Elbow Flashcards
Supracondylar fracture definition, common population
- 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
Supracondylar fracture mechanism
• >96% are extension injuries via FOOSH (e.g. fall off monkey bars); <4% are flexion injuries
Supracondylar fracture clinical features
- pain, swelling, point tenderness
* neurovascular injury: assess median and radial nerves, radial artery (check radial pulse)
Supracondylar fracture investigations
• 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
Supracondylar fracture treatment
• 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
Supracondylar fracture specific complications
- 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)
3 joints at the elbow
Humeroradial
Humeroulnar
Radioulnar
What is the normal carrying angle of the elbow
10o valgus
Radial head fracture terrible triad
Radial head fracture
Coronoid fracture
Elbow dislocation
Radial head fracture common population
a common fracture of the upper limb in young adults
Radial head fracture mechanism
FOOSH with elbow extended and forearm pronated
Radial head fracture clinical features
- 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
Radial head fracture investigations
• 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
Radial head fracture classification and treatment
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
Radial head fracture specific complications
- myositis ossificans – calcification of muscle
* recurrent instability (if MCL injured and radial head excised)
How to avoid elbow stiffness following #
Do not immobilize elbow joint >2-3 weeks
Olecranon #mechanism
• direct rauma to posterior aspect of elbow (fall onto the point of the elbow) or FOOSH
Olecranon #clinical features
- localized pain, palpable defect
* ± loss of active extension due to avulsion of triceps tendon
Olecranon #investigations
X-ray: AP and lateral (require true lateral to determine fracture pattern)
Olecranon #tx
• 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
Most common joint dislocations
- Shoulder
- Patella
- Elbow
Elbow dislocation what is disrupted
anterior capsule
collateral ligaments
Elbow dislocation mechanism
- 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
Elbow dislocation clinical features
- elbow pain, swelling, deformity
- flexion contracture
- ± absent radial or ulnar pulses
Elbow dislocation investigations
• x-ray: AP and lateral views
Elbow dislocation treatment
• 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
Elbow dislocation specific complications
- stiffness (loss of extension), intra-articular loose body, neurovascular injury (ulnar nerve, median nerve, brachial artery), radial head fracture
- recurrent instability uncommon
What is the radio-capitellar line
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
Lateral epiconylitis
“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
Medial epicondylitis
“golfer’s elbow”, inflammation of the common flexor tendon as it inserts into the medial epicondyle
Epicondylitis mechanism
repeated or sustained contraction of the forearm muscles/chronic overuse
Epicondylitis clinical features
- 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
Epicondylitis treatment
• 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
Elbow joint injection
Inject at the centre of the triangle formed by the lateral epicondyle, radial head, and olecranon
