THE INJURED ELBOW

RESTORE NORMAL FUNCTION IN THE SAFEST BUT QUICKEST MANNER

1 stop injury clinic

All types of injuries: - sports, occupational, leisure, day-to-day injuries are seen and treated in the complete 1 stop injury clinic.
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Full clinical assessment + pathological impression. This is a highly important stage and with A&E minor injury and sports injuries experience, will lead to a complete service. Treatment may include soft tissue therapy (sports massage), ultrasound, strapping / support, active recovery techniques. Evidence based therapies are targeted to direct problems. Active injury rehabilitation / maintenance programme, specific stretching / strengthening plan, exercise prescription + those above. Early rehab is important. You will be referred to the most experienced and qualified practitioner / therapist after an initial assessment.
1 stop injury clinic www.1stopinjuryclinic.co.uk SPEED UP RECOVERY FROM SPORT INJURIES

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ANTERIOR VIEW

MEDIAL VIEW

ANTERIOR VIEW

POSTERIOR VIEW

Elbow Injury
History Mechanism of injury:
Child pulled elbow Supracondylar fracture Adult Fall outstretched handFracture radial head Direct blow to elbow- Olecranon fracture Forced rotation of forearm - Dislocation radial head (rare)

LOOK
Position Deformity? Swelling? Either side joint/olecranon bursa Joint effusion Wounds and bruising

FEEL
Palpate olecranon & lateral/medial epicondyles/ radial head (Triangular relationship) Localise tenderness Soft tissues biceps/triceps/brachioradialis tendons Ulnar nerve between medial epicondyle & olecranon Radius and ulna

SENSATION
To touch and sharp / dull. Need to check down forearm as well as hand and fingers.

CIRCULATION
Need to check radial pulses, capillary refill, skin colour, warmth.

MOVE
Flexion Extension Supination Pronation Move against resistance -Flexion against resistance (hold biceps/wrist patient moves against your resistance) Move against extension -push against your hand Wrist extension -make a fist resist you pulling it down

BEWARE Do examine shoulder and wrist for other injuries

Soft Tissue Problems of Elbow

Symptoms Repetitive movement of supination/pronation Pain at elbow exacerbated by pain on resistance to wrist extension Infection/ minor trauma Rheumatoid arthritis Olecranon Bursitis Hot & painful elbow Pain over olecranon Swelling over olecranon Repetitive flexion of wrist caused by throwing movement Pain over medial epicondyle Pain on flexion against resistance Pain insertion point of tendon over radial head Pitchers elbow (Medial epicondylitis) Problem

Tennis Elbow (lateral epicondylitis)

Tenosynovitis

Synovial fluid felt in grooves Arthritis of the elbow between olecranon process and epicondyles ? Boggy soft /fluctuant swelling tenderness around elbow joint

ELBOWS
RANGE OF MOTION Ask the patient to bend and straighten the elbow. With arms at sides and elbows flexed (so that shoulder movements cannot simulate those of the forearm), the patient should then turn palms up (supination) and down (pronation). INSPECTION AND PALPATION Support the patients forearm with your opposite hand so that the elbow is flexed to about 70 degrees. Examine the elbow, including the extensor surface of the ulna and the olecranon process, noting any nodules or swelling. Palpate the grooves between the epicondyles and the olecranon, noting any tenderness, swelling or thickening. Press on the lateral and medial condyles, noting any tenderness.

ELBOWS Identify the medial and lateral epicondyles of the humerus and the olecranon process of the ulna. A bursa lies between the olecranon process and the skin. The synovial membrane is most accessible to examination between the olecranon and the epicondyles. Neither bursa nor synovium is normally palpable. The sensitive ulnar nerve can be felt posteriorly between olecranon and medial condyle. Movements include flexion and extension at the elbow and pronation and supination of the forearm.

CHILDRENS ELBOW INJURIES

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INCIDENCE

8% of fractures in children 2nd most common area of injury in children more common in boys more common in summer

BLOOD SUPPLY During Growth:

Extraosseous -The entrance points of the feeding vessels is governed by the complicated anatomy. Intraosseous - Posterior end vessels to the ossification centres exist within the bone. There is no anastomosis between them and the intraosseous metaphyseal vessels. Thus damage to these vessels due to fracture can lead to avascularity.

