16 - T&O Elbow and Forearm Flashcards
What is the aetiology of a supracondylar fracture?
Usually a paediatric injury aged 5-7 years
From a FOOSH with elbow in extension
Close proximity to neurovascular structures so assess!!!
How does a supracondylar fracture present?
- Follow recent fall sudden onset severe pain and reluctance to move arm
- On exam gross deformity, swelling, limited range of elbow movement, ecchymosis of anterior cubital fossa
- Can be damage to median, anterior interosseous, radial and ulnar nerve so test
- Test for vascular compromise e.g cool temperature, pallor, delayed cap refill, absent pulses
What are some differential diagnoses to consider with a supracondylar fracture?
- Olecranon fracture
- Distal humeral fracture
- Subluxation of radial head
How do you investigate and classify supracondylar fractures?
- AP and Lateral plain radiographs (see image)
- CT for comminute fracture or intrarticular extension
- Gartland Classification I to IV
How are supracondylar fractures managed?
- If Gartland I or II minimally displaced can try conservative with above elbow cast in 90 degrees flexion
- If neurovascular compromise immediate closed reduction in theatre and secure with K-wire fixation for 3-4 weeks
- If Gartland II to IV closed reduction and percutaneous K-wire fixation
- If open do open reduction with percutaneous pinning
What are some complications with a supracondylar fracture?
- Nerve Palsies: injury most likely to damage anterior interosseous nerve and K-wire post likely to damage ulnar
- Malunion: cubitus varus gunstock deformity
- Volkmann’s contracture: if vasculat compromise ischaemia and necrosis then fibrosis so hand and wrist in permanent flexion
- Compartment syndrome
What is the aetiology and pathophysiology of olecranon fractures?
- Bimodal age distribution with high energy in young and low energy indirect in old
- Usually from indirect trauma when a person falls on an outstretched arm so a sudden pull of the triceps OR in young direct trauma and associated with other forearm injuries
- Triceps pull will further distract the fracture
What are the clinical features of an olecranon fracture?
- History of FOOSH
- Pain, swelling, lack of mobility
- Tenderness when palpating back of elbow and possible palpable defect
- Inability to extend the elbow against gravity due to triceps mechanism damaged
May have assocaited injuries, e.g wrist ligaments, radial head fractures/dislocation, shoulder injuries, so examine wrist and shoulder
How should you investigate a suspected olecranon fracture?
- Routine blood tests, clotting screen, G+S
- AP and Lateral radiographs (see image)
- CT if comminuted
MAYO classification and SCHATZKER classification
How are olecranon fractures managed?
- Resuscitate and appropriate analgesia
- Treatment depends on degree of displacement on imaging
Non Operative (<2mm displacement or all over 75s)
- Immobilisation at 60 to 90 degrees elbow flexion and early introduction of range of motion at 1-2 weeks
Operative (<2mm displacement)
- Tension band wiring (if fracture proximal to coranoid process) or olecranon plating (if at level or distal to coranoid)
- Often remove metal working due to how superficial as bothers patient
What is the pathophysiology of a radial head fracture?
Most common fracture of the elbow and usually in people aged 20-60 years (F>M)
Usually by indirect trauma causing radial head to have axial loading against the capitulum of the humerus
Usually trauma in extension and pronation
What are the clinical features of a radial head fracture?
- History of FOOSH
- Elbow pain, swelling and bruising
- Tenderness on palpation of lateral elbow
- Pain and crepitus on pronation/supination
- Limited supination/pronation
- Elbow effusion
FOOSH associated with other wrist ligament and bony injures so examine shoulder and wrist joint
What is an Essex-Lopresti fracture?
Fracture of the radial head with disruption of the distal radio-ulnar joint
Always requires surgical intervention
How do you investigate a suspected radial head fracture?
- Routine bloods, clotting screen, G+S
- AP and Lateral radiographs of elbow and joint below and above (see image)
- CT if comminuted
- MRI if suspect ligament injury
How are radial head fractures classified?
Mason Classification
To do with the degree of displacement and angulation
How are radial head fractures managed?
- Treatment guided by Mason classification, neurovascular compromise and any mechanical block of the elbow (can patient flex-extend/supinate-pronate
- Mason 1: non operatively with sling immobilisation for less than a week and early mobilisation
- Mason 2: if no mechanical block treat like 1, otherwise do ORIF
- Mason 3: ORIF or radial head excision or replacement
Good prognosis but risk of secondary OA
What is the pathophysiology of an elbow dislocation?
Usually occur in young adults not many children or adults.
Can be simple or complex (concurrent fracture) and anterior or posterior
Stabilisers of elbow are damaged during dislocation so ongoing instability
What are the clinical features of an elbow dislocation?
