Elbow

Question 1

Special Exam Maneuvers for Med UCL? Not a RC Q

Answer 1

“Milking maneuver, moving valgus stress test, opens to valgus, tender over posterolateral UH joint, examine ULNAR nerve<div><img></img><br></br></div><div><img></img><br></br></div>”

Question 2

Exam maneuvers for PLRI?

Answer 2

-lateral pivot shift (supination, Forward shoulder flexion, valgus load while moving from ext to flex)<div>-posterolateral rotatory drawer test (flex elbow to 40 deg -> apply AP force on forearm relative to humerus)</div><div>-Chair push up and prone push up <b><i>(combined sens 100% vs 37% for pivot shift)</i></b></div><div><i>-</i>Table top relocation test</div>

Question 3

Additional procedure while addressing elbow OA - not RC Q

Answer 3

-ulnar nerve release/transposition if loss of 30 deg extention<div><br></br></div><div>surgical options</div><div>-debridement: open or arthroscopic</div><div>-arthrodesis</div><div>-TEA</div>

Question 4

<div>What is true about a comminuted distal humerus fracture in an elderly patient? </div>

<div>A. TEA has improved outcome over ORIF at 1 year </div>

<div>B. Patient functional outcomes for TEA are better at 1 year </div>

<div>C. Re-operation rates for ORIF are significantly higher at 1 yr </div>

<div>D. It is “almost impossible” to do a quality ORIF with poor bone</div>

Answer 4

“B<div>-TEA better 6weeks-1 year; at 2 years, TEA = ORIF</div><div>-no diff in ROM, re-op, compo</div><div>-wrt ‘D’ - McKee states that 25% of distal humerus #s are not amenable to fixation</div><div><br></br></div><div><img></img><br></br></div>”

Question 5

Tx approach for stiff elbow - not a RC Q

Answer 5

-non-op: splint, ROM<div>-column procedure (arthrotomy, capsular release, osteophyte excision)- lateral or medial (sometimes need to get to post bundle MCL)</div><div>-TEA</div><div><br></br></div><div>-address ulnar nerve!</div>

Question 6

<div>List 4 long term complications of radial head fractures. (2011, 2013)</div>

Answer 6

Elbow stiffness<div>Radiocapitellar arthrosis<div>Loss of pronation/supination</div><div>Longitudinal forearm instability</div><div>Weaker: Infection PIN injury HO/Synostosis Elbow Instability<br></br></div></div>

Question 7

<div>list 3 stabilizers to posterolateral instability, and which is most impotant?</div>

Answer 7

-LUCL*<div>-RC joint</div><div>-coronoid</div>

Question 8

<div>Regarding elbow dislocation, what is true:</div>

1.An LCL injury should be rehabilitated in supination<div>2.Should be immobilized for at least 3 weeks</div><div>3.Often associated with posterior capitellar impaction</div><div>4. Instability is a common complication<br></br></div>

Answer 8

3.<div><br></br></div><div>LCL injury need pronation (think about sup–> RH goes out the back!)</div><div>instability is uncommon 2%</div>

Question 9

<div>Elbow dislocation with no fracture. Unstable in valgus stress? What is the best management? </div>

hinged external fixation to protect the ligament and allow early ROM.<div>splint at 90 in supination for 1-2 weeks</div><div>splint at 90 in supination for 3-4 weeks</div><div>fix mcl<br></br></div>

Answer 9

B- splint at 90 in supination for 1-2 weeks

Question 10

<div>All are true except:</div>

-Radio capitellar joint bears 20% of the load through elbow<div>-Radial head fractures account for 2-4% of all fractures</div><div>-Radio capitellar joint is only a secondary stabilizer to valgus stress (exact wording!)<br></br></div>

Answer 10

A is false: RC articular accounts for as much as 60% of load transfer across the elbow

Question 11

<div>Which of the following is the most common complication after a distal biceps reconstruction?</div>

<ol> <li>PIN injury</li> <li>Lateral antebrachial cutaneous nerve injury</li> <li>HO</li> <li>Symptomatic elbow flexion contracture</li></ol>