Blood supply at maturity :

There are anastomoses between the metaphyseal vessels and epiphyseal vessels.

X-RAY INTERPRETATION AP-elbow extended Lateral -Elbow flexed, forearm neutral Lateral Film:

Tear drop Shaft condylar angle -Normally 40 degrees Anterior humeral line -Line should pass through middle 1/3 of the ossification centre of the capitellum ossification center. Coronoid line - A line directed posteriorly along coronoid process should just touch the anterior aspect of the lateral condyle

Radiocapitellar line - A line drawn down the long axis of the radius should bisect the capitellum regardless of the degree of flexion of the elbow 10

Fat pad signs - Posterior, Anterior. Posterior more reliable, if present there is almost always an associated #

Common misinterpretations of X-rays:

Pseudofracture of trochlear- due to fragmented trochlear epiphysis On AP film there is normally some angulation of the neck of the radius, which can be mistaken for a #

SUPRACONDYLAR FRACTURES
(Most common child #)

I. Epidemiology
Supracondylar fractures are the most common fractures about the elbow in children with this fracture occurring most commonly in the 3 - 11 year old child. The usual mechanism is for the child to fall with an extended elbow causing posterior displacement (extension type fracture - 95% of displaced supracondylar fractures). Twenty to thirty percent of all supracondylar fractures exhibit little or no displacement and approximately twenty five percent of supracondylar fractures are of the greenstick type. The collateral ligaments and the anterior capsule in children are quite strong thus ligamentous tears without fractures are quite rare.

II. Clinical Exam

Children who present with nondisplaced supracondylar fractures may initially have minimal swelling. The young child may present with vague pain so that the differential diagnosis may include nursemaid's elbow, occult fractures of the radial head, condyle fractures or a septic joint. Children with supracondylar extension fractures may have a prominent olecranon with the distal humeral fragment palpated posteriorly and superiorly because of the pull of the posterior tricep muscle. Patients with a supracondylar flexion fracture may carry their elbow flexed with loss of the olecranon prominence. Pearls in elbow X - rays:

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a. Consider a displaced anterior fat pad or the presence of a posterior fat pad on a lateral elbow X - ray to be consistent with a fracture until proven otherwise. b. The anterior humeral line on the lateral elbow radiograph intersects the posterior two thirds of the capitellum. c. The radius "points" to the capitellum in all views.

III. Fracture Classification

Type I Minimal or no displacement - Stable fractures will require p.o.p. of elbow at 90 degrees for child's comfort. Complications are rare. Due to the potential of neurovascular problems, these are often discussed with the orthopaedics. Some hospitals policy is to admit these for overnight observation on the limb. Type II Angulated fractures which are not completely displaced -The extremity needs immobilization with a posterior long arm splint from the axilla to the metacarpal heads. The child should be hospitalised for potential neurovascular compromise. Type III Completely displaced fractures-These fractures require immediate orthopaedic referral as the potential for neurovascular injuries and compartment syndromes is the greatest. Fractures associated with limb-threatening vascular compromise should be reduced by the experienced emergency physician only when emergent orthopaedic consultation is not available. Initial orthopaedic approaches includes closed reduction followed by percutaneous pin fixation or open reduction if the previous measures were unsuccessful.

IV. Complications
Nerve injuries - up to 12% of all supracondylar fractures. Usually resolve and rarely result in any residual disability. The most common nerve injury is to the anterior interosseous branch of the median nerve Arterial injuries - injury to the brachial artery is the most common. Because of collateral flow, a brachial artery injury may be missed despite normal distal pulses. Cubitus Varus - this is the most common complication in which varus deformities may lead to a "gunstock" deformity. Correct reduction of the distal fragment displaced posteromedially and internally rotated obviates this cosmetic problem. Compartment Syndrome - Forearm compartment syndromes (the sequela of which is Volkmann's contracture) rarely occur in a fracture which is timely reduced and splinted. The diagnosis is made clinically with the child having a tense forearm and severe pain. Management

