Sandra L. Najarian
BICEPS AND TRICEPS TENDON RUPTURES
PATHOPHYSIOLOGY
Tendon ruptures are often the result of microtrauma and overuse. Steroids can contribute to the breakdown of the tendon.
CLINICAL FEATURES
The most common type is rupture of the proximal long head of the bicep, and usually occurs after a sudden or prolonged contraction of the bicep against resistance.
Patients often describe a “snap” or “pop” and complain of pain in the anterior shoulder.
Swelling, tenderness, and crepitus over the bicipital groove can be seen on examination as well as a mid-arm “ball” when the elbow is flexed.
Distal biceps ruptures are less common; weakness in flexion and supination of the forearm is more apparent than in proximal ruptures. Patients have pain, swelling, and a palpable defect in the antecubital fossa.
Triceps ruptures are rare and almost always occur distally, resulting from a direct blow to the olecranon or from a fall on an outstretched hand causing a forceful flexion of the extended forearm.
Patients with triceps ruptures present with pain, swelling, tenderness in the posterior elbow just proximal to the olecranon, and weakness with forearm extension.
A modified Thompson’s test can be used to assess triceps function. With the arm supported, elbow flexed at 90 degrees, and forearm hanging in a relaxed position, squeezing the triceps muscle should produce extension of the forearm unless a complete tear is present.
DIAGNOSIS AND DIFFERENTIAL
Diagnosis is clinical, and radiographs should be obtained to exclude an associated avulsion fracture.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Treatment includes sling, ice, analgesics, and referral to an orthopedic surgeon for definitive management.
EPICONDYLITIS
PATHOPHYSIOLOGY
Repetitive movements involving the muscle groups originating on the lateral and medial epicondyles of the distal humerus result in an overuse syndrome.
CLINICAL FEATURES
Lateral epicondylitis (“tennis elbow”) presents with pain over the lateral elbow and tenderness with forced extension and supination of the forearm against resistance.
Medical epicondylitis (“golfer’s elbow”) presents with pain over the medial elbow and tenderness with forced flexion and pronation of the forearm, wrist, and digits. It may be associated with an ulnar neuropathy.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Conservative treatment is indicated, which includes rest, ice, anti-inflammatory medications, and immo bilization with a counterforce brace.
ELBOW DISLOCATIONS
CLINICAL FEATURES
Most elbow dislocations are posterolateral (90%) and often occur from a fall on the outstretched hand.
The patient holds the elbow in 45 degrees of flexion, and significant swelling often obscures the olecranon, which is displaced posteriorly.
Neurovascular injury occurs in 8% to 21% of cases; the ulnar nerve and brachial artery are the most frequently injured structures (Table 173-1).
Absence of radial pulse before reduction, the presence of other systemic injuries (especially to the head, chest, and abdomen), and open dislocations are often associated with arterial injury.
TABLE 173-1 Sensory and Motor Function Testing of the Radial, Median, and Ulnar Nerves
DIAGNOSIS AND DIFFERENTIAL
Radiographs of the elbow confirm the diagnosis.
The ulna and the radius are displaced posteriorly on the lateral view and displaced medial or lateral on the AP view, but still maintain their normal relationship to each other.
Associated fractures, especially of the radial head and coronoid process, can render the elbow joint unstable and complicate treatment.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
After adequate sedation, closed reduction is indicated. Apply gentle traction on the wrist and forearm while an assistant applies countertraction on the upper arm. With the other hand on the proximal forearm, correct for medial and lateral displacement and apply downward pressure to disengage the coronoid process from olecranon fossa.
Apply a long arm posterior splint to immobilize the elbow in slightly less than 90 degrees of flexion.
Assess neurovascular status, obtain postreduction films, and arrange for urgent orthopedic follow-up.
Patients with instability in extension, neurovascular compromise, or open dislocations require immediate orthopedic consultation.
ELBOW FRACTURES
PATHOPHYSIOLOGY
Radial head fractures are the most common fracture of the elbow and result from a fall on the outstretched hand. Associated injuries around the elbow and even the wrist (Essex-Lopresti lesion) are common.
Intercondylar fractures result from a force directed against the posterior elbow, driving the olecranon against the humeral surface.
