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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
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
26
Dislocation of the Elbow Management
* Closed reduction * Open reduction & soft tissue repair/reconstruction
27
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
28
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
29
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
30
Referral considerations for a Dislocation of the Elbow
* Neurovascular injury * Incomplete reduction * Flexion contracture >45° 3 weeks after injury
31
Monteggia fractures etiology
FOOSH
32
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
33
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
34
Bado Type 1
Extension type with radial head dislocating anteriorly
35
Bado Type 2
Flexion type with radial head dislocating posteriorly
36
Bado Type 3
Lateral type with radial head dislocating to the side
37
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
38
Monteggia fractures Complications
* Mal- or nonunion * Posttraumatic arthritis
39
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.
40
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
41
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
42
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)
43
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
44
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
45
Medial Epicondylitis aka
“Golfer’s Elbow” “Little League Elbow”
46
Medial Epicondylitis etiology
* Activities involving repetitive wrist flexion or forearm pronation * Repetitive overuse theory
47
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
48
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
49
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)
50
Medial Epicondylitis Complications
* NSAIDS cause GI, renal, & hepatic adverse effects * Surgery * Infection * Nerve injury * Incomplete pain relief
51
Lateral Epicondylitis aka
Tennis Elbow”
52
Lateral Epicondylitis etiology
* Overexertion common extensor tendon * repetitive wrist extension & supination * Repetitive overuse theory
53
What is Repetitive overuse theory?
* Microtrauma → degeneration → inflammation of the tendinous complex * Tendon degeneration results, altering elbow biomechanics 2° to weakness & pain
54
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
55
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
56
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
57
Lateral Epicondylitis Complications
* NSAIDS cause GI, renal, & hepatic adverse effects * Surgery * Infection * Nerve injury * Incomplete pain relief
58
Olecranon Bursitis etiology
* Infectious (septic), traumatic, inflammatory or crystal deposition
59
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)
60
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)
61
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
62
Olecranon Bursitis Complications
* Infection * Chronic effusion/recurrence
63
Olecranon Bursitis Referral considerations
* Recurrence (>3 aspirations) * Septic bursitis

MSK Exam 2 (5 decks)

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