Upper extremity disorders: elbow Flashcards
Distal Humerus Fracture clinical presentation
- Pain (focal)
- Swelling (focal)
- Exacerbated by movement
- Possible creptius
- Distal Neurovascular Symptoms
Distal Neurovascular Symptoms of a Distal Humerus Fracture
- Ulnar nerve (MOST AT RISK): finger abduction & adduction
- Have patient cross his/her index & middle finger
- Radial nerve: thumb & wrist extension
- Median nerve: opposition pinching strength of thumb to index finger
- Ulnar nerve: little finger & ulnar aspect of fourth finger
- Radial nerve: radial two-thirds of the dorsal hand
- Median nerve: volar areas of hand spanning the thumb to radial half of fourth finge
Distal Humerus Fracture
Evaluation/Diagnosis
- Diagnostic Testing
- X-ray
- AP & Lateral
- Compare BL in children to r/o growth
plate involvement - CT scan useful for better picture of the
entire fx-coordinate with Ortho
Large anterior fat pad (“sail sign”)
or any posterior fat pad in a true
lateral x-ray view suggests _____
an intra-articular fracture or
dislocation of the elbow
Distal Humerus Fracture
Management
- Goal = stable reduction, restore motion
- Stable, non-displaced fx
- Displaced fx (Most are displaced)
- Severe osteoporosis and/or fx comminution
Distal Humerus Fracture
Complications
- Pain
- ↓ ROM
- Deformity
- Arthritis
- Neuropathy (especially Ulnar)
- Hardware failure
- Infection
Referral considerations for a Distal Humerus Fracture
- Displaced fx = ortho referral
- Neurovascular injury = specialty referral
Management of Nonsurgical cases of a Distal Humerus Fracture
- F/U to monitor for:
- Displacement
- Joint displacement
- Distal vascular compromises
- Failure to regain ROM = Referral
Distal Humerus Fracture
Prevention
- Screen for osteoporosis (more to come on this)
- Be safe & Don’t fall
Olecranon Process Fracture etiology
- MOI = direct blow
- Fall, MVA, assault
- Forced hyperextension of
elbow (less common)
Olecranon Process Fracture
Clinical Presentation
- Pain & swelling (posterior elbow)
- Focal swelling & tenderness (posterior elbow)
- Worse with movement
- Decreased (absent) movement
- Wounds & lacerations
Olecranon Process Fracture
Evaluation/Diagnosis
Distal neurovascular exam
* Ulnar nerve: little finger & ulnar aspect of fourth finger
* Radial nerve: radial two-thirds of the dorsal hand
* Median nerve: volar areas of hand, thumb to radial half of fourth finger
* Evaluate radial & ulnar arteries for signs of compartment syndrome
X-ray
* AP & Lateral
CT for comminuted fx
* Coordinate with ortho
Olecranon Process Fracture
Management if displaced vs. nondisplaced
Non-displaced fx
* Posterior splint, 45° elbow flexion
* F/U x-ray, 10 days
* Ensure no displacement
* Protected ROM at 2-3 weeks
Displaced fx
* Most olecranon fx are displaced
* ORIF
Olecranon Process Fracture
Complications
- ↓ ROM
- Arthritis
- Non-union/displacement
- Infection
Olecranon Process Fracture Referral considerations
- Displace or open fx are referred to
ortho - Neurovascular injury requires
specialty consult
Radial Head Fracture etiology
Fall On an Out Streched Hand (FOOSH)
Radial Head Fracture
Clinical presentation
- Pain & swelling of the elbow/proximal forearm
- Worse with movement
- Focal swelling & tenderness over the elbow/proximal forearm
- Distal neurovascular exam
- Radial nerve (posterior interosseous motor branch) may be injured in
radial neck fractures - Finger & Thumb extension
- Wounds & lacerations may indicate an open fx
Radial Head Fracture
Evaluation/Diagnosis
- X-ray
- AP, Lateral,
Radiocapitellate (Oblique) - Some fx of the radial head &
neck can be missed if
minimally displaced - May consider obtaining computed
tomography (CT) - May considering obtaining magnetic
