10/4 - Elbow Complex Part 1 Flashcards
What are the functions of the elbow complex (4)
- position hand in space
- provide power for lifting activities
- stabilize upper kinetic chain for distal activity (need prox stability for distal mob)
- enable hand to reach mouth for feeding
what are the anatomical articulations of the elbow and how do this play into its function
humeroulnar - flex/ext
humeroradial
prox radioulnar - pronation/supination
what is carrying angle? what are the norms
valgus angulation
- males 11-14°
- females 13-16°
why do we consider carrying angle in PT interventions
important for basic ROM and moving thru PROM
what are the ligamentous complexes which make up the elbow
medial ligament complex
lateral ligament complex
what is in the medial ligament complex? what are each of the functions?
ulnar collateral ligament (UCL)
- anterior bundle - taut in ext
- posterior - taut in flex
- transerse
what is arguable the most important part of the UCL
anterior bundle
- see involvement in USCL injuries
what are the components of the lateral ligament complex
radial collateral ligament
lateral UCL
accessory collateral ligmanet
annular ligament
what is the function of the radial collateral ligament
taut throughout ROM
what is the function off the lateral UCL
1° restraint to varus stress
what is the function of the accessory collateral ligament
blends w annular ligament
what is the function of the annular ligament
- stabilizes prox radioulnar joint
- anterior taut w supination
- posterior taut w pronation
why is the annular ligament so important
not a lot of bony stability and provides stability to prox radioulnar joint
what are the elbow flexors
biceps
brachialis
brachioradialis
pronator teres
which elbow flexor is the strong supinator
biceps
which elbow flexor is the strongest
brachioradialis
why is the brachialis not a strong elbow flexor
poor mechanical advantage
what role does the pronator teres play
secondary elbow flexor
what ms are in the elbow extensor group
triceps
anconeus
what are the origins of the heads of the triceps
long head - infraglenoid tubercle
medial/lateral heads - posterior humerus
what ms group do you typically see overuse injuries in the elbow? what is the pathology often seen?
extensor-supinator group
- medial or lateral tendinopathy
what ms are in the extensor-supinator group (6)
supinator
extensor carpi radialis longus
extensor carpi radialis brevis
extensor digitorum communis
extensor digiti minimi
extensor carpi ulnaris
what ms are in the flexor-pronator group (5)
pronator teres
flexor carpi radialis
palmaris longus
flexor carpi ulnaris
flexor digitorum superficialis
since patients often present w chronic injuries and not acute, how does this change the treatment plan from what as once thought of
focus more on strengthening as opposed to anti-inflammatory
- people w chronic presentation often lack inflammation
what are the 3 main nerves involved in the elbow complex
radial
ulnar
median
what does the radial n. innervate
extensor-supinator group
what does the ulnar n. innervate
flexor carpi ulnaris
what does the median n. innervate
flexor-pronator group
what are the locations of the radial vs ulnar n.
radial - anterior to lateral epicondyle
ulnar - posterior to medial epicondyle
what is the significance of where all the ulnar, radial, and median nerves are located
all in areas that can be compressed
- nerve irritation not just from trauma, think compression from bones and ms around it
what is the impact of valgus force at the elbow
compromises medial structures
what structures should be considered if there is anterior elbow pain (4)
anterior capsule strain
distal biceps tendinopathy / rupture
elbow dislocation
pronator syndrome (throwers) - overuse
what do you often see in the patient after a distal biceps rupture
see some retraction
what structures should be considered for medial elbow pain (6)
medial elbow tendinopathy (flexors)
UCL
ulnar n.
flexor-pronator injury
valgus extension overload
little league elbow (skeletally immature)
what can irritate the ulnar nerve to cause medial elbow pain
ulnar n. is superficial
- repetitive valgus force w throwing can irritate
- irritation to ms that are attaching there can also irritate the n.
