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MSK > Lecture 17 > Flashcards

Lecture 17 Flashcards

1
Q

How would you get a supracondylar fracture?

A
  • FOOSH (90% young children-usually boys)

- falling onto a flexed elbow (5% elderly)

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2
Q

What does a patient present with in a supracondylar fracture?

A
  • pain
  • deformity
  • loss of function
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3
Q

What is the fracture line described as in a supracondylar fracture?

A

Extra-articular
-joint is not involved
Distal fragment usually displaced posteriorly

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4
Q

What are the 3 main complications with a supracondylar fracture?

A
  • malunion, resulting in cubitus varus (gunshot deformity)
  • damage to median (most common), radial or ulnar nerve
  • ischaemic contracture: brachial artery passes very close to fracture site so may be damaged/occluded by displaced fracture. If reflex spasm of collateral circulation around elbow occurs, there will be ischaemia as it impedes arterial flow. Untreated= muscle infarction
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5
Q

What is Volkmann’s contracture?

A

During repair phase of infarcted muscle due to ischaemiua resulting from supracondylar fracture, the dead muscle tissue is replaced by scar tissue via fibrosis. Fibrotic tissue contracts (myofibroblast activity) and results in a flexion contracture

  • wrist is flexed
  • metacarpophalangeal joints extended
  • interphalangeal joints flexed
  • forearm pronated
  • elbow flexed
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6
Q

Why is it important a neurovascular exam is conducted in a patient with a supracondylar fracture?

A
  • median/ulnar/radial nerve may be damaged

- brachial artery damage/reflex spasm of the collateral circulation

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7
Q

How does an elbow dislocation occur?

A

-FOOSH (child) with elbow partially flexed
Configuration of bones contributes to stability of joint of elbow in full extension and flexion, whereas stability of joint in mid-flexion is more reliant on the ligaments making dislocation more likely to occur here
-considerable forces is required, sporting injuries are common

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8
Q

What are the top two most comon joints to dislocate?

A

-Elbow
-shoulder
Due to high frequency of FOOSH’s

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9
Q

What is the most common form of elbow dislocation?

A

Posterior (named by movement of distal fragment)

  • distal end of humerus is driven through joint capsule anteriorly
  • ulnar collateral ligament is usually torn
  • associated fracture
  • ulnar nerve damage
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10
Q

How would you obtain an anterior dislocation of the elbow?

A

Direct blow to posterior aspect of the flexed elbow

-associated fractures commonly seen due to degree of force required to dislocate the joint

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11
Q

What is a pulled elbow? (nursemaids elbow)

A

Subluxation (incomplete dislocation) of the radial head

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12
Q

What do patients present with in a pulled elbow?

A
  • reduced movement at elbow
  • pain over lateral aspect of proximal forearm
  • parents state child is not using their arm
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13
Q

In which age group is a pulled elbow most common and how would you obtain it?

A

2-5 years old

-longitudinal traction applied to arm with forearm pronated

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14
Q

Why does a pulled elbow more commonly occur in pronation of the forearm?

A

In pronation the annular ligament is relaxed, whereas in supination it is taut
-therefore it is easier for subluxation to occur
Longitudinal traction tearsthe distal attachment of annular ligament where it is loosely attached to radial neck. Radial head is then displaced distally through torn ligament

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15
Q

Why is pulled elbow less common the older you get?

A

The annular ligament strengthens as you age

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16
Q

What is the most common elbow fracture in adults?

A

Radial head/neck fractures

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17
Q

What do radial head/neck fractures result from?

A

FOOSH, when radial head impacts the capitellum of the humerus

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18
Q

What does the patient present with in a radial neck/head fracture?

A
  • pain in lateral aspect of proximal forearm
  • loss of range of movement
  • swelling is modest in comparison to supracondylar fractures
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19
Q

What does an X Ray show for a radial neck/head fracture?

A

Fat pad sign (sail sign): indicates an effusion (accumulation of fluid) is present, likely due to haemarthrosis (blood in joint) secondary to intra-articular fracture in the setting of trauma

  • sail shape caused by displacement of anterior fat pad
  • displaced fat pad appears black on XRay
  • some patients have a posterior fat pad sign due to displacement of the cresent of fat located usually within the olecranon fossa
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20
Q

Why is osteoarthritis of the shoulder uncommon?

A

-well matched joint surfaces
-strong stabilising ligaments
Therefore elbow can tolerate large forces without becoming unstable, so less ‘wear and tear’ with age

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21
Q

In whom is OA of the elbow most common?

A

Men
-manual workers
-athletes who engage in throwing
(can be primary or secondary)

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22
Q

What does the patient present with for OA of the elbow?

A
  • creptius (grating)
  • locking (caused by loose fragments of cartilage)
  • swelling due to effusion
  • osteophytes can impinge on ulnar nerve causing paraesthesia and muscle weakness
  • stiffness of elbow
  • loss of extension is tolerated well by patients as results in little limitation to their daily activities
23
Q

What is RA?

A

Autoimmune disease where autoantibodies (rheumatoid factor) attack synovial membrane. Inflamed synovial cells proliferate to form a pannus which penetrates through cartilage and adjacent bone, leading to joint erosion adn deformity

24
Q

What does RA usually affect?

A

-metacarpophalangeal joints
-proximal interphalangeal joints
-feet
-cervical spine
-large joints
Also leads to damage of organs: eyes, skin, lungs, heart, blood vessels, kidneys
-patients with RA often have anaemia of chronic disease

25
Q

What group is most affected by RA?

