A crew is dispatched to attend a girl who is eight years old and has sustained a possible elbow injury after a fall from a swing. The girl is upset and cannot bend her arm, there is no muscular and joint pain, nor joint deformity observed. After an examination, the girl has normal sensation on her left hand. On the other hand, the girl has a normal respiration of 20, SpO2 of 100 which indicate that she has enough supply of oxygen in her blood, a normal temperature reading of 35 and she is very conscious showing a GCS reading of 15 in additional to a normal blood pressure of 107/67.
An elbow is a complex joint in the human body that support the forearm movement, and it is always at risk of various injuries especially during a fall because the first response to a fall is to support the body weight using the hands. Disorder of the elbow can range from chronic to acute problems. The functioning of the upper extremities of the body and an injury to the elbow reduces the ability to extend the arm which is the condition being experienced by the patient. A fully working elbow will allow the forearm to extend at 145 degrees and a 180 degrees rotation during pronation (Krul et al. 2012).
The elbow pain being experienced by the patient is due to a possible fracture of the joint that makes up the elbow or stress on the ligaments that join the joints of the elbow in position. The acute injury on the girl from the trauma of the fall is the reason behind the pain being experienced by the girl. Another possible cause of the pain and the stiffness of the elbow is due to the stress of the ligaments which provide stability to the elbow joint. Also, the elbow muscles and tendons might have been stressed from the fall also causing the pain being experienced by the girl in her elbow joint (Susan 2014).
Initial assessment and intervention
It is important to establish the mechanism through which the injury was sustained and the time and the date of the injury which can help identify the possible approach to use in assessing the elbow injury. Also important in the initial assessment of the patient is the inquiry of any possible past elbow injury and treatments which can provide more insight on the extent of the injury. Also, the initial assessment should assess the medical history of the girl as well as the possibility of any allergies on drugs which can lead to another problem (Iyer et al. 2012).
Focused clinical assessment
In the initial assessment, it is important to be careful and use eyes and gentle touch to identify any deformity, swelling and bruising on the elbow. Through a gentle touch, the initial assessment using a gentle touch should be able to feel any possible bony tenderness and effusion ('Sprain' 2016).
A neurovascular assessment is important in assessing whether the fall has affected the child neurology. This assessment can be carried out through assessment of the color of the skin around the elbow, warmth, sensation and periphery pulses. A neurovascular assessment is important and increases the chance of holistic treatment in case of neuron damage on the arm. The most common nerve damage in case of an elbow injury is on the ulnar neuritis which is a nerve in the elbow (Lavine 1953). Inflammation of this nerve can cause radiating pain from the posterior side of the elbow to the hand and also the fingers. The ulnar nerve injury is only possible in the occurrence of severe fracture of the elbow bones. The damage of the ulnar neuritis is evidenced by the feeling of numbness and tingling of the hand. The other nerve on the elbow is the radial nerve which crosses the elbow below the lateral epicondyle and compression of the nerve from a fall can lead to the malfunction of the elbow and pain. Nerves control the function and sensation around the elbow because they are coordinate the muscles of the elbow with the brain (Josefsson and Danielsson 1986).
Pain assessment refers to the assessment of the level of pain being experienced by the child and it is measured using a pain scale. Elbow joint and other forms of trauma are quite painful, and there is the need of using an effective analgesia method to reduce the pain. Assessment of pain is important in quelling the fears of the child and also can help improve further assessment methods and procedures that will be used to treat and diagnose the elbow (Edgcombe, Carter and Yarrow 2008). After addressing the possible pain in the child's elbow, it is important to take the child for further diagnosis in a well-equipped health clinic where diagnostic equipment is available. The possible observations that can be used to measure pain include the behavioral mechanisms of the child and can be exemplified by behaviors such as rigidity of the elbow, grimacing and frowning when the elbow is subjected to touch (Rowbotham &.Macintyre, 2003).
