Elbow

Question 1

Discuss the relevance of the following areas to mechanism of injury of the elbow

Direct trauma

Answer 1

-A fall or direct blow to the olecranon may result in a comminuted fracture.

Question 2

Discuss the relevance of the following areas to mechanism of injury of the elbow

Fall on outstretched hand

Answer 2

• Indirectly FOOSH with elbow flexed and the triceps contracted may result in a transverse or oblique fracture of the olecranon.
• The most common mechanism for radial head or neck fracture is FOOSH (indirect). With the elbow in extension, the force drives the radius against the capitellum resulting in marginal or neck fracture. With increasing force, comminution, dislocation or displaced fragments occur.
• Over 90% of supracondylar fractures result from the indirect (FOOSH) mechanism.

Question 3

Discuss the relevance of the following areas to mechanism of injury of the elbow

Axial loading or jamming

Answer 3

-The most common mechanism for radial head or neck fracture is FOOSH (indirect). With the elbow in extension, the force drives the radius against the capitellum resulting in marginal or neck fracture. With increasing force, comminution, dislocation or displaced fragments occur.

Question 4

Discuss the relevance of the following areas to mechanism of injury of the elbow

Position of arm

Answer 4

• FOOSH with elbow flexed and the triceps contracted may result in a transverse or oblique fracture of the olecranon.
• The most common mechanism is a direct blow driving the olecranon into the distal humerus at the trochlea resulting in intercondylar fracture. The position of the elbow at the time of impact determines whether there will be extension or flexion displacement of the fragments.

Question 5

Discuss the relevance of the following areas to mechanism of injury of the elbow

Direction of force including position of distal joints

Answer 5

The magnitude and direction of force as well as the position of the elbow and the muscular tone, determine the position of the fracture fragment.

Question 6

What key information is required to assess for red flags

Answer 6

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Question 7

What key information is required in the setting of chronic elbow problems?

Answer 7

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Question 8

What key information would you ask to differentiate atraumatic elbow pain from non musculoskeletal causes?

Answer 8

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Question 9

What key information in a patient’s past medical history is important in elbow prolbems/injuries?

Answer 9

Patients medical history includes investigating illnesses, surgeries, injuries and medication use.

A patient report of recent surgery or major trauma should alert the PT to the potential risk of infection or venous thrombosis.

Question 10

What key information in a patient’s medication history is important in elbow injuries?

Answer 10

Patients seeking services from PT take a variety of medications, some of which require the PT to alter or modify his or her usual examination or intervention schemes. An important principle to guide this screening process is that approximately 80% of adverse drug events are an extension of the therapeutic effects of the drug.

Question 11

What key information in a patient’s social history is important in elbow problem/injuries?

Answer 11

Patients occupation, leisure activities, customs and beliefs all expose the patients to various health risks. In addition, this information may reveal potential obstacles to a successful rehabilitation outcome.

Question 12

What is the relevance of determining any intervention to date?

Answer 12

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Question 13

What is the relevance of determining the compensable status or health insurance status of the patient?

Answer 13

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Question 14

What is the relevance of determining first aid/pre hospital treatment?

Answer 14

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Question 15

What is the relevance of determining the last intake of food or fluids?

Answer 15

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Question 16

Name the vascular supply of the upper limb

Answer 16

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Question 17

How would you assess the neurovascular status of the upper limb

Answer 17

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Question 18

How do you assess the integrity and stability of the elbow joint?

Answer 18

The elbow is tested for laxity with the joint in both 0 and 30 degrees of flexion. Valgus and varus stress is exerted at the patient’s wrist while elbow is stabilised. The degree of joint laxity is compared with the unaffected side.

Question 19

What are the relevance of any local skin changes/open or puncture wounds to the upper limb?

Answer 19

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Question 20

How you would differentiate musculoskeletal elbow pain from non musculoskeletal elbow pain?

Answer 20

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Question 21

What are the most common non-musculoskeletal presentations of elbow pain

Answer 21

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Question 22

When would you consider obtaining an x-ray for a patient with an elbow problem/injury?

