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Yr3 Surgery: Orthopaedics > Elbow > Flashcards

Elbow Flashcards

1
Q

Remind yourself of the boy anatomy of the elbow

A
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2
Q

What is the anterior humeral line?

A

The anterior humeral line is a radiographic line that is drawn down the anterior margin of the humerus and through the middle third of the capitellum.

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3
Q

What is teh radiocapitellar line?

A

Line drawn along the longitudinal axis of the proximal radius. Normally the line passes through the capitellum. If it does not, there is radiocapitellar dislocation.

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4
Q

State some common conditions of the elbow

A
  • Supracondylar fracture
  • Olecranon fracture
  • Radial head fracture
  • Elbow dislocation
  • Olecranon bursitis
  • Lateral epicondylitis
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5
Q

For supracondylar fractures discuss:

  • Who they are common in
  • Common mechanism of injury
  • Symptoms & signs
  • Investigations
  • Classification
    *
A
  • Chidren aged 5-7yrs (rarely happen in adults)
  • Falling on outstretched hand
  • Suden onset pain, reluctance to move arm, deformity, swelling, limited range of movement due to pain, bruising in anterior cubital fossa
  • X-ray (AP & lateral), CT for comminuted fractures or if intrarticular extension suspected
  • Gartland classification (I-IV)
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6
Q

What might you see on x-ray of supracondylar fracture?

A
  • Posterior fat pad sign
  • Displacement of anterior humeral line
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7
Q

What is the management of supracondylar fractures?

A
  • Type 1 or minimally displaced type II: above elbow cast in 90 degrees flexion
  • Type II, III, IV nearly always require closed reduction & percutaneous K wire fixation
  • Open fractures require open reduction and percutaneous pinning
  • If any neurovascular compromise= need closed reduction
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8
Q

State some potential complications of supracondylar fractures

A
  • Nerve palises
    • Anterior interossesous nerve most common after initial injury
    • Ulnar nerve most common post-operatively
  • Malunion
  • Cubitus varus deformity “gunstock deformity”
  • Volkmann’s contracture
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9
Q

For olecranon fractures dicuss:

  • Who they present in
  • Common mechanism of injury
  • Clinical features
A
  • Bimodal: young & old
  • Indirect trauma (e.g. fall on outstretched hand resulting in sudden pull of triceps muscle. Triceps muscle can further distract the fracture) or direct high energy trauma
  • Pain, swelling, reduced moblility, tenderness over posterior elbow, +/- inability to extend elbow against gravity
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10
Q

What investigations should you do for a olecranon fracture?

A
  • Routine blood tests including clotting screen & group and save
  • X-ray (AP & lateral)
  • CT for complex injuries or to assess degree of comminution
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11
Q

Discuss the management of olecranon fractures

A

Treatment usually guided by degree of displacement:

  • Displacement <2mm or if >75yrs
    • Immobilisation with 60-90 degrees elbow flexion
    • Early introduction movement at 1-2 weeks
  • Displacement >2mm
    • Surgical: tension band wiring if prox to coranoid process or olecranon plating if distal to coranoid process
    • Metal work often removed at later date due to superficial nature
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12
Q

What are the most common fractures of the elbow?

A

Radial head fractures

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13
Q

For radial head fractures discuss:

  • Common mechanism of injury
  • Clinical features
A
  • Axial loading of forearm causign radial head to be pushed against capitulum of humerus; most common when arm in extended, pronated position e.g. fall on outstretched hand.
  • Pain, tenderness over lateral aspect of elbow, pain worsened on supination & pronation, crepitation on supination & pronation, swelling, bruising
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14
Q

What is an Essex-Lopresti fracture?

A

Fracture of radial head with disruption of the distal radio-ulnar joint. Always requires surgical intervention.

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15
Q

What investigations would you do for radial head fractures?

A
  • Routine blood tests including clotting screen & group and save
  • X-ray (AP & lateral)
  • CT to evaulate degree of comminution or if complex
  • MRI for associated ligament injuries
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16
Q

What might you see on x-ray of someone with a radial head fracture?

A

Sail sign (elevation of anterior fat pad)

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17
Q

What classification is used to classify radial head fractures?

A

Mason classification; based on degreee of dispalement & intra-articular involvement

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18
Q

Discuss the management of radial head fractures

A

Management depends on mason classification, neurovascular compromise and mechanical compromise of elbow.

