1
Q
Remind yourself of the boy anatomy of the elbow
A
2
Q
What is the anterior humeral line?
A
The anterior humeral line is a radiographic line that is drawn down the anterior margin of the humerus and through the middle third of the capitellum.
3
Q
What is teh radiocapitellar line?
A
Line drawn along the longitudinal axis of the proximal radius. Normally the line passes through the capitellum. If it does not, there is radiocapitellar dislocation.
4
Q
State some common conditions of the elbow
A
- Supracondylar fracture
- Olecranon fracture
- Radial head fracture
- Elbow dislocation
- Olecranon bursitis
- Lateral epicondylitis
5
Q
For supracondylar fractures discuss:
- Who they are common in
- Common mechanism of injury
- Symptoms & signs
- Investigations
- Classification
*
A
- Chidren aged 5-7yrs (rarely happen in adults)
- Falling on outstretched hand
- Suden onset pain, reluctance to move arm, deformity, swelling, limited range of movement due to pain, bruising in anterior cubital fossa
- X-ray (AP & lateral), CT for comminuted fractures or if intrarticular extension suspected
- Gartland classification (I-IV)
6
Q
What might you see on x-ray of supracondylar fracture?
A
- Posterior fat pad sign
- Displacement of anterior humeral line
7
Q
What is the management of supracondylar fractures?
A
- Type 1 or minimally displaced type II: above elbow cast in 90 degrees flexion
- Type II, III, IV nearly always require closed reduction & percutaneous K wire fixation
- Open fractures require open reduction and percutaneous pinning
- If any neurovascular compromise= need closed reduction
8
Q
State some potential complications of supracondylar fractures
A
- Nerve palises
- Anterior interossesous nerve most common after initial injury
- Ulnar nerve most common post-operatively
- Malunion
- Cubitus varus deformity “gunstock deformity”
- Volkmann’s contracture
9
Q
For olecranon fractures dicuss:
- Who they present in
- Common mechanism of injury
- Clinical features
A
- Bimodal: young & old
- Indirect trauma (e.g. fall on outstretched hand resulting in sudden pull of triceps muscle. Triceps muscle can further distract the fracture) or direct high energy trauma
- Pain, swelling, reduced moblility, tenderness over posterior elbow, +/- inability to extend elbow against gravity
10
Q
What investigations should you do for a olecranon fracture?
A
- Routine blood tests including clotting screen & group and save
- X-ray (AP & lateral)
- CT for complex injuries or to assess degree of comminution
11
Q
Discuss the management of olecranon fractures
A
Treatment usually guided by degree of displacement:
- Displacement <2mm or if >75yrs
- Immobilisation with 60-90 degrees elbow flexion
- Early introduction movement at 1-2 weeks
- Displacement >2mm
- Surgical: tension band wiring if prox to coranoid process or olecranon plating if distal to coranoid process
- Metal work often removed at later date due to superficial nature
12
Q
What are the most common fractures of the elbow?
A
Radial head fractures
13
Q
For radial head fractures discuss:
- Common mechanism of injury
- Clinical features
A
- Axial loading of forearm causign radial head to be pushed against capitulum of humerus; most common when arm in extended, pronated position e.g. fall on outstretched hand.
- Pain, tenderness over lateral aspect of elbow, pain worsened on supination & pronation, crepitation on supination & pronation, swelling, bruising
14
Q
What is an Essex-Lopresti fracture?
A
Fracture of radial head with disruption of the distal radio-ulnar joint. Always requires surgical intervention.
15
Q
What investigations would you do for radial head fractures?
A
- Routine blood tests including clotting screen & group and save
- X-ray (AP & lateral)
- CT to evaulate degree of comminution or if complex
- MRI for associated ligament injuries
16
Q
What might you see on x-ray of someone with a radial head fracture?
A
Sail sign (elevation of anterior fat pad)
17
Q
What classification is used to classify radial head fractures?
A
Mason classification; based on degreee of dispalement & intra-articular involvement
18
Q
Discuss the management of radial head fractures
A
Management depends on mason classification, neurovascular compromise and mechanical compromise of elbow.
