Medical Case Study: Elbow Injury

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.

Assessment

Introduction

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 an 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

Medical history

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).

Neurovascular assessment

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

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

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 childs 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).

Computed tomography

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 CTs 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

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).

Pathology

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).

Differential and Working Diagnosis for Elbow Injury

Diagnostic considerations

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

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

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).

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