  • Type I: sling immobilisation for < 1 week then early mobilisation
  • Type II:
    • No mechanical block: treat as type I
    • Mechanical block: ORIF
  • Type III: ORIF, radial head excision or replacement
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19
Q

State some potential complication of radial head fractures

A
  • Neurovascular compromise
  • Osteoarthritis later in life
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20
Q

Elbow dislocations can be simple or complex; explain the difference

A
  • Simple= no concomitant fracture
  • Complex= concomitant fracture
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21
Q

State some clinical features of an elbow dislocation

A
  • Pain
  • Deformity
  • Swelling
  • Decreased function (usually immobile in near full extension)
  • Loss of equilateral triangle of elbow
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22
Q

A good capillary refill can be found in pts who have elbow dislocation and arterial injury; true or false?

A

TRUE; elbow has rich collateral circulation

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23
Q

What investigations should you do if you suspect an elbow dislocation?

A
  • X-rays (AP & lateral)
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24
Q

What would you see on x-ray if pt has elbow dislocation?

A

Loss of radiocapitellar and ulnotrochlear congruence

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25
Q

Discuss the management of elbow dislocations; inlcude management of simple and complex dislocations

A

Initial Management

  • Closed reduction (ensure sufficient analgesia & sedation)
  • Apply above elbow backslab once reduced to keep elbow at 90 degrees
  • X-ray required to confirm reduction

Post -reduction management

  • Simple
    • Immobilisation for 5-14 days
    • Early rehabilitation
  • Complex
    • May require surgial repair
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26
Q

State some potential complications of an elbow dislocation

A
  • Early stiffness with loss of terminla extension
  • Recurrent instability
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27
Q

What is the terrible triad?

A

Elbow dislocation with…

  • Lateral collateral injury
  • Radial head fracture
  • Coronoid frature

Can occur when there is a posterolateral dislocation. Leads to very unstable elbow. Needs operative fixation of each of the components.

28
Q

State come potential causes of non-infected olecranon bursitis highlighting which is most common

A
  • Repetitive flexion-extension movements
  • Gout
  • RA
29
Q

What is most common causative organism of infected olecranon bursitis?

A

Staphylococcus aureus

30
Q

Describe presentation of olecranon bursitis

A
  • Pain
  • Swelling
  • May report small vol of fluid for some time but fluid vol recently increased
  • Erythema
  • Discomfort
  • ROM usually preserved
  • If infected systemic features e.g. fever, lethargy
31
Q

What investigations would you do for olecranon bursitis?

A
  • Bloods
    • FBC
    • CRP
    • RF (if susupect RA)
    • Serum urate (if suspet gout)
  • X-rays
  • Aspiration of fluid for MC&S
32
Q

What investigation provides defintive diagnosis for olecranon bursitis?

A

Aspiration (fluid sent for MC&S)

*NOTE: aspiration can also provide symptomatic relief for pt

33
Q

Discuss the management of olecranon bursitis

A

Management depends on if there is infection.

No infection

  • Analgesia (ideally NSAIDS)
  • Rest
  • +/- splinting of elbow
  • Consider washout in theatre if large & causing discomfort

Infective

  • Abx e.g. flucloxacillin (IV if systemic symptoms)
  • Surgical drainage
  • Consider bursectomy if prolonged or recurrent
34
Q

State some potential complications of olecranon bursitis

A
  • Osteomyelitis
  • Septic arthritis
35
Q

What causes epicondylitis?

A

Microtears in tendons due to repetitive injury.

Tendon adapts to multiple tears leading to formation of granulation tissue, fibrosis and eventually tendinosis

36
Q

Who does epicondylitis typically affect?

A

35-54yrs

Affects men & women equally

37
Q

State the clinical features of epicondylitis

A
  • Pain radiating down forearm
  • Local tenderness
38
Q

What special tests can be performed for lateral epicondylitis?

A
  • Cozen’s test: elbow flexed to 90 degrees, examiner puts one hand over lateral epicondyle whilst other holds pts hand in pronated, radially deviated position. Ask pt to extend wrist against resistance. Pain= positive
  • Mill’s test: palpate pts lateral epicondyle whist pronating pts forearm, flexing wrist and extending elbow
39
Q

Are any investigations required to diagnose lateral epicondylitis?

A

Diagnosis usually clinical; may do MRI to confirm diagnosis

40
Q

Discuss the managment of epicondylitis

A
  • Activity modification
  • Analgesics e.g. NSAIDs
  • Physiotherapy & orthoses
  • Corticosteroid injections every 3-6 months if symptoms persist

If symptoms not controlled through conservative measures then may need open or arthroscopic debridemennt of tendinosis and/or release or repair of damaged tendon inserts.

41
Q

What is valgus deformity?

What is varus deformity?

A
  • Valgus: forearm is excessively laterally deviated in relation to long axis of humerus
  • Varus: forearm is medially deviated in relation to the long axis of humerus “gunstock deformity”
42
Q

How long can it take for lateral epicondylitis to improve?