Answer 11

2. LACB 9% - from aggressive retraction<div><br></br></div><div>HO 7%</div>

Question 12

<div>What are 6 risk factors that will lead to radioulnar synostosis following a both bones forearm fracture. (2010, 2011, 2013, 2014)</div>

Answer 12

<ul> <li>Injury:</li> <ul> <li>Proximal Third</li> <li>Fractures at the same level</li> <li>Comminution of both bones</li> <li>Severe local soft-tissue injury</li> <li>Interosseous membrane injury</li> <li>Head Injury</li> </ul> <li>Surgical Technique:</li> <ul> <li>Delayed Surgical Management</li> </ul> <ul> <li>Single Incision/Boyd Approach</li> <li>Violation of IO membrane</li> <li>Retained bone fragment in IO space</li> <li>Hardware into IO membrane</li> <li>Primary onlay bone grafting</li> </ul></ul>

Question 13

MOI for elbow dislocation?

Answer 13

“think of PLRI: supination, valgus, axial load<div><br></br></div><div><img></img><br></br></div>”

Question 14

Mason classification RH Fracture?

Answer 14

“<img></img>”

Question 15

What remains intact in VPMRI?

Answer 15

MCL, RH<div><br></br></div><div><ul> <li>MOI: Fall backwards onto pronated outstretched hand, varus, axial load</li> <ul> <li>Mechanism (in the name): varus/posteromedial rotation with axial load</li> <li>Results in LCL rupture and compression of AMCF</li> </ul></ul></div>

Question 16

DDX Medial Elbow Pain

Answer 16

<ol> <li>ucl injury (acute rupture, chronic)</li> <ol> <li>Valgus instability</li> </ol> <li>ulnar neuritis (as per reasons listed above)</li> <li>flexor-pronator tendonitis (medial epicondylitis)</li> <li>medial epicondyle apophysitis (peds)</li> <li>valgus extension overload with posterior olecranon impingement due to osteophyte formation</li> <li>olecranon stress fracture</li> <li>ocd of capitellum</li></ol>

Question 17

important ddx for stiff elbow?

Answer 17

INFECTION - RULE OUT!

Question 18

Treatment options for stiff elbow or arthritic elbow?

Answer 18

“<ul> <li>Arthritis</li> <ul> <li>Debridement and capsule release/resection</li> <ul> <li>Open: column procedure</li> <li>Arthroscopic</li> </ul> <li>RA: synovectomy +/- RH excision</li> <li>Fusion</li> <li>TEA</li> </ul> <li>Stiffness</li> <ul> <li>R/O Infection</li> <li>MUA if <3/12 with no progression with physio</li> <li>Column procedure: lateral +/- medial</li> <ul> <li>Consider releasing posterior bundle MCL for deep flexion</li> <li>Ulnar nerve release:</li> <ul> <li>Symptoms pre-op</li> <li>Increasing ROM>50 deg</li> <li>Contracture >90 deg</li> </ul> </ul> <li>Post-op Rads for HO: 700cGy (7Gy)</li> </ul> </ul> <ul> <li><img></img></li></ul>”

Question 19

pathoanatomy of epicondyilitis? tendons involved in lateral vs medial?

Answer 19

<ul> <li>Non-inflammatory, degenerative angiofibroblastic hyperplasia</li> <ul> <li>Inadequate healing response to microtears</li> </ul><li>lateral: ECRB</li><li>medial: FCR, PT, FCU</li><li>80-90% will improve at 1 year</li></ul>

Question 20

options for synostosis of BBFA interposition?

Answer 20

<ul> <li>Excision of synostosis +/- interposition grafting</li> <ul> <li>Fat, muscle, fascia, bone wax, silicone, polyethylene</li> <ul> <li>Non-vascularized fat graft not recommended due to risk of displacement</li> </ul> </ul> <li>No good high quality evidence</li></ul>

Question 21

Complications after distal biceps tendon repair

Answer 21

• LABCn palsy (most common)<div>- Incisional pain</div><div>- Radioulnar synostosis</div><div>- PIN palsy</div>

Question 22

What are the static and dynamic stabilizers of the elbow? Primary and secondary?

