Elbow ProblemsElbow Problems

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AnatomyAnatomy

Hinged joint Hinged joint formed by formed by humerushumerus and ulna and ulna produces flexion produces flexion and extensionand extensionRotation producing Rotation producing pronationpronation and and supinationsupination from from radial head and radial head and humerushumerus

Assessment Assessment

History/Mechanism of injuryHistory/Mechanism of injuryExaminationExamination

LOOKLOOKFEELFEELMOVEMOVE

XX--ray ?ray ?

Most common injuriesMost common injuries

SupraSupra--condylarcondylar fracturefractureRadial head fractureRadial head fractureOlecranonOlecranon fracturefractureDislocationDislocationFracture dislocationFracture dislocation

SupraSupra--condylarcondylar fracturefractureUsually from fall onto Usually from fall onto elbow when flexedelbow when flexedMore common in More common in childrenchildrenOften Often displaced/angulateddisplaced/angulatedGenerally swollen Generally swollen restricted movementrestricted movementLook for complicationsLook for complications

SupraSupra--condylarcondylar fracturefractureComplicationsComplications•• vascular complications: brachial vascular complications: brachial arteyartey•• VolkmannVolkmann’’s s ischaemicischaemic contracture contracture •• median nerve palsymedian nerve palsy

ManagementManagement•• some may require manipulation if displacedsome may require manipulation if displaced

arterial obstructionarterial obstructionoffoff--ending of fractureending of fracture<50% bony contact<50% bony contact

Long arm plaster fixationLong arm plaster fixation

Radial head fracturesRadial head fractures

Fall onto Fall onto outstretched handoutstretched handFemale>maleFemale>male20% all elbow 20% all elbow injuriesinjuriesAssociated with Associated with 10% dislocations10% dislocations

Signs and symptomsSigns and symptoms

Pain on outside of Pain on outside of elbowelbowSwelling in elbow Swelling in elbow jointjointUnable to fully flex Unable to fully flex or extendor extendPain Pain pronation/supinatiopronation/supinationn

Fracture radial headFracture radial head

Fracture may not be visible on initial xFracture may not be visible on initial x--raysrays-- look for effusionslook for effusionsType 1 fractures Type 1 fractures undisplcedundisplced treated with treated with collar and cuffcollar and cuffType 2 fractures Type 2 fractures slghtlyslghtly displaced treated displaced treated conservatively may require surgery if conservatively may require surgery if large pieceslarge piecesType 3 fractures Type 3 fractures comminutedcomminuted causes poor causes poor healing may require excision radial healing may require excision radial head/head/prothesisprothesis

Fracture over Fracture over olecranonolecranon

Mechanism Mechanism --fall on point of fall on point of

elbowelbow--sudden triceps sudden triceps

contraction contraction

DonDon’’t forget t forget epiphyses epiphyses

OlecranonOlecranon fracturesfracturesHairline and Hairline and undisplacedundisplaced fractures fractures can be treated in long can be treated in long arm cast for 3arm cast for 3--4 4 weeks in children and weeks in children and 66--8 weeks in adults8 weeks in adultsIf fragment If fragment large/displaced will large/displaced will require fixation e.g. require fixation e.g. tension band wiringtension band wiring

Elbow dislocationElbow dislocation

Usually fall onto Usually fall onto outstretched handoutstretched handSevere pain at Severe pain at elbow and swellingelbow and swellingMinimal movementMinimal movementCheck Check sensation/pulsessensation/pulses

Dislocation of elbowDislocation of elbow

Posterior lateral dislocation reduction Posterior lateral dislocation reduction by traction in line of the limb under by traction in line of the limb under analgesia and sedationanalgesia and sedationCheck xCheck x--rayrayCrepe bandages and sling 2 weeksCrepe bandages and sling 2 weeksFracture clinicFracture clinic

Elbow |DislocationsElbow |DislocationsBEWARE BEWARE ASSOCIATED ASSOCIATED FRACTURESFRACTURESBEWARE BEWARE COMPLICATIONSCOMPLICATIONSMedian nerve Median nerve injuryinjuryUlna nerve injuryUlna nerve injuryBrachial artery Brachial artery injuryinjury

ComplicationsComplications

Complications damage toComplications damage to•• UlnarUlnar nervenerve•• Median nerveMedian nerve•• Brachial artery uncommonBrachial artery uncommon

