EM Ortho 6: Elbow and Forearm

Question 1

tennis elbow

Answer 1

lateral epicondylitis

tenderness over the lateral epicondyle and
pain with
- resisted wrist extension
- digit extension
- forearm supination

Question 2

golfer’s elbow

Answer 2

medial epicondylitis

less common counterpart to lateral epicondylitis

tenderness over the medial epicondyle and
pain with
- resisted wrist flexion
- forearm pronation

Question 3

frequency of dislocation of large joints

Answer 3

1. glenohumeral dislocation
2. patellofemoral dislocation
3. elbow dislocation

Question 4

most common type of elbow dislocation

Answer 4

posterolateral (90%)

Question 5

“terrible triad” of elbow injury

Answer 5

CoRD
Coronoid fracture
Radial head fracture
Dislocation of elbow

this injury creates an unstable joint and requires EMERGENT orthopedic consultation

Question 6

remarks regarding associated injuries in elbow dislocation

Answer 6

ulnar nerve injury (20%)
brachial artery injury (5-13%)

Question 7

remarks on postreduction of elbow dislocation

Answer 7

If the joint is stable and good neurovascular status has been confirmed,
1. splint with LONG ARM POSTERIOR SPLINT
2. with the forearm and wrist both in neutral position
3. and the elbow at slightly less than 90 degrees of flexion
4. arrange orthopedic follow-up in 1 to 2 days

Question 8

when to obtain emergency orthopedic consultation for elbow dislocation

Answer 8

Instability postreduction
Fractures coexisting
Ireducible dislocations
Open dislocations
Neurovascular compromise

Question 9

remarks on supracondylar fractures

Answer 9

most common fracture about the elbow in children bet 5 and 10 years of age

the appearance extension-type supracondylar fractures may be easily mistaken for a posterior elbow dislocation

Question 10

management of extension-type supracondylar fractures

Answer 10

1. immobilization using a long arm posterior splint, keeping the elbow at 90 degrees of flexion and the forearm in neutral rotation
2. followed by outpatient referral for casting
3. presence of >20 degrees of angulation necessitates orthopedic consultation for reduction under anesthesia and possible pin fixation
4. Displaced fractures must be reduced and require orthopedic consultation
   »admit patients with displaced fractures or signifianct soft tissue swelling for observation of neurovascular function

Question 11

neurologic complications of supracondylar fractures

Answer 11

median nerve
»poseterolateral displacement

anterior interosseous nerve
»high incidence
»no sensory component
»can only be identified through OK sign

radial nerve
»poseteromedial displacement

ulnar nerve
»iatrogenically from pinning

Question 12

most serious complication of supracondylar fractures

Answer 12

Volkmann’s ischemic contracture
- compartment syndrome of the forearm
- findings:
» refusal to open the hand
» pain with passive extension of the fingers
» forearm pain out of proportion to exam findings

Question 13

most common fractures of the elbow

Answer 13

radial head fractures
- result from FOOSH, causing the radial head to drive into the capitellum
- cause pain in the lateral elbow, especially with pronation and supination of the forearm
- tenderness with palpation of the radial head
» pronating and supinating the forearm with the elbow flexed allows the examiner to palpate the radial head

Question 14

analogous to a Maisonneuve injury in the lower extremity

Answer 14

ESSEX-LOPRESTI LESION
- disruption of the triangular fibrocartilage complex of the wrist and the interosseous membrane between the radius and ulna,
- causing dissocation of the distal radioulnar joint

• do NOT miss this injury
• failure to recognize this injury can result in proximal migration of the radius, so obtain EMERGENCY orthopedic consultation

Question 15

management of nondisplaced radial head fractures

Answer 15

sling immobilization
ice
elevation
analgesics
referral to an orthopedist or sports medicine specialist within 1 week

Question 16

when is surgical repair indicated in radial head fractures?

Answer 16

for displaced fractures or those with restricted range of motion
orthopedic referral within 24 hours