Ninety-five percent of supracondylar fractures are extra-articular and are commonly seen in children as the result of a fall on the outstretched hand with the elbow in full extension.
Olecranon fractures often result from direct trauma or forced hyperextension of the elbow.
Articular surface, epicondylar, and condylar fractures are rare.
CLINICAL FEATURES
Radial head fractures produce lateral elbow pain and tenderness and an inability to fully extend the elbow.
Patients with intercondylar and supracondylar fractures will have significant swelling, tenderness, and limited range of motion.
Supracondylar fractures may resemble a posterior elbow dislocation.
The anterior interosseus nerve, a motor branch of the median nerve, has the highest incidence of injury in supracondylar fractures. Anterior interosseus nerve function is demonstrated by flexing the index finger distal interphalangeal joint and thumb interphalangeal joint, forming the “OK” sign.
The most serious complication (Table 173-2) of supracondylar fractures is Volkmann’s ischemic contracture.
Pain with passive extension of the fingers, forearm tenderness, and refusal to open the hand are signs of impending Volkmann’s ischemia.
Acute vascular injuries such as decreased or absent radial pulse are usually secondary to transient vasospasm and are not necessarily a sign of ischemia unless accompanied by the clinical signs described above.
Patients with olecranon fractures present with posterior elbow swelling and tenderness, limited mobility, and weak triceps function.
Ulnar nerve injury is common in olecranon fractures.
TABLE 173-2 Complications of Supracondylar Fractures
DIAGNOSIS AND DIFFERENTIAL
Fracture lines may not be visible on AP and lateral radiographs.
The presence of abnormal fat pads (any posterior effusion or a very prominent anterior fat pad called the “sail sign”) and/or the disruption of the radio-capitellar line (a line drawn from the center of the radial shaft transects the radial head and capitellum in all views) may be the only evidence of injury.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Immobilization in a long arm posterior splint and orthopedic referral are appropriate for nondisplaced fractures.
Nondisplaced radial head fractures with no restrictions in range of motion may be treated with sling immobilization and follow-up with orthopedics in 1 week.
Emergent orthopedic consultation is warranted for all displaced fractures, open fractures, and fractures with evidence of neurovascular compromise.
FOREARM FRACTURES
PATHOPHYSIOLOGY
Both bone forearm fractures usually occur from sig nificant trauma, such as a motor vehicle crash or fall from height.
Isolated ulnar fractures (“nightstick fractures”) usually occur from a direct blow to the forearm.
Radius fractures usually result from direct trauma or from a fall on an outstretched hand.
CLINICAL FEATURES
Both bone forearm fractures present with swelling, tenderness, and deformity.
Isolated ulnar or radius fractures present with localized swelling and tenderness.
Monteggia fracture-dislocation, a fracture of the proximal ulna shaft with radial head dislocation, presents with significant pain and swelling over the elbow.
Galeazzi fracture-dislocation, a fracture of the distal radius with an associated distal radioulnar joint dislocation, presents with localized swelling and tenderness over the distal radius and wrist.
Neurovascular function must be carefully assessed in all forearm fractures. Paralysis of the posterior interosseus nerve (deep branch of the radial nerve) can occur in Monteggia fracture-dislocation. Injury to the ulnar and anterior interosseus nerve can occur in Galeazzi fracture-dislocation.
DIAGNOSIS AND DIFFERENTIAL
AP and lateral radiographs are diagnostic. The amount of displacement, angulation, and shortening needs to be evaluated, and any rotational deformity should be noted.
Isolated ulna fractures are unstable if the proximal third of the ulna is involved, displacement is greater than 50%, or angulation is greater than 10%.
In a Monteggia fracture-dislocation, the radial head dislocation is in the same direction as the apex of the ulna fracture.
In a Galeazzi fracture-dislocation, an increase in the distal radioulnar joint space may be seen on the AP view, and the ulna is displaced dorsally on the lateral view.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Nondisplaced fractures are treated with long arm splint immobilization and referral to orthopedics.
Closed reduction is often adequate for both bone fractures in children.
Urgent orthopedic referral for open reduction and internal fixation is necessary for all displaced fractures in adults and Monteggia and Galeazzi fracture-dislocations.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 267, “Injuries to the Elbow and Forearm,” by Jason H. Bredenkamp, Brian R Jokhy, and Dennis T. Uehara.