Disorders of the elbow Flashcards
1
Q
What common disorders of the elbow are there?
A
- Acute / Traumatic
- Dislocations / Fractures / Fracture Doslocations
- Chronic / Degenerative / Overuse
- Arthiritis / Tendinopathies.
- They can be features of systemic disease.
- Referred pain
2
Q
Elbow dislocation
A
- 2nd most common dislocation
- Fall onto out-stretched hand (with elbow partially flexed) ‘FOOSH’ - secondary injury
- Childen and young adults
- Pain / deformity / loss of function
- Usually posterior +/- Fractures (Named by the movement of the distal part - so radius or ulna rather than humerus)
- Reduce and splint - NVT assessment
- Ulnarcollateral is usually torn - can also be associated fracture of ulnar nerve involvement
- Prognosis
- Good outcome if ‘simple’
- Stiffness / recurrent instability.
- Anterior dislocations (10%) -direct blow to posterior flexed elbow. Olecranon fractures commonly seen along side this due to the force required.
3
Q
Supracondylar fracture distal humerus
A
- FOOSH
- 75% of elbow injuries
- 5-7 yrs, Boys > Girls
- Falling from height with arm hyperextended (falling from money bars)
- Or, falling onto flexed elbow - elderly and less common
- Pain / Swelling / Bruising / Loss of Function / Deformity
- Neurovascular compromise
- Parasthesiae / ‘OK’ sign / Radial pulse / Capillary return
- Displaced v Undisplaced
- Collar and Cuff +/- POP backslab
- Surgery
- MUA +/- K wire stabilisation. (To control it while fracture heals)
- Neurovascular injury, late deformity, late neuropathy
- Can treat with traction (physiotherapy).
4
Q
What complications can occur wiht supracondylar fractures of the distal humerus?
A
- Malunion - resulting in cubitus varius (gunstock deformity)
- Nerve damage - Ulnar (most common), median or radial
- Ischaemic contracture - The brachial artery passes very close to the fracture site and can occasionally be damaged or occluded by a displaced fracture. If reflex spasm of the collateral circulation around the elbow also occurs, there will be ischaemia of the muscles in the anterior compartment of the forearm. This results in oedema and a rise in compartment pressure (compartment syndrome) which further exacerbates the ischaemia as it impedes arterial inflow and, if untreated, the muscle bellies will undergo infarction. During the repair phase, the dead muscle tissue becomes replaced by scar tissue through fibrosis. The fibrotic tissue contracts (by myofibroblast activity) eventually resulting in a frexion contracture known as Volkmanns ischaemic contracture.
The wrist is typically flexed, the fingers are extended at the metacarpophalangeal joints and flexed at the interphalangeal joints, the forearm is often pronated and the elbow is flexed.
In order to minimize the risk of these complications, it is essential that a prompt and thorough neurovascular examination is conducted in any patient with a supracondylar fracture. If there is any compromise of the neurovascular supply of the forearm or hand, emergency reduction and fixation of the fracture (under anaesthetic) is required.
5
Q
Radial head / neck fractures
A
- FOOSH - radial head impacts on the capitellum
- Commonest elbow fracture
- Lateral pain in proximal forearm / mild swelling (compared to supracondylar fractures) / loss of range
- Occult (hidden) fracture
- Haemarthrosis (blood in the joint)
- ‘Fat pad’ / ‘Sail’ Signs - indicates effusion is present
- Displaced fat looks ‘Black’
- Sling and early ROM
- If minimally displaced
- Surgery
6
Q
Subluxation of Radial Head
A
- “pulled elbow” / Nersemaid’s Elbow
- Subluxation from annular ligament (distal attatchment from where it is attatched to the neck of the radius)
- As children age, annular ligament strengthens so condition is less common
- Traction along extended arm (pull uncooperative child)
- Pronation
- Pre-school / 2-5yrs old (but NOT less than 1 as they can’t walk so can’t run away)
- Reduced movements / pain on lateral aspect / ‘Not using it’
- Closed reduction
- Sling and spontaneous resolution
7
Q
Elbow osteoarthrits
A
- Degenerative disease of articular cartilage
- Uncommon in elbow as there are well matched joint surfaces an strong, stabilising ligaments.
