Elbow Red Flags

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“RED FLAG” CONDITIONS OF THE ELBOW

CONSIDERATIONS

The so called “red flag” conditions manifesting as pain in the elbow are those which pose more serious health risks for patients than the common “mechanical” disorders. Examples are:

  • fractures,
  • tumours,
  • infections,
  • inflammatory diseases, and
  • visceral diseases.

The identification of these conditions is of utmost importance because of their serious implications. Every physician has a responsibility to consider the possibilities of “red flags” and not to presume that all cases of elbow pain are “mechanical” in origin. It is purported that clinicians, faced with a low likelihood of grave disease but the serious personal and professional consequences of missed diagnoses will “cover” themselves by ordering investigations. Unfortunately, the basis on which the investigations are ordered is often spurious and the tests are not always dependable for diagnostic purposes.

The literature, clinical experience and formal research have shown that

  1. I. the red flag conditions are mercifully rare; therefore, the pre-test odds are in favour of the patient and the physician.
  2. II. red flag conditions are typically suspected on the basis of the history and/or the clinical examination findings, rather than on the basis of results of special investigations, but

III. when the diagnosis of a serious condition is missed, most often it is not for lack of special investigations but for lack of adequate and thorough attention to clues in the clinical presentation.

  1. IV. certain conditions will be missed even with special investigations, either because the condition is too early in its evolution to be detected or because the investigations are insufficiently sensitive.
  2. V. missing the diagnosis of a serious condition may make not affect its outcome, because even after early diagnosis nothing can be done to avert the progress of some conditions. An example would be that of metastatic malignancy infiltrating bone.

The concept of the red flag condition probably has far less currency in the elbow than in other structures such as the shoulder, neck or lumbar spine. This simply reflects the ready access of the entire circumference of the elbow joint to detailed examination and the superficial nature of most of the major structures of the joint. Contrast the ready diagnosis of olecranon bursitis with the difficulty of establishing a diagnosis of spinal osteomyelitis. Perhaps most importantly, the elbow can be readily viewed by the patient themselves, so that any change in contour or function can be readily appreciated. It is perhaps for these reasons that there is a paucity of data concerning the significance of pain in the elbow as a presenting feature of important, serious illness.''''FRACTURESA history of trauma is the cardinal indicator of the possibility of fracture.Major trauma is the most common cause of fractures in the otherwise healthy population. Healthy bones resist forces of considerable magnitude and, in that population, fractures are sustained only by those who have been subjected to severe, deforming stresses. The typical history is of elbow pain of sudden onset after an incident in which substantial forces were applied to the region. Environmental and behavioural factors are usually the most significant contributors to the causative event. Other risk factors of some relevance include medical conditions such as visual, auditory and balance impairments that predispose individuals to falling, being involved in road accidents or suffering other traumatic events. Elbow fractures usually result from direct trauma to the elbow, such as landing on the elbow in a fall.Minor trauma does not cause fractures unless the patient has some predisposing condition of bone. The most common such condition, by far, is osteoporosis.Osteoporosis affects a majority of elderly women and a significant minority of elderly men in Australia. One large prospective epidemiological study1 has shown that 56% of women and 29% of men over 60 years of age suffer osteoporotic fractures. Of these fractures, 11% involve the humerus, typically the surgical neck of the humerus so that it is unlikely that humeral fractures will present as acute elbow pain. Compressive force applied along the arm, such as in a fall on the outstretched hand have a tendency to cause fractures at the wrist rather than at the elbow.The patient’s age is clearly an important factor to be considered in this regard. Osteoporosis is uncommon below the age of 50 and its incidence increases with age after that. The incidence of osteoporotic fractures of the humerus in a representative Australian population aged 60 years and over is 339 per 100,000 person years for women and 244 per 100,000 person years for men. Other risk factors for osteoporosis include female gender, early menopause, endocrine disturbances etc.2,3as set out in Table SA.1.3.Osteomalacia is another disorder of bone metabolism resulting in osteopenia and tendency to fracture after minor trauma. It is caused by inadequacy of bodily calcium intake, most often due to a malabsorbtion syndrome but occasionally due to dietary insufficiency, leading to defective mineralisation of bone.The pathological fractures associated with neoplasia, Pagetic bone disease etc. may occur after minimal trauma or even without any trauma at all.'

