1. Managing Minor Musculoskeletal Injuries and Conditions First Edition. David Bradley. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/bradley/musculoskeletalwww.wiley.com/go/bradley/musculoskeletal

2. The elbow

3. Elbow 1 FOOSH injury - is there any bone injury? After you have studied it carefully, have a look at the next slide.

4. Elbow 1 - my comments There is a displaced fractured neck of the radius. I have drawn lines to show the tilting of the articular surface: it should be horizontal. The arrow points to the epiphyseal line of the medial condyle of the humerus.

5. Elbow 2 What do you see? When ready, read my notes below.

6. Elbow 3 FOOSH, hurt elbow following a fall, supination and pronation especially painful. Is there any bone or soft tissue injury? What other view would you want taken? Look at the next slide when you have finished.

7. Elbow 3 – my comments There is a fractured head of radius, which is quite common following a FOOSH. The force carries on up the shaft of the radius (large arrow), smashing the concave articular surface of the head into the convex capitellum of the humerus. The thin line highlights what can be seen of the fracture on this view, although star shaped patterns are common. A lateral view is essential.

8. Elbow 4 This is a difficult one for you - a paediatric elbow. To be able to interpret these effectively, you not only have to be up to par with your anatomy, but also spot on with your epiphyses, when they appear and when they fuse. This is difficult if you don’t do it on an everyday basis, so in most instances you will have to refer on. Possibly for a very long time until you become expert at it. When you have had a thorough look at it, turn to the next slide.

9. Elbow 4 – my comments This shows a supracondylar fracture of the humerus. The yellow line approximates the most visible fracture line of the distal fragment. With any fracture like this, your first concern is always the existing circulation of the limb distal to the fracture. Any movement made must be made while feeling the radial pulse.

10. Elbow 5 This shows another supracondylar fracture of the humerus, which is grossly displaced, but this time a lateral view is shown. The yellow line shows normal architecture, going through the upper radial shaft, head and centre of the capitellum. Notice the swelling of the soft tissues around the elbow; this is common. The tissues are very loose, so can accommodate a great deal of swelling.

11. Elbow 6 Yet another FOOSH. Do you see anything, or may the patient just rest it in a sling for a few days? Now look at my comments on the next slide.

12. Elbow 6 – my comments This shows a fractured neck of radius. This is a very difficult one to see unless you are used to these impacted fractures. It is simply the sharp angle at the junction of the head and neck that gives it away (arrow).

13. Elbow 7 Fell off a 6ft ladder; put arm out to save himself. Painful and cannot move the arm. What do you see?

14. Elbow 7 – my comments Find a severely displaced fracture of the lower end of the shaft of the humerus and you will get little praise. Notice a fracture of the mid shaft of the radius and I start to become pleased with you. Notice a fracture of the lower end of the shaft of the ulna and I will be pleased with you. Never find one fracture and stop looking.

15. Elbow 8 What do you see? Any other view required? Any associated problems? When ready, read my notes below.

16. Elbow 9 The patient fell directly onto the elbow. Very swollen and painful. Is it dislocated?

17. Elbow 10 Severe displacement of a supracondylar fracture of the humerus, lateral view. Very happy if you immediately thought of the distal circulation and not long after that the nerve supply. Do any movement at all while feeling the pulse at the wrist on that side, so that you immediately notice any diminution. Finally, an AP view is required.

18. Elbow 11 This shows a fracture of the lateral condyle (white arrow). Note that the whole of the lower humerus is not on the film - this is not acceptable. There is a normal epiphysis at the olecranon (yellow arrow). The yellow line along the anterior border of the humeral shaft, should travel through the middle third of the capitellum.

19. Elbow 12 A fall directly onto the point of the elbow playing rugby. Is there anything there? When complete, go to the final slide.

20. Elbow 12 – my comments This shows a fracture of the olecranon with very minimal displacement. The arrow points to a break in the cortex; the fracture line goes through to the joint surface.