Elbow, Forearm and Wrist Flashcards
What is the aetiology of elbow dislocation?
- Fall onto outstretched hand
- Occurs in adults and children
What is the pathophysiology of an elbow dislocation?
- Directions: posterior, anterior, lateral, medial, divergent
- Pulled elbow in a child can result in sole radial head dislocation (rather than full elbow dislocation)
What is the presentation of elbow dislocation?
pain and swelling over the elbow
What are the investigations of elbow dislocation?
X-ray - AP and lateral
What is the management of an elbow dislocation?
- Reduction - traction in extension +/- pressure over olecranon
- Closed reduction under sedation
- Open reduction rarely required
- 2 weeks in sling and rehabilitation
- Recurrent instability risk is low
What are the complications of elbow dislocation?
Small risk of radial head fractures and coronoid process fractures
What is the aetiology of olecranon fracture?
Common injury from falling onto the elbow
What is the pathophysiology of an olecranon fracture?
The olecranon is the site of insertion of the triceps tendon - responsible for extension of the elbow
What is the presentation of an olecranon fracture?
- Pain well localised to posterior elbow
- Palpable defect indicates displaced fracture/severe comminution
- Inability to extend elbow indicates discontinuity of triceps mechanism
What are the investigations of olecranon fracture?
- X-ray - AP and lateral
- CT if needed for pre-op planning
What is the management of an olecranon fracture?
- Conservative - cast
- Operative - tension band wiring, ORIF plate fixation
What is the aetiology of a supracondylar fracture?
One of the most common traumatic fractures see in children, commonly due to a FOOSH
What is the presentation of a supracondylar fracture?
- Pain
- Refusal to move elbow
- Gross deformity, swelling, ecchymosis
- Limited active elbow motion
- Neurovascular exam - brachial artery, median nerve
What are the investigations for a supracondylar fracture?
- X-ray - AP and lateral
- Assess humerocapitellar alignment
- Posterior fat pad sign - lucency on a lateral view along the posterior distal humerus and olecranon fossa is highly suggestive of occult fracture around the elbow
What is the management of a supracondylar fracture?
- Conservative - cast
- Operative - closed/open reduction and percutaneous pinning
What are the complications of a supracondylar fracture?
- Can damage the brachial artery acutely and if untreated will cause malunite, causing lifelong disability
- Median nerve also at risk of damage
What is lateral epicondylitis?
Tennis Elbow
Overuse injury of the hand, especially finger extensor tendons which originate in the lateral humeral epicondyle
What is the aetiology of lateral epicondylitis?
Most commonly due to repeated or excessive pronation/supination and extension of the wrist (e.g. tennis players)
What is the pathophysiology of lateral epicondylitis?
Micro-tears in the common extensor origin
What is the presentation of lateral epicondylitis?
- Characterised by pain and tenderness over the lateral epicondyle to the attachment of the forearm
- Pain is worse when stretching the muscles e.g. opening a jar
- 10-20% bilateral
- Flex elbow to 90° in pronation, pain on resisted middle finger and wrist extension
What are the investigations for lateral epicondylitis?
- Mainly clinical
- USS and MRI may be required where diagnosis uncertain
- Nerve conduction study should be carried out if there are any nerve symptoms
What is the management of lateral epicondylitis?
- Usually self-limiting
- Conservative - rest, physio, injection of LA and steroids, brace (elbow clasp)
- Surgical release for refractory cases - involves division and/or excision of some of the fibres of common extensor mechanism
- Variable results
What is medial epicondylitis?
Overuse injury of the hand, especially finger flexor tendons which originate in the medial humeral epicondyle
What is the aetiology of medial epicondylitis?
- Can be caused by repetitive strain or degeneration of the common flexor origin
- Less common than lateral epicondylitis
What is the presentation of medial epicondylitis?
- Medial elbow pain with a tender point over the origin of the flexors at the medial epicondyle
- Pain is aggravated by wrist flexion and pronation
- Pain worse upon grasping e.g. opening a jar
- Flex elbow to 90° in supination, pain produced when wrist flexed against resistance
What is the investigations of medial epicondylitis?
