Ep 121 Elbow Injuries – Ten Pitfalls in Diagnosis and Management

Although it doesn’t get the spotlight much in emergency medicine, the ED diagnosis and management of elbow injuries is of significant clinical importance. There are several easy-to-miss injuries that can lead to functional impairment. Even minor errors in management can result in long term consequences for patients. In this EM Cases main episode podcast with Dr. Arun Sayal, the brains behind the CASTED Course and Dr. Dale Dantzer, upper extremity orthopedic surgeon at North York General Hospital, we discuss pitfalls in the diagnosis and management of elbow injuries and answer questions such as: What is an easy way to remember the surgical indications for radial head fractures? What is the significance of a coronoid process fracture and how does it change management when seen with a radial head fracture? What is the best way to assess for pronation and supination of the forearm? Why is it so important to assess for the extensor mechanism on physical exam for patients with olecranon fractures? What is a quick easy way to test the peripheral nerves of the upper extremities? Which often missed soft tissue injuries of the elbow require urgent operative management? and many more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Shaun Mehta and Lorraine Lau, edited by Anton Helman March, 2019 Cite this podcast as: Helman, A. Sayal, A. Dantzer, D. Ten Pitfalls in the Diagnosis and Management of Elbow Injuries. Emergency Medicine Cases. March, 2019. https://emergencymedicinecases.com/elbow-injuries. Accessed [date] Key concepts in elbow injuries diagnosis and management * At 3 weeks of immobilization, there is high risk for chronic elbow stiffness and possible long-term disability * While we don’t need to memorize orthopedic classification systems, we should glean key points from them * Keep your differential broad for elbow injuries just like you would with a patient presenting with chest pain * Learn how to recognize uncommon elbow injuries Radial head fractures: Sometimes not so simple The most common adult elbow fracture is a radial head fracture, often seen following a FOOSH—or fall on an outstretched hand—type of mechanism. Since force is transmitted along the entire extremity, ensure you fully examine from the sternoclavicular joint to the hand. Radial head fracture mechanism of injury Valgus stress = lateral force. The normal carrying angle of the elbow is slightly valgus. The vector of force with a FOOSH therefore goes through the lateral elbow where the radial head meets the elbow. This explains why the radial head and neck are often implicated, and why medial ligamentous structures are susceptible to injury as the medial side "opens up". Radial head fracture physical exam To identify the radial head, make an equilateral triangle using the following landmarks: * Olecranon (laterally) * Lateral condyle (superior and anterior to the olecranon) * Radial head = third point of the triangle Pronating and supinating the forearm brings out the radial head. The elbow is not just a hinge-joint The elbow moves in supination and pronation, as well as flexion and extension. Ensure all ROMs are assessed on physical exam. Testing pronation of the forearm. Ensure the elbows are held tight against the trunk. Normal pronation = 90 degrees with thumbs parallel to the floor. Testing supination of the forearm. Ensure the elbows are held tight against the trunk. Normal supination = 90 degrees with thumbs parallel to the floor. Pearl: Ask your patient to put their thumbs up while pronating and supinating to get a better sense of how close to their full range of motion they can ge...