what are ulnar n. irritation sx (5)
pins/needles
burning
numbness
weakness
distal
what happens w llittle league elbow
valgus forces from throwing can open growth plates
- can see separation in skeletally immature
what structures should be considered if there is posteromedial elbow pain (3)
olecranon tip stress fracture
trochlea chondromalacia
posterior impingement (throwers)
what structures should be considered if there is posterior elbow pain (3)
olecranon bursitis
olecranon process stress fx
triceps tendinopathy
how can pitching result in a change in the range of motion seen in flexion to extension
throwers often lack elbow ext
- d/t constant demand on biceps, working hard and dec ext -» eccentric load/demand on biceps can lead to an end feel of muscular tightness
over time can get bony changes in joint
- bony end feel before full ROM d/t osteophyte growth
what structures should be considered if there is lateral elbow pain (8)
lateral elbow tendinopathy (extensors)
radial collateral ligament complex sprain
capitulum fx
osteochondral degenerative changes
osteochondritis dissecans
posterior interosseous nerve syndrome
radial head fx
radial tunnel syndrome
what structures should be considered if there is forearm pain (3)
radial tunnel syndrome
cubital tunnel syndrome
brachialis tendinopathy
what is often the cause of forearm pain
nerve injury
what is often the MOI of elbow instability
traumatic event (ie FOOSH)
what are considerations of elbow instabililty that should be taken into account
timing - acute, chronic, recurrent
articulations inolved
- humeroulnar
- prox radioulnar
direction of displacement
- anterior, posterior, lateral, divergent
degree of displacement
- subluxation or dislocation
presence/absence of fx
what direction of displacement is most common in the elbow? why?
posterior and posterolateral
d/t MOI of falling
how could someone have a chronic elbow dislocation/subluxation
trauma but no fx
- remaining soft tissue damage has been left and developed chronic sx
why is a traumatic event the most common MOI for an elbow dislocation
elbow joint is fairly constrained w bony structure of olecranon
why do you still often see instabilities after elbow dislocations even after surgical fixations
still soft tissue damage that has to be repaired
what population is supracondylar fracture common in
> 50% of elbow fx in children
MOI of a supracondylar fx
FOOSH
what determines the surgical intervention needed for a supracondylar fx
depends on displacement
- ORIF - displaced fx
- closed - good union of fx, will immobilize
what population is an olecranon fx common in
elderly
MOI of olecranon fx
fall backward onto elbow
how does an olecranon fx present
disruption to triceps function
displaced intra-articular joint fx
what is the goal of a surgery after an olecranon fx
restore humeroulnar congruence
what are common complications of a surgery to restore humeroulnar congruence after an olecranon fx (4)
loss of ext
ulnar neuropathy
post-traumatic arthritis
instability
what is the role of the triceps in management of an olecranon fx
triceps attaches to olecranon - see disruption of triceps function
- need to be careful of triceps firing
- can displace the fx and disrupt healing
what does it mean that an olecranon fx can present as an intra-articular fx
fx line extends into joint space
- likely won’t be same after surgery, loss of ext
what is post-traumatic arthritis
damage to joint d/t injury or surgery will inc risk of arthritis (even soft tissue injuries)
- bc anatomy won’t be same again (even after surgery)
what population is a radial head fx commonly seen in
females (20-60yo)
what is the MOI for a radial head fx
axial load on pronated forearm
direct blow to elbow
hyperflexion injury
how are radial head fx classified?
depending on displacement
type 1 - fx but no displacement
type 2-3 - fx w some displacement
type 4 - fx w dislocation
how does the management of a radial head fx change depending on classification
type 1 - early motion
type 2-4 - immobilize in full ext, surgical
- ORIF
- radial head excision
- radial head replacement
when is a radial head excision indicated
too many pieces to put back together
- worried that if they fixate, won’t heal
what is required for a radial head excision and why
intact UCL
radial head provides stability, if take this out need to make sure have ligamentous stability
what ms compensate after a radial head excision
flexor-pronator mass
what is a con to a radial head excision compared to an ORIF
dec strength post-op
what are the indications for a radial head replacement
type IV fx
UCL or RCL dysfunction & instability
coronoid fx >50%
what is a rehab consideration after a radial head replacement
immediate ROM
why is a radial head replacement done
to restore bony congruence and didn’t have needed ligamentous stability
what OA is more common at the elbow vs knee? why is this thought to be the case
secondary at elbow
primary at knee
difference in WB vs NWB joints
why is strengthening an effective part of managing OA
w limited mobility from OA, more load concentrated over specific area
- stronger the surrounding musculature is, the better they can relieve and off load that weight
what type of arthritis is TEA often implemented in? why not the other?