Undisplaced - Above elbow backslab and # clinic, then active mobilisation Displaced - Open reduction and internal fixation with double plating

PULLED ELBOW
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This usually occurs in children under 5 years of age (usually 1-3 years). The presenting symptom in this condition is that the child will not use his arm. He may complain of pain in the shoulder, elbow or wrist. The parents maybe worried that the arm is dislocated or broken. The Diagnosis is suggested by the history. There has usually been a pull or fall involving the arm. Often the child has nearly fallen and an adult has held the arm to help pull the child up. The child then stops using the arm and holds it to his side. The Mechanism of injury is that the radial head (which is poorly formed at this age) has slipped through the annular ligament at the elbow. The Treatment A pulled elbow is very easily reduced by flexing the elbow at 90 degrees and then supinating the forearm while extending the elbow. Usually a click can be felt or heard, and the child starts using his arm normally. An x-ray of the arm is not necessary unless there is any doubt that the child may have actually fallen or sustained direct trauma to the arm. A pulled elbow will look normal on a radiograph The child may not always start using the arm immediately, particularly if there has been some delay before reduction. Allow the child to play in the department before reassessing. Most children have recovered within 30 minutes. Warn parents that a pulled elbow may reoccur (in either arm) but that the child will grow out of the problem. There will be no long-term damage. Ask parents to avoid pulling on the childs arms.

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ADULTS INJURY / PROBLEMS

Radial Head Fractures (most common #)
Trying to break a fall by putting your hand out in front of you seems almost instinctive, but the force of the fall could travel up your lower forearm bones and injure your elbow. It also could break the smaller bone (radius) in the forearm. The breaks can occur at the wrist (Colles fracture), or near the elbow at the radial "head." Radial head fractures are common injuries, occurring in about 20 percent of all acute elbow injuries. They are more frequent in women than in men and occur most often between 30 and 40 years of age. Approximately 10 percent of all elbow dislocations involve a fracture of the radial head. As the upper arm bone slides back into its appropriate place after the dislocation, it can chip off a piece of the radial resulting in a fracture. Signs and symptoms If you have any of these signs or symptoms after a fall, see your doctor:

Pain on the outside of the elbow. Swelling in the elbow joint. Difficulty in bending or straightening the elbow accompanied by pain. Inability or difficulty in turning the forearm (palm up to palm down or versa).

Fracture types and treatments Radial head fractures are classified according to the degree of displacement (movement from the normal position). Type I fractures (most common) are generally small, like cracks, and the bone pieces fitted together. The fracture may not be visible on initial X-rays, but can seen if the X-ray is taken three weeks after the injury. Nonsurgical involves using a sling and a # clinic appointment followed by early motion. motion is attempted too quickly, the bones may shift and become displaced. Even the simplest of # will probably result in loss of elbow extension. More serious displaced # need to be discussed with the orthopaedic team.

usuall treatmen If t

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Biceps Tendon Rupture

Typically, a rupture of the biceps tendon occurs in the older athlete. Sharp pain and the sensation of muscle tearing often occur after repetitive lifting or acute injury. The hallmark of biceps tendon rupture is the sudden contraction of the biceps muscle. Often, there is minimal pain in these individuals after the tear. Surgery is sometimes required for reattachment of the tendon. However, older athletes may elect not to repair this injury.

Chronic Elbow Injuries

Chronic elbow injuries are typically the result of repetitive injuries, general inflammatory conditions and/or post trauma. They are recognized as greater than 2 weeks in duration. Patients often describe recurrent pain, stiffness and/or loss of elbow range of motion.

Arthritis
Arthritis describes chronic joint pain. The most common forms encountered in the elbow include osteoarthritis (OA), posttraumatic arthritis (PA) and rheumatoid arthritis (RA). OA is the result of calcification of cartilage in the joint spaces. Occurring most often in older age, OA is characterized by pain, stiffness and restricted range of motion. Patients with OA often experience a feeling of locking or catching in the joint which is related to loose cartilage pieces. PA often follows a history of a fracture, dislocation or cartilage injury and results in recurrent pain, stiffness and/or limited motion. RA often presents with pain and symmetrical swelling of multiple joints. Joint deformity may occur.

