Orthopaedics - elbow & forearm

Question 1

Describe the clinical features of elbow dislocations

Answer 1

Typically present following a high-energy fall
Joint will be painful and deformed, with associated swelling and decreased function
Complete neurovascular examination of the upper limb – a deficit is often found in the territory of the ulnar nerve as neuropraxia of this nerve is common, good CRT can be found even in those with an arterial injury

Question 2

List investigations for elbow dislocations

Answer 2

Plain film radiographs of the elbow, both AP and lateral, are required initially
CT imaging is only really useful as an adjunct in cases with associated fractures

Question 3

Describe the management of an elbow dislocation

Answer 3

Initial management requires closed reduction (ensure sufficient analgesia +/- sedation if appropriate & apply an above elbow backslab once reduced to keep the elbow at 90 degrees)
After this:
- For a simple elbow dislocation: further orthopaedic management can be as an outpatient, following a short period of immobilisation
- Dislocation is complicated by a fracture or neurovascular compromise: operative fixation can be considered (ORIF)

Question 4

List complications of elbow dislocation

Answer 4

Early stiffness with loss of terminal extension
Stretching of the ulnar nerve
Recurrent instability

Question 5

What is the terrible triad?

Answer 5

Elbow dislocation with:
1) Lateral collateral ligament injury
2) Radial head fracture
3) Coronoid fracture
Combination of injuries causes a very unstable elbow & associated with a poor outcome
Treatment revolves around operative fixation of each of the components

Question 6

Describe the pathophysiology of lateral epicondylitis

Answer 6

Common extensor tendon attaches to the lateral epicondyle, acting as the common attachment for the superficial extensor muscles of the forearm
Repetitive overuse of the tendons can cause microtears in the tendon at their origin -> formation of granulation tissue, fibrosis and eventually tendinosis

Question 7

List risk factors for lateral epicondylitis

Answer 7

Occupation
Hobbies eg. tennis

Question 8

List clinical features of lateral epicondylitis

Answer 8

Elbow pain and radiating down the forearm
Examination – local tenderness on palpation over the lateral epicondyle & common extensor tendon

Question 9

List the special tests for lateral epicondylitis

Answer 9

Cozen’s test
Mill’s test

Question 10

List differential diagnoses for lateral epicondylitis

Answer 10

Cervical radiculopathy
Elbow osteoarthritis
Radial carpal tunnel syndrome

Question 11

List investigations for lateral epicondylitis

Answer 11

Diagnosis is typically clinical
Ultrasound or MRI imaging

Question 12

Describe the management of lateral epicondylitis

Answer 12

Activity modification
Simple analgesics
Corticosteroid injections can be administered if symptoms persist
Physiotherapy

Question 13

Describe the surgical treatment of lateral epicondylitis

Answer 13

May be warranted if the symptoms are not controlled through conservative measures
Open/arthroscopic debridement of tendinosis and/or release or repair of any damaged tendon insertions
Tendon transfer may be required to ensure function is retained (>50% damage)

Question 14

Describe the clinical features of olecranon bursitis

Answer 14

Pain and swelling over the olecranon
Range of motion is usually preserved
Can be large and systemic symptoms can occur if it becomes infected
Ensure to examine the contralateral elbow joint as well

Question 15

List differential diagnoses for olecranon bursitis

Answer 15

Inflammatory arthropathies
Gout
Cellulitis
Septic arthritis

Question 16

List investigations for olecranon bursitis

Answer 16

Routine bloods, including FBC & CRP, should be taken
Plain film radiographs will help in ruling out any bony injury
Aspiration of the fluid, being sent for microscopy and for culture, which can assess for evidence of infection and for presence of crystals

Question 17

Describe the management of olecranon bursitis

Answer 17

Swellings without an infection – can be treated with analgesia and rest (if patients are in a lot of discomfort, they can undergo a washout)
If there is an infection – IV antibiotics as well as surgical drainage

Question 18

List complications of olecranon bursitis

Answer 18

Most cases resolve spontaneously
Septic arthritis
Osteomyelitis

Question 19

Describe the pathophysiology of olecranon fractures

Answer 19

Intra-articular fractures
Typically result from indirect trauma when a patient falls on an outstretched arm, resulting in the sudden pull of the triceps (site of insertion for triceps)

