16 - T&O Elbow and Forearm

Question 1

What is the aetiology of a supracondylar fracture?

Answer 1

Usually a paediatric injury aged 5-7 years

From a FOOSH with elbow in extension

Close proximity to neurovascular structures so assess!!!

Question 2

How does a supracondylar fracture present?

Answer 2

• 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

Question 3

What are some differential diagnoses to consider with a supracondylar fracture?

Answer 3

• Olecranon fracture
• Distal humeral fracture
• Subluxation of radial head

Question 4

How do you investigate and classify supracondylar fractures?

Answer 4

• AP and Lateral plain radiographs (see image)
• CT for comminute fracture or intrarticular extension
• Gartland Classification I to IV

Question 5

How are supracondylar fractures managed?

Answer 5

• 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

Question 6

What are some complications with a supracondylar fracture?

Answer 6

- 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

Question 7

What is the aetiology and pathophysiology of olecranon fractures?

Answer 7

- 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

Question 8

What are the clinical features of an olecranon fracture?

Answer 8

- 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

Question 9

How should you investigate a suspected olecranon fracture?

Answer 9

• Routine blood tests, clotting screen, G+S
• AP and Lateral radiographs (see image)
• CT if comminuted

MAYO classification and SCHATZKER classification

Question 10

How are olecranon fractures managed?

Answer 10

• 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

Question 11

What is the pathophysiology of a radial head fracture?

Answer 11

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

Question 12

What are the clinical features of a radial head fracture?

Answer 12

• 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

Question 13

What is an Essex-Lopresti fracture?

Answer 13

Fracture of the radial head with disruption of the distal radio-ulnar joint

Always requires surgical intervention

Question 14

How do you investigate a suspected radial head fracture?

Answer 14

• 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

Question 15

How are radial head fractures classified?

Answer 15

Mason Classification

To do with the degree of displacement and angulation

Question 16

How are radial head fractures managed?

Answer 16

• 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

Question 17

What is the pathophysiology of an elbow dislocation?

Answer 17

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

Question 18

What are the clinical features of an elbow dislocation?

Answer 18

• 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

Question 19

What investigations should you do if you suspect an elbow dislocation?

Answer 19

• ATLS protocol
• Plain film radiographs AP and lateral (see image)
• CT imaging

Question 20

How are elbow dislocations managed?

Answer 20

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)

Question 21

What are the complications with an elbow dislocation?

Answer 21

- 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

Question 22

What is the Terrible Triad?

Answer 22

Posterior elbow dislocation with:

1. Lateral collateral ligament injury
2. Radial head fracture
3. Coronoid fracture

Leads to a very unstable elbow and likely to have stiffness, instability, arthrosis. Needs radial head ORIF, LCL reconstruction, coronoid ORI

Question 23

What are the causes of olecranon bursitis? (Infectious and Non-infectious)

Answer 23

Prone to trauma and pressure as superficial structure!!!

• Repetitve flexion-extension movements
• Gout
• RA
• Infected bursa with S.Aureus if skin abrasion

Question 24

How does olecranon bursitis present?

Answer 24

• Pain and swelling over the olecranon that increases over time
• Range of motion preserved with minimal discomfort as doesn’t affect joint capsule
• If infected can have systemic symptoms

Can differentiate from septic arthritis as no range of movement in this as too much pain!

Question 25

How is olecranon bursitis investigated?

Answer 25

- 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

Question 26

How is olecranon bursitis managed?

Answer 26

**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

Question 27

What is the pathophysiology and aetiology of lateral and medial epicondylitis?

Answer 27

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

Question 28

How does lateral epicondylitis present and what are some special tests you can do on examination?

Answer 28

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

Question 29

What are some differential diagnoses for lateral epicondylitis?

Answer 29

Question 30

How is lateral epicondylitis investigated and managed?

Answer 30

**_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

Question 31

What tendons cause Golfer's and Tennis Elbow?

Answer 31

**Lateral:** ECRB **Medial:** PT and FCR

Question 32

What is the aetiology and classification of clavicle fractures?

Answer 32

Usually in adolescence/young adults or \>60s with osteoporosis **Allman Classification**

Question 33

What are the risks associated with each Allman classification of clavicle fracture?

Answer 33

**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

Question 34

What is the pathophysiology of a clavicle fracture?

Answer 34

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

Question 35

How will a clavicle fracture present?

Answer 35

- 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

Question 36

What investigations are done for a clavicle fracture?

Answer 36

- AP and modified axial radiographs

Question 37

What is the prognosis with a clavicle fracture, including any complications?

Answer 37

- 4-6 weeks healing time - Non-union (especially distal third fractures) - Neurovascular injury - Puncture injuries (pneumothorax)

Question 38

How are clavicle fractures managed?

Answer 38

**_Conservative_** ## Footnote - 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

Question 39

What are the two fractures that are highest risk of compartment syndrome?

Answer 39

* Tibial shaft * Supracondylar