- Following a high energy fall painful, deformed, swollen joint
- Decreased function, almost immobile
Need to do a complete neurovascular exam, if any concerns ovrer the pulse of the limb need to do a Doppler US
What investigations should you do if you suspect an elbow dislocation?
- ATLS protocol
- Plain film radiographs AP and lateral (see image)
- CT imaging
How are elbow dislocations managed?
Initial
- Examination and documentation of neurovascular status
- Closed reduction with analgesia and apply above elbow back slab at 90 degrees
- Reassess neurovascular status and take more radiographs
Definitive
- If no associated fracture outpatient with immobilisation for 5-14 days with early rehabilitation
- If fracture or neurovascular compromise do ORIF with soft tissue repair (LCL, MCL)
What are the complications with an elbow dislocation?
- Early stiffness with loss of terminal extension: do rehab to reduce the risk
- Stretching of the ulnar nerve
- Recurrent instability: however low recurrence rate in most
What is the Terrible Triad?
Posterior elbow dislocation with:
- Lateral collateral ligament injury
- Radial head fracture
- Coronoid fracture
Leads to a very unstable elbow and likely to have stiffness, instability, arthrosis. Needs radial head ORIF, LCL reconstruction, coronoid ORI
What are the causes of olecranon bursitis? (Infectious and Non-infectious)
Prone to trauma and pressure as superficial structure!!!
- Repetitve flexion-extension movements
- Gout
- RA
- Infected bursa with S.Aureus if skin abrasion
How is olecranon bursitis investigated?
- Routine bloods including rheumatological screen
- Serum urate levels
- Plain film radiographs can rule out bony injury
Gold standard: aspiration of fluid to send for crystal microscopy and culture. can provide some symptomatic relief. do not aspirate into the joint due to risk of seeding infection
How is olecranon bursitis managed?
No infection: analgesia (NSAIDs), rest, splinting elbow, if large and in pain can do washout in theatre
Infection: IV antibiotics (flucloxacillin or doxycycline if penicillin allergic) and surgical drainage. If prolonged can do bursectomy
What is the pathophysiology and aetiology of lateral and medial epicondylitis?
Microtears in the tendon at their origin due to repetitive injury. The tendon forms granulation tissue, fibrosis and eventually tendinosis
Affects men and women equally from ages 35-54 mostly
Risk factors: occupations and hobbies with excessive use of forearm muscles
How does lateral epicondylitis present and what are some special tests you can do on examination?
Pain affecting the lateral elbow that radiates down the forearm with pain worse over weeks to months.
Local tenderness on palpation of the lateral epicondyle
Reduce grip strength due to pain despite full range of movement
What are some differential diagnoses for lateral epicondylitis?
How is lateral epicondylitis investigated and managed?
Ix
- Diagnosis usually clinical but can do MRI or US
Mx
Conservative: modify activity, analgesia oral and topical, corticosteroid injections every 3-6 months, physiotherapy, elbow or wrist brace
Surgical (if symptoms not controlled): open or arthroscopic debridement of tendinosis and release/repair of any damaged tendon insertions. If tendon really damaged may need tendon transfer
What is the aetiology and classification of clavicle fractures?
Usually in adolescence/young adults or >60s with osteoporosis
Allman Classification
What are the risks associated with each Allman classification of clavicle fracture?
I (most common as middle third is weakest part): generally stable but significant deformity
II: unstable
III: can be associated with neurovascular compromise, pneumothorax, haemothorax as mediastinum sits behind medial third
What is the pathophysiology of a clavicle fracture?
Direct (fall onto clavicle) or indirect (fall onto shoulder)
Most common in middle third
Medial fragment will displace superiorly due to pull of SCM and lateral fragment will displace inferiorly due to weight of arm
How will a clavicle fracture present?
- Sudden onset localised severe pain made worse on movement
- Focal tenderness and deformity at fracture site
Always look for open injuries or threatened skin and neurovascular status as close to brachial plexus
What investigations are done for a clavicle fracture?
- AP and modified axial radiographs
What is the prognosis with a clavicle fracture, including any complications?
- 4-6 weeks healing time
- Non-union (especially distal third fractures)
- Neurovascular injury
- Puncture injuries (pneumothorax)
How are clavicle fractures managed?
Conservative
- Try to manage all this way unless open as no long term benefit and metal work is often prominent
- Sling with early movement of shoulder to prevent frozen shoulder
- Take sling off when pain-free movement
Surgical
- For open, comminuted, shortened or bilateral fractures
- If non-union ORIF done 2-3 months post injury
