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MSK Exam 2 > Upper extremity disorders: elbow > Flashcards

Upper extremity disorders: elbow Flashcards

1
Q

Distal Humerus Fracture clinical presentation

A
  • Pain (focal)
  • Swelling (focal)
  • Exacerbated by movement
  • Possible creptius
  • Distal Neurovascular Symptoms
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2
Q

Distal Neurovascular Symptoms of a Distal Humerus Fracture

A
  • 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
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3
Q

Distal Humerus Fracture
Evaluation/Diagnosis

A
  • 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
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4
Q

Large anterior fat pad (“sail sign”)
or any posterior fat pad in a true
lateral x-ray view suggests _____

A

an intra-articular fracture or
dislocation of the elbow

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5
Q

Distal Humerus Fracture
Management

A
  • Goal = stable reduction, restore motion
  • Stable, non-displaced fx
  • Displaced fx (Most are displaced)
  • Severe osteoporosis and/or fx comminution
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6
Q

Distal Humerus Fracture
Complications

A
  • Pain
  • ↓ ROM
  • Deformity
  • Arthritis
  • Neuropathy (especially Ulnar)
  • Hardware failure
  • Infection
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7
Q

Referral considerations for a Distal Humerus Fracture

A
  • Displaced fx = ortho referral
  • Neurovascular injury = specialty referral
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8
Q

Management of Nonsurgical cases of a Distal Humerus Fracture

A
  • F/U to monitor for:
  • Displacement
  • Joint displacement
  • Distal vascular compromises
  • Failure to regain ROM = Referral
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9
Q

Distal Humerus Fracture
Prevention

A
  • Screen for osteoporosis (more to come on this)
  • Be safe & Don’t fall
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10
Q

Olecranon Process Fracture etiology

A
  • MOI = direct blow
  • Fall, MVA, assault
  • Forced hyperextension of
    elbow (less common)
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11
Q

Olecranon Process Fracture
Clinical Presentation

A
  • Pain & swelling (posterior elbow)
  • Focal swelling & tenderness (posterior elbow)
  • Worse with movement
  • Decreased (absent) movement
  • Wounds & lacerations
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12
Q

Olecranon Process Fracture
Evaluation/Diagnosis

A

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

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13
Q

Olecranon Process Fracture
Management if displaced vs. nondisplaced

A

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

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14
Q

Olecranon Process Fracture
Complications

A
  • ↓ ROM
  • Arthritis
  • Non-union/displacement
  • Infection
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15
Q

Olecranon Process Fracture Referral considerations

A
  • Displace or open fx are referred to
    ortho
  • Neurovascular injury requires
    specialty consult
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16
Q

Radial Head Fracture etiology

A

Fall On an Out Streched Hand (FOOSH)

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17
Q

Radial Head Fracture
Clinical presentation

A
  • 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
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18
Q

Radial Head Fracture
Evaluation/Diagnosis

A
  • 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)
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19
Q

Radial head fx are associated with
other injuries

A
  • MCL injury (54%)
  • LCL injury (80%)
  • Osteochondral injury (29%)
  • Capitellum “bone bruising” (94%)
  • Loose bodies (92%)
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20
Q

Radial Head Fracture
Management

A
  • 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
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21
Q

Radial Head Fracture
Complications

A
  • ↓ ROM
  • Instability
  • Pain
  • Infection
  • Nerve damage
  • Hardware failure
  • Malunion
  • Arthritis
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22
Q

Radial Head Fracture referral considerations

A
  • 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
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23
Q

Dislocation of the Elbow etiology

A
  • Hyperextension injury
  • Compression & shear force
  • Compromises ligamentous support
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24
Q

Dislocation of the Elbow
Clinical Presentation

A
  • Severe elbow pain
  • Obvious deformity
  • Extensive swelling
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25
Q

Dislocation of the Elbow eval/diagnosis

A
  • 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
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26
Q

Dislocation of the Elbow
Management

A
  • Closed reduction
  • Open reduction & soft tissue repair/reconstruction
27
Q

