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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.
- Full clinical assessment + pathological impression. This is a
highly important stage and with A&E minor injury and sportsinjuries 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 clinicwww.1stopinjuryclinic.co.uk
SPEED UP RECOVERY FROM SPORT INJURIES
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These pictures are produced with permission by Chartex products international
ANTERIOR VIEW
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MEDIAL VIEW
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ANTERIOR VIEW
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POSTERIOR VIEW
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Elbow InjuryHistory
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
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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.
MOVEFlexion
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
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Soft Tissue Problems of Elbow
Symptoms Problem
Repetitive movement
of supination/pronation
Pain at elbow exacerbated by
pain on resistance to wrist
extension
Tennis Elbow
(lateral epicondylitis)
Infection/ minor trauma
Rheumatoid arthritis
Hot & painful elbow
Pain over olecranon
Swelling over olecranon
Olecranon Bursitis
Repetitive flexion of wrist
caused by throwing movement
Pain over medial epicondyle
Pain on flexion against
resistance
Pitchers elbow
(Medial epicondylitis)
Pain insertion point of tendon
over radial head
Tenosynovitis
Synovial fluid felt in grooves
between olecranon process and
epicondyles
? Boggy soft /fluctuant
swelling
tenderness around elbow joint
Arthritis of the elbow
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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 elbowis 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 thecomplicated anatomy.
Intraosseous - Posterior end vessels to the ossification centres exist withinthe 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 ossificationcentre of the capitellum ossification center.
Coronoid line - A line directed posteriorly along coronoid process should justtouch 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
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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 neurovascularcompromise.
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).
Thepresenting symptom in this condition is that the child will not usehis arm. He may complain of pain in the shoulder, elbow or wrist. The
parents maybe worried that the arm is dislocated or broken.
TheDiagnosis 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.
TheMechanism of injury is that the radial head (which is poorlyformed 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 usual
seen if the X-ray is taken three weeks after the injury. Nonsurgical treatme
involves using a sling and a # clinic appointment followed by early motion. If
motion is attempted too quickly, the bones may shift and becomedisplaced. Even the simplest of # will probably result in loss of elbow extension.
More serious displaced # need to be discussed with the orthopaedic team.
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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. Thehallmark 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, medialepicondylitis, 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: ChurchillLivingston.
MUNRO, J. AND CAMPBELL, I., 2000.Macleods ClinicalExamination. 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. Vol63, 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 andManagement. 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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