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PassPMR - 07 Musculoskeletal Medicine > 3- Elbow > Flashcards

3- Elbow Flashcards

1
Q

Muscles originating from medial (6) & lateral epicondyle (6) of the humerus 🔑🔑

A

Medial epicondyle of the humerus

  1. Pronator teres
  2. Flexor carpi radialis (FCR)
  3. Palmaris longus
  4. Flexor carpi ulnaris (FCU)
  5. Flexor digitorum superficialis (FDS)
  6. Flexor digitorum profundus (FDP)

Lateral epicondyle of the humerus (wrist extensor)

  1. Supinator
  2. Anconeus
  3. Extensor carpi radialis longus (ECR-L)
  4. Extensor carpi radialis brevis (ECR-B)
  5. Extensor carpi ulnaris (ECU)
  6. Extensor digitorum superficialis

Cuccurollo 4th Edition Chapter 4 MSK pg179

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2
Q

Elbow Arthrodesis 🔑🔑 EXAM

A

Unilateral: Flexion—90 degrees

Bilateral: Flexion—110 degrees in one arm and 65 degrees for the other

Cuccurollo 4th Edition Chapter 4 Musculoskeletal Medicine pg180

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3
Q

Arm Flexion, Pronation and Supination. How to isolate the muscles? 🔑🔑 EXAM 2021

A

FLEXION

  • Biceps muscle is the primary elbow flexor with full forearm supination
  • Brachioradialis is the primary elbow flexor when the forearm is in a thumbs-up position.
  • Brachialis is the primary flexor, with full forearm pronation

PRONATION

  • Pronator teres is tested when the elbow is at 90 degrees
  • Pronator quadratus is tested when the elbow is in full flexion

SUPINATION

Supinator muscle is tested with elbow in extension with the forearm in full supination.

This position inhibits assistance from the biceps

Braddom 6th Edition Chapter 1 History & Physical Examination pg33

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4
Q

Is there anything unique about brachioradialis muscle?🔑🔑

A

The only muscle that flex the arm and supplied by radial nerve (C5-C6)

PMR Secrets 3rd Edition Chapter 44 Elbow pg352

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5
Q

List 4 Radial branches that are spared in PIN neuropathy 🔑🔑

A
  1. Brachioradialis
  2. ECR longus and brevis
  3. +/- Supinator
  4. Superficial Radial Nerve
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6
Q

Lateral Elbow Pain DDx, Mechanism of injury, Invx, PEx & Managment

A

LATERAL EPICONDYLITIS

  • Repetitive wrist extension and/or forearm supination
  • Micro-tearing at enthesis of ECR-B > ECR-L > Extensors

LATERAL ELBOW PAIN

  1. MSK
    1. Lateral Epicondylitis
    2. Radioulnar joint disease
    3. Radiohumeral joint disease
    4. Annular and lateral ligament sprains
    5. Rupture of the common extensor origin
    6. Myofascial pain syndrome
  2. Neuro
    1. Posterior interosseous nerve compression
    2. Cervical radiculopathy (C5-C6)
    3. Radial tunnel syndrome

TRAINING ERROR

  1. Improper technique for backhand swings
  2. Inappropriate string tension → Decrease string tension
  3. Inappropriate grip size → Increase grip size
  4. Overuse injury
  5. Flexibility and strength deficits in wrist extensor
  6. Weakness in the shoulder external rotators and posterior muscles
  7. Inflexibility in the internal rotators

EXAMINATION

  1. Lateral Epicondylitis
    • Pain and weakness in grip strength
    • Tender extensor tendon origin
    • Cozen’s test
    • Mill’s test
  2. Triceps Tendonitis
    • Posterior elbow tenderness, pain on extension

IMAING

  • MRI to evaluate a tear in the common wrist extensor tendon, notably the ECR-B tendon

CR.P.OL.ICE.MA

  1. Control Risk Factors: training errors and relative rest for recovery.
  2. Protection: Splinting, bands
  3. Optimal Loading:
    1. Stretch
    2. Soft-tissue manipulation to ↑ tissue extensibility and promote tendon healing.
    3. Progressive Loading ( isometrics → concentric → eccentric for wrist extensors, flexors, and forearm supination and pronation)
    4. Graded Return To Sport
  4. Aerobic conditioning
  5. Ice, Compression, Elevate: early if pain and swelling was significant.
  6. Modalities: Cryotherapy, TENS, Ultrasound, Acupuncture → facilitate rehabilitation
  7. Analgesics: NSAIDs for 10 to 14 days

