Conditions Of The Elbow And Surgery Flashcards
What is olecranon bursitis?
Inflammation + swelling of the olecaranon bursa
What can cause bursitis?
- repetitive movements > friction
- trauma
- inflammatory conditions (gout or RA)
- infection (septic bursitis)
Presentation of olecranon bursitis
- pain + swelling over the alecranon
- swollen, warm, tender, fluctuant
- normal ROM
Investigations of olecranon bursitis
- routine bloods
- Rf if suggestion of rheumatolgoical cause
- serum urate if suggestive of gout
- X-ray to rule out bony injury
- aspiration of fluid > microscopy + culture
What appearance could aspiration of bursa have?
What would this indicate?
- pus: infection
- straw coloured: infection less likely
- blood strained: trauma, infection or inflammatory cause
- milky: gout or pseudo gout
Management of olecranon bursitis
- RICE
- NSAIDs
- protect elbow from pressure or trauma
- aspiration of fluid
- washout in theatre
- if infected: abx *flucloxacillin first line + surgical drainage
What abx is first line in an infected bursa?
*flucloxacillin
clarithromycin if allergic
What could swelling on the elbow be?
Gouty tophi
Rheumatoid nodules
Olecranon bursitis
What is epicondylitis?
Inflammation at the point where the tendons of the forearm insert into the epicondyle at the elbow
Types of epicondylitis
- Lateral epicondylitis - tennis elbow (more common)
- Medial epicondylitis - Golfer’s elbow
Pathophysiology of epicondylitis
Repetitive overuse of the tendons can cause micro tears in the tendon at the origin > formation of granulation tissue, fibrosis + tendinosis
Outline lateral epicondylitis
What are the special tests for it?
- common extensor origin
- tennis elbow
- pain + tenderness at lateral epicondyle
- radiation down forearm > weakness in grip strength
- Mill’s test + Cozen’s test
What are the special tests for lateral epicondylitis
Mill’s test
Cozen’s test
What is Mill’s test?
What is it used for?
- pt lateral epicondyle is palpated by examiner whilst promoting the forearm, flexing the wrist + extending the elbow
- pain > positive test
- lateral epicondylitis
What is Cozen’s test?
What is it sued for?
- pt elbow is flexed at 90
- examiner places hand over lateral epicondyle
- other hand holds patietns hand in radially deviated position with forearm pronated
- pt extends wrist against resistance
- pain > positive test
- lateral epicondylitis
Outline medial epicondylitis
- common flexor origin
- golfer’s elbow
- pain + tenderness at medial epicondyle
- radiates down forearm > weakness in grip strength
- golfer’s elbow test
What is golfer’s elbow test?
What is it used for?
- stretching flexor muscles of forearm whilst palpating medial epicondyle
- extension of elbow, wrist + fingers, with forearm pronated
- pain > positive
- medial epicondylitis
Management of epicondylitis
- activity modifications
- simple analgesia
- Physiotherapy
- corticosteroid injections
- orthotics e.g. elbow braces or straps
- open or arthroscopic debridement
What certain activities increase the risk of repetitive strain injuries?
- vibrations e.g. power tools
- awkward positions e.g. painting ceiling
- small repetitive activities e.g. scrolling on phone
Management of repetitive strain injuries
- RICE
- activity adaptations
- analgesia
- Physiotherapy
- steroid injections
Most common type of elbow dislocation
Posterior
What factors contribute to the stability of the elbow joint?
- primary static stabilisers: humeroulnar joint capsule, medial + collateral ligaments
- secondary static stabilisers: radiocapetellar joint + joint capsule, common flexor + extensor origin tendons
- dynamic stabilisers: surrounding musculature
What should be suspected when a child has a deformed + painful elbow?
Supracondylar type fracture
Presentation of elbow dislocation
- painful + deformed joint
- swelling
- decreased function
- ulnar nerve damage
Investigations of elbow dislocation
- X-ray AP + lateral
- CT if associated fractures
X-ray findings of elbow dislocation
Loss of radiocapitellar + ulnartrochlea congruence
Managment of elbow dislocation
- closed reduction via in line traction or manipulation of olecranon
- analgesia
- above elbow backslab to keep elbow at 90
- repeat X-ray after reduction
- short period of immobility then early rehabilitation
- if fracture dislocation, open injury or NV compromise: ORIF
Complications of elbow dislocation
- early stiffness
- stretching of ulnar nerve
- recurrent instability
What is the terrible triad?