Olecranon Bursitis
Acute or chronic swelling over the tip of the elbow with increased pain during movement is a sign of the development of olecranon bursitis. Bursitis describes the inflammation of the bursa, the connective tissue structure surrounding the joint space. Typically, blood and serous fluid collect in this subcutaneous structure. It is caused by chronic overuse of the joint, previous injury or infection. People often encounter this condition after leaning on the elbow surface for long periods of time; this condition is also known as miners elbow. A single, acute episode of trauma to the tip of the elbow, such as a fall on a hard surface, may precede this condition. The condition can be either inflammatory, infectious or both. The olecranon region often appears red and is warm to palpation. Initial treatment involves use of NSAIDS (non-steroidal anti-inflammatory agents) to control inflammation and swelling. Fluid collection over the olecranon is easily infected with a simple abrasion, insect bite or cut. If infection is suspected, the region is aspirated to drain infected fluid and perform a bacterial culture. Further treatment with antibiotics and immobilization is required. Without treatment, more serious infections, such as osteomyelitis, bone infection, or septic arthritis can occur.

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Tendinitis
There are three main forms of tendinitis, inflammation of a tendon, encountered in the elbow. These include lateral epicondylitis, often known as tennis elbow, medial epicondylitis, often known as golfers elbow and biceps tendinitis. Each condition is usually the result of repetitive motion injuries to the elbow joint. Tendinosis, on the other hand, is a chronic condition that occurs when the tendon is never allowed adequate time to heal properly, and can linger for months to even years.

Lateral Epicondylitis (LE)

Lateral epicondylitis is a result of microscopic tears and scarring of the extensor carpi radialis brevis tendon located on the lateral (outer) aspect of the elbow. Overuse of the elbow caused by repeated wrist extension against resistance results in lateral pain. Treatment modalities include electrotherapeutic modalities, such as high voltage stimulation or laser treatment, massage, NSAIDS, and/or stretching. Muscle strengthening involving the wrist extensor is important for repair. If unsuccessful, steroid injections are considered for refractory cases. In severe cases, surgery may be required to excise degenerative tissue causing the discomfort. Modifications to both job and sport activities may also be needed.

Medial Epicondylitis (ME)

Also known as golfers elbow, this condition is the result of chronic wrist flexion. It causes inflammation in the forearm flexor muscles and the pronator teres tendon. Pain is localized over the medial (inner) aspect of the elbow and is increased with wrist flexion. Treatment modalities are similar to that of lateral epicondylitis and also involve neural stretching to prevent damage to the ulnar nerve that courses across the medial elbow surface.

Biceps Tendinitis
Inflammation of the biceps tendon results in pain over the anterior aspect of the elbow and is associated with recurrent flexion of the biceps muscle, such as with dips and bench pressing. Patients present with local tenderness over the biceps tendon, there may also be chronic thickening of the tendon with muscle tightening of the biceps. Treatment involves use of NSAIDS, as well as local massage therapy and limiting activity

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ELBOW REFERENCES AND KEY TEXT

BATES, B., 1999. A Guide to physical examination and history taking. London: Lippincott. McRAE, R., 1999. Orthopaedics and fractures. London: Churchill Livingston. MUNRO, J. AND CAMPBELL, I., 2000. Macleods Clinical Examination. 10th ed. London: Churchill Livingston. PHILLIPS, N. AND STANLEY, D., 2002. Diagnosis and immediate care of injuries to the elbow and forearm. Hospital Medicine. June. Vol 63, No 6. P. 352 353. PLATT, B., 2004. Supracondylar fracture of the humerus. Emergency Nurse. May. Vol 12, No 2. P. 22 30. PURCELL, D., 2003. Minor Injury. A clinical guide for nurses. London: Churchill Livingston. SIMMS, R., 2001. Field guide to soft tissue pain. Diagnosis and Management. London: Lippincott. WALSH, M., CRUMBIE, M., REVELEY, S., 1999. Nurse Practitioners. London: Butterworth. WARDROPE, J. AND ENGLISH, B., 1998. Musculo-skeletal problems in emergency medicine. Oxford: Oxford University Press

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