As always a detailed history about how the injury happened, will aid the diagnosis. Knowing exactly how a patient landed, the speed in which they were moving and the direction in which they fell will help you to quickly know the likely injury patterns. For example, if a patient fell backwards landing on their elbow they are likely to have fractured their olecranon, whereas if they tripped and fell forwards with an outstretched arm, a scaphoid, distal radius or radial head fracture would be more likely. Make sure your history taking is detailed and structured:
- What happened?
- When did it happen?
- What was the mechanism of injury?
- What was the range of movement immediately after and since the injury?
- Have they had pain relief?
- What is their pain score?
- Are there any other injuries?
- Are they left or right hand dominant?
- Have they had any previous elbow injuries?
- What is their occupation?
With injuries it is good to follow the Look, Feel, Move approach to assessment. Essentially, what can you see when you look at the injury, what can you feel when you palpate the injury, and can they move it / walk on it / use it?
- Observe the position the arm is held in?
- Is there a gross deformity?
- Is there any swelling?
- Is the any bruising / skin dis-colouration?
- Are there any wounds?
- Is there any pain in the shoulder / clavicle or the wrist? (NB: Always check the joint above and below the site of injury!)
- Is there bony tenderness to the olecranon?
- Is there bony tenderness to the radial head?
- Is there any bony tenderness around the elbow joint?
- What is the site of maximum tenderness?
- Are distal pulses and sensation present?
- Can the patient flex (bend) their arm past 90 degrees?
- Can the patient fully extend (straighten) their arm? **
- Can the patient pronate and supinate their wrist?
- Any bony tenderness present
- Unable to straighten arm
- Any gross deformity
** If a patient cannot fully extend their arm there is almost a 50% chance of there being a fracture on x-ray. Patients unable to fully extend should be routinely x-ray’d.
If in any doubt about whether to X-ray or not, always ask an ENP or Doctor. It is sometimes beneficial to just give analgesia and let that take effect before re-assessment, or based on the history it may be best to have a full, longer assessment before deciding to X-ray.
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