Clinical elbow conditions Flashcards
Most common elbow injury
Supracondylar fracture (extraarticular, joint not involved)
How do supracondylar fractures occur?
FOOSH, elbow hyperextended
eg monkey bars
Age for supracondylar fractures
<10
Peak 5-7 years - more active
Presentation supracondylar fracture
Pain
Deformity
Loss of function
Less common supracondylar fracture
Elderly
Falling on flexed elbow (5%)
Displacement supracondylar fractures
Posterior displacement `
Main complications supracondylar fractures
Cubitus varus (gunstock deformity) Median nerve damage Ischaemic contracture (brachial artery)
Ischaemic contracture explained
Ischaemia –> infarction
Scar tissue (fibrosis)
Fibrous tissue contracts (myofibroblasts)
Volkmann’s ischaemic contracture
Volkmanns ischaemic contracture position
Flexed wrist and elbow
Pronated
Extended fingers at metocarpophalangeal joint
Flexed fingers at interphalangeal joint
Dislocated elbow, how does it occur?
FOOSH, elbow PARTIALLY flexed (strongest in full extension and flexion)
Elbow fracture X-ray
Posterior displaced
Ulna posteriorly displaced
(Humerus –> anterior)
Associated injuries dislocated elbow
Ulna ligament tear
Associated fracture?
Ulnar nerve damage
How do anterior elbow dislocations occur?
Force to posterior aspect of flexed elbow
What is pulled elbow?
Subluxation of radial head (partial disruption)
Due to tear of distal attachment to radius
Pulled elbow who and why?
Children 2-5 years old
Annular ligament weaker
What position is pulled elbow likely to occur in?
Pronated
Longitudinal traction on arm (pulling extended arm)
Why does subluxation occur more in pronated position?
Annular ligament is looser in pronation
Radial head more likely to ‘slip through’
Radial head and neck fracture cause
FOOSH
Radial head impacts on capitulum of humerus
Pulled elbow presentation
Reduced movement
Pain lateral proximal forearm (radial side)
Not using arm
Radial head and neck fracture presentation
Pain lateral proximal forearm
Loss of range of movement
Small swelling
X-ray sign radial head/neck fracture
Fat pad/Sail sign (dark grey patch around joint)
Effusion present
Blood into joint - haemarthrosis
What causes fat pad/sail sign?
Displacement of fat pads from fossas (olecranon)
Fat is less dense - dark black/grey
OA of elbow common people
Men > women
Manual workers
Athletes involving throwing (javelin)
Patient description OA elbow
Grating (crepitus)
Locking (loose cartilage)
Swelling = late
Paraesthesia (ulnar nerve impinged by osteophyte)
Rheumatoid arthiritis?
Autoimmune
Autoantibodies - rheumatoid factor attach synovial membrane
What happens in RA?
Inflammed synovial cells form pannus
Penetrates through cartilage to bone causing erosion and deformity
Where does RA mostly occur?
Metacarpophalangeal joints
Proximal interphalangeal joints
Hands, feet, cervical spine
Other damage RA
Anaemia of chronic disease
Damage to other organs (pericarditis, atherosclerosis, peripheral neuropathy)
RA vs OA
RA: OA:
20-40 Older
Rapid onset (remission/worse) Gradual
Symmetrical Unilateral begins
Pain improves with usage Pain worse with use
Fatigue, malaise No systemic effects
Radiological features RA
LESS
Loss of joint space
Erosions of bone (marginal/juxta-articular)
Soft tissue swelling
See through bones (periarticular osteopenia)
Can have subluxation/gross deformity of joints
What is tennis elbow?
Lateral elbow tendinopathy - Lateral epicondylitis
Lateral elbow tendinopathy presentation
Pain at common extensor origin (lateral epicondyle)
Why does lateral elbow tendinopathy occur?
Extensor carpi radialis brevis usually stabilises wrist when elbow extended
ECRB weakened due to overuse - microscopic tears in origin area
= inflammation and pain
When does pain occur LET?
Extension of wrist = lateral epicondylar pain
People likely to get LET
Tennis players
Painters
Plumbers
Carpenters
(repetitive extension of wrist)
What is golfers elbow?
Medial elbow tendinopathy - medial epicondylitis
What does MET affect?
Common flexor origin - medial epicondyle
Common site of MET
Between pronator teres and flexor carpis radialis origins
Patient presentation MET
Medial elbow ache
Pain on resisted pronation/flexion of wrist
Ulnar nerve symptoms (little finger +1/2 ring finger parathesia)
Causes of swellings of elbow
Olecranon bursitis
Rheumatoid nodules
Gouty Tophi
Assessing radial nerve function
Thumbs up -motor
Sensory - thumb and base of 2 first fingers (dorsum)
Assessing median nerve
Ok sign - motor
Sensory - tips of first two fingers, most palm of hand
Assessing ulnar nerve
Little finger + half ring finger
What is students elbow?
Olecranon bursitis
Due to repeated minor trauma (leaning on desk)
What occurs during olecranon bursitis?
Fills with serous fluid - transilluminates when light shines through it
Treatment olecranon bursitis
Cosmetic If infected (eg septic bursitis) need antibiotics and aspiration
Rheumatoid nodules
Have RA
Usually smoker and more aggressive RA
More prone to other extra-articular complications (eg vasculitis and lung disease)
where do RA nodules occur usually?
Over-exposed regions with repeated microtrauma
Elbow
Fingers
Forearms
Back of heel
What is gout?
Defective purine metabolism
Increased production of URIC ACID
Monosodium urate crystals deposited in synovial cavity
= acute inflammation
Gout treatment
NSAID’s
Xanthine oxidase inhibitors (reduce production of uric acid)
What are gout tophi?
Nodular masses of monosodium urate crystals in soft tissue
Caused by hyperuricaemia (untreated gout)
Complications gout tophi
Usually painless but: Pain Soft tissue damage Deformity Joint destruction Nerve compression
Common sites gout tophi
Fingers
Ears
Olecranon bursa
Elbow subcutaneous tissue (resemble RA nodules here)
What happens to gout tophi as enlarge?
Work way towards skin to drain via forming sinus tract or draining ulcer
Ulnar nerve journey
Posterior to medial epicondyle of humerus
Through cubital tunnel –> forearm
Where is cubital tunnel?
Posterolateral to medial epicondyle
Where does ulnar nerve often get compressed?
Flexor carpi ulnaris = two heads (medial epicondyle and medial olecranon origin)
Tendon arch joins them
Ulnar passes under this arch and can get compressed
How ulnar nerve injured?
Banging elbow on desk
Pain ulnar nerve trauma
Sharp pain radiating from elbow to cutaneous ulnar territory
Effects of ulnar nerve compression
Flexor carpi ulnaris affected
Median half of flexor digitorum profundus
Little finger + 1/2 ring finger parathesia
Treatment ulnar nerve compression
Surgically release and move anterior to medial epicondyle
