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MSK 1 > 10/4 - Elbow Complex Part 1 > Flashcards

10/4 - Elbow Complex Part 1 Flashcards

1
Q

What are the functions of the elbow complex (4)

A
  1. position hand in space
  2. provide power for lifting activities
  3. stabilize upper kinetic chain for distal activity (need prox stability for distal mob)
  4. enable hand to reach mouth for feeding
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2
Q

what are the anatomical articulations of the elbow and how do this play into its function

A

humeroulnar - flex/ext
humeroradial
prox radioulnar - pronation/supination

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3
Q

what is carrying angle? what are the norms

A

valgus angulation
- males 11-14°
- females 13-16°

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4
Q

why do we consider carrying angle in PT interventions

A

important for basic ROM and moving thru PROM

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5
Q

what are the ligamentous complexes which make up the elbow

A

medial ligament complex
lateral ligament complex

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6
Q

what is in the medial ligament complex? what are each of the functions?

A

ulnar collateral ligament (UCL)
- anterior bundle - taut in ext
- posterior - taut in flex
- transerse

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7
Q

what is arguable the most important part of the UCL

A

anterior bundle
- see involvement in USCL injuries

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8
Q

what are the components of the lateral ligament complex

A

radial collateral ligament
lateral UCL
accessory collateral ligmanet
annular ligament

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9
Q

what is the function of the radial collateral ligament

A

taut throughout ROM

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10
Q

what is the function off the lateral UCL

A

1° restraint to varus stress

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11
Q

what is the function of the accessory collateral ligament

A

blends w annular ligament

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12
Q

what is the function of the annular ligament

A
  • stabilizes prox radioulnar joint
  • anterior taut w supination
  • posterior taut w pronation
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13
Q

why is the annular ligament so important

A

not a lot of bony stability and provides stability to prox radioulnar joint

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14
Q

what are the elbow flexors

A

biceps
brachialis
brachioradialis
pronator teres

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15
Q

which elbow flexor is the strong supinator

A

biceps

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16
Q

which elbow flexor is the strongest

A

brachioradialis

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17
Q

why is the brachialis not a strong elbow flexor

A

poor mechanical advantage

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18
Q

what role does the pronator teres play

A

secondary elbow flexor

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19
Q

what ms are in the elbow extensor group

A

triceps
anconeus

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20
Q

what are the origins of the heads of the triceps

A

long head - infraglenoid tubercle
medial/lateral heads - posterior humerus

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21
Q

what ms group do you typically see overuse injuries in the elbow? what is the pathology often seen?

A

extensor-supinator group
- medial or lateral tendinopathy

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22
Q

what ms are in the extensor-supinator group (6)

A

supinator
extensor carpi radialis longus
extensor carpi radialis brevis
extensor digitorum communis
extensor digiti minimi
extensor carpi ulnaris

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23
Q

what ms are in the flexor-pronator group (5)

A

pronator teres
flexor carpi radialis
palmaris longus
flexor carpi ulnaris
flexor digitorum superficialis

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24
Q

since patients often present w chronic injuries and not acute, how does this change the treatment plan from what as once thought of

A

focus more on strengthening as opposed to anti-inflammatory
- people w chronic presentation often lack inflammation

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25
Q

what are the 3 main nerves involved in the elbow complex

A

radial
ulnar
median

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26
Q

what does the radial n. innervate

A

extensor-supinator group

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27
Q

what does the ulnar n. innervate

A

flexor carpi ulnaris

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28
Q

what does the median n. innervate

A

flexor-pronator group

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29
Q

what are the locations of the radial vs ulnar n.

A

radial - anterior to lateral epicondyle
ulnar - posterior to medial epicondyle

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30
Q

what is the significance of where all the ulnar, radial, and median nerves are located

A

all in areas that can be compressed
- nerve irritation not just from trauma, think compression from bones and ms around it

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31
Q

what is the impact of valgus force at the elbow

A

compromises medial structures

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32
Q

what structures should be considered if there is anterior elbow pain (4)

A

anterior capsule strain
distal biceps tendinopathy / rupture
elbow dislocation
pronator syndrome (throwers) - overuse

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33
Q

what do you often see in the patient after a distal biceps rupture

A

see some retraction

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34
Q

what structures should be considered for medial elbow pain (6)

A

medial elbow tendinopathy (flexors)
UCL
ulnar n.
flexor-pronator injury
valgus extension overload
little league elbow (skeletally immature)

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35
Q

what can irritate the ulnar nerve to cause medial elbow pain

A

ulnar n. is superficial
- repetitive valgus force w throwing can irritate
- irritation to ms that are attaching there can also irritate the n.