NEOPLASIA

The predictive values of specific clinical features have not been tested formally in relation to elbow pain. However, a past history of neoplasm should certainly raise suspicion. Age is another indicator: the majority of patients who prove to have a neoplastic cause of their elbow pain are elderly. Other features in the history that raise the suspicion of cancer are weight loss, failure to improve with therapy and prolonged pain. Note that because “failure to improve”, and “prolonged pain” are indicators, the diagnosis of cancer is unlikely to be made at the initial presentation, unless other indicators obtain. Clinical examination findings that suggest the possibility of neoplasia include palpable deformities of bones and other tissues, or bone pain or tenderness in the absence of other features that might incriminate another cause of pain.Whilst diagnostic statistics such as sensitivities, specificities and likelihood ratios have not been determined for features associated with red flag conditions causing elbow pain, they have been for those associated with low back pain (see Table LA.1.1 in Appendix LA.1). In the absence of data specific to the elbow, some inferences may be drawn from the low back figures The strongest negative predictors are age less than 50, no past history of cancer, no weight loss, and no failure to improve with therapy. Patients with this combination of features are extremely unlikely to have cancer as the basis of their elbow pain.''INFECTIONThe pre-test probability in general practice of a patient who presents with elbow pain having an infection as the cause of their pain, (with the exception of infective olecranon bursitis) is not known. It is likely to be very low.The cardinal indicator for infection is fever. Infective organisms must have a portal of entry, either directly into the joint or into other parts of the body. The main risk factors are penetrations, either of the joint or the body generally, by needles, catheters or other instruments, which includes surgical procedures. Patients with underlying joint abnormalities or immunosuppresion are also more at risk of developing bone and joint infections.

INFLAMMATORY ARTHROPATHIESThe elbow can be affected by virtually all of the inflammatory arthropathies, such as rheumatoid arthritis, psoriatic arthritis, crystal arthritis and reactive arthritis. These conditions are characterised by joint effusion and should be considered if the patient presents with joint swelling. The diagnosis of inflammatory arthropathies is notoriously difficult at in their very early stages. It can be achieved over often prolonged periods of time with a combination of vigilance and a systematic consideration of the diagnostic possibilities.

REFERRED PAIN AND VISCERAL DISEASESIt is uncommon for pain to be referred to the elbow by visceral disease processes Although the pain of myocardial ischaemia may be referred to the arms in 30% of cases4, it is highly unlikely that elbow pain would be the sole presenting feature of myocardial infarction. The elbow lies in the sclerotomes of some of the deep tissues of the cervical spine, so that cervical spine disorders may provide a substrate for pain in the region of the elbow5, but such referred pain does not involve the elbow in isolation Conditions that irritate any of the nerves supplying the elbow directly are capable of causing elbow pain. An example would be cervical lymphadenopathy or infiltrative disease of the brachial plexus. However, these would produce pain in a dermatomal pattern, which would typically be over a far larger area than that occupied by the elbow joint.

RECOMMENDATIONS


''''''''''In a patient presenting with elbow pain,'''''''''''''''Fractures should be considered'''''if the pain has been precipitated by major trauma, or'''''if the pain has been precipitated by minor trauma in a patient whose history reveals a risk factor for osteoporosis.'''''In both instances radiography is indicated.'''''''''''''''Neoplasia should be considered if the patient'''''exhibits a palpable mass or deformity consistent with a tumour,'''''has bone pain or tenderness but no incriminating features of any other cause of pain,'''''has a history of cancer and systemic features of cancer,'''''fails to improve and for whom no other cause of pain is evident.'''''''''''''''Infection should be considered if the patient'''''exhibits systemic features of infection,'''''exhibits joint swelling or bursal swelling,'''''exhibits bone tendernes,'''''and has a history of catheterisation, needle puncture or a surgical procedures.



REFERENCES


  1. Jones G, Nguyen T, Sambrook PN. Symptomatic fracture incidence in elderly men and women: the Dubbo Osteporosis Epidemiology Study. Osteporosis Int. 1994; 4:277-282.
  2. Sambrook PN. Osteoporosis. Med J Aust 1996; 165:332-336.
  3. Cummins SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud, Cauley, Black D; Voyt TM. Risk factors for hip fractures in white women. N Engl J Med. 1995; 332:767-773.
  4. Pasternak RC, Braunwald E. Acute Myocardial Infarction. In: Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DL, editors. Harrison's Principles of Internal Medicine. 13th ed. New York: McGraw-Hill, 1994:1066-1085.
  5. Feinstein B, Langton NJK, Jameson RM, Schiller F. Experiments on pain referred from deep somatic tissues. J.Bone Joint Surg.Am. 1954; 36A:981-997.'
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