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Orthopaedics & Rheumatology > The Elbow > Flashcards

The Elbow Flashcards

1
Q

What is the purpose of the condyles in the elbow?

A
  • Tendon attachment points
  • Supinators attach to the lateral condyle
  • pronators attach to the medial condyle
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2
Q

What are the two articulations in the elbow? What are their functions?

A
  1. ulnohumeral: flexion/extension
  2. radioulnar: pronation/supination
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3
Q

What is the primary functional component of the elbow?

A

Flexion

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4
Q

What is the purpose of the olecranon fossa?

A

Provide stability for the elbow from varus and valgus along with the collateral ligaments.

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5
Q

What are the three main ligaments involved in stability of the elbow?

A
  1. Lateral epicondyle: radial collateral ligament - stability in extension, prevent varus and valgus
  2. Medial epicondyle: ulnar collateral ligament - stability in extension, prevent varus and valgus
  3. Annular Ligament - stability of the radial head
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6
Q

Which muscles and nerve(s) are responsible for supination of the forearm?

A
  • Muscles: biceps, supinator
  • Nerves: C5-6
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7
Q

Which muscles and nerve(s) are responsible for pronation of the forearm?

A
  • Muscles: pronator quadratus, pronator teres
  • Nerves: C6-8, T1
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8
Q

What is the typical ROM for pronation/supination?

A
  • Pronation: 70 degrees
  • Supination: 85 degrees
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9
Q

Which views are commonly used in elbow radiography?

A

AP, Lateral, Oblique

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10
Q

What is the sail sign?

A

Fat pad sign, showing effusion (blood) in the joint capsule. Suggests occult supracondyllar fracture in kids or occult radial head fracture in adults.

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11
Q

Lateral Epicondylitis

A
  • “Tennis Elbow”
  • Likely a degenerative process instead of inflammatory
  • “Inflammation” of the extensor origin at their insertion onto the lateral epicondyle
  • May present as a dull ache on the outer aspect of the elbow that increases with grasping, twisting and resisted extension of the wrist or fingers.
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12
Q

Lateral Epicondylitis Physical Exam

A
  • Point tenderness over insertion of extensor tendon on lateral elbow
  • Increasing pain with resisted extension/supination of wrist
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13
Q

Lateral Epicondylitis Treatment

A
  • Rest, avoidance of aggravating activities like gripping
  • Ice if due to acute trauma or repetitive injury (2-3 days)
  • PT, iontophoresis/friction massage
  • Compression, possible ace wrap?
  • Anti-inflammatories
    • NSAIDs
    • +/- steroid injection and marcaine or lidocaine (2-3 max)
  • Surgery: lateral epicondylectomy
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14
Q

Medial Epicondylitis

A
  • AKA golfer’s, pitcher’s, or bowler’s elbow
  • microtrauma to the flexor carpi radialis tendon insertion on the medial epicondyle
  • Physical Findings:
    • tender to palpation on the medial epicondyle
    • increased pain with resisted flexion and pronation of the wrist
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15
Q

Medial Epicondylitis Treatment

A
  • Rest, avoid aggravating activity
  • +/- ice
  • NSAIDs
  • PT for iontophoresis, etc.
  • Referral for resistant cases
  • Use caution when considering injection - ulnar nerve
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16
Q

Olecranon Bursitis

A
  • Inflammation, swelling and +/- pain over the olecranon process
  • Causes:
    • trauma
    • infection - puncture wounds, microscopic (not clinically evident) wounds
    • inflammation - gout, pseudo-gout, rheumatoid arthritis, uremia in renal failure
17
Q

Olecranon Bursitis Risk Factors

A

Diabetes

Chronic alcohol abuse

Occupation/hobbies

Gout

Immunocompromised

18
Q

Olecranon Bursitis Diagnosis

A

x-ray if trauma or suspicion of foreign body and +/- gout

CBC if suspicion of significant infection

ESR, CRP and serum uric acid if suspicion of gout

Aspiration is controversial, consider specialist consult

19
Q

Olecranon Bursitis Treatment

A
  • First line for non-infectious is nothing
    • Rest - avoid direct trauma, elbow padding may help
  • NSAIDs if pain is present (or APAP)
  • Aspiration (specialist)
    • Gram stain & culture
    • > 5000 WBC/mL indicates infection
  • If infection present, staph aureus is most common pathogen
  • Do NOT inject steroids unless positive there is no infection
  • Typically resolves in 2-4 weeks
  • Consider close follow-up after steroid injections
20
Q

