Elbow injuries

Question 1

1. what is a supracondylar fracture?
2. what is the most common mechanism of injury?
3. who is most affected by a supracondylar fracture?

Answer 1

1. most common type of elbow fracture
2. falling from moderate height onto an outstretched hand with hyperextended elbow joint
3. most commonly seen in children <10
   * (falling onto a flexed elbow can also cause this fracture but it is far less common and mostly affects the elderly)
   * the X-ray shows the fracture line is articular (joint not involved) and distal fragment is displaced posteriorly

Question 2

what are the complications associated with a supracondylar fracture?

Answer 2

1. malunion resulting in cubitus varus -
2. damage to the median nerve (most common), radial nerve or ulnar nerve
3. Volkmann’s ischaemic contracture - brachial artery mayb become damaged or occluded by fracture, this causes ischaemia of muscles in anterior compartment of arm, oedema, pressure rises in compartment causing compartment syndrome, muscle undergoes infarction, muscle is repaired but is replaced by fibrous scar tissue, fibrotic tissue contracts which results in flexion contracture of arm

Question 3

how does volkmann’s ischaemic contracture present?

Answer 3

wrist is flexed
fingers extended at metacarpophalangeal and flexed at interphalangeal joint
forearm is pronated and elbow is flexed

Question 4

how are complications associated with a suprachondylar fracture treated?

Answer 4

• prompt neurovascular examination done
• if neurovasculature is compromised then emergency reduction + fixation of fractured (under anaesthetics) needs to be done

Question 5

1. what is an elbow dislocation?
2. what is the most common mechanism of injury?
3. who is most affected by a dislocated elbow?

Answer 5

1. elbow dislocation refers to displacement of ulna/radius relative to humerus
2. fall onto an outstretched hand with elbow paritally flexed
3. most common type of dislocation in children and second most common type of dislocation in adults (becauses falls onto outstretched hands are common)

Question 6

1. what is a pulled elbow?
2. what is the most common mechanism of injury?
3. who is most affected by a pulled elbow?

Answer 6

1. subluxation (partial dislocation) of the radial head
2. longitudinal traction is applied to the arm with forearm pronated or occurs during falls or over-reaching for an object
3. injury most commonly occurs in children aged 2-5 years (child presents with reduced movement of elbow + pain over lateral aspect of proximal forearm)

Question 7

why does pulled elbow occur more commonly with the arm pronated?

Answer 7

• the annular ligament is relaxed in pronation so it is easier for subluxation to occur
• longitudinal traction on radial head tears the distal attachment of the annular ligament from where it is loosely attached to the neck of the radius
• radial head is then displaced distally through the torn ligament

Question 8

1. what is a lateral elbow tendinopathy (tennis elbow)?
2. how does lateral elbow tendinopathy present?
3. who is most affected by a lateral elbow tendinopathy?

Answer 8

1. overuse disorders of the tednons in the lateral epicondyle leads to inflammation
2. the extensor carpi radialis brevis normally helps stabalise the wrist when the elbow is straight - when this is weakened due to overuse tears form in the tendon where it attaches to the lateral epicondyle causing inflammation + pain in the lateral epicondyle when the wrist is extended
3. tennis players, painters, plumbers and carpenters (approximately 3% of people aged 40-60)

Question 9

how is lateral elbow tendinopathy treated?

Answer 9

patients are advised to modify activities to give tendon time to heal
90% of patients recover by themselves within 1 year
sometimes physiotherapy and bracing is needed

Question 10

1. what is medial elbow tendinopathy?
2. how does medial elbow tendinopathy present?
3. who is most affected by medial elbow tendinopathy?

Answer 10

1. overuse disorder of the tendons in the medial epicondyle results in inflammation
2. affects the common flexor origin at the medial epicondyle (most common site is interface between the pronator teres and the flexor carpi radialis). pain is produced on resisted flexion or pronation of wrist + ulnar nerve symptoms may be present
3. golfers (10 x less common than LET)

Question 11

what causes swelling around the elbow?

Answer 11

1. olecranon bursitis
2. rhematoid nodules
3. gouty tophi

Question 12

1. what is olecranon bursitis?
2. what is the most common mechanism of injury?
3. how is olecranon bursitis treated?

Answer 12

1. inflammation of the olecranon bursa, situated between the skin and olecranon process of ulna
2. usually due to repeated minor trauma, and contents will be serous fluid, swelling is soft, cystic and transilluminates OR bursitis is a result of infection in which case compression and antibiotics is needed
3. conservative with compression bandaging +/- aspiration (withdrawing fluid with needle) or if it is caused by infection in which case compression and antibiotics is needed

Question 13

1. what are rheumatoid nodules?
2. what is the most common mechanism of injury?
3. who is most affected?
4. how are rheumatoid nodules treated?

Answer 13

1. most common extra-articular manifestation of rheumatoid arthritis
2. repeated minor trauma
3. people with rheumatoid arthritis who are also smokers and those who have a more aggressive joint disease
4. treated by improving medical control of underlying rheumatoid arthritis

Question 14

1. what is gout?
2. how is gout treated?

Answer 14

1. inflammatory condition caused by hyperuricaemia - people cant get rid of urate or produce too much urate - uric acid concentration increases in blood causing supersaturation and precipitation - urate crystals form in joints, tendons and sorrounding tissue - crystals trigger an innate immune response causing acute inflammation
2. treated with non-steroidal anti-inflammatory drugs during acute phase, then after acute phase is over drugs should be given to reduce uric acid and therefore further risks

Question 15

1. what is gouty tophi?
2. who does gouty tophi affect ?
3. how do patients with gouty tophi present?
4. how does gouty tophi appear?

Answer 15

1. tophi are nodular masses of monosodium urate crystals deposited in soft tissue
2. late complication of patients with hyperuricaemia and untreated gout
3. usually painless but complications include pain, soft tissue damage and deformity, joint destruction or nerve compression
4. resemble rheumatoid nodules but contain a white pasty material, as they enlarge they work towards the skin to drain, forming a sinus tract or a continuously draining ulcer

Question 16

1. what is cubital tunnel syndrome?
2. what is the most common mechanism of injury?
3. how does cubital tunnel syndrome present?
4. how is cubital tunnel syndrome treated?

Answer 16

1. compression of the ulnar nerve near the tendinous arch as the ulnar nerve enters the cubital tunnel
2. minor trauma to ulnar nerve in cubital tunnel
3. sharp pain radiating from elbow to the cutaneous ulnar nerve territory. compression of the ulnar nerve results in parasthesia in cutaneous territory of ulnar nerve + may cause weakness in muscles supplied by ulnar nerve
4. decompress the nerve (surgically release it and move it anterior to the medial epicondyle)