Elbow and Arm

Question 1

in what age group are supracondylar fractures most common and what is the main mechanism of injury

Answer 1

most common in aged 5-7 yrs.

most common paediatric injury and are almost never seen in adults

main mechanism is FOOSH with elbow in extension

Question 2

supracondylar fractures are associated with a high risk of neurovascular injury, what nerves are essential to examine post fracture

Answer 2

median nerve

anterior interosseous nerve (deep motor branch of the median nerve)

radial nerve

ulnar nerve

Question 3

what is the sensory and motor distribution of the median nerve

Answer 3

sensory = skin over the anterolateral surface of the hand (thumb and first 2 and a half digits)

motor = thumb flexion and opposition, wrist flexion, forearm pronation and flexion of digits 2 and 3

Question 4

what is the sensory and motor distribution of the radial nerve

Answer 4

motor = arm, wrist and finger extension, forearm supination

sensory = most of the back of the hand

Question 5

what is the sensory and motor distribution of the ulnar nerve

Answer 5

sensory = medial forearm, medial wrist and medial one and a half digits

motor = wrist flexion, finger adduction and abduction, flexion of digits 4 and 5

Question 6

what are the 2 nerves of the hand

Answer 6

median nerve - supplies thumb and digits 2 and 3 (flexion and sensory)

ulnar nerve - supplies digits 4 and 5 (flexion and sensory)

Radial nerve (extension)

Question 7

what are some signs of vascular compromise in the hand post supracondylar fracture

Answer 7

cool temp

delayed cap refill time

absent pulses

Question 8

what is the classification system used in supracondylar fractures

Answer 8

Gartland classification system

Question 9

what type of supracondylar fractures can be managed conservatively

Answer 9

type I and minimally displaced type II

Question 10

management of supracondylar fractures with associated neurovascular compromise

Answer 10

immediate closed reduction

reduction then secured with K wires - which are removed in clinic after 4 weeks

Question 11

what is a Volkmann’s contracture and how do they happen

Answer 11

occurs following vascular compromise with a supracondylar fracture

ischaemia and subsequent necrosis of the flexor muscles of the forearm - begin to fibrose and form a contracture

this results in the wrist and hand being held in permanent flexion as a claw-like deformity

Question 12

what does the olecranon articulate with

Answer 12

trochlea of the humerus

Question 13

what muscle inserts onto the olecranon

Answer 13

triceps brachii

Question 14

where is the site of insertion for the triceps brachii muscle

Answer 14

olecranon

Question 15

what main neurovascular function should you check that will indicate a olecranon fracture

Answer 15

extension of the elbow against gravity

disruption of the triceps mechanism

Question 16

management of an olecranon fracture

Answer 16

conservative - for minimally displaced fractures, immobilise arm in 60-90 degrees elbow flexion and physio

surgical - for displaced fractures, tension band wiring or olecranon plating

Question 17

what bony structure does the radial head articulate with to form the elbow joint

Answer 17

capitulum of the humerus

Question 18

main mechanism of radial head fractures

Answer 18

FOOSH with arm in pronation

the radial head is pushed against the capitulum of the humerus

Question 19

what is an Essex-Lopresti fracture

Answer 19

a fracture of the radial head with disruption of the distal radio-ulnar joint

will always require surgical intervention

Question 20

what system is used to classify radial head fractures

Answer 20

classified according to degree of displacement and intra-articular involvement using the Mason classification system

Mason type 1 - non displaced

mason type 2 - partial articular fracture with minimal displacement

mason type 3 - comminuted fracture and displacement

Question 21

management of radial head fractures

Answer 21

mason type 1 = short period of immobilisation in sling followed by early mobilisation

mason type 2 = if no mechanical block then treated as per type 1, if mechanical block is present then ORIF

mason type 3 = ORIF or radial head excision or replacement

Question 22

when might a ‘sail sign’ be seen on lateral X-ray

Answer 22

radial head fracture

Question 23

what is the most common type of elbow dislocation

Answer 23

90% are posterior dislocations

Question 24

what muscles, tendons, ligaments stabilise the elbow joint

Answer 24

medial and collateral ligaments

common flexor and extensor origin tendons

anconeus, brachialis and triceps brachii

Question 25

what is the most common nerve to be damaged in elbow fractures and dislocations

Answer 25

ulnar nerve

Question 26

management of an elbow dislocation

Answer 26

closed reduction with sufficient analgesia

then apply an above elbow backslab to keep the elbow at 90 degrees (5-14 days)

early rehab

Question 27

what is the terrible triad in elbow dislocations

Answer 27

refers to an elbow dislocation with (1) lateral collateral ligament injury (2) radial head fracture (3) coronoid fracture

results in a very unstable elbow

requires surgical fixation

Question 28

mechanism of olecranon bursitis

Answer 28

due to repetitive flexion-extension movements at the elbow

less common non-infective causes can be gout and rheumatoid arthritis

Question 29

how is the range of movement affected in olecranon bursitis

Answer 29

it isn’t

the joint capsule is not involved and as such the ROM remain intact

Question 30

what is the blood test if you suspect gout

Answer 30

serum urate levels

Question 31

what do you need to make a definitive diagnosis of olecranon bursitis

Answer 31

aspiration of fluid - then send off for microscopy and for culture and to assess for presence of crystals

Question 32

management of infective olecranon bursitis

Answer 32

if systemic symptoms present then IV antibiotics

and surgical drainage

Question 33

what is epicondylitis

Answer 33

chronic symptomatic inflammation of the forearm tendons at the elbow

overuse syndrome caused by microtears in the tendons attaching to the epicondyles of the elbow

Question 34

what are the 2 common types of epicondylitis called

Answer 34

lateral epicondylitis - tennis elbow (more common)

medial epicondylitis - golfers elbow

Question 35

what tendons attach to the lateral epicondyle of the elbow

Answer 35

common extensor tendon (common attachment for the superficial extensor muscles of the forearm)

Question 36

pathophysiology of epicondylitis

Answer 36

repetitive overuse of the tendons can cause microtears in the tendon at their origin

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

Question 37

specific test for lateral epicondylitis

Answer 37

Cozen’s test - patients elbow is held flexed at 90 degrees, with examiners one hand over the lateral epicondyle, whilst the other hand holds the patients forearm in a pronated position, the patient is then asked to flex their wrist against the resistance from the examiner

Question 38

investigations into lateral epicondylitis

Answer 38

diagnosis is mainly clinical

but US and MRI can be used to aid diagnosis

Question 39

management of epicondylitis

Answer 39

Conservative;

modify the activity that caused it in the first place

analgesia and NSAIDs and if symptoms persist then corticosteroid injections

physiotherapy

surgical;

open or athroscopic debridement of tendinosis