Ulnar Nerve Entrapment Syndromes Basics

A
  • May be from acute trauma such as a fracture or dislocation
  • Initial treatment requires prompt reduction
  • Document neurovascular status before and after reduction
21
Q

Cubital Tunnel Syndrome

A
  • AKA “truck driver’s elbow”
  • Chronic pressure on the ulnar nerve where it passes between bone, tendons and ligaments at the elbow
  • Can also be entrapment of the nerve from hypertrophy of the triceps or the flexor/pronator musculature
  • May be remote result of trauma
22
Q

Tardy Ulnar Palsy

A

ulnar neuropathy remotely after an injury at the condylar groove

23
Q

Ulnar Nerve Entrapment Syndromes Symptoms

A
  • paresthesias in the ring and small fingers
  • weakness of the intrinsic muscles of the hand
  • weakness of abduction of 5th digit
  • chronic entrapment –> Pope’s Blessing Sign
  • Positive Froment’s sign
24
Q

Ulnar Nerve Entrapment Syndromes Diagnosis & Treatment

A
  • Diagnosis:
    • Clinical
    • EMG
  • Treatment:
    • Splinting, NSAIDs, Surgery
25
Q

Radial Nerve Palsy

A
  • AKA Saturday Night Palsy
  • wrist drop and loss of sensation in dorsal web space between thumb and index finger
  • cock-up splint for wrist
  • orthopedic follow-up
  • occupational therapy
  • claw hand in non-resolving cases
  • painless loss of ability to extend the wrist and fingers
26
Q

Radial Tunnel Syndrome

A
  • Actually posterior interosseous nerve in forearm
  • Use caution with tennis elbow straps
  • Loss of motor function
27
Q

Nursemaid’s Elbow

A
  • Subluxation of radial head
    • non-calcified radial head is pulled out from under the annular ligament
    • usually pt is around 2 years old, peak age 1-4
  • About 20% of all upper extremity injuries in children
  • Sudden longitudinal pull on arm with forearm pronated
  • Arm usually held in slight flexion and pronation
  • Child will not want to use arm to grap anything
  • Xray first if question of fracture
  • Reduction technique - supinate the forearm and flex the elbow. feel over radial head for click
  • Re-examine in about 10 min
28
Q

Nursemaid’s Elbow Follow-up

A
  • sling for pain for 1-2 days
  • APAP or ibuprofen for pain
  • generally the child will begin using the arm immediately but will be sore for 3-5 days
  • educate parent on mechanism and what to avoid
29
Q

Elbow Dislocation

A
  • Most commonly posterior dislocation
  • Associated with fall on nearly extended elbow or other similar energy applied to joint
  • If ulnohumeral joint is dislocated there is often an injury to the radial head too
  • Flexion and extension are extremely painful. Pronation and supination will be painful if radial head is also injured.
30
Q

Elbow Dislocation Management

A
  • Initial Management:
    • immobilize in sling, posterior splint or pillow splint, narcotic analgesics
  • Evaluation:
    • X-rays
    • Physical exam: document neurovascular exam
  • Reduction:
    • IV conscious sedation, stabilize upper arm, in line traction of lower arm, flexion of elbow, push toward hand on olecranon, long arm posterior splint, post-reduction xrays, record CMS in hand, specialist referral
31
Q

Fracture of Radial Head

A
  • Mechanism:
    • FOOSH
    • Radial head driven into capitellum
  • Symptoms:
    • Elbow pain, +/- swelling
  • Physical Exam:
    • Tenderness over radial head
    • Limitation of motion, especially in extension and pro-supination
  • Diagnosis:
    • AP, lateral and oblique xray series
    • Radial head views if needed
    • Positive fat pad sign - fluid in the anterior joint capsule
  • Treatment:
    • Sling for comfort
    • Ice for swelling, pain
    • Analgesics, avoid NSAIDs in fractures
    • Encourage early AROM
    • Follow xrays week 1,3,6
32
Q

Elbow Fractures

A
  • Fall backward on partly extended elbow
  • Be suspicious for vascular compromise, especially brachial artery
  • Be suspicious for nerve injury of median, ulnar or radial nerve
  • Not a primary care fracture
  • Treatment:
    • initial - closed reduction or ORIF
  • Complications:
    • loss of ROM/joint contracture
    • post-traumatic arthritis if articular surface is disrupted
    • non-union of fx site
    • infection
    • tardy ulnar palsy
    • nerve or vascular injury
33
Q

Elbow Arthritis

A
  • Post Traumatic:
    • most common
    • arthroplasty is becoming better but not a great option
    • injection technique is difficult
  • Rheumatoid:
    • best managed with DMARDs

Orthopaedics & Rheumatology (5 decks)

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