Elbow Red Flags

From WikiMSK

Introduction

Red flag conditions to exclude:

Red Flags
Red flags signal the most serious clinical risks that are easily missed. The list is not comprehensive. Each one meets all of these criteria:<ul><li>It indicates a serious differential diagnosis, or high risk of deterioration without intervention, or severe treatment risk.</li><li>It is commonly missed, or not widely known.</li><li>If missed, it can significantly threaten the patient's health or have legal consequences for the clinician.</li></ul>
  • fractures
  • tumours
  • infections
  • inflammatory diseases
  • visceral diseases.

Red flag conditions are rare in the elbow.

Fractures

  • Is there a history of major trauma such as a fall directly on to the elbow / MVA / high speed accidents
  • Is there a history of minor trauma in an individual with risk factors for osteoporosis. 11% of osteoporotic fractures involve the humerus, mostly surgical neck.

Elbow fractures make up 10% of all upper limb fractures, and 6% of all adult fractures. The incidence is 7.4 per 10,000, and is slightly higher in woman at 7.4 compared to 7.1 for men. There is an association between social deprivation and increased proximal forearm elbow fractures [1]

Elbow fractures incidence.png

Malignancy

Risk factors (theoretical) are age > 50 yrs, past history of cancer, unexplained weight loss, and malaise. The clinician should also be suspicious if the patient fails to improve or is non-responsive to therapy. Suspicious examination findings are palpable soft tissue or bony deformity, and bone tenderness.

Infection

It is unclear what is the incidence of infected elbow joints and olecranon bursitis.

The Cardinal indicators for infection are:

  • Fever
  • Penetrating wound
  • Recent procedure with needle, catheter or other instrument
  • Immunosuppressed patients
  • Children – hematogenous spread most common
  • On examination
    • Joint swelling / bursal swelling
    • Bone tenderness

Inflammatory Arthropathies

Rheumatic disease accounts for over 7% of all conditions presenting to GP’s [2]. The most common condition is osteoarthritis at 5-10% of the population. The incidence for arthritis/arthralgia is 38.6 per 1000 population. Rheumatoid arthritis is the most important condition of the inflammatory arthritides to involve the elbow. The population incidence of rheumatoid arthritis is 2-3%.

Systemic diseases that predispose to arthropathy:

  • Connective tissue disorders
  • Diabetes mellitus
  • Bleeding disorders
  • Previous tuberculosis
  • Spondyloarthropathies
  • SBE, hepatitis B, rheumatic fever, HIV infection
  • Vasculitides

Incidence OA hand hip and knee.png

Referred Pain and Visceral Diseases

Ischaemic cardiac pain refers into the upper limb in 30% of cases Myofascial cervical spine and shoulder girdle structures can refer to the upper limb Radicular pain syndromes and other neurological syndromes can cause pain in the upper limb

Scalene trigger point.jpg

Recommendations

In a patient presenting with elbow pain,

Fractures should be considered

  • in a history of major trauma
  • minor trauma with a background of osteoporosis

Malignancy should be considered

  • Palpable mass
  • History of cancer or systemic features of cancer
  • No other cause found or failure to improve

Infection should be considered

  • Systemic features of infection
  • Local features of infection
  • Bone tenderness
  • History of interventional procedures

References

This article is still missing information. Please help WikiMSK by expanding it.
  1. Aiken SA et al. The epidemiology of fractures around the elbow joint. Elective Medicine Journal. 2014: 2(3): 189 – 194
  2. UK National Morbidity Survey