2.05 Trauma and Orthopaedics - The Elbow Flashcards
Give some factors that contribute towards elbow joint stability.
- humeroulnar joint
- radiocapetellar joint
- joint capsule
- medial and collateral ligaments
- common flexor and extensor origin tendons
- surrounding musculature (ie. anconeus, brachialis, triceps brachii)
What are the clinical features of elbow dislocation?
- typically present following high-energy fall
- painful and deformed joint
- swelling
- decreased function
What neurovascular findings are common OE of elbow following dislocation?
- neuropraxia of the ulnar nerve causes deficit in the territory of the ulnar nerve
- elbow has rich collateral circulation, so good capillary refill even in those with arterial injury
What investigations can be used to assess elbow dislocation?
- plain film radiographs (AP and lateral)
What X-ray findings are consistent with an elbow dislocation?
Loss of radiocapitellar and ulnotrochlea congruence.
How is elbow dislocation managed?
- closed reduction
- sufficient analgesia / sedation
- apply above elbow backslab
- plain film radiograph to confirm reduction
If the dislocation is complicated by a fracture, open type injury, or has neurovascular compromise, ORIF may be used to surgically fix the injury.
What are the common complications of elbow dislocation?
- neuropraxia of the ulnar nerve
- recurrent instability
- early stiffness
What is the terrible triad of an elbow dislocation?
An elbow dislocation associated with:
1) lateral collateral ligament injury
2) radial head fracture
3) coronoid fracture
The combination of injuries causes a very unstable elbow, and patients are likely to have recurrent problems with instability, stiffness and arthrosis.
Treatment involves ORIF and surgical reconstruction of LCL.
What is the common aetiology of olecranon bursitis?
Repetitive flexion-extension movements at the elbow causes irritation of the bursa, due to its superficial position and its vulnerability to pressure and trauma.
What are the clinical features of olecranon bursitis?
- pain and swelling
- range of motion preserved
- systemic symptoms
What are the differential diagnoses for olecranon bursitis?
- inflammatory arthropathies
- gout
- cellulitis
- septic arthritis
What investigations can be used to assess olecranon bursitis?
- bloods (FBC, CRP)
- serum urate if history is suggestive of gout
- ACPA if history suggestive of rheumatological cause
- plain film radiograph to rule out bony injury
- aspiration of fluid for microscopy and culture (GOLD STANDARD)
How is olecranon bursitis treated?
Swellings without infection can be treated with analgesia and rest.
If infection is present, IV abx and surgical drainage / washout indicated.
What are the main complications of infected olecranon bursitis?
- septic arthritis
- osteomyelitis
Most cases will resolve spontaneously
What is epicondylitis?
A chronic and symptomatic inflammation of the forearm tendons at the elbow, classified as an overuse syndrome in the elbow.
Caused by microtears in the tendons following repetitive injury.
Out of lateral and medical epicondylitis, which is more common?
Lateral epicondylitis is more common, affecting 4-7 people per 1000 per year.
What is the pathophysiology of lateral epicondylitis?
Repetitive overuse of common extensor tendon causes microtears at its origin (lateral epicondyle).
This leads to the formation of granulation tissue, fibrosis and eventually tendinosis.
What is the main risk factor for lateral epicondylitis?
Occupations and hobbies that are associated with excessive use of extensive forearm muscles.
Commonly named tennis elbow.
What are the clinical features of lateral epicondylitis?
- pain at elbow and radiating down to forearm
- worsens over weeks to months
OE localised tenderness on palpation over the lateral epicondyle and common extensor tendon.
What special tests can be used to identify lateral epicondylitis?
Cozen’s test - positive test if pain over lateral epicondyle against wrist extension.
Mill’s test
What special tests can be used to identify lateral epicondylitis?
Cozen’s and Mill’s test
https://www.youtube.com/watch?v=8K7jzDIUpLI
https://www.youtube.com/watch?v=r_A84ox9JRM
What investigations are required to diagnose lateral epicondylitis?
Diagnosis is clinical, with no further imaging needed.
Occasionally ultrasound or MRI imaging used to detect structural abnormality if suspected.
How is lateral epicondylitis managed?
- modify activities to reduce repetitive actions
- simple analgesia and topical NSAIDs
- corticosteroid injections
- physiotherapy
If conservative measures do not control symptoms, surgical intervention via open or arthroscopic debridement may be warranted.
What is the prognosis of lateral epicondylitis?
Usually self-limiting and spontaneously improves in most patients within 2 years.
What is the pathophysiology of medial epicondylitis?
Repetitive overuse of pronator teres and flexor carpi radialis causes microtears at their origin (medial epicondyle).
This leads to the formation of granulation tissue, fibrosis and eventually tendinosis.
AKA golfers elbow.
What is the typical MOI of a supracondylar humeral fracture?
Common paediatric elbow injury (peak 5-7yo).
MOI is FOOSH with elbow in extension.
What are the clinical features of a supracondylar humeral fracture?
- recent fall or direct trauma (FOOSH)
- sudden onset severe pain
- limited ROM
- gross deformity
- swelling
- ecchymosis at ACF
Which nerves are most at risk in a supracondylar fracture?
- median nerve
- anterior interosseous nerve
- radial nerve
- ulnar nerve
Which x-ray findings are consistent with a supracondylar fracture?
- posterior fat pad sign
- displacement of anterior humeral line
CT imaging may be useful to aid surgical planning.
What classification system is used to grade supracondylar humeral fractures?
Gartland classification system
How are supracondylar fractures managed?
- immediate closed reduction is neurovascular compromise
- above elbow cast at 90° flexion if undisplaced
- percutaneous K-wire fixation if displaced
- open reduction with pinning if open fracture
What are the complications of supracondylar fracture?
- anterior interosseous nerve injury (most common)
- ulnar nerve at risk during insertion of medial K-wire
- malunion
- Volkmann’s contracture
Outline the pathophysiology of Volkmann’s contracture following supracondylar humeral fracture.
- fracture causes vascular compromise to flexor muscles of the forearm
- flexor muscles necrose and then fibrose
- contracture forms, resulting in the wrist and hand to be held in a permanent flexion, claw-like deformity
Outline the pathophysiology of an olecranon fracture.
FOOSH resulting in sudden pull of triceps and brachialis, resulting in an avulsion fracture of the olecranon.
What are the clinical features of an olecranon fracture?
- FOOSH
- elbow pain
- swelling
- low ROM
-tenderness
Associated injuries at the wrist and shoulder joints also common, so should be assessed.
What investigations are warranted to diagnose olecranon fracture?
- routine blood tests, incl. clotting screen and group and save
- AP and lateral plain film radiograph
What is the management of olecranon fractures?
- immobilise elbow at 90°; early reintroduction of movement
- tension band wiring
When is operative management of an olecranon fracture indicated?
Displacement >2mm
What is the commonest mechanism of injury of a radial head fracture?
Axial loading of the forearm causing the radial head to be pushed against the capitulum of the humerus.
What are the clinical features of radial head fractures?
- FOOSH
- elbow pain
- swelling / bruising
Which x-ray findings are consistent with a radial head fracture?
- elbow effusion
- fat bad sign
- fracture line in radial head
How are radial head fractures classified?
Using Mason classification system
What is the management of radial head fractures?
- adequate analgesia
- sling
- ORIF
- radial head arthroplasty
What is a Essex-Lopresti fracture?
A fracture of the radial head and dislocation of the distal radio-ulnar joint.
Important to assess wrist and shoulder joint when assessing elbow injury.