Answer 22

Patients with a significant loss of elbow motion or function, or who have sustained significant trauma to the elbow, generally warrant imaging with plain radiographs.

Question 23

When would a CT scan be indicated for a patient with an elbow problem/injury?

Answer 23

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Question 24

When would an MRI scan be indicated for a patient with an elbow problem/injury?

Answer 24

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Question 25

When would an ultrasound be indicated for a patient with an elbow problem/injury?

Answer 25

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Question 26

When would you consider obtaining blood investigations for a patient with an elbow problem/injury?

Answer 26

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Question 27

Analgesic agents for pain control

Answer 27

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Question 28

Anti-inflammatory agents

Answer 28

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Question 29

Antibiotics

Answer 29

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Question 30

Tetanus immunoglobulin and vaccinations

Answer 30

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Question 31

Discuss the signs, symptoms and management in the ED setting of

Supracondylar fracture of the humerus

Answer 31

A supracondylar fracture is a transverse fracture of the distal humerus above the joint capsule, in which the diaphysis of the humerus dissociates from the condyles. In children, approximately 60% of all elbow fractures are supracondylar. The incidence is highest between ages 3- 11.
Supracondylar fractures are subdivided based on the position of the distal humeral segment into extension or flexion type. 95% of displaced supracondylar fractures are of the extension type.

MOI: 2 mechanisms - with the elbow in flexion, a direct blow can result in a fracture. The indirect mechanism involves a FOOSH. the magnitude and direction of force as well as the position of the elbow and the muscular tone, determine the position of the fracture fragment. Over 90% of supracondylar fractures result from the indirect mechanism.

Imaging: Subtle changes such as the presence of a posterior fat pad, an abnormal anterior humeral line or abnormal carrying angle may be the only radiographic clues to the presence of a fracture.

Associated injuries: Supracondylar fractures are often associated with neurovascular complications.

Treatment:
Extension supracondylar fracture - Supracondylar fractures that are not displaced or angulated are immobilised in a posterior long-arm splint, extending from the axilla to a point just proximal to the MC heads for 3 weeks followed by early motion.
Emergent reduction by emergency physician is indicated only when the displaced fracture is associated with vascular compromise. Delayed swelling with subsequent compartment syndrome and neurovascular compromise is common following these fractures.

Flexion supracondylar fracture - Displaced flexion supracondylar fracture also require orthopaedic consultation for reduction.

Complications:

1. Neurovascular injuries. Compartment syndrome may necessitate fasciotomy. Ulnar nerve palsy is a delayed complication.
2. Cubitus valgus or varus deformities are commonly seen in children due to malposition of the distal humerus fragments.
3. Stiffness and loss of elbow motion.

Question 32

Discuss the signs, symptoms and management in the ED setting of

Radial head and neck fracture

Answer 32

MOI: The most common mechanism is FOOSH (indirect). With the elbow in extension, the force drives the radius against the capitellum resulting in marginal or neck fracture. With increasing force, comminution, dislocation or displaced fragments occur.

Examination: TOP over the radial head with swelling secondary to a hemarthrosis. Supination is painful and restricted. Children wit epiphyseal injuries may have very little swelling but will have pain on palpation and movement. If the patient has associated wrist pain, disruption of distal radioulnar joint should be suspected and referred to orthopaedics.

Associated injuries: Fracture of the capitellum should be suspected in all proximal radius fractures. Disruption of the interosseous membrane between the radius and ulna and injury to the distal radiolunar joint may also occur. A valgus strain often results in MCL sprain or rupture.

Management:
Marginal (intra-articular) nondisplaced - Long-arm posterior splint for 3-4 days.
Marginal (intra-articular) displaced - Long-arm posterior splint and referral
Neck nondisplaced - Long-arm posterior splint and orthopaedic referral
Neck displaced - Long-arm posterior splint and orthopaedic referral
Comminuted - Long-arm posterior splint

Question 33

Discuss the signs, symptoms and management in the ED setting of

Olecranon fracture

Answer 33

All olecranon fractures should be considered intra-articular. It is essential taht near-perfect anatomic reduction be achieved to ensure full ROM.