- Mainly clinical
- USS and MRI may be required where diagnosis uncertain
- Nerve conduction study should be carried out if there are any nerve symptoms
What is the management of medial epicondylitis?
- Conservative - rest, NSAIDs, physio, injection of LA and steroids
- Injection carries a risk of injury to the ulnar nerve
- Surgical release for refractory cases
What is cubital tunnel syndrome?
Involves compression of the ulnar nerve at the elbow behind the medial epicondyle (‘funny bone’ area)
What is the aetiology of cubital tunnel syndrome?
Compression can be due to a tight band of fascia forming the roof of the tunnel (known as Osborne’s fascia) or due to tightness at the intermuscular septum as the nerve passes through or between the two heads at the origin of flexor carpi ulnaris
What is the presentation of cubital tunnel syndrome?
- Paraesthesia in the ulnar 1½ fingers
- Night symptoms - caused by sleeping with the arm in flexion
- Tinel’s test over the cubital tunnel is usually positive
- Weakness of ulnar nerve innervated muscles may be present including the 1st dorsal interosseous (abduction index finger) and adductor pollicis
- Weakness of adductor pollicis can be assessed with Froment’s test - thumb flexes at the IPJ joint while pinching a piece of paper to compensate for a weak adductor pollicis muscle
What are the investigations for cubital tunnel syndrome?
nerve conduction studies
What is the management of cubital tunnel syndrome?
- Conservative - NSAIDs, activity modification, nighttime elbow extension splinting
- Operative - surgical release of tight structures
What is the aetiology of radius and ulnar shaft fractures?
Common fracture of the forearm caused by direct or indirect trauma
What is the pathophysiology of radius and ulnar shaft fractures?
- Radius and ulna are connected by the proximal and distal radioulnar joints - form a ring
- Usually if there is a fracture of one bone, there is an injury of the other
Describe monteggia fractures
fracture of proximal third of the ulna with dislocation of the proximal head of the radius
Describe Galeazzi fractures
fracture of the distal third of the radius with dislocation of the distal radioulnar joint
What are nightstick fractures?
isolated fracture of the ulna shaft
What is seen on this x-ray?
Galeazzi
What is seen on this x-ray?
Monteggia
What is seen on this x-ray?
Nightstick
What is the presentation of a radius and ulnar shaft fractures?
- Pain and swelling
- Loss of forearm and hand function
- Gross deformity
- Neurovascular exam
- Radial and ulnar pulses
- Median, radian and ulnar nerve function
What are the investigations for radius and ulnar shaft fractures?
X-ray - AP and lateral
What is the management of a radius and ulnar shaft fracture?
- Conservative - cast
- Operative - ORIF
What is carpal tunnel syndrome?
Peripheral neuropathy caused by acute or chronic compression of the median nerve by the transverse carpal ligament
What is the aetiology of carpal tunnel syndrome?
- Mostly idiopathic
- Can occur secondary to many conditions
- RA - synovitis means less space
- Acromegaly
- Conditions resulting in fluid retention e.g. pregnancy, diabetes, chronic renal failure, hypothyroidism
- In pregnancy the symptoms usually subside after birth
- Can be a consequence of fractures around the wrist
- Women affected up to 8x more than men
What is the pathophysiology of carpal tunnel syndrome?
- The carpal tunnel of the wrist is formed by the carpal bones and the flexor retinaculum
- The median nerve passes through the carpal tunnel along with 9 flexor tendons (4 x FDS, 4 x FDP, 1 x FPL) with their synovial covering
- Medial nerve supplies motor innervation to LOAF muscles, and sensory innervation to palmar aspect of hand, thumb, index, middle and radial half of ring finger
- Any swelling within the confines of the carpal tunnel may result in median nerve compression
- Whilst the flexor tendons are not particularly susceptible to pressure, nerves are highly sensitive
What is the presentation of carpal tunnel syndrome?