- Primary or secondary
- Males > Females 4:1
- Manual workers
- Symptoms may be minor - crepitus or locking, swelling occurs late and due to effusion
- Stiffness tolerated well
- Prasthesia if osteophytes impinge on ulna nerve and/or muscle weakness.
- Treatment only if symptomatic
- Injections
- Surgical Debridement
- Rarely total Elbow Replacement
8
Q
Elbow Rheumatoid Arthrits
A
- Systemic Autoimmune disease
- inflammatory arthropathy
- Sero-positive for RhF (rheumatoid factor) -It attacks the synovial membrane
- Symmetric
- Morning stiffness
- Metacarpopharyngeal joints and proximal interphalangeal joints of the hands, feet and cervical spine (Small joints). But, can also affect large joints
- Autoimmune process leads to damage to organs and anaemia of chronic disease.
- Synovial pannus caused by proliferation of inflammed synovial cells- Joint destruction by eroding through cartilage and adjacent bone leading to joint erosion and deformity.
- Early medical treatment
- Usually Medication rather than surgery. .
- Biologics
- DMARDs
- Surgery - Sometimes surgery to relive pain and improve mobility
9
Q
Four clinical signs of Rheumatoid Arthritis
A
- Joint space narrowing
- Oeriarticular osteopenia
- Juxta-articular (also called marginal) bony errosions (in non-cartilage protected bone)
- Sibluxation and gross deformity
10
Q
Lateral Elbow Tendinopathy
A
- Lateral Epicondylitis / Tennis Elbow
- Degenerative tendinopathy
- Common extensor tendon (origin) at the lateral epicondyle.
- Commonest cause of elbow pain
- Manual workers (repetative strain)
- 40-60 (3% prevalence)
- Sports
- Activity modification / Physiotherapy - self limiting.
- 90% recover within a year
- Pain over lateral epicondyle during extension of the wrist, especially if this is against resistance.
- Injections
- Surgery
- Radiating pain from neck or shoulder
11
Q
Medial Elbow tendinopathy
A
- Golfer’s elbow / Medial Epicondylitis
- Golf and sports that place valgus stress on the elbow (bowlers, archers, weightlifters)
- Degenerative tendinopathy
- Common flexor origin at medial epicondyle
- Interface between pronator teres and the flexor carpi radialis origins
- 10x less common than LET
- Presentation - silimar to LET
- Aching pain over medial elbow.
- Pain produced on resisted flexion or pronation of the wrist
- Ulna nerve symptoms - 20% of cases due to close proximity.
- Treatment options - similar to LET
- Outcome - Less good than LET
12
Q
What are three causes for swelling around the elbow?
A
- Olecranon bursitis
- Rheumatoid nodules
- Gouty Trophy
13
Q
Olecranon Bursitis
A
- Students elbow
- Inlammation of olecranon bursa (between skin and olecranon process of the ulna) due to repeated minor trauma or friction
- The swelling is soft, cystic (fluid filled) Transilluminates (light can be shined through)
- Cosmetic concerns
- Can become infected
- Treatment:
- Leave alone (conservative)
- Aspiration +/- injection of hydrocortisone
- Compression bandages
- Surgery - if infected (Give antibiotics and do all things above too)
14
Q
Rheumatoid nodules
A
- Commonest extra-articular manifestations of RA
- 20% of RhA
- More aggressive disease and / or smokers
- Also prone to over extra articular manifestations of RA inc vasculitis and lung diseae
- Due to Repeated minor trauma
- fingers / forearm / back of heel
- Non tender
- Cosmetic concerns
- Treatment
- Underlying disease (RA)
- Surgery
15
Q
Gouty Trophi
A
- Disorder of purine metabolism leading to Hyperuricaemia
- ophi are nodular monosodium urate crystals deposition in soft tissues
- Primary and Secondary
- Painless
- Joints
- Reccurent attatcks of ‘Arthritis’
- Soft tissue deposition
- Ear, Elbow, fingers and Achilles tendon
- Contain Pasty white material - enlarge - move towards skin to drain. Forms a sinus tract or a continuously draining ulcer
- Treatment
- Underlying condition
- NSAIDS
- Xanthine oxidase inhibitors (allopurinol)
