Lecture 5: UE Injuries Part 2 Flashcards
What joints are found in the elbow?
- Ulnohumeral & Radiocapitellar articulation: Flex/Extend + Pronate/Supinate
- Proximal radioulnar articulation: Pronate/Supinate
a Rad Cap = radius articulates with capitellum
Main 3 ligaments of the elbow
- Ulnar collateral ligament
- Radial collateral ligament
- Annular ligament
Main 3 nerves of the elbow
- Ulnar
- Median
- Radial
Main 3 arteries of the elbow
- Brachial
- Radial
- Ulnar
XRAY views for the elbow
- AP
- Lateral
- Oblique (radcap view, 45deg): best for radial head visualization
Interpreting elbow imaging rules
- Anterior humeral line should bisect middle third of capitellum
- Radcap line should pass through center of capitellum (3-4)
- Disruption may indicate fx
Lateral Elbow XR
AP Elbow XR
Top 3 MC Elbow complaints
- Pain
- Stiffness
- Swelling
Order of Elbow Assessment
- Inspect
- Palpate
- ROM
What does flexion/supination of the elbow use? Extension? Pronation?
Muscles & Nerves
- Flexion/supination: Biceps, C5-C6, musculocutaneous nerve
- Extension: Triceps, C7-C8
- Pronation: Pronator teres, median nerve, C6-C7
Describe a valgus stress test on the elbow.
- Tests medial ligament strength. (UCL)
- Elbow 20deg flexed with supinated forearm
- Apply pressure LATERALLY
VaL = Lateral
Describe a varus stress test on the elbow.
- Tests lateral collateral ligament
- Elbow 20 deg flexed and supinated forearm
- Apply pressure from the MEDIAL SIDE
FOOSH
Falling on an outstretched hand
MCC of distal humerus factures
- Direct trauma
- Axial loading during FOOSH
MC Fracture patterns seen for distal humerus
- Type A: supracondylar is MC in children.
- Type B: epicondylar is medial/lateral.
- Type C: intercondylar is MC overall.
Growth plate = looks like type A location
What nerves can get injured with a distal humerus fx?
- Ulnar nerve: sensory + flexion/adduct of wrist, 4/5 DIP joint flexion, finger abduction
- Radial nerve: sensory + wrist extension
How does a distal humerus fx present?
- Pain, swelling, tender, bruising, crepitus
- ROM limited
- Shortening if displaced fx
- Make sure to check NV status above and below!
XRAY findings for distal humerus fx
- Fat pad sail sign indicates intra-articular bleeding or occult fx, MC in kids
- If you see a posterior fat pad: ALWAYS PATHOLOGIC
AP and lateral
Type A supracondylar fx XR
Type B Epicondylar fx XR
Type C intercondylar fx XR
Management of Type A/supracondylar elbow fx
- If no displacement/angulation: long arm cast at 90 deg
- If displaced/angulated/NV compromise: ORIF
Management of type B epicondylar elbow fx
- Isolated, minimal displacement (< 2 mm): 90 deg splint.
- For medial condyle: Pronate forearm
- For lateral condyle: Supinate forearm
- Mod displacement (2-4mm): Perc pinning or ORIF
- Severe: ORIF
Long Arm Posterior Splint
Type A supracondylar fx
If epi: you would pronate for medial, supinate for lateral
Top 2 MOI for olecranon fx
- Falling on a semi-flexed, supinated forearm (avulsion)
- Direct trauma
Triceps contracting, yanking a piece of olecranon off
How does an olecranon fx present?
- Normal stuff over olecranon process
- Limited ROM
- Deformity if associated dislocation
- MC Nerve affected: Ulnar
How to image an olecranon fx?
- Start with AP and lateral views
- Radcap view if unclear or complicated
Management of a nondisplaced olecranon fx with minimal displacement (< 2 mm displacement)
- Long arm posterior with elbow at any deg of flexion.
- Forearm neutral
- Squeeze rubber ball 5 mins/d
- Repeat XR in 7-10 days
Management of displaced olecranon fx
- Closed fx: Splint and ORIF
- Open: IV abx and consult ortho
CI to surgery for olecranon fx
- Elderly
- Too many comorbidities
Sling and start ROM as pain allows
What is the MC fx of the elbow?
Radial Head/Neck Fx
What is the MOI for a radial head/neck fx?
FOOSH resulting in compression of radial head into capitellum
What are the 4 Mason classifications for radial head/neck fx?