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36
Q

what are ulnar n. irritation sx (5)

A

pins/needles
burning
numbness
weakness
distal

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37
Q

what happens w llittle league elbow

A

valgus forces from throwing can open growth plates
- can see separation in skeletally immature

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38
Q

what structures should be considered if there is posteromedial elbow pain (3)

A

olecranon tip stress fracture
trochlea chondromalacia
posterior impingement (throwers)

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39
Q

what structures should be considered if there is posterior elbow pain (3)

A

olecranon bursitis
olecranon process stress fx
triceps tendinopathy

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40
Q

how can pitching result in a change in the range of motion seen in flexion to extension

A

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

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41
Q

what structures should be considered if there is lateral elbow pain (8)

A

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

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42
Q

what structures should be considered if there is forearm pain (3)

A

radial tunnel syndrome
cubital tunnel syndrome
brachialis tendinopathy

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43
Q

what is often the cause of forearm pain

A

nerve injury

44
Q

what is often the MOI of elbow instability

A

traumatic event (ie FOOSH)

45
Q

what are considerations of elbow instabililty that should be taken into account

A

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

46
Q

what direction of displacement is most common in the elbow? why?

A

posterior and posterolateral
d/t MOI of falling

47
Q

how could someone have a chronic elbow dislocation/subluxation

A

trauma but no fx
- remaining soft tissue damage has been left and developed chronic sx

48
Q

why is a traumatic event the most common MOI for an elbow dislocation

A

elbow joint is fairly constrained w bony structure of olecranon

49
Q

why do you still often see instabilities after elbow dislocations even after surgical fixations

A

still soft tissue damage that has to be repaired

50
Q

what population is supracondylar fracture common in

A

> 50% of elbow fx in children

51
Q

MOI of a supracondylar fx

A

FOOSH

52
Q

what determines the surgical intervention needed for a supracondylar fx

A

depends on displacement
- ORIF - displaced fx
- closed - good union of fx, will immobilize

53
Q

what population is an olecranon fx common in

A

elderly

54
Q

MOI of olecranon fx

A

fall backward onto elbow

55
Q

how does an olecranon fx present

A

disruption to triceps function
displaced intra-articular joint fx

56
Q

what is the goal of a surgery after an olecranon fx

A

restore humeroulnar congruence

57
Q

what are common complications of a surgery to restore humeroulnar congruence after an olecranon fx (4)

A

loss of ext
ulnar neuropathy
post-traumatic arthritis
instability

58
Q

what is the role of the triceps in management of an olecranon fx

A

triceps attaches to olecranon - see disruption of triceps function
- need to be careful of triceps firing
- can displace the fx and disrupt healing

59
Q

what does it mean that an olecranon fx can present as an intra-articular fx

A

fx line extends into joint space
- likely won’t be same after surgery, loss of ext

60
Q

what is post-traumatic arthritis

A

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)

61
Q

what population is a radial head fx commonly seen in

A

females (20-60yo)

62
Q

what is the MOI for a radial head fx

A

axial load on pronated forearm
direct blow to elbow
hyperflexion injury

63
Q

how are radial head fx classified?

A

depending on displacement

type 1 - fx but no displacement
type 2-3 - fx w some displacement
type 4 - fx w dislocation

64
Q

how does the management of a radial head fx change depending on classification

A

type 1 - early motion
type 2-4 - immobilize in full ext, surgical
- ORIF
- radial head excision
- radial head replacement

65
Q

when is a radial head excision indicated

A

too many pieces to put back together
- worried that if they fixate, won’t heal

66
Q

what is required for a radial head excision and why

A

intact UCL
radial head provides stability, if take this out need to make sure have ligamentous stability

67
Q

what ms compensate after a radial head excision

A

flexor-pronator mass

68
Q

what is a con to a radial head excision compared to an ORIF

A

dec strength post-op

69
Q

what are the indications for a radial head replacement

A

type IV fx
UCL or RCL dysfunction & instability
coronoid fx >50%

70
Q

what is a rehab consideration after a radial head replacement

A

immediate ROM

71
Q

why is a radial head replacement done

A

to restore bony congruence and didn’t have needed ligamentous stability

72
Q

what OA is more common at the elbow vs knee? why is this thought to be the case

A

secondary at elbow
primary at knee

difference in WB vs NWB joints

73
Q

why is strengthening an effective part of managing OA

A

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

74
Q

what type of arthritis is TEA often implemented in? why not the other?

