The elbow and forearm form a functional unit whose primary role is to accurately position the hand in space. viewÂ
An elbow contusion results from blunt direct trauma and produces muscle strains and ligament sprains. viewÂ
Fractures about the elbow are the result of high energy injuries.Â viewÂ
Compartment syndrome in all extremities is an orthopedic emergency. view
Wounds occurring in the forearm and elbow must be treated as an emergency because the risk of infection if left open increases about 7 hours after an injury has occurred. view
Arthritis in the elbow can occur after an injury (post-traumatic arthritis), congenital lack of blood supply to the bone causing flaking off of the cartilage called Osteochondritis Dessicans. view
Cubital tunnel syndrome is the compression of the ulnar nerve at the level of the elbow. view
Pronator syndrome is the compression of the median nerve around the elbow and palmar side of the forearm. Because it is the same nerve that causes carpal tunnel syndrome, there is overlap in the symptoms making the diagnosis difficult, at times. view
Radial tunnel syndrome and posterior Interosseous Nerve palsy are both a result of compression of the Posterior interosseous nerve with a more severe compression occurring in posterior interosseous nerve palsy. view
Lateral epicondyltis also called tennis elbow and medial epicondylitis called golfers elbow is a condition affecting the forearm musclesâ€™ on the humeral bone at the elbow called the lateral and medial epicondylitis respectively. view
The cause of a stiff elbow is either at the bony level or the collagen capsule/ligament level or both. view
The elbow, like the shoulder is well perfused with ample blood supply allowing for circulating white blood cells to offer excellent protection against infection and, consequently an elbow infection is uncommon. view
Tumors are divided into benign and malignant types. A benign tumor is an abnormal growth of a particular cell type presenting as a mass. view
Wounds occurring in the forearm and elbow must be treated as an emergency.
Injuries open for 7 hours or longer have increased risk of infection. If a wound presents after 7 hours, closure of the wound is not advised, especially if the wound results from an animal bite.
When a wound is evaluated, the type of instrument or weapon making the wound must be inquired about. When the patientâ€™s last tetanus shot was given is important to know so a booster can be applied if necessary. The depth of the wound and type of bleeding witnessed is also important.
Types of Bleeding
When an open wound presents to an emergency room, the examination of active elbow, forearm and digital motion is evaluated to determine if a muscle, tendon or motor portion of a nerve has been cut. The sensation of the fingers is also checked to see if the nerves have been cut.
An amputation is the severing of a body part. Classifying Amputations:
When an amputation occurs from the mid-palm to the level of the shoulder, it is a true emergency. The limb must be replanted in no more than 4-6 hours with warm ischemia. The time can be extended to 8 hours if it is cold ischemia (when the part is placed in an ice bath) after injury. The oxygen demands and metabolism of the muscles is high, causing tissue death, or necrosis, if the blood supply is not restored within this time period.
The necrotic changes taking place in the amputated part, which lacks oxygen, will cause a dumping of necrotic material into the bloodstream.
This causes a systemic collapse called Disseminated Intravascular Coagulation (DIC), putting the replantation patientâ€™s life at risk. If this occurs, the amputated part must be removed.
Amputations from mid-palm to fingers have more time to be replanted because less muscle is found in this area. Time to successfully replant fingers can be as long as 15 hours post amputation because no muscle is present, but the sooner the replantation is done, the better.
The treatment of an open wound begins with obtaining a clear history.
Patient History Must:
The exam will confirm the injured tissue and the history will provide the direction the wound should be extended during surgical exploration.
The cleaning of the wound, repair of muscle, artery and tendon is done with the use of a microscope. The improved magnification allows for accurate approximation of the injured tissue.
Tetanus shot is updated if it has been longer than 10 years. For a dirty wound, the tetanus must be no longer than five years current. This avoids the danger of acquiring gas gangrene, a deadly infection from the organism, clostridium perfringens.
For one week after the repair, oral antibiotics covering skin flora are used to avoid the risk of infection.
If the wound is a farm injury or dirty, penicillin is also used to cover clostridium perfringens.
When the wound was caused by a dog bite, the use of antibiotics covering animal flora like pasturella multicida, pseudomonas, staphylococcus and streptococcus must be used.
Human bites, as in a clenched fist injury, also require antibiotics covering eikenella corrodens like augmentin.
The treatment of an amputation starts immediately after the amputation is sustained. The amputated part must be immediately wrapped in saline moistened gauze and placed in ice slush. Ice slush is made by crushing ice in a zip lock plastic bag and put in a cooler. The amputated part can then be transported to ROC for replantation.
Upon arriving at ROCâ€™s emergency facility, the patient is prepared for surgery while the amputated part is taken to the operating room, cleaned and dissected out under a microscope to prepare for replantation.
Replantation is typically successful with amputations beginning at the base of the nail and more proximal amputations towards the shoulder.
Successful replantations are related to the size of the arteries and veins which become too small to repair if it is beyond the nail base.
Steps of Replantation
The results of replantations performed from the level of the forearm to the shoulder are more functional if:
Partial amputations with the skin still attached should be left attached since valuable blood supply may be provided by the retained tissue.
With avulsion type amputations, which is a pulling injury, or a severe crush injury, the likelihood of a successful replantation is significantly less.
Special splints are applied after surgery to avoid certain movements that might damage a repair performed. The injured extremity must be elevated to at least heart level to avoid swelling of the limb. Limb swelling causes moderate pain, cuts off the blood supply and delays wound healing if allowed to occur.
Regardless of the type of amputation, it is advisable to bring in the amputated part immediately for the surgeon to examine.
The surgeon can assess the likelihood of replantation success or may use the tissue from the amputated limb as donor tissue to treat the wound base where the amputation occurred.