T&O: elbow presentations incl. triceps, biceps

Question 1

A child sustains a supracondylar fracture of the elbow following a FOOSH. What structures could be damaged and what can this lead to?

Answer 1

• Brachial artery affected by direct damage from fracture.
• This can lead to ischaemia —> Volkmann’s ischaemic contracture.
• Can affect radial, medial or ulnar nerve.
• In children, supracondylar fracture can lead to ‘pale, pulseless’ limb —> need emergency surgery

Question 2

What do fractures of the olecranon result in?

Answer 2

Result in the sudden pull of the triceps (and brachialis) muscle.

Question 3

What do olecranon fractures present with on examination?

Answer 3

Tenderness when palpating over posterior aspect of the elbow. Inability to extend the elbow against gravity, as triceps mechanism is disrupted.

Question 4

What XR views would you request for suspected olecranon fracture?

Answer 4

Plain AP and lateral of affected joint (+/- joint above and below).

Question 5

What movements are preserved and weakened in the Short head of biceps rupture?

Answer 5

Flexion is weakened but supination is preserved

Question 6

What is a humeral shaft fracture

Answer 6

• Fracture of middle third of humerus

Question 6

What are the RF for humeral shaft fractures?

Answer 6

• Osteoporosis
• Increasing age
• high velocity injury in young people
• may also be pathological fractures

Question 6

How would someone present with a humeral shaft fracture

How would you examine a pt with a humeral shaft fracture

Answer 6

1. pain and deformity.
   * if radial nerve is involved: loss of sensation on 1st dorsal webspace and weakness of wrist extension
2. Examine radial nerve and do a full neurovascular examine, assess for open wounds and any concurrent injuries

Question 7

Management of humeral shaft fracture?

Answer 7

• mainstay of management is the re-alignment of the limb
• majority of humeral shaft fractures can be treated conservatively in a functional humeral brace (or U-slab if these are not available)
• fractures that are <20o anterior angulation, <30o varus or valgus angulation, and with <3cm of shortening: suitable for conservative management
• patients need regular follow-up with repeated plain film imaging and around 90% of patients will go on to full union within 8-12 weeks.

SURGICAL
ORIF
IM nailing in pathological fractures

Question 8

Complications of humeral shaft fracture?

Answer 8

• non-union or malunion (rare)
• Varus angulation
• 90% of radial nerve injuries will improve in 3 months

Question 9

Why are radial nerve injuries common in humeral shaft fractures?

Answer 9

• radial nerve sits in the spiral groove therefore vulnerable

Question 10

How does biceps tendon rupture happen?

Answer 10

• sudden forced extension of flexed elbow

Question 12

RF for biceps tendon rupture?

Answer 12

• previous biceps tendon rupture
• steroid use
• smoking
• chronic kidney disease (CKD)
• use of fluoroquinolone antibiotics.

Question 13

Clinical features of biceps tendon rupture?

Answer 13

• sudden onset pain and weakness
• marked swelling and bruising in ACF
• reverse popeye sign

Question 14

Outline the hook test?

Answer 14

• for biceps tendon rupture
• The elbow is actively flexed to 90º and fully supinated, the examiner attempts to ‘hook’ their index finger underneath the lateral edge of the biceps tendon (which cannot be done in a ruptured biceps tendon)

Question 15

Diagnosis for biceps tendon rupture?

Answer 15

• clinical
• confirmation by USS
  *

Question 16

Management of biceps tendon rupture?

Answer 16

• discussion with pt
• able to still flex and supinate however will be easily fatigued and weaker
• Can use analgesia and physion

Surgical
* should occur a few weeks after the injury

Question 17

Complications of biceps tendon rupture surgery?

Answer 17

• injury to lateral antebrachial cutaneous nerve,
• posterior interosseous nerve
• radial nerve