- Paresthesia in the median nerve innervated digits (thumb and radial 3½ fingers) which is usually worse at night
- Loss of sensation and sometimes weakness of the thumb
- Relieved by shaking the hand
- Palmar sensation often spared
- Clumsiness in the areas of the hand supplied by the median nerve
- Demonstrable loss of sensation and/or muscle wasting of the thenar eminence (with chronic severe cases) - examine LOAF muscles especially APB
- Symptoms can be reproduced by performing Tinel’s test (percussing over the median nerve) or Phalen’s test (holding the wrists hyper‐flexed, which decreases space in the carpal tunnel)
What are the investigations of carpal tunnel syndrome?
- Questionnaire to stratify for nerve conduction study
- Nerve conduction studies - slowing of conduction across the wrist
What is the management of carpal tunnel syndrome?
Conservative
- Wrist splints at night to prevent flexion
- Corticosteroid injections
Surgical
- Carpal tunnel decompression involves division of the transverse carpal ligament under local anaesthetic
- Usually a highly successful operation, although there is risk of damage to the median nerve or one of its smaller branches
What is De Quervain’s Tenosynovitis?
Inflammation of the tendon sheaths within the first compartment - contains APL and EPB
What is aetiology of De Quervain’s Tenosynovitis?
- Most common in women 30-50 years
- Associated with pregnancy and RA
What is the presentation of De Quervain’s Tenosynovitis?
- Typically presents as a repetitive strain injury with pain over the radial styloid process at the wrist
- Pain often radiates proximally into the forearm
- Wrist usually swollen, sometimes redness
- Finkelstein’s test - patient makes a fist over the thumb and the hand is ulnar deviated to reproduce pain
What are the investigations for De Quervain’s Tenosynovitis?
USS and x-ray to rule out CMC joint OA which can mimic DQ
What is the management of De Quervain’s Tenosynovitis?
Conservative
- Splint, rest, physio, analgesics
- Steroid injection
Surgical
- Surgical decompression
What is the aetiology of scaphoid fractures?
Often occurs due to a fall on outstretched hand
What is the presentation of scaphoid fractures?
Pain and tenderness in the anatomical snuffbox
What are the investigations for scaphoid fractures?
- Extra views taken at x-ray - AP, lateral, two obliques
- Despite the extra views, scaphoid fractures can be invisible - a repeat x-ray after 10 days, or MRI scan, can be helpful to confirm or exclude a fracture
What is the management of a scaphoid fracture?
- Conservative - cast
- Operative - percutaneous screw fixation, ORIF
What are the complications of scaphoid fractures?
- The dorsal branch of the radial artery (supplies 80% of the blood to the scaphoid) enters in the distal pole of the scaphoid and blood travels in a retrograde fashion towards the proximal pole
- Fractures can compromise the blood supply → increased risk of non-union, AVN and early wrist OA
What is the aetiology of distal radius fractures?
Often occurs due to a fall on outstretched hand
What is a Colles fracture?
fracture of distal radius with posterior displacement of distal fragment
What is a Smith’s fracture?
fracture of distal radius with anterior displacement of distal fragment
What is a Barton’s fracture?
intra-articular fracture of the distal radius with dislocation of the radiocarpal joint
What are the presentations of distal radius fractures?
- Wrist pain and swelling
- Wrist deformity
- Ecchymosis and swelling
- Diffuse tenderness
- Motion limited by pain
What are the investigations of distal radius fractures?
- X-ray - AP, lateral, oblique
- CT - evaluate intra-articular involvement, indicated in surgical planning
- MRI - indicated in evaluation of soft tissue injury
What is the management of distal radius fractures?
- Conservative - cast
- Operative - ORIF or MUA and K-wires or external fixation
What are the complications of distal radius fractures?
- Median nerve compression from stretch of the nerve or a bleed into the carpal tunnel can accompany a Colles fracture
- Fractures of the distal radius that heal in a poor position (malunion) may result in impaired grip strength due to loss of extension