Answer 22

Primary static constraints:<div>1. Ulnohumeral articulation</div><div>2. Anterior bundle of the MCL</div><div>3. LCL complex</div><div><br></br></div><div>Secondary static constraints:</div><div>1. Radiocapitellar articular</div><div>2. CFO</div><div>3. CEO</div><div>4. Capsule</div><div><br></br></div><div>Dynamic constraints</div><div>1. Triceps</div><div>2. Anconeus</div><div>3. Brachialis</div>

Question 23

What is the anatomy and function of the MCL?<div>- Function</div><div>- Origin</div><div>- Insertion</div>

Answer 23

Function<div>- Primary static stabilizer. Resists valgus.</div><div>- Anterior band is tight in extension</div><div>- Posterior band is tight in flexion</div><div><br></br></div><div>Origin</div><div>- Anterior, inferior and lateral aspect of the medial epicondyle</div><div>- <b>Posterior to the elbow axis of rotation</b></div><div><br></br></div><div>Insertion</div><div>- Sublime tubercle and UCL ridge (ridge extends distally as the ligament tapers out)</div><div>- Recently shown to have a longer and distally tapered insertion (extending beyond the sublime tubercle)</div>

Question 24

What is the anatomy of the LUCL?<div>- Function</div><div>- Origin</div><div>- Course</div><div>- Insertion</div>

Answer 24

“Function<div>- Primary static stabilizer - resists varus</div><div>- Resists PLRI</div><div><br></br></div><div>Origin</div><div>- CENTER of capitellum, ANTERIOR to lateral epicondyle</div><div><br></br></div><div>Course</div><div>- Attached to the annular ligament, located at the 8-9 o’clock position of the radial head</div><div>- Acts as a hammock to the radial head</div><div><br></br></div><div>Insertion</div><div>- From lesser sigmoid notch to the supinator crest</div><div>- Proximal edge is 7mm distal to the proximal radial head</div>”

Question 25

What is the progression of soft tissue disruption around the elbow at the time of dislocation?

Answer 25

Controversial - some believe MCL is always disrupted<div><br></br></div><div>Circle of Horii</div><div>- Stage I: Disruption of the LUCL. Results in PLRI</div><div>- Stage II: Disruption of other lateral ligamentous structures and anterior and posterior capsule. Incomplete PL dislocation.</div><div>- Stage III: Disruption of MCL. Complete posterior dislocation.</div><div><br></br></div><div>IIIA: Posterior band of MCL</div><div>IIIB: Entire MCL</div><div>IIIC: Distal humerus stripped of soft tissue; flexor-pronator origin disrupted</div>

Question 26

What is the immediate ED management of a PLRI injury?

Answer 26

1. Procedural sedation<div>2. Closed reduction. Traction with elbow in extension to allow coronoid to clear distal humerus, followed by flexion.</div><div>3. Assess stability. With the forearm in PRONATION, bring the elbow back to extension to determine at which degree of flexion the elbow subluxates. <b>If >30 degrees = elbow is unstable.</b></div><div>4. Asses the DRUJ to rule out Essex-Lopresti injury</div><div>5. Splint the elbow in 90 degrees of flexion with forearm in pronation</div><div>6. Post-reduction X-rays and CT scan</div>

Question 27

What are the indications for non-operative management of a posterolateral rotatory injury?

Answer 27

1. Small, minimally displaced radial head fracture with no mechanical block to supination/pronation<div>2. Small coronoid tip fracture (Regan-Morrey type 1 or 2)</div><div>3. Stable during post-reduction testing (elbow should extend to 30 degrees before becoming unstable)</div><div>4. Concentric reduction of the ulnotrochlear and radiocapitellar joints</div>

Question 28

What is the general surgical management for PLRI (terrible triad) injury?

Answer 28

1. Fixation of the coronoid<div>2. Fixation or replacement of the radial head</div><div>3. Repair of the LUCL complex</div><div>4. Possible repair of the MCL</div><div>5. External fixator if the elbow remains unstable</div>

Question 29

When performing a radial head replacement, how do you assess height of the radial head in relation to the ulna?