- Type I: sling immobilisation for < 1 week then early mobilisation
- Type II:
- No mechanical block: treat as type I
- Mechanical block: ORIF
- Type III: ORIF, radial head excision or replacement
19
Q
State some potential complication of radial head fractures
A
- Neurovascular compromise
- Osteoarthritis later in life
20
Q
Elbow dislocations can be simple or complex; explain the difference
A
- Simple= no concomitant fracture
- Complex= concomitant fracture
21
Q
State some clinical features of an elbow dislocation
A
- Pain
- Deformity
- Swelling
- Decreased function (usually immobile in near full extension)
- Loss of equilateral triangle of elbow
22
Q
A good capillary refill can be found in pts who have elbow dislocation and arterial injury; true or false?
A
TRUE; elbow has rich collateral circulation
23
Q
What investigations should you do if you suspect an elbow dislocation?
A
- X-rays (AP & lateral)
24
Q
What would you see on x-ray if pt has elbow dislocation?
A
Loss of radiocapitellar and ulnotrochlear congruence
25
Discuss the management of elbow dislocations; inlcude management of simple and complex dislocations
_Initial Management_
* Closed reduction (ensure sufficient analgesia & sedation)
* Apply above elbow backslab once reduced to keep elbow at 90 degrees
* X-ray required to confirm reduction
_Post -reduction management_
* Simple
* Immobilisation for 5-14 days
* Early rehabilitation
* Complex
* May require surgial repair
26
State some potential complications of an elbow dislocation
* Early stiffness with loss of terminla extension
* Recurrent instability
27
What is the terrible triad?
Elbow dislocation with...
* Lateral collateral injury
* Radial head fracture
* Coronoid frature
Can occur when there is a posterolateral dislocation. Leads to very unstable elbow. Needs operative fixation of each of the components.
28
State come potential causes of non-infected olecranon bursitis highlighting which is most common
* **Repetitive flexion-extension movements**
* Gout
* RA
29
What is most common causative organism of infected olecranon bursitis?
Staphylococcus aureus
30
Describe presentation of olecranon bursitis
* Pain
* Swelling
* May report small vol of fluid for some time but fluid vol recently increased
* Erythema
* Discomfort
* ROM usually preserved
* If infected systemic features e.g. fever, lethargy
31
What investigations would you do for olecranon bursitis?
* Bloods
* FBC
* CRP
* RF (if susupect RA)
* Serum urate (if suspet gout)
* X-rays
* Aspiration of fluid for MC&S
32
What investigation provides defintive diagnosis for olecranon bursitis?
Aspiration (fluid sent for MC&S)
*\*NOTE: aspiration can also provide symptomatic relief for pt*
33
Discuss the management of olecranon bursitis
Management depends on if there is infection.
_No infection_
* Analgesia (ideally NSAIDS)
* Rest
* +/- splinting of elbow
* Consider washout in theatre if large & causing discomfort
_Infective_
* Abx e.g. flucloxacillin (IV if systemic symptoms)
* Surgical drainage
* Consider bursectomy if prolonged or recurrent
34
State some potential complications of olecranon bursitis
* Osteomyelitis
* Septic arthritis
35
What causes epicondylitis?
Microtears in tendons due to repetitive injury.
Tendon adapts to multiple tears leading to formation of granulation tissue, fibrosis and eventually tendinosis
36
Who does epicondylitis typically affect?
35-54yrs
Affects men & women equally
37
State the clinical features of epicondylitis
* Pain radiating down forearm
* Local tenderness
38
What special tests can be performed for lateral epicondylitis?
* **Cozen's test:** *elbow flexed to 90 degrees, examiner puts one hand over lateral epicondyle whilst other holds pts hand in pronated, radially deviated position. Ask pt to extend wrist against resistance. Pain= positive*
* **Mill's test:** *palpate pts lateral epicondyle whist pronating pts forearm, flexing wrist and extending elbow*
39
Are any investigations required to diagnose lateral epicondylitis?
Diagnosis usually clinical; may do MRI to confirm diagnosis
40
Discuss the managment of epicondylitis
* Activity modification
* Analgesics e.g. NSAIDs
* Physiotherapy & orthoses
* Corticosteroid injections every 3-6 months if symptoms persist
If symptoms not controlled through conservative measures then may need open or arthroscopic debridemennt of tendinosis and/or release or repair of damaged tendon inserts.
41
What is valgus deformity?
What is varus deformity?
* Valgus: forearm is excessively laterally deviated in relation to long axis of humerus
* Varus: forearm is medially deviated in relation to the long axis of humerus *"gunstock deformity"*
42
How long can it take for lateral epicondylitis to improve?
