Carrying Angle of the Elbow

The carrying angle of the elbow is the clinical measurement of the varus-valgus angulation of the arm with the elbow fully extended and the forearm fully supinated. With the arms extended at the sides and the palms facing forward, the forearm and hands are normally slightly away from the body.

axis The intersection of the axis of the upper arm and axis of the forearm defines the carrying angle. The carrying angle is greater in shorter persons compared to taller persons. The shorter the forearm bone length is, the greater the carrying angle will be. The normal carrying angle of the elbow is between 5-15°. The carrying angle is greater in women and in throwing athletes. It is difficult to assess if there is a flexion contracture of the elbow. This angle permits the forearms to clear the hips in swinging movements during walking, and is important when carrying objects.

carrying angleCubitus varus is the opposite of cubitus valgus, causing the elbow to have inward angulation towards the midline of the body. Cubitus valgus is a deformity which causes the forearm when it is fully extended to be angled away from the body in a greater degree than normal. Supracondylar fractures usually occur in children.

If the fracture is malaligned and if it heals in a malaligned position, the fracture may develop into a severe varus deformity of the elbow which decreases the carrying angle of the elbow. This decrease of the carrying angle causes the elbow to have more of an inward angulation towards the midline of the body. This creates what is called a “gunstock deformity”. The deformity is caused by fracture malunion. This is usually a cosmetic deformity with little functional limitation.leading

A fracture of the lateral condyle of the humerus can lead to:

  1. Cubitus Valgus
  2. Stretching of the ulnar nerve

If the fracture did not heal or the fracture is malaligned, the medial part of the humerus will grow and the lateral part will not grow. The forearm will drift into valgus malalignment. The carrying angle will increase (cubitus valgus) and the ulnar nerve will be stretched and may need transposition. The nonunion of the lateral condyle of the humerus may need fixation in order to stop progression of the valgus deformity. 30° of varus or valgus angulation is tolerated in fractures of the humerus without any clinical functional significance.thirty

 

Advertisements

Haemarthrosis of the Knee

Hemarthrosis is blood inside the knee or bleeding into the knee joint space. The swelling and fluid inside the knee joint is usually relieved with an aspiration. During the aspiration, the physician will insert the needle on the lateral side of the knee, just above the upper border of the patella. The needle enters below the patella into the suprapatellar bursa which is continuous with the joint cavity. This aspiration technique is different than how physicians perform injections. For a knee injection, the needle is inserted at the lower border of the patella on either side of the patellar tendon at the soft spot.

aspiration v inspirationThe color of the fluid aspirated—not bloody effusion—is probably due to synovial irritation caused by chronic processes such as gout, pseudogout, arthritis, rheumatoid arthritis, or degenerative meniscus. A degenerated meniscus may be associated with swelling and fluid collection; usually not bloody. The peripheral portion of the meniscus is vascular (about 3-5 mm). The blood supply of the meniscus originates from the medial and lateral genicular arteries. Although a degenerative meniscus effusion is not bloody, a traumatic tear of the meniscus may cause bleeding inside the knee joint.

arthrA bloody effusion could be trauma related or non-trauma related. For example, hemarthrosis can be caused by trauma or injury to the structures of the knee such as the ACL, PCL, or meniscus. Hemarthrosis can also occur due to tibial plateau fractures, chondral fractures, patellar dislocations, or a meniscal tear. Non-traumatic conditions that can cause hemarthrosis include: PVNS, sickle cell anemia, hemophilia, anticoagulation, or hemorrhage following total knee replacement.

Hemoarthrosis from trauma or injury indicates a significant knee injury such as ACL (75-80%) or a meniscal tear. If aspirations of the knee after trauma shows hemarthrosis, early evaluation of the injury may be necessary to define the extent of damage. The physician may get an MRI early.

meniscusAbsence of hemarthrosis does not mean a less severe ligament injury—the blood may escape without distending the capsule. A severe injury may cause minimal or severe joint effusion. More than 20cc of fluid may affect the quadriceps function and prevent full extension of the knee. A hematoma should be evacuated. The bloody aspirate should be examined for fat to rule out a fracture. The aspirate may vary in color depending on the severity of the injury and the duration of the symptoms. Fat is less dense than blood and fat floats on the surface, whereas blood is heavier and stays on the bottom.