Median Nerve InjuryMedian Nerve InjuryOccasionally damaged Occasionally damaged in in supracondylarsupracondylarfracturesfracturesMore commonly in More commonly in wrist lacerationswrist lacerationsProduces loss of Produces loss of sensation as shownsensation as shownHigh injuries produce High injuries produce decreased strength in decreased strength in wrist flexion, loss wrist flexion, loss ofulnaofulna deviation and deviation and thumb oppositionthumb opposition

Ulna nerve injuriesUlna nerve injuriesLoss of sensation Loss of sensation as shownas shownMotor supply to Motor supply to small muscles of small muscles of hand except hand except thenarthenarmuscle and 1muscle and 1stst two two lumbricalslumbricalsProduces Produces decreased grip decreased grip strengthstrength

Lateral Lateral EpicondylitisEpicondylitisCommonly known as Commonly known as tennis elbowtennis elbowOccurs in mostly 30Occurs in mostly 30--50 years age group50 years age groupDue to degeneration Due to degeneration of the tendon fibres of the tendon fibres over the lateral over the lateral epicondyleepicondyle which are which are involved in wrist involved in wrist extensionextension

SymptomsSymptomssevere burning severe burning pain on outside of pain on outside of elbowelbowPain worse on Pain worse on gripping or gripping or lftinglftingobjects and with objects and with direct pressure direct pressure over lateral over lateral epicondyleepicondylePain may radiate Pain may radiate down forearmdown forearm

TreatmentTreatment

Mostly self limitingMostly self limitingAnalgesia Analgesia --NSAIDSNSAIDSAvoid activities which produce symptomsAvoid activities which produce symptomsOrthoticsOrthoticsShould improve in 6Should improve in 6--8 weeks if not 8 weeks if not consider steroid injectionconsider steroid injectionPhysiotherapyPhysiotherapySurgerySurgery

Medial Medial EpicondylitisEpicondylitisCommonly called Commonly called GolferGolfer’’s elbows elbowSimilar to Tennis Similar to Tennis elbowelbowMost common in men Most common in men 2020--50 years50 yearsPain medial elbow Pain medial elbow may radiate down may radiate down inner forearminner forearmPain worse when Pain worse when mkemkefist/shake handsfist/shake hands

TreatmentTreatment

R.I.C.E.R.I.C.E.AnalgesiaAnalgesiaPhysiotherapyPhysiotherapySteroid injectionSteroid injectionSurgery Surgery

Ulna neuritisUlna neuritisDue to entrapment of Due to entrapment of the ulna nerve at the the ulna nerve at the elbowelbowProduces Produces paraesthesiaparaesthesiaof ring and little fingerof ring and little fingerAching pain on inside Aching pain on inside of elbow and difficultyof elbow and difficultyWeakness of Weakness of grips/poor finger grips/poor finger coordination coordination Muscle wasting if Muscle wasting if chronic chronic

TreatmentTreatment

Avoid frequent use with the arm bentAvoid frequent use with the arm bentAvoid pressure over the areaAvoid pressure over the areaKeep elbow straight when sleepingKeep elbow straight when sleepingNSAIDSNSAIDSPhysiotherapyPhysiotherapySteroid injectionsSteroid injectionsSurgery Surgery

OlecranonOlecranon BursitisBursitis

Infection/inflammaInfection/inflammation of bursation of bursaCausesCauses--Trauma Trauma Prolonged pressureProlonged pressureInfection Infection Medical conditions Medical conditions e.g.rheumatoide.g.rheumatoidarthritis/goutarthritis/gout

Symptoms/TreatmentSymptoms/TreatmentSwelling Swelling PainPainErythemaErythema/heat if /heat if infectedinfectedInfection may spreadInfection may spreadR.I.C.E.R.I.C.E.NSAIDSNSAIDS?Antibiotics?Antibiotics?Aspiration?AspirationSurgery Surgery

Remember kidsRemember kids

CC--capitulumcapitulum 2yrs2yrsRR--radial head 4yrsradial head 4yrsII--internal(medialinternal(medialepicondyleepicondyle) 6yrs) 6yrsTT--trochleatrochlea 8yrs8yrsOO--olecranonolecranon 10yrs10yrsLL--lateral lateral epicondyleepicondyle12yrs12yrs