Elbow Flashcards
Special Exam Maneuvers for Med UCL? Not a RC Q
“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>”
Exam maneuvers for PLRI?
-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>
Additional procedure while addressing elbow OA - not RC Q
-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>
<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>
“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>”
Tx approach for stiff elbow - not a RC Q
-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>
<div>List 4 long term complications of radial head fractures. (2011, 2013)</div>
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>
<div>list 3 stabilizers to posterolateral instability, and which is most impotant?</div>
-LUCL*<div>-RC joint</div><div>-coronoid</div>
<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>
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>
<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>
B- splint at 90 in supination for 1-2 weeks
<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>
A is false: RC articular accounts for as much as 60% of load transfer across the elbow
<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>
- LACB 9% - from aggressive retraction<div><br></br></div><div>HO 7%</div>
<div>What are 6 risk factors that will lead to radioulnar synostosis following a both bones forearm fracture. (2010, 2011, 2013, 2014)</div>
<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>
MOI for elbow dislocation?
“think of PLRI: supination, valgus, axial load<div><br></br></div><div><img></img><br></br></div>”
Mason classification RH Fracture?
“<img></img>”
What remains intact in VPMRI?
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>
DDX Medial Elbow Pain
<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>
important ddx for stiff elbow?
INFECTION - RULE OUT!
Treatment options for stiff elbow or arthritic elbow?
“<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>”
pathoanatomy of epicondyilitis? tendons involved in lateral vs medial?
<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>
options for synostosis of BBFA interposition?
<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>
Complications after distal biceps tendon repair
- LABCn palsy (most common)<div>- Incisional pain</div><div>- Radioulnar synostosis</div><div>- PIN palsy</div>
What are the static and dynamic stabilizers of the elbow? Primary and secondary?
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>
What is the anatomy and function of the MCL?<div>- Function</div><div>- Origin</div><div>- Insertion</div>
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>
What is the anatomy of the LUCL?<div>- Function</div><div>- Origin</div><div>- Course</div><div>- Insertion</div>
“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>”
What is the progression of soft tissue disruption around the elbow at the time of dislocation?
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>
What is the immediate ED management of a PLRI injury?
- 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>
What are the indications for non-operative management of a posterolateral rotatory injury?
- 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>
What is the general surgical management for PLRI (terrible triad) injury?
- 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>
When performing a radial head replacement, how do you assess height of the radial head in relation to the ulna?
- 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>
When performing a radial head replacement, how do you size the radial head diameter?
- 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>
What are the consequences of overstuffing the RC joint when performing a radial head arthroplasty?
- Decreased elbow flexion<div>2. Capitellar erosion</div><div>3. Pain</div><div>4. Early PTOA</div>
Where does the LCL avulsion occur from?
Almost always from the humeral attachment
“What is the ““hanging arm test””?”
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>
What are the indications for MCL repair in a terrible triad injury?
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>
Where does the MCL avulsion occur?
Variable. Humerus, intrasubstance or sublime tubercle. Repair where it is avulsed from.
Complications associated with terrible triad injuries
Instability<div>Malunion</div><div>Nonunion</div><div>Stiffness</div><div>HO</div><div>Infection</div><div>Ulnar neuropathy</div>
What is the mechanism of a varus posteromedial injury?
Axial load, combined with varus and pronation at the elbow
What is the progression of injured structures in a varus posteromedial injury?
- 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>
“In varus PMI, what type of O’Driscoll coronoid fracture occurs?”
Type II<div>- A: anteromedial rim</div><div>- B: anteromedial rim + tip</div><div>- C: anteromedial rim + sublime tubercle</div>
What radiographic features indicate a varus posteromedial rotatory instability?
“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>”
What is the general surgical management of a varus posteromedial rotatory instability?
- Anteromedial facet of coronoid fixation<div>2. LCL repair</div>
“What is the recommended surgical management of anteromedial facet fractures based on the O’Driscoll subtype?”
“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>”
