Orthopaedics: Elbow

Elbow

General Principles

·                 articulation between distal humerus, proximal ulna. proDmal radiUll (humeromdial, humeroulnar and radioulnar joints)

·                 fractures and dislocations of the elbow are evident on AP, lateral and oblique radiographs

Supracondylar Fracture

·                 most common in pediatric population (peak age -7 years old), rarely seen in adults

·                 anterior interosseous nerve (AIN) injury commonly associated with extension type

Mechanism

·                 >96% are extension injuries via FOOSH (e.g. fall off monkey bars); <496 are flexion Injuries

Clinical Features

·                 pain. swelling. point tenderness

·                 neurovascular Injury- assess median and radial nerve, radial artery

Investigations

·                 x-rays: AP, lateral of elbow; assess for fat pad sign

Treatment

·                 non-operative

o       nondisplaced: cast in 900 :flexion for 3 weeks

·                 operative

o       Indications: displaced, vascular injury, open fracture

o       requires perc11taneous pinning followed by limb cast with elbow flexed >90"

o       in adults, ORIF is necessary

Specific Complications (see General Fracture Complications)

·                 brachial artery injury, median or ulnar nerve injury, compartment syndrome (leads to Volkmann's ischemic contracture), malallgnment cubitus varus (distal fragment tilted into varus)

Radial Head Fracture

·                 a common fracture of the upper limb in young adults

Mechanism

·                 FOOSH with elbow extended and forearm pronated

Clinical Features

·                 marked local tenderness on palpation over radial head (lateral elbow)

·                 decreased ROM at elbow, mechanical block to forearm pronation and supination

·                 pain on pronation/supination

Investigations

·                 x-ray: enlarged anterior fat pad ("sail" sign") or the presence ofa posterior fat pad indicate occult radial head fractures

Specific Complications (see General Fracture Complications)

·                 myositis ossificans

·                 recurrent inst8bility (if medial collateral ligament injured and radial head excised)

Olecranon Fracture

Mechanism

·                 direct trauma to posterior aspect of elbow (fall onto the point of the elbow)

Clinical Features

·                 ± loss of active extension due to avulsion of triceps tendon

Treatment

·                 undisplaced ( <2 mm, stable): cast x 3 weeks (elbow in 45° flexion) then gentle ROM

·                 displaced: ORIF (plate and Screws or tension band wiring) and early ROM if stable

Elbow Dislocation

·                 third most common joint dislocation after shoulder and patella

·                 most commonly occurs in young people (5-25 yean) in sporting events or high speed MVAs, dislocation of ulna

·                 90% are posterior/posterolateral, anterior are rare

·                 collateral ligaments disrupted

Mechanism

·                 elbow hyperextension via FOOSH or valgus/supination stress during elbow flexion

Clinical Features

·                 elbow pain, swelling. Deformity

·                 flexion contracture

·                 ± absent radial or ulnar pulses

Treatment

·                 closed reduction under anesthesia (pori-reduction x-rays required)

·                 long-arm splint with forearm in neutral rotation and elbow in 90 degree flexion

·                 early ROM (<2 weeks)

Specific Complications (see General Fracture Complications)

·                 sti1fness (loss of extension), intra-articular loose body, neurovascular injury (ulnar nerve, median nerve, brachial artery), radial head fracture

Epicondylitis

·                 lateral epicondylitis = "tennis elbow", inflammation of the common extensor tendon as it inserts into the lateral epicondyle

·                 medial epicondylitis = "golfer's elbow': inflammation of the common flexor tendon as it inserts into the medial epicondyle

Mechanism

·                 repeated or sustained contraction of the forearm muscles

Clinical Features

·                 point tenderness over humeral epicondyle

·                 pain upon resisted wrist extension (lateral epicondylitis) or wrist flexion (medial epicondylitis)

·                 generally a self-limited condition. but may take 6-18 months to resolve

Treatment

·                 rest, ice, NSAIDs

·                 use brace/strap

·                 PT, stretching and strengthening

·                 corticosteroid injection

·                 Surgery: percutaneous or open release of common tendon from epicondyle (only after 6-12 months of conservative therapy)