The Elbow and Forearm

INJECTIONS AND ASPIRATIONS

Elbow Joint Injection

Description of Procedure

Position the patient either supine or seated depending on which position is more comfortable for the patient. The elbow can be in any position, but a position of slight (˜45°) flexion is optimal.
Prepare the skin with an antimicrobial agent such as alcohol, Betadine, or chlorhexidine gluconate (our preference).
Optional: The overlying skin is anesthetized with 2 to 3 cc of 1% lidocaine without epinephrine using a 25G to 30G needle. The use of local anesthetic is debatable. Some physicians feel it is not helpful because only the skin will be anesthetized, and a second injection is required. We do not routinely use local anesthetic prior to skin penetration. However, the needle should penetrate the skin quickly to minimize pain.
Palpate three structures which form a triangle on the posterolateral aspect of the elbow: the lateral epicondyle, radial head, and lateral tip of olecranon. The soft spot in the center of this triangle is the entry point for the needle (Fig. 3-1).
The needle should enter the joint easily, and a small amount of synovial fluid is aspirated to confirm intraarticular placement. If performing an injection, the fluid should enter the joint with little to no resistance.

Tips and Other Considerations

Lacerations around the elbow are common. Often, a saline load test is used in the setting of an open wound to evaluate for the presence of a traumatic arthrotomy. To evaluate for a traumatic arthrotomy, inject 50 cc of normal saline (optional: use diluted methylene blue for improved visualization) into the joint using the described technique and observe for extravasation of the solution out of the open wound.
In the presence of a radial head fracture, it is often difficult to evaluate the elbow for a mechanical block because of guarding secondary to pain. Aspiration of the hematoma and infusion of 5 cc of 1% lidocaine into the elbow joint anesthetizes the elbow, enabling a range of motion examination. This allows the practitioner to distinguish guarding secondary to pain from a mechanical block from intraarticular incongruency.

FIGURE 3-1

Olecranon Bursa Aspiration/Injection

Description of Procedure

Position the patient supine, with the arm at the patient’s side resting on a stack of towels. Prepare the skin with a sterile prep.
Palpate the fluctuant mass directly over the tip of the olecranon. The needle is inserted into the bursa and the contents are aspirated. Often, the bursa contains septations which must be broken by sweeping the needle through the bursa while intermittently aspirating (Fig. 3-2).
If infusion of a therapeutic agent is desired, a hemostat is used to stabilize the needle while removing the syringe used to aspirate and replacing it with a syringe loaded with corticosteroid or sclerosing agent.
A compression bandage should be wrapped snuggly to discourage reaccumulation of fluid.

Tips and Other Considerations

Do not inject any therapeutic agents (corticosteroid or sclerosing agent) if septic olecranon bursitis is suspected.

Lateral Epicondylitis Injection

Description of Procedure

The patient is positioned supine with the elbow slightly flexed and pronated. The area of maximal tenderness is identified by the patient, confirmed by palpation, and marked. The skin is prepared in a sterile fashion (Fig. 3-3).
At the marked spot, a 22G needle is inserted down to bone and withdrawn 1 mm. The solution is slowly injected (Fig. 3-4).

Tips and Other Considerations

A variety of therapeutic agents can be injected. We typically inject 2 ml of 1% lidocaine mixed with 1 ml of methylprednisolone (40 mg/ml). More recently, botulinum toxin, whole blood, and platelet-rich plasma injections have been used to treat lateral epicondylitis.

FIGURE 3-3

FIGURE 3-4

CLOSED REDUCTIONS

In adults, the majority of displaced fractures and fracture dislocations around the elbow and forearm are treated surgically to provide the best functional outcome. This includes most displaced intraarticular distal humerus, radial head, olecranon, and diaphyseal forearm fractures. Therefore, closed reduction maneuvers for these injuries are not described below. However, two common injuries about the elbow and forearm that are frequently treated nonsurgically are the simple elbow dislocation and the nightstick ulnar shaft fracture.

