Elbow

Question 1

Examples of elbow problems

Answer 1

-Trauma: supracondylar fractures (paeds), olecranon fractures
-Elective: lateral epicondylitis, medial

Question 2

General principles of elbow injury

Answer 2

-There a many neurovascular structures intimately related to the elbow joint; these are often injured in elbow trauma.
-Stiffness is common and persistent after elbow trauma and surgery:
=Extension is frequently reduced, but functionally unimportant
=Flexion is infrequently affected, but has profound functional impact

BRACHIAL ARTERY ON MEDIAL SIDE, medial nerve very close to brachial artery, ulnar nerve near medial epicondyle

Question 3

Describe supracondylar fractures

Answer 3

-Paediatric fractures (~ 4-8 y/o)
-Commonly a/w neurovascular injury ->
=Anterior Interosseous Nerve (AiN)
=Brachial artery

Question 4

Investigation of supracondylar fractures

Answer 4

-On a normal elbow X/R
=Anterior humeral line should intersect the capitellum
=No posterior fat pad

-Gartland classification:
=Type 1 (humoral line intersecting)
=Type 2 (no hinge)

Higher classification, more likely neurovascular injury

Question 5

Management of supracondylar fractures

Answer 5

BOAST guidelines:
-Carefully assess and document the:
=Neurological status – you must name the individual nerves
=Vascular status, inc. the presence / absence of the radial artery
-Above-elbow backslab in the in situ position – do not attempt fracture reduction in ED

-Theatre for CRPP (closed reduction, percutaneous pinning) the same day (if daytime) or following day (ifOOH)
-Theatre immediately if:
=Absent radial pulse and / or features of impaired perfusion
=Open # (or impending open #)

Question 6

Describe olecranon fractures

Answer 6

-The olecranon is the site of the insertion of the triceps tendon -> loss of extension (if displaced)
-Usually a result of a FOOSH, but may be due to direct trauma to the olecranon
-Generally a benign injury, but associated with several more serious conditions:
=Fracture dislocation
=Transolecranon ‘terrible triad’
==Elbow dislocation
==Coranoid #
==Radial head #

Question 7

Presentation of olecranon fractures

Answer 7

-O/E:
=Look: Grossly swollen elbow +/- ecchymosis
=Feel: Boggy
=Move: ?Lack of extension – do not assume it is absent

Question 8

Investigation of olecranon fractures

Answer 8

X ray

Question 9

Management of olecranon fractures

Answer 9

-Acute:
=Above elbow back slab

-Definitive:
=If undisplaced and extension intact -> cast1/52 then begin ROM
=If displaced and >75 y/o (even if extension is absent ) -> cast 1/52
=If displaced and <75y/o -> surgical fixation(TBW or ORIF)

Question 10

Describe lateral epicondylitis

Answer 10

-Tennis elbow, common aged 45-55, affects typically dominant arm
-Due to repeated, or unaccustomed, extension of the wrist (house painting)
=Inflammation of the common extensor origin (i.e., at the lateral epicondyle), predominantly ECRB
-They report pain during resisted wrist and digit extension, and during passive wrist flexion with the elbow extended.

-Most common cause of persistent elbow pain, typically lasts between 6 months and 2 years, acute pain for 6-12 weeks
=Wrist extension is required for all gripping activities -> unavoidable

Question 11

Presentation of tennis elbow

Answer 11

-Look: NAD
-Feel: tenderness of lateral epicondyle (~2-3mm distal)
-Move: pain worsened by resisted wrist and finger extension/ wrist extension against resistance with elbow extended or supination of forearm with elbow extended

Question 12

Investigation of tennis elbow

Answer 12

-Clinical
-XR often done -> may show calcification of ECRB origin (20%)

Question 13

Management of tennis elbow

Answer 13

-NSAIDs, activity modification (avoid muscle overload), physiotherapy, rest, ice, brace/strap
-+/- steroid injections
-If persistent: surgical release and debridement of ECRB

Question 14

Describe medial epicondylitis

Answer 14

Golfer’s elbow

-P: pain and tenderness localised to medial epicondyle, pain aggravated by wrist flexion and pronation, may be accompanied by numbness, tingling in 4th and 5th finger due to ulnar nerve involvement

Question 15

Describe olecranon bursitis

Answer 15

-Swelling over the posterior aspect of the elbow.
-There may be associated pain, warmth and erythema.
-It typically affects middle-aged male patients

Question 16

Describe radial tunnel syndrome

Answer 16

-Most commonly due to compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.

