of 90 Upper Extremity Trauma ElbowPart & Forearm 2: Wrist Upper Extremity Trauma Elbow & Forearm Fall On Out-Stretched Hand (FOOSH) Fall On Palm Heel (FOPH) H Anatomy R Anatomy U Radiographs Radiographs M A U TRO CAP FOPH D L FOPH BBFF I N BBFF Monteggia U A Monteggia Which load R Hyperextend Hyperextend S U A Galeazzi Wrist Wrist Galeazzi dominates Essex-Lop. Essex-Lop. ulna or L D radius N I Fat Pads Fat Pads determines A U Peds Elbow S Peds Elbow the pattern S of injury Supracond. HAND Supracond. Up Ulna Load Axial Lat.condyle Lat.condyle Up Radius Load Axial CARPUS Med.epicon. Med.epicon. Forearm Up Axial Load PALM 4 4 Fall On Fall On FOOSH Palm Palm www.schreibman.info Marty age 8½ www.schreibman.info Marty age 8½ Heel Heel © 2013 Ken L Schreibman, PhD/MD Slide 15 of 90 © 2013 Ken L Schreibman, PhD/MD Slide 16 of 90 Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Forearm is a Ring Forearm is a Ring H H Anatomy “You can’t break a ring in 1 place” U Anatomy You CAN break a ring in 1 place U Radiographs M Radiographs M FOPH This is not entirely true… TRO CAP FOPH With a direct blow, TRO CAP BBFF Yes, with a fall on the palm heel, BBFF like from a stick, Monteggia R Monteggia the forearm ring breaks in 1 place R Galeazzi causing an axial load, U A Galeazzi U A the forearm ring breaks in 2 places L D L D Essex-Lop. N I Essex-Lop. N I Fat Pads “Both Bone Forearm Fracture” Fat Pads “Nightstick fracture” A U Ulna A U Peds Elbow Fracture/Dislocations S Peds Elbow S Mid-shaft Supracond. Monteggia Supracond. Lat.condyle Lat.condyle Uncommon fracture Med.epicon. Galeazzi CARPUS Med.epicon. Uncommon mechanism CARPUS Fall On 4 Essex-Lopresti Palm 4 Heel www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 17 of 90 © 2013 Ken L Schreibman, PhD/MD Slide 18 of 90 ©Ken L Schreibman, PhD/MD 6/4/15 www.schreibman.info Upper Extremity Trauma: page 4 of 15 Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm About to get a nightstick fracture… Nightstick (isolated ulna) fracture Anatomy Anatomy Treated Radiographs Radiographs w/cast FOPH FOPH BBFF BBFF Monteggia Monteggia After 1 month After 2 months Galeazzi Galeazzi Essex-Lop. Essex-Lop. Fat Pads Fat Pads Peds Elbow Peds Elbow Supracond. Supracond. Lat.condyle Lat.condyle Med.epicon. Med.epicon. 4 4 www.schreibman.info Chicago, 1968 www.schreibman.info S,E 9yoM, friend fell on the patient’s arm © 2013 Ken L Schreibman, PhD/MD Slide 19 of 90 © 2013 Ken L Schreibman, PhD/MD Slide 20 of 90 Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Forearm Ring: Both Bone Forearm Fracture Adult BBFF H Anatomy Common pattern U Anatomy Radiographs M Radiographs TRO CAP Cast not FOPH Children 7 FOPH BBFF 75% distal ⅓* months BBFF sufficient Monteggia Heal, remodel later R Monteggia for such Galeazzi <10yo, <25° U A Galeazzi unstable L D fracture. Essex-Lop. angulation OK** N I Essex-Lop. Fat Pads >10yo, >10° A U Fat Pads S So next Peds Elbow unlikely to correct Peds Elbow day… Supracond. Up Ulna Load Axial Supracond. Adult Up Radius Load Axial Lat.condyle Lat.condyle Med.epicon. Most require CARPUS Med.epicon. ORIF Fall On 4 Palm 4 Heel www.schreibman.info *wheelessonline.com P,Z 12yoM www.schreibman.info K,N 54yoF © 2013 Ken L Schreibman, PhD/MD **wheelessonline.com Slide 21 of 90 © 2013 Ken L Schreibman, PhD/MD Slide 22 of 90 Upper Extremity Trauma Elbow & Forearm Upper Extremity Trauma Elbow & Forearm Forearm Ring: Monteggia Fracture #1: Radial Head Points to Capitellum H Radial dislocation Need to look Anatomy Fracture proximal ⅓ ulna U Anatomy not so obvious closely at lateral Lateral--------- Not a True Lateral Radiographs M Radiographs + dislocation radial head TRO CAP FOPH FOPH BBFF relative to capitellum BBFF Monteggia Not uncommon Ulna fx is fx/dislocations Monteggia R Monteggia obvious… Galeazzi I see several of these a year U A Galeazzi can be quite Important not to miss the L D subtle Essex-Lop.