Surgical

  1. Steroid injection short term only, activity should be restricted for at least 7 to 10 days
    1. S/E skin depigmentation and atrophy, structural weakness, tendon rupture if not rest
    2. Not more than three times in a year.
  2. PRP injection is superior
  3. ECR-B debridement
    • Rehabilitation for 4 to 6 months before resumption of full activity

Cuccurollo 4th Edition Chapter 4 MSK pg181-182

DeLisa 5th Edition Chapter 35 UL Injury pg917-919

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7
Q

Which muscle is implicated in extensor tendinopathy, and why?

A

ECRB. It crosses both the wrist and elbow joint.

If asked to name 3 muscles involved: ECRB, ECRL, and ECU

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8
Q

Corrective strategies in tennis have included

A
  1. Switching to a two-handed backhand
  2. Using the largest comfortable grip
  3. Lowering string tension below 55 lb
  4. Switching to a more flexible and lightweight frame
  5. Playing with a softer ball
  6. Wearing a counterforce forearm brace
    1. Decrease the force of contraction from the forearm extensors and redistribute the force distal to the insertion at the lateral epicondyle

DeLisa 5th Edition Chapter 35 UL Injury pg918

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9
Q

Medial Epicondylitis: Mechanism of injury, Invx, PEx & Managment 🔑🔑 Leak 21

List 4 DDx and how to differentiate between them.

A

MEDIAL EPICONDYLITIS

  • Repetitive valgus stress causes microtrauma & inflammation of medial elbow structures
  • Seen in baseball pitchers and golfers
  • Late cocking and acceleration phase → significant valgus stress on the elbow

ATTACHMENTS

  1. Pronator teres
  2. Flexor carpi radialis (FCR)
  3. Palmaris longus
  4. Flexor carpi ulnaris (FCU)
  5. Flexor digitorum superficialis (FDS)
  6. Flexor digitorum profundus (FDP)

RISK FACTORS

  1. Training Errors: Repetitive valgus stress seen in golf, tennis, baseball
  2. Over Training: Repetitive forearm pronation and flexion “throwing”
  3. Inappropriate Equipments: Heavy racket
  4. Biomechanical Abnormalities: Posterior deltoid weakness

DEFRENTIALS

Musculoskeletal Caused of Medial Elbow Pain

  1. Medial Epicondylitis
  2. Valgus Extension Overload (VEO)
  3. Little Leaguer’s elbow
    • Medial epicondylitis and traction apophysitis
    • Osteochondritis dissecans (OCD) of the capitellum
    • Panner’s disease (osteochondrosis of the capitellum)
  4. Medial (Ulnar) Colateral Ligament Sprain
    • Medial pain or instability on valgus stress with the elbow, flexed 20 degrees to 30 degrees if the UCL is torn
  5. Muscular strain of the forearm flexors or pronator teres

Neuro-Vascular Caused of Medial Elbow Pain

  1. Cervical Radiculopathy
    • Dermatomal distrebution, Hx of Neck Pain
  2. Thoracic Outlet syndrome
    • Positive Allen, Adison, Roos
  3. Ulnar Entrapment: Cubital Tunnel Syndrome
    • Atrophy of 1st dorsal interossei
    • Pain and numbness in dorsal and palmar ulner cutaneous n.
    • Weakness in 4th and 5th digit, PAD/DAP
    • Positive Tinel and Froment’s Sign
  4. Median Entrapment
    • AIN entrapment (pronator teres syndrome)
    • Weakness of FDP, FPL and PQ
    • Abnormal OK Sign

EXAMINATION

  1. Tenderness and pain on pronation and flexion
  2. Pain worsen with wrist flexion and pronation
  3. Grip strength is weak and worsen the pain

IMAGING

  • Xray to r/o avulsion of medial epicondyle
  • MRI can show edema in the medial epicondyle apophysis