Elbow Dislocation

Description of Procedure

For all techniques, patient comfort is paramount. We routinely perform closed reduction after an intraarticular elbow injection of 5 cc of 1% lidocaine. Alternatively, conscious sedation can be used to provide anesthesia for reduction. All techniques start with correction of medial/lateral displacement, followed by traction and flexion.

SUPINE TECHNIQUE

Position the patient supine, with the bed height adjusted to place the elbow at the level of your waist. With the elbow extended, stabilize the arm while using your other hand to manipulate the proximal forearm to correct any medial/lateral displacement. This will allow the trochlea and ulna to align and allow reduction of the trochlea in the next step of the procedure (Fig. 3-5).
With an assistant providing countertraction, pull gentle longitudinal traction with the elbow extended. Place the thumb of your contralateral hand on the tip of the olecranon and grasp the anterior humerus to provide counterpressure. Now, use your thumb to place a firm anterior force on the olecranon. As the elbow is slowly flexed, the reduction occurs, often with a palpable clunk (Fig. 3-6).
Perform a stability examination.
Place the elbow at 90° of flexion and neutral rotation in a long-arm posterior splint.

FIGURE 3-5

FIGURE 3-6

PRONE TECHNIQUE

The patient is placed prone, with the arm hanging over the side of the bed.
Correct any medial/lateral displacement as described above.
An assistant pulls longitudinal traction. Cup the elbow with both thumbs on the tip of the olecranon and digits in the antecubital fossa. As your assistant flexes the elbow, place firm anterior force on the olecranon. Reduction will occur with a palpable clunk (Fig. 3-7).
Perform a stability examination, and apply a splint as described above.

FIGURE 3-7

Tips and Other Considerations

To anesthetize the elbow using an intraarticular injection, use the same technique as described above. However, you will have a larger area to aim for since the joint is dislocated, opening up a wide intraarticular space. Aspiration of the hematoma confirms intraarticular needle placement and assists with pain relief.
After a successful reduction, it is paramount to perform a stability examination to guide further treatment. We prefer to bring the elbow through its range of motion while observing the lateral image under live minifluoroscopy. Record the degree of extension at which the elbow starts to subluxate. Next, an anteroposterior image is viewed while providing gentle varus and valgus stress with the elbow at 30° of flexion. Alternatively, the stability examination can be easily done clinically without fluoroscopy.
The majority of patients with simple elbow dislocations are sufficiently stable to start early range of motion at 3 to 5 days postreduction. To prevent stiffness, these patients should be given early follow-up appointments.

Ulnar Shaft Fracture: “Nightstick Fracture”

Tolerances

<50% translation and <10° angulation.

Description of Procedure

Place the patient supine, with the arm draped over the chest.
A hematoma block may be used for anesthesia during reduction. After a sterile preparation at the fracture site, use a 22G needle to pierce the skin over the subcutaneous border of the ulna at the fracture site. When the needle enters the fracture site, aspirate the hematoma confirming accurate placement and inject 5 cc of 1% lidocaine.
Typically, the fracture is most stable in supination; however, we recommend only moderate (≤45°) supination because the patient will quickly lose pronation if splinted in full supination.
A long-arm cast is placed to hold the arm in this position. A flat mold over the dorsoulnar border of the forearm is used to straighten the ulna. To achieve this, we rub a flat palm firmly over this surface. Alternatively, a flat object can be used to mold the cast.

PEDIATRIC CONSIDERATIONS—CLOSED ELBOW REDUCTIONS

Supracondylar Humerus Fractures

Indication

Nondisplaced fractures are treated without manipulation by immobilization in a long-arm cast.

Closed reduction and splinting/casting may be indicated for displaced supracondylar humerus fractures in children with an intact posterior cortex (Fig. 3-8).

FIGURE 3-8

Widely displaced fractures, defined by lack of posterior cortical contact, should have definitive surgical repair. We do not routinely perform a provisional closed reduction of widely displaced fractures unless there is skin compromise or neurovascular injury. In the absence of these soft tissue injuries, the elbow is splinted in a position of comfort prior to operative treatment (Fig. 3-9).

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