Session 9 Clinical Flashcards
What comprise up to 75% of all elbow injuries
Supracondylar fractures
Most common mechanism of supracondylar fracture
Falling from moderate height onto outstretched hand with elbow hyperextended
Presents with pain, deformity and loss of function
Fracture line is usually extra-articular (joint not involved) distal fragment displaced posteriorly
3 main complications of supracondylar fracture
Malunion resulting in cubitus varus gunstock deformity)
Damage to median nerve, or radial or ulnar nerve
(Volkmann’s) Ischaemic contracture (brachial artery) or compartment syndrome
Usual mechanism of dislocated elbow
Fall onto outstretched hand with elbow partially flexed
Usually posterior (displacement of distal fragment- radius and ulna, is posterior)
Distal end of humerus driven through joint capsule anteriorly, ulnar collateral ligament usually torn
Mechanism of anterior dislocation of elbow
Direct blow to posterior of a flexed elbow
Often with associated fractures of the olecranon
What is pulled elbow/nursemaids elbow
Subluxation of the radial head (incomplete dislocation)
Children 2-5
Reduced movement of elbow and pain over lateral aspect of proximal forearm
Classic mechanism of pulled elbow
Longitudinal traction with forearm pronated (annular ligament torn as weak in kiddies)
Falls or over-reaching for an object
Most commonly in pronation as annular ligament is relaxed
Mechanism of radial head and neck fractures
Fall on outstretched hand when radial head impacts on the capitellum of humerus
Pain in lateral aspect of proximal forearm and loss of ROM
Modest swelling
Radial head and neck fracture x ray
Difficult to see
Fat pad sign/sail sign indicates an effusion is present
Likely due to haemarthrosis secondary to an intra-articular fracture
Features of OA of elbow
Uncommon
More common in men - manual workers or athletes
Crepitus and locking
Osteophytes can impinge on ulnar nerve and cause Parasthesia
RA basic principles
Autoantibodies known as rheumatoid factor attack the synovial membrane
Inflamed synovial cells proliferate to form a pannus
This penetrated through the cartilage and adjacent bone leading to joint erosion and deformity
RA particularly affects
MCPJ and PIPJ of hands, feet and cervical spine
Autoimmune process leads to damage to other organs and anaemia of chronic disease
Women more affected by men
X ray features of RA
Joint space narrowing
Periarticular osteopenia
Juxta-articular (marginal) bony erosions (in non-cartilage protected bone)
Subluxation and gross deformity
Management of RA
Medically- prescription of disease modifying medication
Can have surgery for joint replacement
What is lateral elbow tendinopathy/tennis elbow
Chronic over use
Pain at site of common extensor origin at lateral epicondyle
Extensor carpi radialis brevis weakened from overuse
Microscopic tears form
Inflammation and pain
Typical LET presentation
Pain over lateral epicondyle during extension
Tennis players, painters, plumbers and carpenters
LET treatment
Asked to modify activity, can have physio or bracing, or injections and surgery
What is medial elbow tendinopathy (golfers elbow)
Less common than LET
Affects common flexor origin at medial epicondyle
Associated with sports that place valgus stress on the elbow
Most common site of pathology is interface between Pronator teres and flexor carpi radialis
MET presentation
Aching pain over medial elbow,
Often noticed during acceleration phase of throwing
Pain produced on resisted flexion or pronation
Can have ulnar nerve symptoms
MET treatment
Usually activity mods
Same as LET
3 common causes of swelling around the elbow
Olecranon bursitis
Rheumatoid nodules
Gouty tophi
What is olecranon bursitis (students elbow)
Inflammation of olecranon bursa
Situated between the skin and olecranon process of ulna
Due to repeated minor trauma
Contents will be serous fluid
Olecranon bursitis presentation and treatment
Usually present due to cosmetic concern
Conservative with compression bandaging and aspiration
Hydrocortisone injection is sometimes needed
Can be a result of infection in which case aspiration, compression and antibiotics are needed and maybe even surgical drainage and washout
What are rheumatoid nodules
Commonest extra-articular manifestation of RA
Tend to be smokers or have more aggressive joint disease
Occur over exposed regions subject to repeated minor trauma
Usually non tender although overlying skin can ulcerate and become infected
Presentation and treatment of Rheumatoid nodules
Present due to cosmetic concerns
Improve medial control of RA
Response variable
What is gout
Inflammatory condition
Defective purine metabolism
Increased Uric acid
Crystals form in cavity of joints, tendons and tissues
Urate crystals trigger immune response and lead to acute inflammation
Gout treatment
NSAIDs in actue
Xanthine oxidase inhibitors such as allopurinol can be prescribed to reduce production or uric acid and reduce risk of future attacks
What does gout increase risk of
Secondary OA due to damage of articular cartilage
What are tophi
Nodular masses of mono sodium urate crystals deposited in soft tissues
Late complication of hyperuricaemia
Contain white pasty material and as they enlarge work their way towards skin surface to drain either forming sinus tract or continuously draining ulcer
Complications of gouty tophi
Pain, soft tissue damage, deformity, joint destruction and nerve compression
Most common site of tophi
Fingers and ears
Olecranon bursa and subcutaneous tissues of elbow
Can resemble rheumatoid nodules
What is cubital tunnel syndrome
Ulnar nerve passes behind medial epicondyle of the humerus to enter the forearm
Common site for ulnar nerve compression- two heads of flexor carpi ulnaris unified by tendinous arch (ulnar nerve passes beneath)
What happens when you capture funny bone
Minor trauma to ulnar nerve in cubital tunnel
Result of compression of ulnar nerve in cubital tunnel
Parasthesia in cutaneous territory of ulnar nerve
Weakness in muscles
Treatment is to decompress the nerve (surgically release it and transpose it anterior to medial epicondyle)