mri.The presence of a fat/fluid level is diagnostic of a fracture even if a fracture is not seen on an x-ray (occult). Fat/fluid level is usually seen with tibial plateau, chondral, and patellar fractures. The cross table lateral view of the knee shows it well. When a fat/fluid level is seen, look for intra-articular fractures. Lipohemarthrosis is only seen on horizontal x-ray beams with the beam parallel to the floor. It occurs in 40% of all fractures inside the joint.

lipohemoarthrosis

Galeazzi Fracture

Galeazzi Fractures are a type of fracture of the radial shaft which is associated with dislocation of the distal radio-ulnar joint (DRUJ). This particular fracture is name after Ricardo Galeazzi who was an Italian surgeon in Milan. This injury is uncommon and only accounts for about 7% of all forearm fractures in adults.

 

A radius fracture may be short, oblique, or transverse and involves a fractures at the junction of the middle third and distal third of the radius with associated injury to the distal-ulnar joint. The closer the fracture is to the DRUJ, the more likely that it will be unstable. Dislocation of the DRUJ is usually dorsal. It may be associated with either a ligamentous injury or fracture of the styloid process of the ulna.

styloid fx

A fracture is usually located above the proximal border of the pronator quadratus muscle. The distal fragment usually moves towards the ulna. Galeazzi fractures are best treated with open reduction and internal fixation of the radius and assessment of the distal radio-ulnar joint.

unstable

Surgery is necessary. Nonsurgical treatment in adults usually results in recurrent dislocations of the distal ulna and a bad outcome. Surgery is done by a volar plate fixation. Followed by assessment of the Distal Radio Ulnar Joint (DRUJ), if stable, the forearm will be splinted in supination for six weeks. If the joint is unstable, reduce and pin the distal radio-ulnar joint in supination for about four weeks. If the joint is not reducible, open and explore the joint. Check for entrapment of the ECU.

reduction

 

 

Tarsal Coalition

Tarsal coalition is a congenital anomaly in which the tarsal bones fuse together, leading to a rigid flat foot, foot pain, and multiple ankle sprains. There are two types of tarsal coalition. The first is known as a Talocalcaneal Coalition, which is a coalition between the talus and the calcaneus. The second is referred to as a calcaneonavicular coalition which is a coalition between the calcaneus and the navicular. When talocalcaneal coalition occurs, it usually happens around 12-15 years of age. The calcaneonavicular coalition presents at an earlier age. About 50% of coalitions are bilateral, and around 20% have multiple coalitions in the same foot. Coalition may be fibrous, cartilaginous, or bony and occurs due to failure of segmentation. It could be associated with fibular hemimelia or Apert’s syndrome.

tarsal anatomy

Symptoms typically consist of patient’s complaining of a painful foot, a history of repeated ankle sprains, and a flat foot deformity. Tarsal coalition may result in a peroneal spastic flat foot. During the physical examination, the physician may find hindfoot valgus. On toe standing, the arch does not reconstitute and heel cord contracture may also be evident during the exam. Furthermore, there may be restriction in the subtalar joint’s range of motion. It is important to check both feet as the condition may be bilateral.

hindfoot

The best imaging study is a CT scan. It can determine the size and location of the coalition. And MRI is also useful in detecting a fibrous or cartilaginous coalition. AP, Lateral, and Oblique view x-rays should be ordered. On a lateral view x-ray, the Calcaneonavicular Coalition can be identified by the “anteater nose sign” and the elongation of the anterior calcaneal process.

ant

A lateral view of a Talocalcaneal Coalition may show talar beaking which is a traction spur that occurs due to the limited motion of the subtalar joint. Additionally, the C sign may be seen which is a radiological sign outlining the talar dome and the sustentaculum. A 45° oblique view is the best for showing calcaneonavicular coalitions.

45oblique

Nonoperative treatment usually consists of anti-inflammatory drugs, modified activities, or the use of a brace or cast. Surgical treatment for the calcaneonavicular coalition usually consists of resection with an interposition of the extensor digitorum brevis muscle or a fat graft no matter the size of the coalition. Similarly, Talocalcaneal coalitions that involve less than 50% of the subtalar joint are also resected. A triple arthrodesis procedure is performed for large coalitions, failed resections, or advanced conditions.