Nerve femoralis injury
Illustration of a healthy shoulder showing the bursa in purple

Definition

Subacromial bursitis consists in the inflammation and swelling of the bursa located beneath the acromion. It is a frequent pathology causing tenderness and restriction of the shoulder movement.

‍Overuse of the flexor and pronator muscles and tendons underlies Golfer's elbow pathology

Pathology

Golfer’s elbow is a similar but less common condition to tennis elbow, which occurs to the opposite, outer aspect of the elbow. It arises mainly from overuse of the muscles and tendons of the forearm, namely the flexor and pronator muscles (pronator teres and the flexor carpi radialis origins). 

These muscles function during forearm pronation and wrist flexion. With a golf swing the forces accumulate in the medial epicondyle tendon when griping the club. A continuous strain placed on these muscles with strenuous, repetitive movements can injure the medial epicondyle tendon creating microtears. It is believed that tendonosis (rather than tendonitis, or inflammation of the tendon), is the problem underlying medial epicondylitis. Tendonosis involves a gradual degeneration of the collagen fibres forming the tendon followed by the accumulation of cells called fibroblasts leading to scar formation, tendon rigidity and increased risk of rupture. 

Associated pathologies

Medial epicondylitis can be associated with ulnar neuropathy as well as changes in the medial collateral ligament. The involvement of the ulnar nerve is seen in approximately 50% of patients with Golfer’s elbow.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Golfing is the most frequent cause of medial epicondylitis

Causes

Medial epicondylitis is common in individuals between 35 and 55 years of age. Overuse is the main cause of this pathology especially in older people as the tendons become weaker with ageing. It mostly develops with swing movements of the wrist typical of golfing or throwing activity in ball sports, bowling, weight lifting and arching and racquet sports. It can also arise from a wrong posture, when working at a computer desk, driving and DIY activities or sudden trauma.

Not only golfing poses a risk of the disease. Logging is also a risk factor

Risk factors

There are a number of predisposing risk factors for medial epicondylitis:

Golfing

Racquet sports

Throwing sports

Muscle weakness

Poor flexibility of the forearm

Training errors

Improper technique

Wrong equipment

Manual occupations involving repetitive wrist flexion and forearm pronation (carpentry, manufacturing, sewing, logging).

Pain and pelvic instability are major symptoms of a pelvic fracture

Symptoms

In addition to the typical symptoms consequent to a pelvic fracture such as pain, swelling and bruising the patient may present manifestations indicative of injuries to the abdominal organs, vessels and nerves:

Tenderness at touch

Pelvic instability

Inability to move or reduced range of movement

Haematuria (blood in urine)

Rectal and/or vaginal bleeding

Neurological deficit of lower extremities 

In more severe cases, damage to internal organs may lead to persistent shock or loss of vital signs:

Low blood pressure < 90 mm HG

Pulse >100

Central venous pressure (CVP) < 5 cm with a water manometer

Urine output < 30ml/hour (despite fluid replacement)

Absence of vital signs torrential haemorrhage >12 units of blood/2 hours

Medical examination for the diagnosis of Golfer's elbow

Diagnosis

The clinical presentation is usually the best method for the diagnosis of Golfer's elbow. The patient’s history of sport or profession involving physical activities posing a risk for this pathology and past injuries will be discussed with the examiner. 

Clinical investigation focuses on the characteristics of pain at rest and during elbow activity, tenderness at touch and changes in the range of movement. Ultrasound is often sufficient to detect changes in the structure of the tendon including the presence of tears and swelling.

X-rays are only taken to exclude arthritis to the elbow or other bone-related conditions and visualise calcium deposits in the tendon. MRI is only rarely recommended. Electrodiagnostic studies are undertaken with suspected injury to the ulnar nerve, the median nerve or the medial antebrachial cutaneous nerve.

Treatment

Chinese finger traps are used for traction of the fractured distal radius

Nonoperative treatment

Conservative treatment is recommended in uncomplicated distal radius fracture (undisplaced and stable) or when bone quality is compromised in elderly patients. This approach includes:

Closed reduction under anaesthesia to reposition the bone in case of minor displacement

Traction of the fracture with a Chinese finger trap (see figure)

Plaster above elbow that is replaced as swelling subsides

Monitoring fracture healing with X-rays every 3 weeks to confirm a correct bone alignment

Cast removal and rehabilitation after 6 weeks

Three methods for surgical treatment of the fractured distal radius: external fixator (left), ORIF with plate and screws (middle) or simply screws (right)

Surgical treatment

if the fracture is complicated surgery is necessary. This achieves a reposition of the bone fragments into a correct and functional anatomy to prevent secondary complications such as arthritis, nerve and vascular damage and bone necrosis, among others. Several surgical techniques are available for the treatment of distal radius fracture:

Open reduction and internal fixation (ORIF) using plates and screws

Screws in unstable fracture of the radial process styloid

Dorsal plate with bone graft for unstable fractures

Volar plate

External fixator in open fractures with severe soft tissue damage (screws inserted from the skin into the radius)

Joint replacement with artificial joint or wrist arthroplasty

Complications

A number of complications can occur following distal radius fracture such as:

Damage to blood vessels and bleeding

Compression or injury to the median nerve at the carpal tunnel (temporary or permanent)

Chronic Regional Pain Syndrome (CRPS) of the fractured area with persisting symptoms

Defects in fracture healing: non-union and mal-union when closure and alignment of the fracture fail

Damage to the cartilage leading to arthritis of the wrist joint (stiffness, pain) possibly requiring surgery

Wrist fusion consequent to chronic arthritis, meaning fusion of the radius with carpal and metacarpal bones

Anatomical reduction of bone fragments to minimise the risks of post-traumatic arthritis arising from mechanical grinding

Development of avascular necrosis of the fractured bone(s).

Wrist mobilisation is critical to restore flexibility after a distal radius fracture

Rehabilitation

Early after distal radius fracture, the rehabilitative therapy focuses on:

Arm elevation (to reduce swelling/pain)

Pain management with NSAIDs or morphine for a few days, if pain is severe

Ice or heat pads

Antibiotics in case of open fractures

Replacement of cast when swelling subsides to keep the arm firm

Intensive physical therapy one to two months after cast removal or surgery and includes:

Massage

Joint mobilisation

Stretches

Dry needling

Electrotherapy

Activity modification advice

Return to sport/work plan

Postural taping

Gentle exercise to improve flexibility and strength.

Vigorous exercises can commence after three to six months from injury. Full recovery is expected after one year or longer in more complex fractures or in case of poor bone healing. Although most patients return to normal activities after radius head fracture, some may suffer some degree of pain, which will decrease over two years.

The use of devices for prevention of falls can reduce the incidence of injuries such as a distal radius fractures

Prevention

In older osteoporotic patients, assessment of bone density and administration of calcium and Vitamin D may be necessary to help preventing bone fractures. Reducing the risk of falls in elderly patients remains an efficacious prevention for future distal radius fractures and other injuries. In young individuals, wearing a wrist brace or taping is advised especially when sport is resumed after the fracture.