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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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