Elbow dislocation with:
- lateral collateral ligament injury
- radial head fracture
- coronoid fracture
Management of terrible triad
Radial head ORIF
Or
Arthropalsty with LCL reconstruction + coronoid ORIF
Demographic of subluxation of radial head (pulled elbow)
Young children 2-5 due to weak annular ligament
Cause of subluxation of radial head
Longitudinal traction with extended arm + forearm pronated
Causes radial head to sublux from annular ligament
parents swinging child by arms
Management of subluxation of radial head
Analgesia
Reverse the forces - flex elbow + supinate
What is the most common paediatric elbow fracture?
Supracondylar humeral fracture
Mechanism of supracondylar humeral fracture
FOOSH with elbow in extension
Presentation of supracondylar fracture
- young child
- gross deformity
- swelling
- limited ROM secondary to pain
- ecchymosis in anterior cubital fossa
Investigations of supracondylar fracture
- X-ray AP + lateral
- CT imaging if comminuted
- neurovascular exam
X-ray findings of supracondylar humeral fracture
- posterior fat pad sign
- displacement of anteior humeral line
Classification of supracondylar fracture
Gartland classification
- type I: undisplaced
- type II: displaced with intact posterior cortex
- type III: displaced in 2 or 3 planes
- type IV: displaced with complete periosteal disruption
Management of supracondylar fracture
- immediate closed reduction
- above elbow cast in 90 degrees flexion is undisplaced or minimally displaced
- if displaced: closed eduction + percutaneous K wire fixation
- open fracture: open reduction with percutaneous pinning
What structure is most at risk during surgery for supracondylar fracture?
Ulnar nerve
What nerve is most commonly damaged by supracondylar fracture?
Anterior interosseous nerve
Complications of supracondylar fractures
- damage to anterior interosseous nerve
- damage to ulnar nerve post op
- Malunion > cubitus varus deformity (gunstock deformity)
- Volkmann’s ischaemic contracture
What deformity can occur due to Malunion of supracondylar fracture ?
Cubital varus deformity
(Gunstock deformity)
What is the most common elbow fracture?
Radial head fractures
Pathophysiology of radial head fractures
- Via indirect trauma
- axial loading of the forearm
- casues the radial head to be pushed against the Capitulum of the humerus
- most commonly when arm is extended + pronated FOOSH
Articulation of radial head
Capitulum or humerus
Proximal ulnar
Presentation of radial head fractures
- tenderness on palpation over lateral aspect of elbow + radial head
- pain + crepitation on supination + pronation
- limited supination + pronation
Infestations of radial head fractures
- routine bloods incl clotting + G+S
- AP + lateral X ray +/- joints above + below
- CT if more complex
- MRI if associated ligament injuries
Classification of radial head fractures
Mason classification
- type I: non displaced or minimally displaced <2mm
- type II: partial articular fracture + displacement >2mm or angulation
- type III: comminuted fracture + displacement
Management of radial head fractures
- neurovascular exam
- mason type 1: short period of immobilisation with sling > early mobilisation
- mason type 2: ORIF
- mason type 3: ORIF or raidal head excision or replacement
What is a Essex-Lopresti fracture?
Fracture of radial head with dislocation of radio-ulnar joint
Presentation of olecranon fracture
- history of FOOSH
- elbow pain
- swelling
- lack of mobility
- tenderness on posterior elbow
- inability to extend elbow against gravity
Investigations of olecranon fractures
- routine bloods incl clotting, G+S
- X-ray AP + lateral
- CT if more complex
Classification of olecranon fractures
Mayo classification
Schatzker classification
Management of olecranon fractures
- analgesia
- displacement <2mm: immobilisation in 90 elbow flexion
- displacement >2mm: tension band wiring or olecranon plating
What is cubital tunnel syndrome?
Compression of ulnar nerve in cubital tunnel between the two heads of flexor carpi ulnaris
Presentation of cubital tunnel syndrome
- numbness in ring + little finger
- worse with elbow flexion + at night
- hand pain
Treatment of cubital tunnel syndrome
- splinting at night 45 degrees
- analgesia
- nerve gliding exercises
- adapting activities
- elbow pad
