Session 9 Clinical

Question 1

What comprise up to 75% of all elbow injuries

Answer 1

Supracondylar fractures

Question 2

Most common mechanism of supracondylar fracture

Answer 2

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

Question 3

3 main complications of supracondylar fracture

Answer 3

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

Question 4

Usual mechanism of dislocated elbow

Answer 4

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

Question 5

Mechanism of anterior dislocation of elbow

Answer 5

Direct blow to posterior of a flexed elbow

Often with associated fractures of the olecranon

Question 6

What is pulled elbow/nursemaids elbow

Answer 6

Subluxation of the radial head (incomplete dislocation)

Children 2-5

Reduced movement of elbow and pain over lateral aspect of proximal forearm

Question 7

Classic mechanism of pulled elbow

Answer 7

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

Question 8

Mechanism of radial head and neck fractures

Answer 8

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

Question 9

Radial head and neck fracture x ray

Answer 9

Difficult to see
Fat pad sign/sail sign indicates an effusion is present
Likely due to haemarthrosis secondary to an intra-articular fracture

Question 10

Features of OA of elbow

Answer 10

Uncommon
More common in men - manual workers or athletes
Crepitus and locking
Osteophytes can impinge on ulnar nerve and cause Parasthesia

Question 11

RA basic principles

Answer 11

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

Question 12

RA particularly affects

Answer 12

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

Question 13

X ray features of RA

Answer 13

Joint space narrowing
Periarticular osteopenia
Juxta-articular (marginal) bony erosions (in non-cartilage protected bone)
Subluxation and gross deformity

Question 14

Management of RA

Answer 14

Medically- prescription of disease modifying medication

Can have surgery for joint replacement

Question 15

What is lateral elbow tendinopathy/tennis elbow

Answer 15

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

Question 16

Typical LET presentation

Answer 16

Pain over lateral epicondyle during extension

Tennis players, painters, plumbers and carpenters

Question 17

LET treatment

Answer 17

Asked to modify activity, can have physio or bracing, or injections and surgery

Question 18

What is medial elbow tendinopathy (golfers elbow)

Answer 18

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

Question 19

MET presentation

Answer 19

Aching pain over medial elbow,
Often noticed during acceleration phase of throwing
Pain produced on resisted flexion or pronation

Can have ulnar nerve symptoms

Question 20

MET treatment

Answer 20

Usually activity mods

Same as LET

Question 21

3 common causes of swelling around the elbow

Answer 21

Olecranon bursitis
Rheumatoid nodules
Gouty tophi

Question 22

What is olecranon bursitis (students elbow)

Answer 22

Inflammation of olecranon bursa
Situated between the skin and olecranon process of ulna
Due to repeated minor trauma
Contents will be serous fluid

Question 23

Olecranon bursitis presentation and treatment

Answer 23

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

Question 24

What are rheumatoid nodules

Answer 24

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

Question 25

Presentation and treatment of Rheumatoid nodules

Answer 25

Present due to cosmetic concerns

Improve medial control of RA

Response variable

Question 26

What is gout

Answer 26

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

Question 27

Gout treatment

Answer 27

NSAIDs in actue

Xanthine oxidase inhibitors such as allopurinol can be prescribed to reduce production or uric acid and reduce risk of future attacks

Question 28

What does gout increase risk of

Answer 28

Secondary OA due to damage of articular cartilage

Question 29

What are tophi

Answer 29

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

Question 30

Complications of gouty tophi

Answer 30

Pain, soft tissue damage, deformity, joint destruction and nerve compression

Question 31

Most common site of tophi

Answer 31

Fingers and ears

Olecranon bursa and subcutaneous tissues of elbow

Can resemble rheumatoid nodules

Question 32

What is cubital tunnel syndrome

Answer 32

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)

Question 33

What happens when you capture funny bone

Answer 33

Minor trauma to ulnar nerve in cubital tunnel

Question 34

Result of compression of ulnar nerve in cubital tunnel

Answer 34

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)