resonance imaging (MRI)
Radial head fx are associated with
other injuries
- MCL injury (54%)
- LCL injury (80%)
- Osteochondral injury (29%)
- Capitellum “bone bruising” (94%)
- Loose bodies (92%)
Radial Head Fracture
Management
- Most managed outpatient
- Non-displaced & involving less than 1/3 of articular surface fracture
- sling & early mobilization of elbow after 2 days
- All others: posterior long arm splint
- Operative repair
- Involving > 1/3 of articular surface
- > 30° angulation
- > 3 mm displacement
- A “mechanical block” or limited range of motion of elbow from an
obstructing piece of cartilage or bony fragment
Radial Head Fracture
Complications
- ↓ ROM
- Instability
- Pain
- Infection
- Nerve damage
- Hardware failure
- Malunion
- Arthritis
Radial Head Fracture referral considerations
- Type II fx with ↓ rotation or involve >
30% of the head - Type III
- Any fx with associated elbow
dislocation/instability - Failure of non-surgical tx
- Pain/limited ROM
Dislocation of the Elbow etiology
- Hyperextension injury
- Compression & shear force
- Compromises ligamentous support
Dislocation of the Elbow
Clinical Presentation
- Severe elbow pain
- Obvious deformity
- Extensive swelling
Dislocation of the Elbow eval/diagnosis
- Clinical diagnosis
- Confirmed by typical abnormal bone alignment on AP & lateral x-rays
- If radial head fx is also seen, assume a coronoid process fracture
- Distal neurovascular exam (assess before & after repositioning attempts)
- CT with 3-dimensional reconstructions if fracture is suspected
Dislocation of the Elbow
Management
- Closed reduction
- Open reduction & soft tissue repair/reconstruction
Closed reduction of the elbow
- Assess neurovascular status prior to any reduction maneuvers
- Conscious sedation or general anesthesia be necessary
- Obtain post-reduction x-rays & assess instability
- Most simple dislocations can be managed with posterior elbow splint, can begin ROM at 5-7 days, use locking brace that limits full extension
Open reduction for Dislocation of the Elbow
- May be required if closed reduction cannot be achieved or maintained
- Surgical intervention required for elbows that remain unstable when
placed in flexion & pronation, or require 50-60° of flexion to remain stable - Post-reduction rehabilitation
- multiple therapy sessions per week, 1-2 weeks
- Active assisted & gentle passive ROM x 6 weeks
- Strengthening exercises 4-6 weeks following surgery
Dislocation of the Elbow
Complications
- ↓ ROM (esp. extension)
- ↓ elbow stability
- Fracture & neurovascular injury
from reduction (median nerve
entrapment) - Vascular compromise (tight
compression, splinting >100°
flexion - Contracture
- Pain
Referral considerations for a Dislocation of the Elbow
- Neurovascular injury
- Incomplete reduction
- Flexion contracture >45° 3 weeks
after injury
Monteggia fractures etiology
FOOSH
Monteggia fractures
Clinical Presentation
- Patients c/o pain in the proximal forearm and elbow
- ↑ with supination and pronation
- Swelling and tenderness at forearm and elbow
- Dislocated radial head may be palpable
- Radial nerve damage may be associated with Monteggia fractures
- Test finger and thumb extension strength
- Look for any wounds/lacerations = open fracture
Monteggia fractures
Diagnosis
- X-ray of the forearm (anteroposterior [AP], lateral) and elbow (AP, lateral,
oblique) - An additional dedicated radial head view of the elbow may help to exclude a
radial head fracture - Bado Type 1, 2, or 3
Bado Type 1
Extension type with radial head
dislocating anteriorly
Bado Type 2
Flexion type with radial head
dislocating posteriorly
Bado Type 3
Lateral type with radial head
dislocating to the side
Monteggia fractures
Management
