Elbow

Question 1

Supracondylar fracture definition, common population

Answer 1

• subclass of distal humerus fracture: extra-articular, fracture proximal to capitulum and trochlea, usually transverse
• most common in pediatric population (peak age ~7 yr old), rarely seen in adults

Question 2

Supracondylar fracture mechanism

Answer 2

• >96% are extension injuries via FOOSH (e.g. fall off monkey bars); <4% are flexion injuries

Question 3

Supracondylar fracture clinical features

Answer 3

• pain, swelling, point tenderness

* neurovascular injury: assess median and radial nerves, radial artery (check radial pulse)

Question 4

Supracondylar fracture investigations

Answer 4

• X-ray: AP lateral of elbow
■ disruption of anterior humeral line suggests supracondylar fracture
■ fat pad sign: a sign of effusion and can be indicative of occult fracture

Question 5

Supracondylar fracture treatment

Answer 5

• reduction indications: evidence of arterial obstruction, unacceptable angulation, displaced (>50%)

• non-operative
■ nondisplaced: long arm plaster slab in 90° flexion x 3 wk

• operative
■ indications: displaced, vascular injury, open fracture
■ requires percutaneous pinning followed by limb cast with elbow flexed <90°
■ in adults, ORIF is necessary

Question 6

Supracondylar fracture specific complications

Answer 6

• AIN (median nerve) injury commonly associated with extension type
• stiffness is most common

• brachial artery injury (kinking can occur if displaced fracture), median or ulnar nerve injury, 
compartment syndrome (leads to Volkmann’s ischemic contracture), malalignment cubitus varus (distal fragment tilted into varus)

Question 7

3 joints at the elbow

Answer 7

Humeroradial

Humeroulnar

Radioulnar

Question 8

What is the normal carrying angle of the elbow

Answer 8

10o valgus

Question 9

Radial head fracture terrible triad

Answer 9

Radial head fracture

Coronoid fracture

Elbow dislocation

Question 10

Radial head fracture common population

Answer 10

a common fracture of the upper limb in young adults

Question 11

Radial head fracture mechanism

Answer 11

FOOSH with elbow extended and forearm pronated

Question 12

Radial head fracture clinical features

Answer 12

• marked local tenderness on palpation over radial head (lateral elbow)
• decreased ROM at elbow, ± mechanical block to forearm pronation and supination
• pain on pronation/supination

Question 13

Radial head fracture investigations

Answer 13

• X-ray: enlarged anterior fat pad (“sail sign”) or the presence of a posterior fat pad indicates effusion which could occur with occult radial head fractures

Question 14

Radial head fracture classification and treatment

Answer 14

Mason Class 1
Nondisplaced #
Tx: elbow slab or sling x 3-5 d with early ROM

Mason Class 2 
Displaced fracture 
Tx: ORIF if 
- angulation >30o 
- involves 1/3+ of the radial head 
- if 3+mm of joint incongruity exists 

Mason Class 3
Comminuted #
Tx: radial head excision +/- prosthesis if ORIF not feasible

Mason Class 4
Comminuted fracture with posterior elbow dislocation
Tx: radial head excision +/- prosthesis

Question 15

Radial head fracture specific complications

Answer 15

• myositis ossificans – calcification of muscle

* recurrent instability (if MCL injured and radial head excised)

Question 16

How to avoid elbow stiffness following #

Answer 16

Do not immobilize elbow joint >2-3 weeks

Question 17

Olecranon #mechanism

Answer 17

• direct rauma to posterior aspect of elbow (fall onto the point of the elbow) or FOOSH

Question 18

Olecranon #clinical features

Answer 18

• localized pain, palpable defect

* ± loss of active extension due to avulsion of triceps tendon

Question 19

Olecranon #investigations

Answer 19

X-ray: AP and lateral (require true lateral to determine fracture pattern)

Question 20

Olecranon #tx

Answer 20

• non-operative
■ non-displaced (<2 mm, stable): cast x 3 wk (elbow in 90° flexion), then gentle ROM

• operative ■ displaced: ORIF (plate and screws or tension band wiring) and early ROM if stable

Question 21

Most common joint dislocations

Answer 21

1. Shoulder
2. Patella
3. Elbow

Question 22

Elbow dislocation what is disrupted

Answer 22

anterior capsule

collateral ligaments

Question 23

Elbow dislocation mechanism

Answer 23

• elbow hyperextension via FOOSH or valgus/supination stress during elbow flexion
• usually the radius and ulna are dislocated together, or the radial head dislocates and the ulna remains (“Monteggia”)
• 80% are posterior/posterolateral, anterior are rare and usually devastating

Question 24

Elbow dislocation clinical features

Answer 24

• elbow pain, swelling, deformity
• flexion contracture
• ± absent radial or ulnar pulses

Question 25

Elbow dislocation investigations

Answer 25

• x-ray: AP and lateral views

Question 26

Elbow dislocation treatment

Answer 26

• assess NVS before reduction: brachial artery, median and ulnar nerves (can become entrapped during manipulation) • non-operative ■ closed reduction under conscious sedation (post-reduction x-rays required) ■ Parvin’s method: patient lies prone with arm hanging down; apply gentle traction downwards on wrist; as olecranon slips distally, gently lift up the arm at elbow to reduce joint ■ long-arm splint with forearm in neutral rotation and elbow in 90° flexion ■ early ROM (<2 wk) • operative ■ indications: complex dislocation or persistent instability after closed reduction ■ ORIF

Question 27

Elbow dislocation specific complications

Answer 27

* stiffness (loss of extension), intra-articular loose body, neurovascular injury (ulnar nerve, median nerve, brachial artery), radial head fracture * recurrent instability uncommon

Question 28

What is the radio-capitellar line

Answer 28

The radio-capitellar line refers to an imaginary line along the longitudinal axis of the radial neck that passes through the centre of the capitellum, regardless of the degree of elbow flexion. If the radio-capitellar line does not pass through the centre of the capitellum a dislocation should be suspected

Question 29

Lateral epiconylitis

Answer 29

“tennis elbow”, inflammation of the common extensor tendon as it inserts into the lateral epicondyle Tennis Elbow laTeral epicondylitis pain associated with exTension of wrist

Question 30

Medial epicondylitis

Answer 30

“golfer’s elbow”, inflammation of the common flexor tendon as it inserts into the medial epicondyle

Question 31

Epicondylitis mechanism

Answer 31

repeated or sustained contraction of the forearm muscles/chronic overuse

Question 32

Epicondylitis clinical features

Answer 32

* point tenderness over humeral epicondyle and/or distal to it * pain upon resisted wrist extension (lateral epicondylitis) or wrist flexion (medial epicondylitis) * generally a self-limited condition, but may take 6-18 mo to resolve

Question 33

Epicondylitis treatment

Answer 33

``` • non-operative (very good outcomes) ■ rest, ice, NSAIDs ■ use brace/strap ■ physiotherapy, stretching, and strengthening ■ corticosteroid injection ``` • operative ■ indication: failed 6-12 mo conservative therapy ■ percutaneous or open release of common tendon from epicondyle

Question 34

Elbow joint injection

Answer 34

Inject at the centre of the triangle formed by the lateral epicondyle, radial head, and olecranon