ER - POLICE - MIS

  1. Control Risk Factors: Training errors and relative rest for recovery.
  2. Protection: Splinting, Medial counterforce strap 50-60% force
  3. Optimal Loading:
    • Stretch
    • Improve trunk rotation
    • Restoring full, pain-free range of motion at the elbow is necessary before initiating strengthening.
    • Strength exercises → wrist flexors and pronator teres
  4. Ice, Compression, Elevate: Early if pain and swelling was significant.
  5. Modalities: Cold, Laser & ECSWT
  6. Medications: NSAIDs for 10 to 14 days
  7. Injection:
    • Steroid injection (risk of tendon degeneration and ulnar n. injury)
    • PRP Injection
  8. Surgical for Unstable elbow

Cuccurollo 4th Edition Chapter 4 MSK pg180-181

DeLisa 5th Edition Chapter 35 UL Injury pg919

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10
Q
A

Mechanism

  • Repetitive valgus forces during the throwing motion
  • Valgus forces cause tensile stress in the medial elbow and lateral shear stress in the posterior aspect of the elbow (posteromedial olecranon)
  • Result in Olecranon osteophytosis → Surgical removal

Test for VEO

  • Posterior elbow pain with lack of full elbow extension
  • Flex elbow to 30 degrees
  • Repeatedly extend the elbow fully while applying a valgus stress
  • Pain may be elicited, particularly at the last 5 degrees to 10 degrees of extension.
  • Valgus stress test should also be performed at >90 degrees to rule out UCL injury

Postoperative physical therapy (PT)

  1. Stretching
  2. Strengthening eccentric elbow flexors to better control rapid elbow extension
  3. Evaluation of pitching biomechanics

Cuccurollo 4th Edition Chapter 4 MSK pg185

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11
Q

Forearms and hand pain. Weak grip. DDx and Management. List 4 Entrapments of median nerve

A

Presentation

  • Dull aching pain in the proximal forearm just distal to the elbow
  • Numbness in the median nerve distribution of the hand
  • Symptoms exacerbated by pronation

Median Nerve Compression Sites

  1. Ligament of Struthers or supracondylar spur
  2. Lacertus fibrosus
  3. Pronator teres muscle
  4. Between the two heads of the flexor digitalis superficialis (FDS)

Examination

  1. Absence of sensory symptoms
  2. Preservation of forearm pronation strength
  3. Weakness of “OK muscles”
    1. Flexor pollicis longus
    2. Flexor digitorum profundus (digits 1 and 2)
    3. Pronator quadratus.

Imaging

  • Plain films: Rule out bone spur
  • EDX: median neuropathy

Management

  1. Modification of activities
  2. Avoid aggravating factors
  3. Stretching and strengthening program
  4. Surgical release median nerve if no progression within 4-6 months

Cuccurollo 4th Edition Chapter 4 MSK 186-187

DeLisa 5th Edition Chapter 35 UL Injuries pg921

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12
Q

List 4 causes of ulnar nerve palsy at the elbow level.

Presentation & Examination 🔑🔑 - Investigation 🔑🔑 - Management

A

💡 Hyperirritability or injury of the ulnar nerve

Ulnar Palsy at Elbow

  1. Arcade of Struthers
  2. Hypermobility of the ulnar nerve
  3. Excessive valgus force at the elbow
  4. Impingement from osteophytes or loose bodies

Presentation

  • Medial forearm aching pain
  • Paresthesias radiating distally to the fourth and fifth digits
  • Atrophy of intrinsic hand muscles (particularly the first dorsal interosseous)
  • Weak grip strength
    • Flexor carpi ulnaris and flexor digitorum profundus are spared
  • Positive Tinel’s sign at the elbow
  • Positive Froment’s sign
    • Weakness in the adductor pollicis
    • Compensate with the flexor pollicus longus
  • Maintaining the elbow in a fully flexed position for up to 5 minutes (elbow flexion test)

Investigation

  • Xray looking osteophytes or loose bodies (hx trauma, stress fracture)
  • MRI soft tissue abnormalities if indicated, prior to surgery
  • EMG/NCS
    • Above and below the elbow (conduction block ↓ CMAP by 50%)
    • R/O cervical radiculopathy, plexopathy, and distal entrapment neuropathies at the wrist.

