T&O elbow and forearm Flashcards
What is the aetiology of a supracondylar fracture?
Usually a paediatric injury aged 5-7 years
From a FOOSH with elbow in extension
Close proximity to neurovascular structures so assess!!!
How does a supracondylar fracture present?
Follow recent fall sudden onset severe pain and reluctance to move arm
On exam gross deformity, swelling, limited range of elbow movement, ecchymosis of anterior cubital fossa
Can be damage to median, anterior interosseous, radial and ulnar nerve so test
Test for vascular compromise e.g cool temperature, pallor, delayed cap refill, absent pulses
What are some differential diagnoses to consider with a supracondylar fracture?
Olecranon fracture
Distal humeral fracture
Subluxation of radial head
How are supracondylar fractures managed?
If Gartland I or II minimally displaced can try conservative with above elbow cast in 90 degrees flexion
If neurovascular compromise immediate closed reduction in theatre and secure with K-wire fixation for 3-4 weeks
If Gartland II to IV closed reduction and percutaneous K-wire fixation
If open do open reduction with percutaneous pinning
What are some complications with a supracondylar fracture?
- Nerve Palsies: injury most likely to damage anterior interosseous nerve and K-wire post likely to damage ulnar
- Malunion: cubitus varus gunstock deformity
- Volkmann’s contracture: if vasculat compromise ischaemia and necrosis then fibrosis so hand and wrist in permanent flexion
Compartment syndrome
What are the clinical features of an olecranon fracture?
- History of FOOSH
- Pain, swelling, lack of mobility
- Tenderness when palpating back of elbow and possible palpable defect
- Inability to extend the elbow against gravity due to triceps mechanism damaged
May have assocaited injuries, e.g wrist ligaments, radial head fractures/dislocation, shoulder injuries, so examine wrist and shoulder
How are olecranon fractures managed?
Resuscitate and appropriate analgesia
Treatment depends on degree of displacement on imaging
Non Operative (<2mm displacement or all over 75s)
Immobilisation at 60 to 90 degrees elbow flexion and early introduction of range of motion at 1-2 weeks
Operative (<2mm displacement)
Tension band wiring (if fracture proximal to coranoid process) or olecranon plating (if at level or distal to coranoid)
Often remove metal working due to how superficial as bothers patient
What are the clinical features of a radial head fracture?
History of FOOSH
Elbow pain, swelling and bruising
Tenderness on palpation of lateral elbow
Pain and crepitus on pronation/supination
Limited supination/pronation
Elbow effusion
FOOSH associated with other wrist ligament and bony injures so examine shoulder and wrist joint
How are radial head fractures managed?
Treatment guided by Mason classification, neurovascular compromise and any mechanical block of the elbow (can patient flex-extend/supinate-pronate
- Mason 1: non operatively with sling immobilisation for less than a week and early mobilisation
- Mason 2: if no mechanical block treat like 1, otherwise do ORIF
- Mason 3: ORIF or radial head excision or replacement
Good prognosis but risk of secondary OA
What are the clinical features of an elbow dislocation?
Following a high energy fall painful, deformed, swollen joint
Decreased function, almost immobile
Need to do a complete neurovascular exam, if any concerns ovrer the pulse of the limb need to do a Doppler US
How are elbow dislocations managed?
Initial
Examination and documentation of neurovascular status
- Closed reduction with analgesia and apply above elbow back slab at 90 degrees
- Reassess neurovascular status and take more radiographs
Definitive
If no associated fracture outpatient with immobilisation for 5-14 days with early rehabilitation
If fracture or neurovascular compromise do ORIF with soft tissue repair (LCL, MCL)
What are the complications with an elbow dislocation?
- Early stiffness with loss of terminal extension: do rehab to reduce the risk
- Stretching of the ulnar nerve
- Recurrent instability: however low recurrence rate in most
What is the Terrible Triad?
Posterior elbow dislocation with:
Lateral collateral ligament injury
Radial head fracture
Coronoid fracture
Leads to a very unstable elbow and likely to have stiffness, instability, arthrosis. Needs radial head ORIF, LCL reconstruction, coronoid ORI
What are the causes of olecranon bursitis? (Infectious and Non-infectious)
Prone to trauma and pressure as superficial structure!!!
Repetitve flexion-extension movements
Gout
RA
Infected bursa with S.Aureus if skin abrasion
How is olecranon bursitis investigated?
Routine bloods including rheumatological screen
Serum urate levels
Plain film radiographs can rule out bony injury
Gold standard: aspiration of fluid to send for crystal microscopy and culture. can provide some symptomatic relief. do not aspirate into the joint due to risk of seeding infection
How is olecranon bursitis managed?
A
No infection: analgesia (NSAIDs), rest, splinting elbow, if large and in pain can do washout in theatre
Infection: IV antibiotics (flucloxacillin or doxycycline if penicillin allergic) and surgical drainage. If prolonged can do bursectomy
What are some differential diagnoses for lateral epicondylitis?
cervical radiculopathy
elbow OA
radial carpel tunnel syndrome
How is lateral epicondylitis investigated and managed?
Ix
Diagnosis usually clinical but can do MRI or US
Mx
Conservative: modify activity, analgesia oral and topical, corticosteroid injections every 3-6 months, physiotherapy, elbow or wrist brace
Surgical (if symptoms not controlled): open or arthroscopic debridement of tendinosis and release/repair of any damaged tendon insertions. If tendon really damaged may need tendon transfer
What is the pathophysiology of a clavicle fracture?
Direct (fall onto clavicle) or indirect (fall onto shoulder)
Most common in middle third
Medial fragment will displace superiorly due to pull of SCM and lateral fragment will displace inferiorly due to weight of arm
What is the prognosis with a clavicle fracture, including any complications?
4-6 weeks healing time
Non-union (especially distal third fractures)
Neurovascular injury
Puncture injuries (pneumothorax)
What are the two fractures that are highest risk of compartment syndrome?
tibial shaft
supracondylar
How are clavicle fractures managed?
Try to manage all this way unless open as no long term benefit and metal work is often prominent
Sling with early movement of shoulder to prevent frozen shoulder
Take sling off when pain-free movement
Surgical
For open, comminuted, shortened or bilateral fractures
If non-union ORIF done 2-3 months post injury