Initial intervention is important before after and before the assessment of the injury with the aim of reducing the child pain and discomfort at the elbow. Administration of a simple analgesia should be an initial intervention to reduce the pain that the child is going through. Administration of Ibuprofen 10mg/kg 3 times a day can help reduce subsequent pain before treatment and also after treatment ('First aid' 2016). Advising the patient on how to handle her hand also is an important initial intervention because it will help stop further damage to the hand (Lee et al. 2005).
Working diagnosis and investigations
There are some approaches that can be used to carry out further diagnosis on the child and the diagnostic method should be chosen out of the convenience of the method and the extent of the injury on the child’s elbow. After the preliminary assessment of the injury and transferring the patient to a nearby health clinic with the necessary equipment that can be used to carry out a further assessment of the elbow (Van der Meijden, Gaskill, and Millett, 2012).
The rapid scanning and helical imaging of modern CT scanners make accurate and prompt imaging of elbow trauma possible. Planning for elbow surgery also benefits from CT’s ability to reformat images in any plane required and to provide 3-D volume renderings. CT displays fractures, loose bodies, osteochondral lesions, and other bony abnormalities well. Aside from fracture fragment evaluation, CT with IV contrast also is beneficial for blood vessel evaluation following trauma. Similar to conventional arthrography of the elbow, CT arthrography can highlight the joint capsule and filling defects from synovitis or loose bodies. CT arthrography also is helpful in evaluating MCL tears (Krul et al. 2012).
Ultrasonography is another approach that can be used to carry out a scan on the child's elbow, and it is the efficient and less expensive approach of evaluating, tendons, ligaments, and nerves that could have been affected by the fall. Ultrasonography is also an efficient approach of imaging young patients and infants because it enables the imaging of the epiphyses that are not noticeable in radiography (Rabiner et al. 2013).
Although pathology is not considered routinely, it is a significance assessment for elbow injuries. The pre-operative investigation should be carried out on the admission of the child to ensure that the elbow is well assessed (Morrissy and Weinstein 2008).
In the case of an elbow injury, there are some considerations that should be carried out before the diagnosis of the injury. Exhausting all the diagnostic considerations help to capture all possible causes and the extent of the injury and will promote holistic care and diagnosis (Sheps DM, Hildebrand and Boorman 2004).
Anterior capsule strain
Anterior capsular elbow strain is a significant diagnosis after an elbow injury, and this condition is also called the climber's elbow. This condition involves the inflammation of the brachialis muscle on the upper arm. This condition causes pain in the elbow, and the muscle is critical to the movement of the forearm at the elbow joint hence, it should be considered in the elbow diagnosis (Beaty and Kasser 2010). The symptoms of a climbers elbow include; pain, redness on the front of the elbow, and the inability to straighten the elbow. The climber's elbow is caused by strain from sudden trauma or direct hit on the elbow which could explain the difficulty in moving the elbow and excessive stress on the elbow (Hines, Herndon, and Evans 1987).
Distal biceps rupture
Tendon rupture of the brachial biceps should be considered for diagnosis on the child. The size and orientation of the biceps on the shoulder and the elbow makes it highly involved in the functions of the elbow and the upper limb. The bicep is attached to the scapula with tendons, and their rupture can cause extreme pain on the elbow. The diagnosis of the tendon rupture can be detected using a physical examination of the elbow as well as magnetic resonance imaging which can rule out other possibilities (Beaty and Kasser 2010).
Synovitis of the elbow
This refers to the inflammation of the synovial membrane which surrounds the elbow joint. This causes stiffness of the joint and increases the temperature and redness around the elbow joint. An MRI scan can be used to assess the elbow and also the fluid around the elbow joint can be taken for testing. However, it should be noted that synovitis is a secondary problem that is caused by another problem on the elbow such as trauma as a result of falling (Beaty and Kasser 2010).
Lateral epicondyle avulsion fracture
This condition should also be considered for assessment because it affects the elbow and small children. This type of injury on the elbow is believed to be caused by sudden trauma or traction on the extensor musculature. For holistic assessment of this condition, it is important to consider lateral epicondyle avulsion fracture which can cause a shift in the treatment of the elbow (Beaty and Kasser 2010).