MOI: Usually of one of 2 mechanisms. A fall or direct blow to the olecranon may result in a comminuted fracture. The amount of triceps tone and the integrity of the triceps aponeurosis determine if the fracture will be displaced. Indirectly FOOSH with elbow flexed and the triceps contracted may result in a transverse or oblique fracture.

Examination: the patient will present with a painful swelling over the olecranon and a haemorrhagic effusion. Patient will have difficulty with triceps extension. It is not uncommon for comminuted fractures to result in ulnar nerve injury.

Imaging: lateral view is best for demonstrating olecranon fractures and displacement.

Treatment
Nondisplaced fracture - immobilisation in a long-arm splint with elbow flexed only 50-90 degrees and forearm in neutral position. Supination and pronation exercise can start in 3-5 days and flexion/extension movements at 1-2 weeks.
Displaced - These fractures are intra-articular and necessitate anatomic reduction through operative fixation. Emergent orthopaedic referral is indicated.

Question 34

Discuss the signs, symptoms and management in the ED setting of

Medial and lateral epicondylar fracture

Answer 34

Epicondylar fractures are most commonly seen in children. Medial epicondyle fractures are much more common than lateral.

Question 35

Discuss the signs, symptoms and management in the ED setting of

Capitellum fracture

Answer 35

Articular surfaces include the capitellum and trochlea and are very uncommon as isolated injuries but may be seen in conjuction with posterior dislocation of the elbow.

The fracture mechanism is usually the result of a blow inflicted on the outstretched hand. The force is transmitted up the radius to the capitellum. The capitellum has no muscle attachments and consequently the fragment may be nondisplaced. In some circumstances, secondary displacement occurs from elbow motion.

On examination, there may be painful or restricted elbow flexion.

Commonly associated with radial head fractures and/or rupture of the ulnar collateral ligaments.

Emergency management consists of immobilisation in a posterior splint, ice, elevation and analgesics. Orthopaedic referral is indicated.

Question 36

Discuss the signs, symptoms and management in the ED setting of

Intercondylar Y or T fractures

Answer 36

Intercondylar fractures generally occur in patients older than 50 years. This is actually a supracondylar fracture with a vertical component. The terms T and Y indicate the direction of the fracture line.

MOI: the most common mechanism is a direct blow driving the olecranon into the distal humerus at the trochlea. The position of the elbow at the time of impact determines whether there will be extension or flexion displacement of the fragments.

Examination: on examination there is shortening of the forearm. With extension fractures, there is a concavity of the posterior arm with prominence of the olecranon.

Associated injuries: Neurovascular injuries are infrequently associated with these fractures

Treatment:
Nondisplaced fractures are treated with long-arm posterior splint with forearm in neutral for 2-3 weeks.
Displaced, rotated or comminuted fractures are splinted in position of presentation and referred.

Complications:

1. The most common complication is loss of elbow joint function.
2. Posttraumatic arthritis
3. Neruovascular complications
4. Malunion and non-union

Question 37

Discuss the signs, symptoms and management in the ED setting of

Elbow dislocations

Answer 37

Elbow dislocations are one of the most commonly seen dislocations in the body. The most common elbow dislocation is a posterior dislocation (90%).

Posterior dislocation is associated with fall on the extended and abducted arm.

Early reduction is advocated, as delay may damage the articular cartilage or result in excessive swelling or circulatory compromise.

Question 38

Discuss the signs, symptoms and management in the ED setting of

Medial or lateral collateral ligament injury

Answer 38

Sprains involving the ulnar and radial collateral ligaments of the elbow follow acute injuries or chronic overuse. these injuries are diagnosed by appropriate stress testing of the involved ligaments. Treatment with immobilisation of the elbow in flexed position is the appropriate ED management in most cases.