Answer 29

1. Align the proximal surface of the implant with the proximal portion of the lesser sigmoid notch<div>2. Assess for gapping of the lateral ulnohumeral joint (direct visualization more reliable than fluoro)</div><div>3. Assess congruency of the medial ulnohumeral joint (fluoro)</div><div>4. Assess radiocapitellar gap in flexion and extension (should be equal)</div><div>5. Proximal aspect of the implant should be at lateral edge of coronoid</div>

Question 30

When performing a radial head replacement, how do you size the radial head diameter?

Answer 30

1. Reconstruct the fragments of the head on the back table<div>2. Optimal diameter is the minor diameter of the native elliptical head (usually 2mm less than the maximum diameter)</div><div>3. When in between sizes, choose the smaller diameter</div>

Question 31

What are the consequences of overstuffing the RC joint when performing a radial head arthroplasty?

Answer 31

1. Decreased elbow flexion<div>2. Capitellar erosion</div><div>3. Pain</div><div>4. Early PTOA</div>

Question 32

Where does the LCL avulsion occur from?

Answer 32

Almost always from the humeral attachment

Question 33

“What is the ““hanging arm test””?”

Answer 33

Perform after coronoid, radial head and LCL repair<div>Humerus is placed on a stack of towels with the elbow in full extension and forearm in supination, which allows gravity to produce a dislocation force, confirm a concentric reduction with fluoroscopy</div><div>If unstable (subluxation) - repair the MCL +/- coronoid fixation (in inadequately addressed), via medial approach</div>

Question 34

What are the indications for MCL repair in a terrible triad injury?

Answer 34

Instability following coronoid, radial head and LCL repair, as determined by:<div>1. Postive hanging arm test</div><div>2. Instability with ROM in supination, pronation, and neutral rotation</div><div>- If the elbow remains congruous from approximately 30 degrees to full flexion in one or more positions of forearm rotation, repair of the MCL is NOT necessary</div>

Question 35

Where does the MCL avulsion occur?

Answer 35

Variable. Humerus, intrasubstance or sublime tubercle. Repair where it is avulsed from.

Question 36

Complications associated with terrible triad injuries

Answer 36

Instability<div>Malunion</div><div>Nonunion</div><div>Stiffness</div><div>HO</div><div>Infection</div><div>Ulnar neuropathy</div>

Question 37

What is the mechanism of a varus posteromedial injury?

Answer 37

Axial load, combined with varus and pronation at the elbow

Question 38

What is the progression of injured structures in a varus posteromedial injury?

Answer 38

1. LCL avulsion as a result of the varus force<div>2. Anteromedial coronoid facet fracture, as the trochlea impacts the facet</div><div>3. Coronoid dislocation posterior to the trochlea</div>

Question 39

“In varus PMI, what type of O’Driscoll coronoid fracture occurs?”

Answer 39

Type II<div>- A: anteromedial rim</div><div>- B: anteromedial rim + tip</div><div>- C: anteromedial rim + sublime tubercle</div>

Question 40

What radiographic features indicate a varus posteromedial rotatory instability?

Answer 40

“1. AP: narrowed medial joint space and gapping of the RC space<div>2. Lateral: ““double crescent”” sign indicating a depressed anteromedial facet fracture</div>”

Question 41

What is the general surgical management of a varus posteromedial rotatory instability?

Answer 41

1. Anteromedial facet of coronoid fixation<div>2. LCL repair</div>

Question 42

“What is the recommended surgical management of anteromedial facet fractures based on the O’Driscoll subtype?”

Answer 42

“1. Posterior midline incision<div>2. AMF subtype 1 - LCL repair along</div><div>3. AMF subtype 2 + 3 - LCL repair and buttress plate (T-plate, miniplate or precontoured plate)</div><div>4. If elbow unstable after LCL and AMF fixation, assess for MCL injury</div><div><br></br></div><div><br></br></div><div><img></img><br></br></div>”