Question 20

List the clinical features of olecranon fractures

Answer 20

Elbow pain, swelling and lack of mobility
Examination – tenderness, inability to extend the elbow against gravity, ensure to check the neurovascular status of the affected limb
Shoulder and wrist joints should also be examined

Question 21

List investigations for a suspected olecranon fracture

Answer 21

Routine blood tests – clotting screen & group and save
Plain AP and lateral radiographs
CT imaging can be useful in evaluating more complex injuries

Question 22

Describe the management of olecranon fractures

Answer 22

Adequate analgesia
Usually guided by the degree of displacement on imaging:
1) Non-operative management: displacement <2mm, with immobilisation in 60-90 degrees elbow flexion and early introduction of range of motion at 1-2 weeks
2) Operative management: usually indicated for displacement >2mm, requiring techniques such as tension band wiring/olecranon plating

Question 23

Describe the pathophysiology of radial head fractures

Answer 23

Typically occur via indirect trauma – axial loading of the forearm causing the radial head to be pushed against the capitulum of the humerus
- Most commonly occurs with the arm in extension and pronation

Question 24

List clinical features of radial head fractures

Answer 24

Elbow pain
Variable degrees of swelling and bruising at the elbow
Examination – tenderness on palpation over the lateral aspect of elbow and radial head, with pain & crepitation on supination and pronation
Shoulder and wrist joints should also be examined

Question 25

List investigations for radial head fractures

Answer 25

Routine blood tests
Plain AP and lateral radiographs (can be easily missed on plain radiographs)
- Elbow effusions may be seen ‘sail sign’
CT imaging for more complex injuries & MRI imaging can be used to assess suspected associated ligament injuries

Question 26

What is the Mason classification?

Answer 26

Radial head fractures are classified according to the degree of displacement and intra-articular involvement
Type 1 – non-displaced/minimally displacement (<2mm)
Type 2 – partial articular fracture with displacement >2mm or angulation
Type 3 – comminuted fracture and displacement (a complete articular fracture)

Question 27

Describe the management of radial head fractures

Answer 27

Provide adequate analgesia
Treatment is usually guided by the severity of the fracture on imaging
Mason type 1 injuries: treated non-operatively, with a short period of immobilisation with sling followed by early mobilisation
Mason type 2 injuries: if mechanical block is present, then may need surgery (ORIF), otherwise can be treated as per a type 1 injury
Mason type 3 injuries: either ORIF/radial head excision/replacement

Question 28

What is the most common age group for supracondylar humeral fractures?

Answer 28

Peak age of incidence is 5-7 years

Question 29

Describe clinical features of supracondylar fractures

Answer 29

Sudden-onset severe pain and reluctance to move the affected arm
Examination: signs of gross deformity, swelling, limited range of elbow movement and ecchymosis of the anterior cubital fossa
Carefully examine the median nerve, anterior interosseous nerve, radial nerve & ulnar nerve
Check the hand for features of vascular compromise

Question 30

List differential diagnoses of supracondylar fractures

Answer 30

Distal humeral fractures
Olecranon fractures

Question 31

List investigations for suspected supracondylar fractures

Answer 31

Plain film radiographs in both AP and lateral views of the elbow
Subtle signs on plain film radiographs:
- Posterior fat pad sign
- Displacement of the anterior humeral line
CT imaging may be useful for comminuted features/intra-articular extension is suspected

Question 32

What is the Gartland classification?

Answer 32

Type I – undisplaced
Type II – displaced with an intact posterior cortex
Type III – displaced in two or three planes
Type IV – displaced with complete periosteal disruption

Question 33

Describe conservative management of supracondylar fractures

Answer 33

Patients with neurovascular compromise – need immediate closed reduction
Can be trialled with type I fractures/minimally displaced type II fractures, which can be managed in above elbow cast in 90 degrees flexion

Question 34

Describe the surgical management of supracondylar fracture

Answer 34

Type II, type III and type IV supracondylar fractures will nearly always require a closed reduction and percutaneous K-wire fixation
Open fractures = open reduction with percutaneous pining
Any ongoing vascular compromise may need discussion with vascular surgeons for potential vascular exploration

Question 35

List complications of a supracondylar fracture

Answer 35

Nerve palsies are common (anterior interosseous nerve)
Malunion is an important complication to assess for following a supracondylar fracture, more common in those fractures managed suboptimally
Cubitus varus deformity
A Volkmann’s contracture can occur as well