Upper Arm and Elbow

Upper Arm and Elbow

Exam

·        In the elbow, look for: · Joint effusion

o   Lumps: rheumatoid nodules, gouty tophi, enlarge olecranon bursa

o   Feel: especially for tenderness over the lateral epicondyle (tennis elbow) or medial epicondyle

o   (golfer‟s elbow)

·        Move: Normal range is from 0° – 150°.  Limitation of extension Þ early synovitis

·        Radiology of elbow:

o   If looking for effusion on an x-ray (eg blood in joint following fracture of the head of the radius) look for protrusion of the Haversian fat pads in the coronoid and olecranon fossa ® radiolucent triangles 

o   Avulsion of the medial epicondyle in children: „Little leaguers‟ injury from pitching in baseball

o   Medial = Trochlear articulates with the ulnar (literally = „pulley‟)

o   Lateral = Capitalum articulates with the radius

 Injury

·        Fracture of proximal humerus:

o   Mechanism: Fall on outstretched arm, most common in post menopausal women 

o   Clinical: Appearance of large bruise on upper arm. Signs of axillary nerve or brachial plexus injury should be sought. Exclude dislocation of the shoulder 

o   Treatment: Sling. Begin mobilising early as pain permits: gentle arm swinging, climbing fingers up the wall. If > 2 parts fractured, then surgery

o   Major complication: shoulder stiffness

·        Humeral shaft fractures:

o   Most treated conservatively – u-slab, collar and cuff, sling, brace, etc.

o   Complication: risk of radial nerve injury in spiral grove

·        Supra-condylar fracture of the humerus:

o   Eg child falling onto outstretched hand.

o   Radial pulse may not return for 24 hours 

o   Can lead to Volkmann‟s Ischaemic Contracture due to disruption to the brachial artery. Muscle necrosis (especially FPL and FDP) ® flexion deformity at elbow and wrist. Arm is blue, there is no radial pulse and passive finger extension is painful (the key sign) 

o   Cast in < 90º flexion

·        Fractured Head of Radius:

o   Mechanism: fall on outstretched hand forces elbow into valgus. Common in adults

o   Clinical: Painful rotation of forearm, tender on lateral side of elbow

o   Treatment: Sling

·        Fractures of Olecranon:

o   Mechanism: Direct blow or fall on elbow causes a comminuted fracture. Clean transverse break is due to traction when patient falls on hand whilst triceps contracted (attaches to olecranon)

o   Clinical: Graze or bruise over elbow. With a transverse fracture there may be a palpable gap and they are unable to extend elbow against resistance

o   Treatment: Undisplaced transverse needs immobilisation in cast at 60 degrees flexion for 2-3 weeks then exercises begun

·        Pulled Elbow:

o   Mechanism: Radial head stretching annular ligament and slipping out from under its cover. Usually kids 2 – 6 years old when parents have pulled on child‟s arm (esp when crossing road)

o   Clinical: Tenderness over lateral aspect, supination limited

o   Treatment: Sling, usually results in spontaneous reduction

·        Tennis Elbow: enthesitis of the common extensor origin on the lateral epicondyle of the humerus ®

·        pain on contraction/stretching of the forearm extensors. Management: rest, physio, NSAIDs in the early stages, steroid injections, surgery later on

·        Golfer‟s Elbow (or any throwing sport): Enthesitis of the common flexor origin on the medial epicondyle

·        Ulnar Nerve Entrapment:

o   Fracture at elbow or prolonged or recurrent pressure on the ulnar nerve ® compression of the nerve in the cubital tunnel

o   Presentation: wasting of the ulnar innervated muscles (hypothenar eminence and the interossei) with sensory loss in the little and ulnar side of 4^th fingers

o   Treatment: Decompression

o   NB: Deep motor branch of the ulnar in the hand can be damaged by recurrent pressure from tools (screw-drivers, handlebars, crutches, etc)