- Most cases of Monteggia fracture-dislocations can be managed outpatient, if a closed reduction of the ulna and radial head can be achieved
- Adults: most fractures will require operative repair
- Children: many often heal well with conservative, nonoperative management
- Fractures associated with neurovascular injuries need emergent reduction and operative repair
Monteggia fractures
Complications
- Mal- or nonunion
- Posttraumatic arthritis
Radial Head Subluxation (Nursemaid’s Elbow) etiology
A subluxation of the radial head out of the annular ligament caused by a
sudden traction force (pull) on an extended pronated arm
-Dynamed.com,. (2016). Retrieved 2 March 2016, from http://www.dynamed.com/topics/dmp~AN~T903394/Radial-head-subluxation-nursemaid-elbow-emergency-management#General-Information
-Erickson MA, Caprio B. Orthopedics. In: Hay WW, Jr., Levin MJ, Deterding RR, Abzug MJ. eds. CURRENT Diagnosis & Treatment: Pediatrics, 22e. New York, NY: McGraw-Hill; 2013. http://accessmedicine.mhmedical.com/content.aspx?bookid=1016&Sectionid=61602466. Accessed
March 01, 2016.
Radial Head Subluxation (Nursemaid’s Elbow Clinical Presentation
- Brought in by parents c/o elbow pain
- History of the child’s arm having been pulled
- Generalized pain in the arm, exacerbated by movement
Radial Head Subluxation (Nursemaid’s Elbow) diagnosis
- Clinical
- Infant/child refuses to use injured arm
- Arm held in pronation with the elbow mildly flexed & abducted
(self-splinted against the body) - Tenderness over the radial head
- Elbow x-rays (AP & lateral) are usually unnecessary
- Useful if concerned for fractures or after unsuccessful closed reduction
Radial Head Subluxation management
- Treatment involves a closed reduction of the subluxation
- Splinting & immobilization are unnecessary after reduction
- Pain medications prn
- Reduction (hyperpronation or supination methods)
Hyperpronation method
Position the patient’s elbow at 90 degrees
* Use your contralateral hand to cup patient’s elbow with your thumb
stabilizing the radial head
* Ex: Use your right hand to support the patient’s injured left elbow
* Using your other hand, grasp the patient’s hand or wrist (as if you are
about to shake hands) & hyperpronate the patient’s wrist
* If subluxation still not reduced, flex the elbow
Supination method
- Position the patient’s elbow in slight extension beyond 90 degrees
- Use your contralateral hand to cup patient’s elbow with your thumb
stabilizing the radial head - Ex: use your right hand to support the patient’s injured left elbow
- Using your other hand, grasp the patient’s hand or wrist (as if you are
about to shake hands) & supinate the patient’s wrist while also flexing at
the patient’s elbow
Medial Epicondylitis aka
“Golfer’s Elbow” “Little League Elbow”
Medial Epicondylitis etiology
- Activities involving repetitive wrist flexion or forearm pronation
- Repetitive overuse theory
Medial Epicondylitis
Clinical presentation
- pain (medial elbow)
- exacerbated by repeated wrist or elbow bending ADLs
- Wrist flexion & forearm pronation
- Insidious onset
- athletes may notice pain during late cocking or early acceleration phases of throwing motion
- pain persists despite rest
Medial Epicondylitis
Evaluation/Diagnosis
- Clinical diagnosis
- Area of tender to palpation just distal (5-10 mm) to the medial epicondyle
- Painful forearm pronation against resistance
- Painful wrist flexion against resistance
- X-ray?
- AP & Lateral r/o arthritis or osteochondral loose bodies
- MRI can identify diagnosis & severity
- Not typically useful in treatment
- US may be useful both for diagnosis and guided injection therapy
Medial Epicondylitis
Management
MODIFY/ELIMINATE ACTIVITY CAUSING SYMPTOMS
* R.I.C.E.