Torn brachialis muscle
A torn brachialis should be considered for diagnostic because it causes the inflammation of the brachial plexus that lead to pain in the arm and the elbow. The pain on the brachial plexus is attributed to the inflammation of the nerves that control the arm and shoulder. This condition causes severe pain and should be considered for diagnosis because the patient is experiencing extreme pain (Chessare et al. 1975).
Differential diagnosis is important in assessing injury situations where there is the probability of a condition causing another problem. Differential diagnosis should be carried out during the assessment of other possible causes of the elbow condition. There is always a possibility of diseases causing or accounting for a patient condition, and it can only be reviewed by carrying a differential diagnosis assessment (Balint 2008).
Elbow dislocation is a common dislocation in children and should be given priority in differential diagnosis after a child has an elbow injury. The elbow is made stable by the bony anatomy and does not rely on the ligaments for stability. The considerable force from a swing fall increases the chances of an elbow dislocation and should be considered for diagnosis. Early recognition of an elbow dislocation is required because early intervention is necessary in the case of an elbow injury. The early diagnosis of an elbow dislocation increases the chances of the normal functioning of the elbow (Beaty and Kasser 2010).
Olecranon Bursitis is the swelling on the back of the elbow, and it is caused by trauma or falling on the back of the elbow. In the differential diagnosis of the child with elbow injury Olecranon Bursitis should be considered to ensure a holistic approach to treatment is created (Hankin 1984).
This conditions should be considered for diagnosis because it is caused by the overuse of the elbow or trauma which affects the flexor-pronator muscle at the humerus. This condition causes medial elbow pain and should be considered for treatment and management after an elbow injury (Anakwe et al. 2011).
A working diagnosis is an established condition that will be considered for treatment and further diagnosis after carrying out a differential diagnosis and diagnostic considerations. A working diagnosis is usually established by assessing the history of the patient, the physical examination of the elbow and the diagnostic testing results available ('Sports medicine' 2016). The chosen working diagnosis in our case is an elbow dislocation because the physical assessment agrees largely with a possible elbow dislocation which rules out other possible differential diagnosis and diagnosis considerations which have been identified. Elbow dislocation is the chosen working diagnosis because the patient circumstances of the injury point largely on the dislocation since there is no redness or inflammation on the elbow. The pain that the child is experiencing when she tries to move her elbow is associated with the possible dislocation of the elbow, and the muscles and the ligaments holding the upper arm and the lower arm are still intact. Elbow dislocation is also the most qualified working diagnosis because it also includes brachial artery rupture and ulnar nerve injury (Duun et al. 1994).
Management of a dislocated elbow
An elbow dislocation refers to the situation in which the joint surfaces of the elbow are separated as a result of possible trauma. Elbow dislocation can be partial or complete. In our case, the young girl is suffering from a partial elbow dislocation because the joint surfaces are partially separated. However, the Magnetic resonance imaging can be used to establish the extent of the extent of the elbow dislocation and the possible damage to the other internal tissues and ligaments at the elbow (Louahem et al. 2010).
The elbow anatomy
The elbow is a hinge joint and a ball and socket joint which allows it to have two unique motions at the elbow. Three bones come together to create the elbow joint. The upper bone is the humerus, and two bones from the forearm create the lower part of the elbow which is made by the ulnar and the radius. Rotation occurs at the ball and socket joint which allows the rotation palm up and palm down movement (Beaty and Kasser 2010). On the other hand, the bending at the hinge joint allows the elbow to bend and straighten. Elbow dislocation affect the bending and rotation movement of the elbow, and they are caused by falls on an outstretched hand. The elbow is made stable by bone surfaces, ligaments and muscles and when the elbow suffers a dislocation all the structures that make the elbow are affected at different levels (Wilson et al. 1988).
