Upper Limb - elbow

Question 1

What is the most common mechanism of injury for a supracondylar fracture?

Answer 1

Fall on an outstretched hand (FOOSH)

Question 2

What are two key symptoms of a supracondylar fracture?

Answer 2

Pain and refusal to move the elbow

Question 2

What are three common signs of a supracondylar fracture?

Answer 2

Gross deformity, swelling, and brusing

Question 3

Which neurovascular structures are most at risk in a supracondylar fracture?

Answer 3

Brachial artery and median nerve

Question 4

What is the significance of the posterior fat pad sign on an X-ray?

Answer 4

It indicates an occult fracture around the elbow

Question 5

What are the two main treatment approaches for a supracondylar fracture?

Answer 5

1. Conservative (cast immobilisation)
2. Operative (closed/open reduction with percutaneous pinning)

Question 6

What is a serious vascular complication of a supracondylar fracture?

Answer 6

Brachial artery injury, which can lead to Volkmann’s ischaemic contracture

Question 7

What nerve injury is commonly associated with supracondylar fractures?

Answer 7

Median nerve injury, leading to sensory and motor deficits

Question 8

Which shoulder movement is the axillary nerve responsible for?

Answer 8

The axillary nerve innervates the deltoid muscle, which is responsible for shoulder abduction from 15 degrees onwards

Question 9

Which is the main flexor of the elbow?

Answer 9

Biceps brachii

Question 10

What is the most important aspect of examination when assessing a patient with a supracondylar fracture of the humerus?

Answer 10

Assessing neurovascular status is crucial

The brachial artery, median nerve, and radial nerve are at risk.

Vascular compromise requires urgent theatre intervention for reduction and possible on-table angiogram

Question 11

What is the management of suspected but not radiologically confirmed scaphoid fractures?

Answer 11

If highly suspicious** of scaphoid fracture, treatment should commence even if there is no initial radiological evidence of fracture, with repeat X-rays taken after 10 days for repeat imaging

Question 12

Which type of fracture can cause an ulnar nerve palsy?

Answer 12

Supra-condylar fracture of the humerus

Question 13

What is Froment’s sign?

Answer 13

Froment’s sign is a sign specific for ulnar nerve palsy

= The patient is asked to hold a piece of paper between their thumb and index finger by adducting the thumb as the paper is pulled away

Question 14

A 5-year-old girl is playing on the swings when she goes too high and falls off, onto her outstretched hand.
On examination, her elbow is very swollen and slightly flexed.
What would be the next step of your examination?

Answer 14

Neurovascular examination of the limb

Question 15

A 34-year-old man presents to A&E following a motorcycle accident. He complains of pain in his left arm.
On examination, there is swelling and tenderness over his left upper arm. He can perform shoulder abduction, adduction, flexion and extension. His pulse rate is 120 bpm and regular, and his blood pressure is 136/79 mmHg.
An X-ray shows a mid-shaft fracture of the left humerus

What muscle is most likely to be affected?

Answer 15

Brachioradialis

Question 16

A 5-year-old boy presents to the hospital following a fall from a tree onto his left hand. His parents report that his arm was fully extended on impact. The boy complains of elbow pain and refuses examination. An elbow x-ray shows a partially displaced transverse supracondylar fracture of the humerus

What is the most appropriate management?

Answer 16

Admit for neurovascular observation and closed reduction

Question 17

A 14-year-old boy is brought to the emergency department for pain and swelling in the left elbow after a fall during his physical education class. On examination, there is tenderness, swelling and ecchymosis over the left elbow with limited range of movement. He is unable to make a complete fist and adduct his thumb on the left side. There is also reduced sensation over the left hypothenar eminence

An x-ray of the left elbow shows a medial supracondylar fracture. What structure is most likely injured in this patient?

Answer 17

Ulnar nerve

Question 18

What nerve is affected in cubital tunnel syndrome?

Answer 18

The ulnar nerve

Question 18

Where does compression occur in cubital tunnel syndrome?

Answer 18

Behind the medial epicondyle at the cubital tunnel

Question 19

What are two common causes of ulnar nerve compression in the cubital tunnel?