-Features
=symptoms are similar to lateral epicondylitis making it difficult to diagnose
=however, the pain tends to be around 4-5 cm distal to the lateral epicondyle
=symptoms may be worsened by extending the elbow and pronating the forearm

Question 17

Describe cubital tunnel syndrome

Answer 17

-Due to the compression of the ulnar nerve (cubital tunnel posterior to medial epicondyle)
-Females 40-60 most at risk

-Features
=initially intermittent tingling in the 4th and 5th finger/ medial sided pain
=may be worse when the elbow is resting on a firm surface or flexed for extended periods
=later numbness in the 4th and 5th finger with associated weakness

-Exam: positive Tinel’s sign induced above or below medial epicondyle (clinical diagnosis)
-Electromyogram and nerve conduction evaluation to determine extent of nerve damage and assess zone of compression

Question 18

Epidemiology of biceps rupture

Answer 18

-One of these tendons separates from its attachment site or is torn across it’s full width. This most frequently occurs at the long tendon (90%), but rarely can occur in the distal tendon (10%).
-Biceps ruptures are more common in men than women at a 3:1 ratio
-Proximal biceps tendon ruptures generally occur in older patients, over the age of 60 and account for 90% of biceps tendon ruptures (1). This occurs at the long tendon.
-Distal biceps tendon ruptures are much less common and only account for 10% of cases (1). The mean age of presentation is 40, it almost always occurs in men and at a rate of 2.55 per 100,000 patient-years (2).

Question 19

Risk factors for biceps rupture

Answer 19

-Heavy overhead activities
-Shoulder overuse or underlying shoulder injuries which may stress the biceps tendon
-Smoking
-Corticosteroids; these weaken tendons

Question 20

Mechanism of injury biceps tendon

Answer 20

-Proximal biceps long tendon ruptures: typically occurs when the biceps are lengthened and contracted and a load is applied. e.g. the descent phase of a pull-up.
-Distal biceps tendon ruptures: Usually when a flexed elbow is suddenly and forcefully extended whilst the biceps muscle is contracted. already

Question 21

Presentation of biceps tendon rupture

Answer 21

-A sudden ‘pop’ or tear either at the shoulder (long tendon), or at the antecubital fossa (distal tendon) which is followed by pain, bruising and swelling
-Rupture of the proximal tendon causes ‘Popeye’ deformity; this is when the muscle bulk results in a bulge in the middle of the upper arm. Seen more easily in muscular individuals and less obvious in overweight or cachectic patients
-Rupture of the distal tendon can cause ‘reverse Popeye’ deformity but this is not a reliable sign.
-Weakness in the shoulder and elbow typically follows including difficulty with supination
-Some patients who may have had chronic shoulder pain prior to tendon rupture might notice an improvement in their pain.

Question 22

Investigation of biceps tendon rupture

Answer 22

-Start with a basic examination, palpate the long head and distal biceps tendon and assess neurovascular function the upper extremities
-The biceps squeeze test: If it is intact then a squeeze will cause forearm supination
-Musculoskeletal ultrasound by a skilled clinician and should always be the first investigation for suspected biceps tendon rupture
-For suspected long head biceps tendon rupture there is little role for further imaging given the conservative management. -However MRI can be considered if there is a limited examination or likely concomitant pathology.
-For suspected distal biceps tendon rupture, an urgent MRI should be performed as a diagnosis on clinical signs alone is challenging, and this usually requires surgical intervention.

Question 23

Describe radial nerve entrapment

Answer 23

-Compression over spinal groove (Saturday night palsy)
=Vasculitis/ segmental demyelination/ inflammation/ malignancy/ infection

-awakening with complete or partial wrist drop, often described by patient as ‘my entire arm is numb and/or weak’; painless; alcohol and/or drug intoxication on night symptoms developed

marked weakness of thumb, finger, and wrist extension; weakness of brachioradialis (tested by having patient flex elbow against resistance with thumb facing the ceiling); patients may appear to have weakness of the finger abductors because of the inability to stabilise the fingers in extension (required to abduct fingers) unless tested with hand placed flat on table; sensory loss is usually identified over dorsum of hand between thumb and index finger

nerve conduction studies and electromyography:
confirm isolated radial neuropathy and localise site of lesion to spiral groove

Question 24

Describe cervical radiculopathy

Answer 24

pain and/or tingling radiating from the neck into the arm and/or hand; exacerbation of the pain or sensory symptoms with neck movement, cough, or sneeze; pain tends to be persistent; paraesthesiae intermittent

decreased triceps reflex in C7 radiculopathies; decreased biceps and/or brachioradialis reflexes in C5 or C6 radiculopathies (reflex judged to be decreased based on comparison with same reflex in unaffected arm); weakness and altered sensation in the distribution of the affected nerve root in severe cases

CT or MRI:
nerve root compression by disc, osteophyte, or other mass lesionMore
nerve conduction studies and electromyography:
denervation in myotomal (nerve root) distribution