RA
rare in OA bc limited longevity
when might be an operative management be implemented in an OA case
if can’t get full ROM bc of bony spurs
- can lead to adaptive ms length changes (contractures)
how are joints and ms connected when it comes to adaptive changes
if one of them is restricted, the other will adapt
why don’t you see the elbow used as commonly as other joint replacements
not a guaranteed great outcome
- lot of possible complications
how is it decided between unconstrained and semiconstrained TEAs
what the ligamentous structures are doing
- unconstrained requires good bone stock & strong capsuloligamentous support
what are varus constraints of the elbow (3)
RCL
common extensor origin
posterolateral capsule
what are 3 causes of varus instability
elbow dislocation
varus elbow stress
iatrogenic causes
what are some examples of iatrogenic causes of varus instability
over-aggressive lateral tendinopathy surgery
corticosteroid injection
what is an example of varus elbow stress that can cause varus instability
UE WB (crutches)
- for significant lengths of time
what happens in a lateral tendinopathy surgery that could lead to varus instability
debriding necrotic tissue from ms
- take too much away can impact stability
when do you get mechanical sx w varus instability
when joint changes happen
what movement do you and what movements don’t you get mechanical sx w when varus instability is present
supination/pronation
- not flex/ext
what are differential dx for varus instability (5)
PLRI vs RCL insufficiency
lateral epicondylalgia
wrist ext tendinopathy
radial tunnel syndrome
C-spine referral
what patient population is UCL insufficiency often seen in
pitchers/throwers
- chronic overuse
how do the forces of throwing lead to valgus instability
high forces associated with:
- elbow ext
- valgus stress (inc w shoulder ER)
- pronation of supinated arm
when elbow ext
- irritates flexor/pronator group and UCL
how can limited shoulder strength lead to valgus elbow instability
more load is placed on elbow
- relying on distal musculature for prox stability
what are commonly associated injuries if there is a traumatic valgus instability
pronator flexor group
radial head fx
at what position do you see the greatest UCL laxity
elbow flex 70deg
what is the goal of any tests to r/i or r/o
reproduce the sx
what is the moving valgus stress test simulating
throwing
what are 5 differential dx for valgus instability
medial tendinopathy
valgus ext overload syndrome
- postero-medial impingement
- ulno-humeral compression
radio-capitellar overload syndrome
elbow OA
ulnar neuritis
what is a big way to differentiate between the differential dx for valgus instability
looking at end feels
how does the MOI of a little leaguer’s elbow change between children and adolescent
children - apophysitis & fragmentation
teen - avulsion of medial epicondyle
if the goal is to get a little leaguer back to their sport, what treatment are we recommending
operative
- non op successful in non-throwing athletes
operative repair options for valgus instability
primary repair - suture ligament to bone (if true avulsion)
reconstruction - palmaris longus graft over UCL
what is the importance of noting the end feel when someone has a loss of ROM
can tell you what the restriction might be
what is a common reason that the UCL gets damaged (BSF wise)
d/t proximal component
- RC or scap ms
what is osteochondritis dissecans
lateral compression of radiocapitellar joint in adolescent population
what population is at high risk for osteochondritis dissecans
overhead and WB (UE)
- male pitchers
- female gymnasts
90% of time is active male population
what determines if osteochondritis dissecans is operative or not
nonoperative
- intact cartilage over detached fragment»_space; first attempt to let it heal on its own
operative
- won’t heal on its own
- not getting blood flow
- displacement
osteochondritis dissecans operative indications (4)
worsening of sx
fx of articular cartilage
sx loose bodies
displaced radiocapitellar lesion
what is the focus for treating OA
mobility
ms length
strength
what is the treatment focus for a traumatic injury
potential for bone damage which needs to be addressed first
- lower threshold for rec radiographs