Answer 19

Osborne’s fascia tightness or compression at the intermuscular septum

Question 20

What are the key symptoms of cubital tunnel syndrome?

Answer 20

1. Paraesthesia in the ulnar 1½ fingers (ring and little fingers)
2. Night symptoms due to elbow flexion

Question 21

What is a key clinical sign of cubital tunnel syndrome on examination?

Answer 21

Tinel’s test over the cubital tunnel is positive

Question 22

What is Froment’s sign, and what does it indicate?

Answer 22

The thumb flexes at the IP joint when pinching a piece of paper due to adductor pollicis weakness

= indicating ulnar nerve dysfunction

Question 23

What is Wartenberg’s sign?

Answer 23

Abduction of the little finger due to weak ulnar nerve-innervated muscles

Question 24

What is ulnar clawing?

Answer 24

1. Hyperextension at the MCP joints 2. Flexion at the IP joints of the ring and little fingers due to ulnar nerve damage

Question 25

What investigations confirm cubital tunnel syndrome?

Answer 25

1. Nerve conduction studies 2. Tinel’s test 3. Froment’s test 4. Modified Phalen’s test (elbow flexion test).

Question 26

What is the first-line treatment for cubital tunnel syndrome?

Answer 26

Conservative management – NSAIDs, activity modification, and nighttime elbow extension splinting

Question 27

When is surgery indicated for cubital tunnel syndrome?

Answer 27

If conservative treatment fails, ulnar nerve decompression is performed

Question 28

Which fingers are affected by tingling and numbness in cubital tunnel syndrome?

Answer 28

The 4th (ring) and 5th (little) fingers

Question 29

What action typically worsens the pain in cubital tunnel syndrome?

Answer 29

Leaning on the affected elbow

Question 30

How do the sensory symptoms progress over time in cubital tunnel syndrome?

Answer 30

They start off as intermittent tingling and numbness and then become constant

Question 31

What are two common risk factors for cubital tunnel syndrome?

Answer 31

Osteoarthritis and prior trauma to the area

Question 32

What is another name for lateral epicondylitis?

Answer 32

Tennis elbow

Question 32

Which forearm muscle is most commonly affected in lateral epicondylitis?

Answer 32

Extensor carpi radialis brevis (ECRB)

Question 32

What is the primary cause of lateral epicondylitis?

Answer 32

Overuse of the finger extensor tendons that originate from the lateral humeral epicondyle

Question 33

What type of movement is most associated with lateral epicondylitis?

Answer 33

Repeated or excessive pronation/supination and wrist extension

Question 34

Where is the pain located in lateral epicondylitis?

Answer 34

Over the lateral epicondyle, radiating down the posterior forearm

Question 35

What activity commonly worsens the pain in lateral epicondylitis?

Answer 35

Stretching the muscles, such as opening a jar

Question 36

How can lateral epicondylitis be diagnosed clinically?

Answer 36

(1) Pain on resisted middle finger (2) Wrist extension with the elbow flexed to 90° in pronation

Question 37

Why might a nerve conduction study be performed in suspected lateral epicondylitis?

Answer 37

To rule out nerve involvement if neurological symptoms are present

Question 38

Which arm is typically affected in lateral epicondylitis?

Answer 38

The dominant arm

Question 39

How long do episodes of lateral epicondylitis usually last?

Answer 39

Between 6 months and 2 years

Question 40

A 48-year-old man presents to the GP with right-sided elbow pain. This started last week after painting the stairwell of his home. On examination, the pain is worse on wrist extension against resistance and supination of the forearm whilst the elbow is extended. What is the most likely diagnosis?

Answer 40

Lateral epicondylitis

Question 41

A 43-year-old woman presents with pain in the right elbow. This has been present for the past month and she reports no obvious trigger. On examination, she reports pain on wrist extension against resistance whilst the elbow is extended. What is the most likely diagnosis?

Answer 41

Lateral epicondylitis

Question 42

A 46-year-old man presents to his general practitioner with pain around the right elbow that has persisted for 2 weeks. He does not recall any specific injury; he works in an office and is an avid sportsman. He has no significant past medical history. On examination, pain is elicited with resisted extension of the right wrist while the elbow is extended. Pain is also elicited with the supination of the forearm. Why would the answer be Lateral epicondylitis?