Closed reduction of the elbow

A
  • 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
28
Q

Open reduction for Dislocation of the Elbow

A
  • 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
29
Q

Dislocation of the Elbow
Complications

A
  • ↓ ROM (esp. extension)
  • ↓ elbow stability
  • Fracture & neurovascular injury
    from reduction (median nerve
    entrapment)
  • Vascular compromise (tight
    compression, splinting >100°
    flexion
  • Contracture
  • Pain
30
Q

Referral considerations for a Dislocation of the Elbow

A
  • Neurovascular injury
  • Incomplete reduction
  • Flexion contracture >45° 3 weeks
    after injury
31
Q

Monteggia fractures etiology

A

FOOSH

32
Q

Monteggia fractures
Clinical Presentation

A
  • 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
33
Q

Monteggia fractures
Diagnosis

A
  • 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
34
Q

Bado Type 1

A

Extension type with radial head
dislocating anteriorly

35
Q

Bado Type 2

A

Flexion type with radial head
dislocating posteriorly

36
Q

Bado Type 3

A

Lateral type with radial head
dislocating to the side

37
Q

Monteggia fractures
Management

A
  • 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
38
Q

Monteggia fractures
Complications

A
  • Mal- or nonunion
  • Posttraumatic arthritis
39
Q

Radial Head Subluxation (Nursemaid’s Elbow) etiology

A

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.

40
Q

Radial Head Subluxation (Nursemaid’s Elbow Clinical Presentation

A
  • 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
41
Q

Radial Head Subluxation (Nursemaid’s Elbow) diagnosis

A
  • 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
42
Q

Radial Head Subluxation management

A
  • Treatment involves a closed reduction of the subluxation
  • Splinting & immobilization are unnecessary after reduction
  • Pain medications prn
  • Reduction (hyperpronation or supination methods)
43
Q

Hyperpronation method

A

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

44
Q

Supination method

A
  • 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
45
Q

Medial Epicondylitis aka

A

“Golfer’s Elbow” “Little League Elbow”

46
Q

Medial Epicondylitis etiology

A
  • Activities involving repetitive wrist flexion or forearm pronation
  • Repetitive overuse theory
47
Q

Medial Epicondylitis
Clinical presentation

A
  • 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
48
Q

Medial Epicondylitis
Evaluation/Diagnosis

A
  • 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
49
Q

Medial Epicondylitis
Management

A

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)

50
Q

Medial Epicondylitis
Complications

A
  • NSAIDS cause GI, renal, & hepatic
    adverse effects
  • Surgery
  • Infection
  • Nerve injury
  • Incomplete pain relief
51
Q

Lateral Epicondylitis aka

A

Tennis Elbow”

52
Q

Lateral Epicondylitis etiology

A
  • Overexertion common extensor tendon
  • repetitive wrist extension & supination
  • Repetitive overuse theory
53
Q

What is Repetitive overuse theory?

A
  • Microtrauma → degeneration → inflammation of the tendinous complex
  • Tendon degeneration results, altering elbow biomechanics 2° to
    weakness & pain
54
Q

Lateral Epicondylitis
Clinical presentation

A
  • 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
55
Q

Lateral Epicondylitis
Diagnosis

A
  • 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
56
Q

Lateral Epicondylitis
Management

A
  • 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
57
Q

Lateral Epicondylitis
Complications

A
  • NSAIDS cause GI, renal, & hepatic
    adverse effects
  • Surgery
  • Infection
  • Nerve injury
  • Incomplete pain relief
58
Q

Olecranon Bursitis etiology

A
  • Infectious (septic), traumatic,
    inflammatory or crystal deposition
59
Q

Olecranon Bursitis clinical presentation

A
  • 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)
60
Q

Olecranon Bursitis
Evaluation/Diagnosis

A

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)

61
Q

Olecranon Bursitis
Management

A
  • 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
62
Q

Olecranon Bursitis
Complications

A
  • Infection
  • Chronic effusion/recurrence
63
Q

Olecranon Bursitis Referral considerations

A
  • Recurrence (>3 aspirations)
  • Septic bursitis

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