A

RA
rare in OA bc limited longevity

75
Q

when might be an operative management be implemented in an OA case

A

if can’t get full ROM bc of bony spurs
- can lead to adaptive ms length changes (contractures)

76
Q

how are joints and ms connected when it comes to adaptive changes

A

if one of them is restricted, the other will adapt

77
Q

why don’t you see the elbow used as commonly as other joint replacements

A

not a guaranteed great outcome
- lot of possible complications

78
Q

how is it decided between unconstrained and semiconstrained TEAs

A

what the ligamentous structures are doing
- unconstrained requires good bone stock & strong capsuloligamentous support

79
Q

what are varus constraints of the elbow (3)

A

RCL
common extensor origin
posterolateral capsule

80
Q

what are 3 causes of varus instability

A

elbow dislocation
varus elbow stress
iatrogenic causes

81
Q

what are some examples of iatrogenic causes of varus instability

A

over-aggressive lateral tendinopathy surgery

corticosteroid injection

82
Q

what is an example of varus elbow stress that can cause varus instability

A

UE WB (crutches)
- for significant lengths of time

83
Q

what happens in a lateral tendinopathy surgery that could lead to varus instability

A

debriding necrotic tissue from ms
- take too much away can impact stability

84
Q

when do you get mechanical sx w varus instability

A

when joint changes happen

85
Q

what movement do you and what movements don’t you get mechanical sx w when varus instability is present

A

supination/pronation
- not flex/ext

86
Q

what are differential dx for varus instability (5)

A

PLRI vs RCL insufficiency
lateral epicondylalgia
wrist ext tendinopathy
radial tunnel syndrome
C-spine referral

87
Q

what patient population is UCL insufficiency often seen in

A

pitchers/throwers
- chronic overuse

88
Q

how do the forces of throwing lead to valgus instability

A

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

89
Q

how can limited shoulder strength lead to valgus elbow instability

A

more load is placed on elbow
- relying on distal musculature for prox stability

90
Q

what are commonly associated injuries if there is a traumatic valgus instability

A

pronator flexor group
radial head fx

91
Q

at what position do you see the greatest UCL laxity

A

elbow flex 70deg

92
Q

what is the goal of any tests to r/i or r/o

A

reproduce the sx

93
Q

what is the moving valgus stress test simulating

A

throwing

94
Q

what are 5 differential dx for valgus instability

A

medial tendinopathy
valgus ext overload syndrome
- postero-medial impingement
- ulno-humeral compression
radio-capitellar overload syndrome
elbow OA
ulnar neuritis

95
Q

what is a big way to differentiate between the differential dx for valgus instability

A

looking at end feels

96
Q

how does the MOI of a little leaguer’s elbow change between children and adolescent

A

children - apophysitis & fragmentation

teen - avulsion of medial epicondyle

97
Q

if the goal is to get a little leaguer back to their sport, what treatment are we recommending

A

operative
- non op successful in non-throwing athletes

98
Q

operative repair options for valgus instability

A

primary repair - suture ligament to bone (if true avulsion)

reconstruction - palmaris longus graft over UCL

99
Q

what is the importance of noting the end feel when someone has a loss of ROM

A

can tell you what the restriction might be

100
Q

what is a common reason that the UCL gets damaged (BSF wise)

A

d/t proximal component
- RC or scap ms

101
Q

what is osteochondritis dissecans

A

lateral compression of radiocapitellar joint in adolescent population

102
Q

what population is at high risk for osteochondritis dissecans

A

overhead and WB (UE)
- male pitchers
- female gymnasts

90% of time is active male population

103
Q

what determines if osteochondritis dissecans is operative or not

A

nonoperative
- intact cartilage over detached fragment&raquo_space; first attempt to let it heal on its own

operative
- won’t heal on its own
- not getting blood flow
- displacement

104
Q

osteochondritis dissecans operative indications (4)

A

worsening of sx
fx of articular cartilage
sx loose bodies
displaced radiocapitellar lesion

105
Q

what is the focus for treating OA

A

mobility
ms length
strength

106
Q

what is the treatment focus for a traumatic injury

A

potential for bone damage which needs to be addressed first
- lower threshold for rec radiographs

MSK 1 (31 decks)

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