CR.P.OL.ICE.MA

  1. Control Risk Factors: training errors and relative rest for recovery.
  2. Protection: Night splint with 45 degree flexion
  3. Optimal Loading:
  4. Ice, Compression, Elevate: early if pain and swelling was significant.
  5. Modalities:
  6. Analgesics: NSAIDs for 10 to 14 days

Surgical

  1. Ulnar nerve transposition
  2. Ulnar nerve release

Cuccurollo 4th Edition Chapter 4 MSK pg187

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13
Q

Mention 5 possible causes of olecranon bursitis & Managment 🔑🔑 MOCK

A

Olecranon bursitis

  • Inflammation of the bursa located between the olecranon and skin

Causes

  1. Gout
  2. Pseudogout
  3. Rheumatoid arthritis
  4. Repetitive trauma
  5. Tuberculosis
  6. Chondrocalcinosis
  7. Xanthomatosis
  8. Infection

Examination

  • Swelling and pain in the posterior aspect of the elbow
  • Decreased elbow ROM
  • Warm, erythematous elbow may indicate infection

Managment

  1. Fluid aspiration: gram stain, culture, sensitivity & crystals
  2. Rest, NSAIDs, elbow padding
  3. Local cortisone injection
  4. Septic bursitis: Oral ABx or incision and drain
  5. Surgical excision

Cuccurollo 4th Edition Chapter 4 MSK pg182-183

DeLisa 5th Edition Chapter 35 UL Injury pg919

PMR Secrets 3rd Edition Chapter 44 Elbow pg354

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14
Q

29 y.o female with Rt elbow OA: list 8 causes for her OA.

A

INJURY

  1. Trauma - fracture
  2. Iatrogenic – post-surgical

INFELTRATION

  1. Neoplastic – osteosarcoma, chondrosarcoma
  2. Gout
  3. Pseudogout

INFECTION/INFLAMMATION

  1. Rheumatoid arthritis
  2. Idiopathic primary OA
  3. Septic arthritis

METABOLIC

  1. Drugs – corticosteroid use
  2. Endocrine – pagets disease
  3. Avascular necrosis
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15
Q

Spot diagnosis & management

A

Mechanism

  • Subluxation of the radial head secondary to an annular ligament tear (2-5 yr old children).
  • Occurs from a sudden pulling force/traction on the child arm.

Manegement

  • Supination technique
    • while holding the arm supinated the elbow is then maximally flexed
    • the physician’s thumb applies pressure over the radial head and a palpable click is often heard with reduction of the radial head
  • Hyperpronation technique
    • involves hyperpronation of the forearm while in the flexed position

Ref: http://www.orthobullets.com/pediatrics/4012/nursemaids-elbow

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16
Q

What are the common locations for osteochondritis dissecans to occur? 🔑🔑 EXAM

A
  1. Knee (femoral condyle)
  2. ankle (talar dome)
  3. elbow (capitelum > olecranon/trochlea)
17
Q

Osteochondrosis vs Osteochondritis List common places of Osteochondritis Dissecans 🔑🔑

A

OSTEO-CHONDROSIS (PANNER DISEASE)

💡 Epiphysial aseptic necrosis of the capitellum Osteochondrosis of the capitellum of the elbow.

  • Interference in blood supply to epiphysis, leading to resorption of the ossification center initially, followed by repair/replacement
  • Symptoms relieved by rest and aggravated by activity
  • Tenderness and swelling on the lateral aspect of the elbow
  • Limited extension seen on ROM
  • Plain films: Sclerosis, patchy areas of lucency with fragmentation

OSTEO-CHONDRITIS DISSECANS

💡 Avascular necrosis causing localized fragmentation of the bone and cartilage Bone underneath the cartilage of a joint dies due to lack of blood flow

Location

  1. Knee (femoral condyle)
  2. ankle (talar dome)
  3. elbow (capitelum > olecranon/trochlea)

Management

  • Immobilization, then gradual ROM

Cuccurollo 4th Edition Chapter 4 MSK pg187-188

PassPMR - 07 Musculoskeletal Medicine (8 decks)

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