Types of elbow dislocations
Elbow dislocations range from simple dislocation that does not have any severe effect on the elbow bones and the ligaments, a complex injury that can have severe effects on the bones and the ligaments and the severe elbow dislocation in which the blood vessels and the nerves that are across the elbow are injured. In the case of a severe elbow injury, there is the possibility of losing the affected arm (Beaty and Kasser 2010).
Symptoms of an elbow dislocation
Elbow dislocation is a painful experience as evidenced in the experience of the girl who does not want to be touched after the falling due to the pain. Another physical symptom of an elbow dislocation is that the arm will seem deformed and twisted at the elbow. Partial elbow dislocation is difficult to detect because it does not show externally. Elbow dislocation results in pain when the elbow is moved and bruising on the inside of the elbow can be experienced as the ligaments which have been torn and stretched move. It is important to ensure complete healing of the ligaments because the partial dislocation can recur if the ligaments do not heal well or when the elbow is exposed to stress before it heals (Kamath et al. 2009).
Diagnosis of elbow dislocation
Diagnosis of the elbow will be carried out through physical examination of the elbow in which the tenderness, deformity, and swelling of the young girl elbow will be observed. Pulses at the arm and the skin will also be inspected to establish possible skin damage after the fall. The numbness of the hand will indicate that the nerves around the arm have been injured. On the other hand, if the hand is cool to touch there is the possibility that the arteries around the elbow have been affected. It is important to note that the taking of X-ray and CT scan should be carried out after the dislocated elbow is put back in place (Farsetti et al. 2001).
Magnetic Resonance Imaging
In the case where the patient does not have the full range of motion as a result of the fall and also in the presence of bony tenderness. Magnetic resonance imaging is the primary approach that is used in conducting imaging of the elbow to identify possible damage on the ligaments, nerves and the tendons of the elbow. Magnetic resonance imaging is a primary approach that can be used despite the challenges experienced in positioning the elbow in the magnetic resonance machine. For the elbow, the child can lie on her stomach with the arm above the head. However, considering the pain experienced by the child as a result of the fall can make it difficult for the child to use this approach to secure a magnetic resonance imaging.
There are different approaches to treating an elbow dislocation depending on the severity of the dislocation. Elbow dislocation should be considered as an emergency injury which should receive immediate treatment to ensure that the elbow is returned to its normal alignment. The long term of elbow dislocation treatment is the restoration of the function of the arm (Meyn and Quigley 1974).
Partial elbow dislocation treatment
Loomis argues that partial dislocation of the elbow is usually treated through nonsurgical approaches. However, it is important to sedate the patient before realigning the elbow to reduce the pain. The process of restoring the elbow to its normal position is called reduction maneuver. Simple dislocation of the elbow is carried out by ensuring that the elbow is immobile in a splint or a sling for a maximum of three weeks (Parvin 1957). After putting the elbow in a splint or a sling, the patient should be encouraged to carry out motion exercises, this is because putting an elbow immobile for three weeks will affect the movement of the elbow and there will be the need for motion exercises to regain the full function of the arm. It is important for the child to undergo further X-rays to ensure that the elbow recovers and the bones of the elbow joint are in good alignment (Bede, Lefebvre and Rosman 1977).
In severe elbow dislocation conditions, a surgical operation should be carried out to restore the joints alignment and also repair the damaged ligaments. After surgery in case of an extreme elbow dislocation an external hinge can be put in place if the arteries, the ligaments, and the nerves have been affected by an elbow dislocation, it is important to carry out an additional surgery to repair the nerves and vessels. If necessary, the patient can undergo a late reconstructive surgery which removes the affected tissue and bone growth to remove all the obstacles affecting the movement of the elbow.
Chances for recovery in simple elbow dislocation are high, but some people with severe elbow dislocation can have the permanent disability. Moving the elbow early after the treatment increases the chances of complete recovery from an elbow injury.
