Orthopaedics - elbow & forearm Flashcards
Describe the clinical features of elbow dislocations
Typically present following a high-energy fall
Joint will be painful and deformed, with associated swelling and decreased function
Complete neurovascular examination of the upper limb – a deficit is often found in the territory of the ulnar nerve as neuropraxia of this nerve is common, good CRT can be found even in those with an arterial injury
List investigations for elbow dislocations
Plain film radiographs of the elbow, both AP and lateral, are required initially
CT imaging is only really useful as an adjunct in cases with associated fractures
Describe the management of an elbow dislocation
Initial management requires closed reduction (ensure sufficient analgesia +/- sedation if appropriate & apply an above elbow backslab once reduced to keep the elbow at 90 degrees)
After this:
- For a simple elbow dislocation: further orthopaedic management can be as an outpatient, following a short period of immobilisation
- Dislocation is complicated by a fracture or neurovascular compromise: operative fixation can be considered (ORIF)
List complications of elbow dislocation
Early stiffness with loss of terminal extension
Stretching of the ulnar nerve
Recurrent instability
What is the terrible triad?
Elbow dislocation with:
1) Lateral collateral ligament injury
2) Radial head fracture
3) Coronoid fracture
Combination of injuries causes a very unstable elbow & associated with a poor outcome
Treatment revolves around operative fixation of each of the components
Describe the pathophysiology of lateral epicondylitis
Common extensor tendon attaches to the lateral epicondyle, acting as the common attachment for the superficial extensor muscles of the forearm
Repetitive overuse of the tendons can cause microtears in the tendon at their origin -> formation of granulation tissue, fibrosis and eventually tendinosis
List risk factors for lateral epicondylitis
Occupation
Hobbies eg. tennis
List clinical features of lateral epicondylitis
Elbow pain and radiating down the forearm
Examination – local tenderness on palpation over the lateral epicondyle & common extensor tendon
List the special tests for lateral epicondylitis
Cozen’s test
Mill’s test
List differential diagnoses for lateral epicondylitis
Cervical radiculopathy
Elbow osteoarthritis
Radial carpal tunnel syndrome
List investigations for lateral epicondylitis
Diagnosis is typically clinical
Ultrasound or MRI imaging
Describe the management of lateral epicondylitis
Activity modification
Simple analgesics
Corticosteroid injections can be administered if symptoms persist
Physiotherapy
Describe the surgical treatment of lateral epicondylitis
May be warranted if the symptoms are not controlled through conservative measures
Open/arthroscopic debridement of tendinosis and/or release or repair of any damaged tendon insertions
Tendon transfer may be required to ensure function is retained (>50% damage)
Describe the clinical features of olecranon bursitis
Pain and swelling over the olecranon
Range of motion is usually preserved
Can be large and systemic symptoms can occur if it becomes infected
Ensure to examine the contralateral elbow joint as well
List differential diagnoses for olecranon bursitis
Inflammatory arthropathies
Gout
Cellulitis
Septic arthritis
List investigations for olecranon bursitis
Routine bloods, including FBC & CRP, should be taken
Plain film radiographs will help in ruling out any bony injury
Aspiration of the fluid, being sent for microscopy and for culture, which can assess for evidence of infection and for presence of crystals
Describe the management of olecranon bursitis
Swellings without an infection – can be treated with analgesia and rest (if patients are in a lot of discomfort, they can undergo a washout)
If there is an infection – IV antibiotics as well as surgical drainage
List complications of olecranon bursitis
Most cases resolve spontaneously
Septic arthritis
Osteomyelitis
Describe the pathophysiology of olecranon fractures
Intra-articular fractures
Typically result from indirect trauma when a patient falls on an outstretched arm, resulting in the sudden pull of the triceps (site of insertion for triceps)
List the clinical features of olecranon fractures
Elbow pain, swelling and lack of mobility
Examination – tenderness, inability to extend the elbow against gravity, ensure to check the neurovascular status of the affected limb