Answer 42

worse on resisted wrist extension/suppination whilst elbow extended

Question 43

A 45-year-old man presents to his GP with pain in the lateral aspect of his right elbow. He has recently started a new job as a painter-decorator, and the pain has started to affect his work, as he is right-handed. Upon examination, his pain is worse on wrist extension against resistance with his elbow extended. Given the most likely diagnosis, what other movement would you expect to cause pain upon examination?

Answer 43

Supination of the wrist

Question 44

A 45-year-old man has 6 months of gradually worsening pain in his right elbow. He works in construction and reports that the pain intensifies with activities involving gripping or lifting. Despite using paracetamol, he has had minimal relief. His vital signs are normal. Tenderness is noted over the lateral epicondyle of the right elbow. There is no swelling or erythema, and his range of motion is otherwise normal. Which additional feature is most likely to be seen?

Answer 44

Resisted wrist extension while the elbow is extended worsens pain

Question 45

How does radial tunnel syndrome differ from lateral epicondylitis in terms of pain location and aggravating movements?

Answer 45

(1) In radial tunnel syndrome, pain is typically distal to the lateral epicondyle and worsens with elbow extension and forearm pronation (2) Whereas in lateral epicondylitis, pain is localised to the lateral epicondyle and worsens with wrist extension against resistance

Question 46

What is another name for medial epicondylitis?

Answer 46

Golfer's elbow

Question 47

What part of the forearm is affected by medial epicondylitis?

Answer 47

The finger flexor tendons that originate from the medial humeral epicondyle

Question 48

How is medial epicondylitis different from lateral epicondylitis in terms of the affected area?

Answer 48

Medial epicondylitis affects the flexor tendons at the medial epicondyle, while lateral epicondylitis affects the extensor tendons at the lateral epicondyle

Question 49

What movements typically aggravate the pain in medial epicondylitis?

Answer 49

Wrist flexion and pronation, and grasping activities like opening a jar

Question 50

Where does the pain radiate in medial epicondylitis?

Answer 50

Down the anterior forearm

Question 51

How is medial epicondylitis diagnosed clinically?

Answer 51

Pain is produced when the elbow is flexed to 90° in supination, and the wrist is flexed against resistance

Question 52

What risk is associated with steroid injections in medial epicondylitis?

Answer 52

A risk of injury to the ulnar nerve

Question 53

What is the characteristic location of pain in medial epicondylitis?

Answer 53

Pain and tenderness are localised to the medial epicondyle

Question 54

What surgical option is available for refractory cases of medial epicondylitis?

Answer 54

Surgical release

Question 55

What movements typically worsen the pain in medial epicondylitis?

Answer 55

Wrist flexion and pronation.

Question 56

What neurological symptoms may accompany medial epicondylitis?

Answer 56

Numbness and tingling in the 4th and 5th fingers due to ulnar nerve involvement

Question 57

What nerve is commonly involved in medial epicondylitis when there are neurological symptoms?

Answer 57

The ulnar nerve

Question 58

A 55-year-old accountant presents to the GP with a painful right elbow. He points to the medial epicondyle of the humerus. He does not recall any predisposing injury but describes exacerbation of the pain when using the arm, which can extend into the forearm. This has caused him to stop playing golf. He is otherwise well and takes no medications. From the history alone, a particular diagnosis is suspected. Examination supports this supposition. What examination finding is most consistent with the suspected diagnosis?

Answer 58

Worsening symptoms with the wrist flexed and pronated

Question 59

lateral epicondylitis movements

Answer 59

wrist extended pronated elbow can be supinated

Question 60

medial epicondylitis movements

Answer 60

wrist flexed supinated elbow can be pronated

Question 61

What muscle would experience paralysis in cubital tunnel syndrome? and why?

Answer 61

adductor pollicis muscle = Paralysis of the adductor pollicis muscle results in impaired thumb adduction, also known as Froment’s sign

Question 62

A patient presents with numbness and tingling along the ulnar border of his wrist and forearm. On examination you also note weak flexion of all the digits including the thumb. What is the most likely diagnosis?

Answer 62

C8 radiculopathy