Improves within 1-2yrs in 80-90% people
43
What tendons are most commonly involved in:
* Lateral epicondylitis
* Medial epicondylitis
* Lateral: extensor carpi radialis brevis
* Medial: pronator teres and flexor carpi radialis
44
NOTE: symptoms for medial same (just on medial side). Management same
45
State some key questions to ask about in an elbow related history
* Pain
* Worse in particualr position?
* Weakness
* Parasthesia
* Instability
* Stiffness
* History of injury
* Occupation
* Impact on lifestyle
* PMH & surgical history
46
What is the carrying angle of the arm?
Angle between long axis of humerus and long axis of radius
47
What is the normal carrying angle in:
* Men
* Women
* Men: 7 degrees
* Women: 14 degrees
48
Who is biceps tendinopathy more common in?
* Young, active individuals due to sports with repetitive flexion movements
* Older individuals with degenerative tendinopathy
49
Biceps tendinopathy can occur in both proximal & distal bicep tendons; true or false?
True
50
How does biceps tendinopathy present?
* Pain
* Worse when flexing elbow & hence using tendon
* Weakness (flexion & supination)
* Tenderness over affected tendon
* If avoided using muscle due to pain, may be disuse atrophy
51
State the special test for:
* Proximal biceps tendinopathy
* Proximal biceps tendinopathy
* **Proximal = speed test** *(pt stand with elbow extended and forearms supinated then flex their shoulders to 90 degrees- bring arms in front- examiner applies downward pressure and pt tries to resist. Positive= pain in shoulder).*
* **Distal= Yergason's test** *(pt stands with elbows flexed at 90 degreees with forearm pronated. Actively supinate against examiners resistance. Pain in shoulder/biciptal groove= positive)*
52
Are investigations required for biceps tendinopathy?
Diagnosis= largely clinical
May do investigations to rule out other pathhology
53
Discuss the management of biceps tendinopathy
* Analgesia e.g. NSAIDs
* Ice therapy
* Physiotherapy
* USS guided steroid injections
* Surgery (tenodesis or tenotomy)= rare
54
State a potential complication of chronic biceps tendinopathy
Biceps tendon rupture
55
State the common mechanism of injury of biceps tendon rupture
Sudden forced extension of flexed elbow
56
State some risk factors for a ruptured biceps tendon
* Previous episodes of bicep tendinopathy
* Steroid use
* Smoking
* CKD
* Fluoroquinolone abx
57
State the clinical features of a ruptured biceps tendon; include any specific signs for proxmial and distal tendon rupture
* Sudden onset pain
* Weakness *(flexion & supination still possible due to brachialis & supinator)*
_Proximal *(injury usually to long head)*_
* Popeye sign
_Distal_
* Swelling & bruising in antecubital fossa
* Reverse pop eye sign
* Report feeling a 'pop'
58
What special test is done to identify a distal biceps tendon rupture?
Hook test
* Elbow flexed to 90 degrees, supinated
* Examiner tries to hook index finger under lateral edge of biceps tendon
* Cannot be done in rupture of distal biceps tendon
59
What investigations are required for a potential distal bicep tendon rupture?
* USS *(helps surgeons localise distal end of biceps tendon)*
* MRI *(if USS inconclusive)*
60
Discuss the mangement of a ruptured biceps tendon
* For lower demand pts conservative treatment with analgesia & physiotherapy *(will be weakness of flexion & supination but physio can help improve muscle strength)*
* For those who require surgery, as higher demand, surgical repair to reattach tendon should be done within few weeks of initial injury as tendon will retract and sar
61
What is cubital tunnel syndrome?
Compression or irritation of ulnar nerve as it passes through cubital tunnel
62
State clinical features of cubital tunnel syndrome
* Parasthesia of little & ring finger *(worsened when elbow is bent)*
* Weakened grip
* Pain around medial elbow
* Wasting of muscles between fingers
63
What investigations may be done for cubital tunnel syndrome?
NCS (nerve conduction studies)/ EMG (electromyography)
64
Discuss the conservative management of cubital tunnel syndrome
* Avoid bending elbow for prolonged periods of time
* Rest/activity modification- particulary from repetitive tasks that bend the elbow
* Elbow splints (worn at night)
65
If conservative treatment for cubital tunnel syndrome fails, what is the aim of surgical treatment?
Decompress ulnar nerve