Shoulder and wrist joints should also be examined
List investigations for a suspected olecranon fracture
Routine blood tests – clotting screen & group and save
Plain AP and lateral radiographs
CT imaging can be useful in evaluating more complex injuries
Describe the management of olecranon fractures
Adequate analgesia
Usually guided by the degree of displacement on imaging:
1) Non-operative management: displacement <2mm, with immobilisation in 60-90 degrees elbow flexion and early introduction of range of motion at 1-2 weeks
2) Operative management: usually indicated for displacement >2mm, requiring techniques such as tension band wiring/olecranon plating
Describe the pathophysiology of radial head fractures
Typically occur via indirect trauma – axial loading of the forearm causing the radial head to be pushed against the capitulum of the humerus
- Most commonly occurs with the arm in extension and pronation
List clinical features of radial head fractures
Elbow pain
Variable degrees of swelling and bruising at the elbow
Examination – tenderness on palpation over the lateral aspect of elbow and radial head, with pain & crepitation on supination and pronation
Shoulder and wrist joints should also be examined
List investigations for radial head fractures
Routine blood tests
Plain AP and lateral radiographs (can be easily missed on plain radiographs)
- Elbow effusions may be seen ‘sail sign’
CT imaging for more complex injuries & MRI imaging can be used to assess suspected associated ligament injuries
What is the Mason classification?
Radial head fractures are classified according to the degree of displacement and intra-articular involvement
Type 1 – non-displaced/minimally displacement (<2mm)
Type 2 – partial articular fracture with displacement >2mm or angulation
Type 3 – comminuted fracture and displacement (a complete articular fracture)
Describe the management of radial head fractures
Provide adequate analgesia
Treatment is usually guided by the severity of the fracture on imaging
Mason type 1 injuries: treated non-operatively, with a short period of immobilisation with sling followed by early mobilisation
Mason type 2 injuries: if mechanical block is present, then may need surgery (ORIF), otherwise can be treated as per a type 1 injury
Mason type 3 injuries: either ORIF/radial head excision/replacement
What is the most common age group for supracondylar humeral fractures?
Peak age of incidence is 5-7 years
Describe clinical features of supracondylar fractures
Sudden-onset severe pain and reluctance to move the affected arm
Examination: signs of gross deformity, swelling, limited range of elbow movement and ecchymosis of the anterior cubital fossa
Carefully examine the median nerve, anterior interosseous nerve, radial nerve & ulnar nerve
Check the hand for features of vascular compromise
List differential diagnoses of supracondylar fractures
Distal humeral fractures
Olecranon fractures
List investigations for suspected supracondylar fractures
Plain film radiographs in both AP and lateral views of the elbow
Subtle signs on plain film radiographs:
- Posterior fat pad sign
- Displacement of the anterior humeral line
CT imaging may be useful for comminuted features/intra-articular extension is suspected
What is the Gartland classification?
Type I – undisplaced
Type II – displaced with an intact posterior cortex
Type III – displaced in two or three planes
Type IV – displaced with complete periosteal disruption
Describe conservative management of supracondylar fractures
Patients with neurovascular compromise – need immediate closed reduction
Can be trialled with type I fractures/minimally displaced type II fractures, which can be managed in above elbow cast in 90 degrees flexion
Describe the surgical management of supracondylar fracture
Type II, type III and type IV supracondylar fractures will nearly always require a closed reduction and percutaneous K-wire fixation
Open fractures = open reduction with percutaneous pining
Any ongoing vascular compromise may need discussion with vascular surgeons for potential vascular exploration
List complications of a supracondylar fracture
Nerve palsies are common (anterior interosseous nerve)
Malunion is an important complication to assess for following a supracondylar fracture, more common in those fractures managed suboptimally
Cubitus varus deformity
A Volkmann’s contracture can occur as well