Question 39

Discuss the signs, symptoms and management in the ED setting of

Subluxation and dislocation of radial head

Answer 39

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Question 40

Discuss the signs, symptoms and management in the ED setting of

Olecranon bursitis

Answer 40

Olecranon bursitis is the most common form of elbow bursitis seen in the ED. It is secondary to trauma, overuse, crystal disease, autoimmune disease or infection. One-third of cases are infectious (septic) and it should be noted that trauma may cause both septic and nonseptic bursitis.

On examination there will be swelling in the posterior aspect of the elbow with slight restriction of flexion due to the inflamed bursa. The bursa will be tender to palpation and erythema may be present in patients with both septic and nonseptic bursitis.

Early recognition of septic bursitis is critical to prevent severe sequelae. For this reason, aspiration is recommended in all cases, and fluid is sent for analysis for crystals, cell count, gram’s strain, and culture.

In cases of suspected septic bursitis, patients should have the bursa aspirated and they should be given antibiotics.

Question 41

Discuss the signs, symptoms and management in the ED setting of

Epicondylitis

Answer 41

Lateral epicondylitis is typically caused by micro tearing/micro avulsions of the ECRB and ECRL tendons. Clinical findings include: local tenderness directly over the lateral epicondyle, pain aggravated by resisted wrist extension and radial deviation, pain aggravated by gripping or decreased grip strength and normal elbow ROM

Question 42

Discuss the signs, symptoms and management in the ED setting of

Condylar fractures

Answer 42

The humeral condyle includes an articular portion and a nonarticular epicondylar portion. Condylar fractures incorporate both and may involve either the medial (trochlea and medial epicondyle) or lateral (capitellum and lateral epicondyle) condyle.

Question 43

Discuss the signs, symptoms and management in the ED setting of

Essex-Lopresti fracture

Answer 43

Fracture of the radial head, dislocation of the distal radioulnar joint and rupture of the interosseous membrane.

Question 44

Discuss the signs, symptoms and management in the ED setting of

Loose bodies/osteochondritis dissecans

Answer 44

Osteochondritis dissecans refers to a condition in which focal subchondral bone necrosis leads to the disruption of articular cartilage and displacement of a bony fragment into the joint space.

Symptoms include locking, giving way and crepitus on ROM. Radiographs may reveal a loose body within the joint or demonstrable osteochondritis dissecans.

Treatment is conservative unless there are loose bodies within the joint that require removal. The athlete must refrain from competitive sport for 6-8 weeks. If mechanical symptoms persist, artroscopic intervention to remove loose bodies is necessary.

Question 45

Discuss the signs, symptoms and management in the ED setting of

Tendinopathy

Answer 45

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Question 46

Discuss the signs, symptoms and management in the ED setting of

Calcific tendonitis

Answer 46

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Question 47

Discuss the signs, symptoms and management in the ED setting of

Nerve entrapment

Answer 47

The ulnar, radial and median nerve course in close proximity to the elbow. Any disease process affecting the elbow can involve these nerves or their branches and cause sensory or motor symptoms in the hand.
Ulnar neuropathy is the most common compression neuropathy affecting the elbow. In mild cases, symptoms include numbness and paraesthesia over the ring and small fingers. In more severe cases, weakness of the interossei becomes apparent.

Question 48

Discuss the signs, symptoms and management in the ED setting of

Rheumatological joint conditions

Answer 48

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Question 49

Elbow X-ray

Answer 49

AP view:
Carrying angle - intersection of a line drawn through the midshaft of the humerus and a line through the midshaft of the ulna on an AP dimension determines the carrying angle. Normal angle is between 0-12 degrees.

Lateral view:
Radiocapitellar line - A line drawn through the midportion of the radius normally passes through the centre of the capitellum on the lateral view of the elbow. In a fracture at the epiphysis of the radial head in children, this line will be displaced away from the centre of the capitellum.

Anterior humeral line - The anterior humeral line is a line drawn on a lateral radiograph along the anterior surface of the humerus through the elbow. Normally, this line transects the middle third of the capitellum. With a supracondylar extension fracture, this line will either transect the anterior third of the capitellum or pass anteriorly to it.

Fat pad - The presence of a bulging anterior fat pad or a posterior fat pad sign is indicative of significant joint capsule distension.