The Elbow Flashcards
How do supracondylar humeral fractures occur and who gets them?
Common paediatric elbow injury (almost never adults)
Peak 5-7yrs
FOOSH (most common)
Landing flexed elbow (<10%)
Thorough assessment neurovascular structures needed
Clinical features of supracondylar humeral fractures
Recent trauma
Sudden onset severe pain
Gross deformity
Swelling
Limited range movement
Ecchymosis
Median, anterior interosseous, radial, ulnar N - potential damage
Vascular compromise - cool temp, delayed capillary refill, absent pulses
Investigations of supracondylar humeral fractures
Plain film radiograph AP & lateral (posterior fat pad sign, displacement of anterior humeral line)
CT - comminuted
Garland classification of supracondylar humeral fractures
Type 1 - undisplaced
Type 2 - displaced with intact posterior cortex
Type 3 - displaced 2/3 planes
Type 4 - displaced complete periosteal disruption
Management of supracondylar humeral fractures
Associated NV compromise - immediate closed reduction
Conservative trialled type 1/ minimal,y displaced type 2 - above elbow cast 90d flexion
Surgical
- Closed reduction & percutaneous K-wire fixation
- open fractures open reduction with percutaneous pinning
Complications of supracondylar humeral fractures
- nerve palsies
Neuropraxia 10% rarely permanent
Anterior interosseous N mostly - Malunion
May develop cubital varus deformity (gunstock) - Volkmann’s contracture
Following vascular compromise
Ischaemia flexor muscles -> claw like
Pathophysiology & clinical features of olecranon fractures
Bimodal
All intra- articular fractures
Typically indirect trauma FOOSH -> sudden pull triceps
Younger direct trauma
Clinical features: Elbow pain Swelling Lack mobility Tenderness Inability extend elbow Shoulder & wrist should be checked
Investigations & management of olecranon fractures
Routine bloods (clotting, G&S)
Plain AP & lateral radiographs
(Degree displacement)
CT - more complex injuries
Management:
Resus
Analgesia
Non- operative (displacement <2mm) immobilisation 60-90d elbow flexion, range of motion 1-2wks
Operative:
Tension band wiring, olecranon plating
Which structure does the olecranon articulate with?
Trochlea
In an olecranon fracture which muscle displaces the proximal fracture fragment?
Triceps brachii
What is the most common fracture of the elbow?
Radial head fractures (1/3rd)
20-60yrs, fms
Pathophysiology & clinical features of radial head fractures
Typically indirect trauma - axial loading forearm -> radial head pushed against capitulum
Features: FOOSH Elbow pain Crepitation & pain supination & pronation Elbow effusion Shoulder & wrist checked
Investigations radial head fractures
Routine bloods
(Clotting & G&S)
Plain AP & lateral radiographs (elbow effusion - sail sign elevation anterior fat pad)
CT - more complex injuries, degree of comminution
MRI - more complex injuries, degree comminution, ligament injuries
Mason Classification of radial head fractures
According to the degree of displacement & intra articular involvement
Mason type 1 - non/ minimally displaced (<2mm)
Mason type 2 - partial articular fracture with displacement (>2mm or angulation)
Mason type 3 - comminuted fracture & displacement (complete articular fracture)
Management of radial head fractures
Resus
Stabilised
Analgesia
Check neurovascular compromise
Management based on mason classification
1 - non op, <1wk immobilisation sling
2 - no mechanical block - as above
May need surgery open reduction internal fixation
3 - nearly always surgery ORIF/ radial head excision or replacement
Which bony structure does the radial head articulate with to form the elbow joint?
Capitulum of humerus & proximal ulna
What is an Essex-lopresti fracture?
Fracture of radial head with disruption/ dislocation distal radio-ulna joint
✅surgery always
Who tends to get elbow dislocations? In what two ways can they be defined?
Young adults
(Rare children - suspect supracondylar humeral fracture)
25% elbow injuries
Simple
Complex - associated concomitant fracture
90% occur posteriorly
50% suffering bony injury
How is the elbow joint stabilised?
Primary static stabilisers - humeroulnar joint, medial/ collateral ligaments
Secondary static - radiocapetellar joint, joint capsule, common flexor & extensor origin tendons
Dynamic stabilisers - surrounding musculature: anconeus, brachialis, triceps brachii
Clinical features of elbow dislocations & investigations
High energy fall typically
Painful
Deformed
Swelling
Decreased function
NV examination essential
Investigations:
Resus
Stable - plain film radiograph AP Lateral (loss radiocapiteller & ulnotrochlea congruence)
CT - adjunct fractures
Management of elbow dislocations
Closed reduction Analgesia \+/- sedation Above elbow backslab once reduced keep at 90d - in line traction - manipulation olecranon -> flexed 90d -> backslab Radiograph confirm
Immobilisation 5-14days
Early rehab
If fracture/ open/ NV compromise - operative fixation
Open reduction & internal fixation
Soft tissue repair
What is the terrible triad injury?
Elbow dislocation with
Lateral collateral ligament injury
Radial head fracture
Coronoid fracture
-> v unstable
Posterolateral dislocation
Recurrent problems likely
✅operative fixation
What is epicondylitis? What are the two types?
Chronic symptoms inflammation of forearm tendons at elbow
Overuse syndrome
Microtears tendons -> granulation tissue -> tendonitis
35-54yrs
Lateral epicondylitis (tennis elbow) more common Medial epicondylitis (golfers elbow)
Clinical features of epicondylitis & two test for lateral epicondylitis
Pain elbow radiation down
Worsens over weeks to months
Tenderness
Tests of LE:
➕ pain
- Cozen’s test
Elbow held flexed 90d, hand over LE, pts hand radially deviated forearm pronated - pt extend wrist against resistance
- Mill’s test
LE palpated whilst pronating forearm , flexing wrist, extending elbow
Investigations & management of epicondylitis
Clinical
USS/ MRI confirm
Management: Modify activities Analgesics Corticosteroid injections Physiotherapy
Surgical:
Not controlled conservatively
Open/ arthroscopic debridement of teninosis &/or release or repair of any damaged tendon insertions
>50% damage tendon transfer
LE Spontaneously improves 80-90% 1-2yrs
ME -tenderness promator teres & FCR tendons
How to people get olecranon bursitis?
Repetitive flexion extension movements elbow -> irritation bursa
Less common gout, RA
Rarely fluid infected skin abrasion or
Puncture (S.aureus)
Features of olecranon bursitis & investigations
Pain Swelling Range motion preserved Infected - systemic Examine contralateral
Routine bloods (FBC, CRP)
Rheumatologist causes - specialised tests
Serum urate - gout
Plain film radiograph rule out bony injury
Aspiration fluid - infection/ crystals ✅
Management of olecranon Bursitis
Dependent if infected - IV antibiotics, surgical drainage
Prolonged - bursectomy
Analgesia
Rest
Splinting elbow
Large - washout