A

40-50 years
Women
(there is a juvenile form affecting children)

26
Q

What are the XRay features of RA?

A
  • joint space narrowing
  • periarticular (around joint) osteopenia
  • juxta-articular (near joint) bony erosions in non cartilage protected bone
  • subluxation and gross deformity
27
Q

How is RA managed/treated?

A

Medically rather than surgically via disease-modifying medication
-surgery may be required to relieve pain and improve mobility

28
Q

What is lateral elbow tendinopathy?

A

Tennis elbow
-tendinopathy is used to describe overuse of tendons
Occurs during a tennis downstroke. Extensor carpi radialis brevis helps to stabilise the wrist when the elbow is straight. When the ECRB is weakened from overuse microscopic tears form in the tendon where it attaches to lateral epicondyle
=inflammation and pain at site of common extensor origin

29
Q

Who usually get tennis elbow?

A

Tennis players, painters, plumbers, carpentersdue to repetitive nature of activity at the wrist and elbow

30
Q

What will a patient with tennis elbow present with?

A

Pain over the lateral epicondyle during extension of the wrist, especially if this is against resistance

31
Q

How is tennis elbow treated?

A

Modification of activities to give tendon time to heal
-sometimes physiotherapy and bracing are required and some need injections/surgery
(90% of patients recover within a year)

32
Q

What is medial elbow tendinopathy?

A

Golfer’s elbow

  • affects the common flexor origin at medial epicondyle
  • associated with golfing and throwing sports which places valgus stress on the elbow
33
Q

What is the most common site of pathology in golfer’s elbow?

A

Between the pronator teres and flexor carpi radialis

34
Q

What do patients with golfer’s elbow usually present with?

A
  • aching pain over medial elbow often noticed during acceleration phase of throwing
  • pain on resisted flexion/pronation of wrist
  • sometimes ulnar nerve symptoms due to proximity of ulnar nerve to medial epicondyle
35
Q

How do you treat golfer’s elbow?

A

Simple activity modification

36
Q

What are 3 common causes of swelling around the elbow?

A
  • olecranon bursitis
  • rheumatoid nodules
  • gouty tophi
37
Q

What is olecranon bursitis?

A

Student’s elbow

  • inflammation of the olecranon bursa (situated between skin and olecranon process of ulna)
  • due to repeated minor trauma
  • content will be serous fluid
38
Q

What can the swelling in student’s elbow be described as?

A

-soft
-cystic (fluid filled)
-transilluminates
Cosmetic concern

39
Q

How do you treat olecranon bursitis?

A

-compression bandaging
-aspiration
-hydrocortisone injection sometimes in chronic cases
Sometimes it is due to infection of the bursa: septic bursitis following penetrating injury to elbow: aspiration, compression and antibiotics are required
-occasional surgical drainage and washout under anaesthetic

40
Q

What are the most common extra-articular manifestation of RA?

A

Rheumatoid nodules

41
Q

Which patients are likely to develop RN’s?

A

-smokers
-people with more aggressive joint disease
They are also more likely to get other extra-articular (outside the joint) manifestations of RA: vasculitis, lung disease

42
Q

Where are RN’s usually found?

A

-over exposed regions subject to repeated minor trauma
-fingers, elbow, forearms, back of heel
Usually non-tender but overlying skin can sometimes ulcerate and become infected

43
Q

How do you treat RN’s?

A

Imporving medical control of underlying rheumatoid disease
-response to existing nodules is variable
(patients present due to cosmetic concerns)

44
Q

What is gouty tophi?

A

Tophi: nodular masses of monosodium urate crystals deposited in soft tissues

  • late complication of hyperuricaemia (develop in >50% of patients with untreated gout)
  • often painless
45
Q

What are some symptoms of gouty tophi?

A
  • pain
  • soft tissue damage
  • deformity
  • joint destruction
  • nerve compression
46
Q

What does gout increase the risk of?

A

-acute attacks of arthritis
-secondary arthritis
Due to damage it causes to articular cartilage

47
Q

Where would you normally find tophi?

A

-fingers
-ears
-olecranon bursa
-subcutaneous tissues of the elbow
(can resemble RN’s)

48
Q

What do tophi look like?

A

Contain white pasty material, as they enlarge they work their way towards the skin surface to drain
-formind a sinus tract (tunnel from site) or continously draining ulcer

49
Q

Where does the ulnar nerve pass in relation to the elbow?

A

In cubital tunnel, passing behind medial epicondyle of humerus to enter forearm

50
Q

What is cubital tunnel syndrome?

A

Ulnar nerve compression

  • flexor carpi ulnaris has 2 heads which are united by a tendinous arch
  • ulnar nerve passes beneath this arch to go into cubital tunnel
51
Q

What causes the ‘catching of the funny bone’?

A

Minor trauma to ulnar nerve in cubital tunnel= sharp transient pain radiating from elbow to cutaneous ulnar territory

52
Q

What does compression of ulnar nerve in cubital tunnel cause?

A

Paraesthesia in cutaneous territory of the ulnar nerve

May result in muscle weakness in muscles supplied by ulnar nerve

53
Q

How do you treat cubital tunnel syndrome?

A

Decompress the nerve

-surgically release it and transpose it anterior to medial epicondyle

MSK (12 decks)

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