A

Improves within 1-2yrs in 80-90% people

43
Q

What tendons are most commonly involved in:

  • Lateral epicondylitis
  • Medial epicondylitis
A
  • Lateral: extensor carpi radialis brevis
  • Medial: pronator teres and flexor carpi radialis
44
Q

NOTE: symptoms for medial same (just on medial side). Management same

A
45
Q

State some key questions to ask about in an elbow related history

A
  • Pain
    • Worse in particualr position?
  • Weakness
  • Parasthesia
  • Instability
  • Stiffness
  • History of injury
  • Occupation
  • Impact on lifestyle
  • PMH & surgical history
46
Q

What is the carrying angle of the arm?

A

Angle between long axis of humerus and long axis of radius

47
Q

What is the normal carrying angle in:

  • Men
  • Women
A
  • Men: 7 degrees
  • Women: 14 degrees
48
Q

Who is biceps tendinopathy more common in?

A
  • Young, active individuals due to sports with repetitive flexion movements
  • Older individuals with degenerative tendinopathy
49
Q

Biceps tendinopathy can occur in both proximal & distal bicep tendons; true or false?

A

True

50
Q

How does biceps tendinopathy present?

A
  • Pain
    • Worse when flexing elbow & hence using tendon
  • Weakness (flexion & supination)
  • Tenderness over affected tendon
  • If avoided using muscle due to pain, may be disuse atrophy
51
Q

State the special test for:

  • Proximal biceps tendinopathy
  • Proximal biceps tendinopathy
A
  • Proximal = speed test (pt stand with elbow extended and forearms supinated then flex their shoulders to 90 degrees- bring arms in front- examiner applies downward pressure and pt tries to resist. Positive= pain in shoulder).
  • Distal= Yergason’s test (pt stands with elbows flexed at 90 degreees with forearm pronated. Actively supinate against examiners resistance. Pain in shoulder/biciptal groove= positive)
52
Q

Are investigations required for biceps tendinopathy?

A

Diagnosis= largely clinical

May do investigations to rule out other pathhology

53
Q

Discuss the management of biceps tendinopathy

A
  • Analgesia e.g. NSAIDs
  • Ice therapy
  • Physiotherapy
  • USS guided steroid injections
  • Surgery (tenodesis or tenotomy)= rare
54
Q

State a potential complication of chronic biceps tendinopathy

A

Biceps tendon rupture

55
Q

State the common mechanism of injury of biceps tendon rupture

A

Sudden forced extension of flexed elbow

56
Q

State some risk factors for a ruptured biceps tendon

A
  • Previous episodes of bicep tendinopathy
  • Steroid use
  • Smoking
  • CKD
  • Fluoroquinolone abx
57
Q

State the clinical features of a ruptured biceps tendon; include any specific signs for proxmial and distal tendon rupture

A
  • Sudden onset pain
  • Weakness (flexion & supination still possible due to brachialis & supinator)

Proximal (injury usually to long head)

  • Popeye sign

Distal

  • Swelling & bruising in antecubital fossa
  • Reverse pop eye sign
  • Report feeling a ‘pop’
58
Q

What special test is done to identify a distal biceps tendon rupture?

A

Hook test

  • Elbow flexed to 90 degrees, supinated
  • Examiner tries to hook index finger under lateral edge of biceps tendon
  • Cannot be done in rupture of distal biceps tendon
59
Q

What investigations are required for a potential distal bicep tendon rupture?

A
  • USS (helps surgeons localise distal end of biceps tendon)
  • MRI (if USS inconclusive)
60
Q

Discuss the mangement of a ruptured biceps tendon

A
  • For lower demand pts conservative treatment with analgesia & physiotherapy (will be weakness of flexion & supination but physio can help improve muscle strength)
  • For those who require surgery, as higher demand, surgical repair to reattach tendon should be done within few weeks of initial injury as tendon will retract and sar
61
Q

What is cubital tunnel syndrome?

A

Compression or irritation of ulnar nerve as it passes through cubital tunnel

62
Q

State clinical features of cubital tunnel syndrome

A
  • Parasthesia of little & ring finger (worsened when elbow is bent)
  • Weakened grip
  • Pain around medial elbow
  • Wasting of muscles between fingers
63
Q

What investigations may be done for cubital tunnel syndrome?

A

NCS (nerve conduction studies)/ EMG (electromyography)

64
Q

Discuss the conservative management of cubital tunnel syndrome

A
  • Avoid bending elbow for prolonged periods of time
  • Rest/activity modification- particulary from repetitive tasks that bend the elbow
  • Elbow splints (worn at night)
65
Q

If conservative treatment for cubital tunnel syndrome fails, what is the aim of surgical treatment?

A

Decompress ulnar nerve

Yr3 Surgery: Orthopaedics (14 decks)

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