* Crushed ice ½ hr q 2 hr
* NSAIDS
* Physical rehabilitation
* Corticosteroid injection for persistent/resistant symptoms
* May worsen symptoms over the subsequent couple days thereafter
* Surgery for severe, recurrent/chronic (~6 months) symptoms (debridement of
tendonosis)
Medial Epicondylitis
Complications
- NSAIDS cause GI, renal, & hepatic
adverse effects - Surgery
- Infection
- Nerve injury
- Incomplete pain relief
Lateral Epicondylitis aka
Tennis Elbow”
Lateral Epicondylitis etiology
- Overexertion common extensor tendon
- repetitive wrist extension & supination
- Repetitive overuse theory
What is Repetitive overuse theory?
- Microtrauma → degeneration → inflammation of the tendinous complex
- Tendon degeneration results, altering elbow biomechanics 2° to
weakness & pain
Lateral Epicondylitis
Clinical presentation
- Pain, (achy-sharp), lateral elbow
- extension of the wrist or
supination of the forearm - Lifting, turning a screwdriver
(…or a tennis backhand) - May cause inability to lift or
hold objects
Lateral Epicondylitis
Diagnosis
- Clinical diagnosis
- tenderness at or near lateral epicondyle
- usually observed anterior & distal to lateral epicondyle
- pain with resisted wrist extension or third finger extension
- highly specific test (73% sensitive, 97% specific)
- Imaging unnecessary
Lateral Epicondylitis
Management
- 85% success with nonsurgical tx
- MODIFY/ELIMINATE ACTIVITY CAUSING SYMPTOMS
- R.I.C.E.
- Crushed ice ½ hr q 2 hr
- NSAIDS
- Physical rehabilitation
- Corticosteroid injection for persistent/resistant symptoms
- May worsen symptoms over the subsequent couple days thereafter
- Surgery for severe, recurrent/chronic (~6 months) symptoms (debridement of
tendonosis) - Corticosteroid injection vs. placebo injection
Lateral Epicondylitis
Complications
- NSAIDS cause GI, renal, & hepatic
adverse effects - Surgery
- Infection
- Nerve injury
- Incomplete pain relief
Olecranon Bursitis etiology
- Infectious (septic), traumatic,
inflammatory or crystal deposition
Olecranon Bursitis clinical presentation
- Swelling over proximal olecranon
- Tender to palpate in 20%-45% of cases of aseptic bursitis
- > septic bursitis
- Septic bursitis more likely to present with bursal warmth
- nearly 100% with septic vs. 50% with aseptic bursitis)
- Peribursal cellulitis
- (60% with septic vs. 25% with aseptic bursitis)
- Tenderness
- Clinically significant fever (>100.4° in ~40% of patients, septic bursitis)
Olecranon Bursitis
Evaluation/Diagnosis
Diagnosed clinically based on swelling over posterior olecranon
* swelling without pain almost always non-septic olecranon bursitis
* Pain, warmth, & tenderness
* Aspiration
* Purulent fluid indicates septic bursitis
* Serosanguineous or hazy fluid may be seen in both aseptic & septic
bursitis
* Send aspirate to lab for WBC, crystals, Gram stain, & culture
* If origin is traumatic
* X-ray (AP & Lateral)
Olecranon Bursitis
Management
- Aseptic olecranon bursitis
- treated conservatively with padding on elbow & ADL modification
- steroid injection may be considered
- Septic bursitis
- treat with antibiotics & aspirate
- amoxicillin/clavulanic acid (Augmentin®), clindamycin (Cleocin®)
- corticosteroid injections contraindicated with suspected infection
- May require surgical options
- Excision & drainage or debridement for septic bursitis
- bursectomy for septic or aseptic bursitis
Olecranon Bursitis
Complications
- Infection
- Chronic effusion/recurrence
Olecranon Bursitis Referral considerations
- Recurrence (>3 aspirations)
- Septic bursitis