Alternative elbow injury management methods
The usual reduction method used in the treatment and management of elbow dislocations is less effective because its results are less optimal. The extensive reduction during the reduction process, as well as early mobilization after reduction, might lead to instability of the elbow. Also, post-surgical immobilization which is aimed at improving the stability of the hand leads to motion difficulties. An alternative method has been developed which creates a cruciate ligament that helps in providing stability while early mobilization of the elbow is encouraged (O’Driscoll et al. 2000).
The prone and supine method
The reduction of the dislocated elbow through the prone approach is considered the primary approach because it allows greater muscular relaxation. Multiple approaches can be used for reduction to ensure the best approach is used, and optimal recovery of the arm function is achieved. In the prone approach, the arm is located in the prone location after which the correction of the lateral dislocation or the ulnar is carried out. The physician should grab the wrist of the arm that has a dislocated elbow and apply a traction force as well as gentle supination to the forearm (Smith and Pierz 2011).
A new approach to aligning the dislocated elbow is carried out in a modern operating table, unlike the normal prone approach. Using this approach the patient is induced in a general anesthesia in the supine position. The operating table is fixed with gel bolsters which are placed longitudinally for the purpose of providing support to the torso. A hand table is attached to the table in this method besides the bed on the side of the injured hand. The patient lies on the bed and places the injured arm on the hand table. A tourniquet should be placed on the upper arm and the patient placed in the prone position. The fracture in the arm is reduced using the flexion and pronation without pulling excessively after the reduction, the arm with the dislocation can be restored (Hennrikus 2011).
The prone and supine methods compared there are different results which can be achieved from the supine approach and the prone approach. Patients who use the prone approach require the patients to remove the hardware placed on the arm for stability due to irritation. On the other hand, the supine method the patients had more irritation as well as challenges in positioning patients whose shoulder characteristics hinders the movement of the shoulder. The prone approach of treating elbow dislocation is more advantageous compared to the supine position. The prone approach places less tension on the dislocated arm hence being more productive in carrying out elbow dislocation treatment (Kumar and Ahmed 1999).
Evidence-based approaches that can improve elbow dislocation treatment and management
Elbow dislocation are common injuries experienced by many people but the ideal reduction to treat elbow dislocation remain limited. However, there are some novel approaches that can be used to increase positive results. The complex anatomy of the elbow joint and its proximity to neurovascular structures increases the challenge of reducing the elbow. All the methods used to treat elbow dislocation require special positioning, counter traction, trained healthcare personnel, and sedation. Pulling and pushing of the elbow to restore its position is also necessary for all reduction methods. A method that does not require specialized equipment and can be performed by one person has been established which is more effective than the traditional reduction approaches. The novel approach places the patient in a supine position and the arm affected is exposed at the edges of the stretcher which gives enough access to the injured elbow. The physician should stretch his left elbow on an axial traction that is created on the patient arm. The physician should place one arm on the injured arm over the injured elbow. After this, the physician should flex his/her elbow into position and grab the patient wrist. This action helps realign the dislocated elbow.
Many reduction methods are used to realign a dislocated elbow. These methods of treatment vary from one healthcare organization to another and also it will significantly depend on the choice of the patient. Reduction methods are largely effective in less severe elbow dislocations whereas severe dislocations require a surgical operation to reconstruct the ligaments and the arteries that could be affected. A sling or a splint on the side are used to hold the elbow in alignment after a corrective procedure is carried to realign the affected elbow. Usually, healing of the elbow takes place after three weeks, and the arm can regain its function. It is important for the patient to carry out motion exercises which are necessary after an elbow had been immobile for long. The early the patient starts carrying out the motion exercises the greater the results on the functionality of the arm. However, it is important to note that in cases of extensive and severe elbow dislocation the function of the elbow can be difficult to regain which results in lifetime disability. With modern technology and inventions in surgery, a post operation can be carried out on the patient which can increase the functionality of the arm. Children whose elbow and bones are still developing have the greatest potential to complete recovery whereas the old people full function of the elbow is reduced. The single person technique is a novel approach of realigning dislocated elbows that do not require further surgery. This approach does not require any special equipment, and it is effective if the patient is treated immediately after an accident.
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