- Type 1: < 2 mm displacement
- Type 2: Displaced > 2 mm
- Type 3: Comminuted
- Type 4: radial head fx + elbow dislocation
How does a radial head/neck fx present? (3)
- Pain/tenderness along lateral aspect of elbow
- Limited ROM, esp with pronation/supination
- +/- swelling/ecchymosis
What is often seen on AP and lateral views of the elbow for a radial head/neck fx?
- Fx line
- Fat pad line
A posterior fat pad is always pathological.
How do we manage a Mason Type 1 Radial head/neck fx? (4)
1 = < 2 mm displacement
- Sling (can be w/ or w/o posterior splint)
- AROM after 24-48h (full extension + flexion, Pronation and supination with elbow flexed at 90d)
- Ortho f/u in 1 week
- Can aspirate if hemarthorsis is blocking early ROM
How do we manage a Mason type 2-3 Radial head/neck fx? (2)
2 = > 2 mm displacement, 3 = comminuted
- Sling + splint
- Ortho f/u in 2-3 days to dicuss ORIF
How do we manage a type IV radial head/neck fx? (1)
Fx + dislocation
CONSULT ORTHO IMMEDIATELY
What is Radial Head subluxation more colloquially known as?
Nursemaid’s elbow
What ligament does the radial head sublux through in nursemaid’s elbow?
Annular ligament
Who is radial head subluxation MC in?
Children under 5 years
What is the MOI for a radial head subluxation?
Pulling on a pronated forearm with elbow extended
Like you’re holding a kid’s hand as they walk
Once radial head subluxation occurs, how does it present? (4)
- Arm held semi-flexed, adducted, pronated
- Refusing ROM
- Tenderness over radial head
- No swelling or ecchymosis
It is not a fx, so swelling is rare.
Dx of radial head subluxation
Clinical
Only need imaging if you suspect a different injury.
Management of radial head subluxation (3)
- Reduction via supination-flexion or hyperpronation
- Make sure to premedicate with tylenol or motrin
- You can try 3-4 times, but less likely to succeed if its been 1+ day since injury
You want to reduce it IMMEDIATELY
Describe the supination-flexion reduction technique.
Radial head subluxation
- Hold elbow with thumb over radial head
- Quickly supinate forearm completely
- Quickly flex forearm
Describe the hyperpronation technique (3)
- Hold elbow with your thumb over the radial head
- Hyperpronate forearm
- Completely extend and then flex the forearm.
EBM prefers this for the first attempt.
If reduction fails for a radial head subluxation, what do we do? (2)
- Order XRs
- Splint (posterior long-arm) and refer
If reduction succeeds for a radial head subluxation, what do we do? (3)
- Tylenol/motrin PRN
- +/- sling
- Parent education
What tendinosis is MC: Lateral wrist (extensors) or Medial wrist (flexors)?
Lateral epicondylitis, aka tennis elbow
Medial is golfer’s elbow
What is the usual MOI for epicondylitis?
Chronic repetitive overuse
When is epicondylitis MC? (age range)
30-50
What causes pain in lateral epicondylitis? (2)
- Wrist extension
- Gripping (shaking hands, computer mouse, screwdriver, back-handed tennis swing)
Extension and supination
Where does point tenderness occur in epicondylitis?
1 cm distal to the epicondyle
Medial is the same.
What causes pain in medial epicondylitis? (2)
- Pronation and wrist flexion (golf, overhead throw, bowling)
- Gripping weakness
Dx of epicondylitis
Clinically
Managment of epicondylitis (5)
- Activity modification
- NSAIDs + Ice
- PT if failure of conservative tx
- Counterforce brace
- Steroids x 3 max
When should you refer to ortho regarding epicondylitis?
Symptoms persists for 6 months despite conservatie therapy
MOIs for olecranon bursitis (3)
- Trauma: fall, direct blow
- Inflammation: excessive leaning, RA, gout
- Infection: Septic bursitis MC d/t staph or strep
Presentation of chronic olecranon bursitis (2)
- Gradual swelling of bursa up to 6cm
- +/- pain, mild tenderness, limited ROM
Presentation of acute olecranon bursitis
- Sudden swelling of bursa
- Pain/tenderness/limited ROM
- Redness and warmth
When is aspiration indicated for olecranon bursitis? (1)
Large & Symptomatic
Analyze fluid with CBC, gram stain, C&S, and for crystals
When is AP and lateral XR indicated for olecranon bursitis? (1)
Hx of trauma