Clinical elbow conditions Flashcards by Rebekah Agunede

Most common elbow injury

Supracondylar fracture (extraarticular, joint not involved)

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How do supracondylar fractures occur?

FOOSH, elbow hyperextended

eg monkey bars

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Age for supracondylar fractures

<10

Peak 5-7 years - more active

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Presentation supracondylar fracture

Pain
Deformity
Loss of function

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Less common supracondylar fracture

Elderly

Falling on flexed elbow (5%)

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Displacement supracondylar fractures

Posterior displacement `

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Main complications supracondylar fractures

Cubitus varus (gunstock deformity)
Median nerve damage
Ischaemic contracture (brachial artery)

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Ischaemic contracture explained

Ischaemia –> infarction
Scar tissue (fibrosis)
Fibrous tissue contracts (myofibroblasts)
Volkmann’s ischaemic contracture

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Volkmanns ischaemic contracture position

Flexed wrist and elbow
Pronated
Extended fingers at metocarpophalangeal joint
Flexed fingers at interphalangeal joint

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Dislocated elbow, how does it occur?

FOOSH, elbow PARTIALLY flexed (strongest in full extension and flexion)

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Elbow fracture X-ray

Posterior displaced
Ulna posteriorly displaced

(Humerus –> anterior)

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Associated injuries dislocated elbow

Ulna ligament tear
Associated fracture?
Ulnar nerve damage

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How do anterior elbow dislocations occur?

Force to posterior aspect of flexed elbow

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What is pulled elbow?

Subluxation of radial head (partial disruption)

Due to tear of distal attachment to radius

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Pulled elbow who and why?

Children 2-5 years old

Annular ligament weaker

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What position is pulled elbow likely to occur in?

Pronated

Longitudinal traction on arm (pulling extended arm)

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Why does subluxation occur more in pronated position?

Annular ligament is looser in pronation

Radial head more likely to ‘slip through’

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Radial head and neck fracture cause

FOOSH

Radial head impacts on capitulum of humerus

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Pulled elbow presentation

Reduced movement
Pain lateral proximal forearm (radial side)
Not using arm

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Radial head and neck fracture presentation

Pain lateral proximal forearm
Loss of range of movement
Small swelling

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X-ray sign radial head/neck fracture

Fat pad/Sail sign (dark grey patch around joint)
Effusion present
Blood into joint - haemarthrosis

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What causes fat pad/sail sign?

Displacement of fat pads from fossas (olecranon)

Fat is less dense - dark black/grey

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OA of elbow common people

Men > women
Manual workers
Athletes involving throwing (javelin)

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Patient description OA elbow

Grating (crepitus)
Locking (loose cartilage)
Swelling = late
Paraesthesia (ulnar nerve impinged by osteophyte)

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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