elbow Flashcards
Elbows vascular supply
brachial artery
radial artery
ulnar artery
middle and radial collateral arteries
superior and inferior ulnar arteries
Anterior elbow symptoms possible causes
- anterior capsular sprain
- distal biceps tendon rupture or tendinopathy
- elbow dislocation
- pronator syndrome (throwers)
Medial elbow symptoms
- medial elbow tendinopathy
- ulnar collateral ligament sprain
- ulnar nerve injury
- flexor- pronator muscle injury
- little league elbow
- valgus extension overload
postermedial elbow symptoms
- olecranon tip stress fracture
- posterior impingement (throwers)
- trochlea chondroalcia
posterior elbow symptoms
- olecranon bursitis
- olecranon process stress fracture
lateral elbow symptoms
- capitulum fracture
- lateral elbow tendinopathy
- radial collateral ligament complex sprain
- osteochondral degenerative changes
- osteochondritis dissecans (Panners disease)
- posterior interosseous nerve syndrome
- radial head fracture
- radial tunnel syndrome
- synovitis
forearm symptoms
- radius or ulna stress fracture
- radial tunnel syndrome
- cubital tunnel syndrome
- brachialis tendinopathy
other non elbow causes of pain
- C6/C7 radiculopathy (radiates to lateral elbow)
- shoulder pathology
- TOS
- Brachial plexus
- primary nerve
- peripheral nerve entrapment
- DM
What range do the majority of ADL’s happen in
50 degrees of pronation-supination
30-130 elbow flexion
Elbow flexion Test
CUBITAL TUNNEL SYNDROME
- elbow is maximally flexed and held from 60-3 minutes
- (+) is paresthesias in ulnar distribution
+LR 1.0 - 45.99
-LR .99 - .54
Pressure provocation test
CUBITAL TUNNEL SYNDROME
- full flexion and apply pressure to ulnar nerve for 30 seconds.
- (+) fourth and fifth tingling/numbness
+LR 45
-LR- .11
Tinel Sign
CUBITAL TUNNEL SYNDROME
- taps lightly at ulnar nerve at medial epiondyle
(+) tingling/numbness to 4/5 digit
+LR 1.3 - 53.99
-LR .72 - .46
scratch collapse
CUBITAL TUNNEL SYNDROME
- patient seated, arms adducted, elbows flexed to 90, hands outstretched. asked to perform simultaneous resisted bilateral shoulder external rotation. PT pushes in internal rotation, then PT scratches skin over nerve.
- (+) if patient has momentary loss of ER in affected side
+LR 68.99
-LR .31
Cubital tunnel special tests
- elbow flexion test
- pressure provocation
- tinel sign
- scratch collapse
- crossed finger
- shoulder internal rotation
- chair sign
Posterolateral Rotary Instability tests
- chair sign
- push up sign
- table-top relocation
UCL testing
- valgus stress
- milking maneuver (anterior portion)
- moving valgus stress test
MET testing
- passive medial elbow tendinopathy
- ## active wrist flexion against resistance
LET testing
- Cozen
- maudsley
- mill
distal biceps tendon rupture
- biceps squeeze
3 etiologies of tendonopathy
- vascular
- mechanical- repetitive loading of tendon
- neural modulation- neurally mediated mast cell degranulation and release of substance P
Possible cause of tendonopathy
too much or too little stimulation to tissue
Ideal Isometric prescription for tendonopaty
24 reps of 10 seconds
or
6 reps of 40 seconds
LET primarily occurs in who?
jobs requiring repetitive grasping, forceful or heavy manual tasks, non-neutral wrist postures
Primary symptom of LET
pain
Three common tests for LET
Cozen
Mill
Maudsley
Other DD for LET
- radiocapitellar chondromalacia
- posterolateral elbow instability
- plical irritation
- intra-articular loose bodies
- malignancy
- cervical radiculopathy (6 or 7)
- radial tunnel syndrome
- compression of posterior interosseous nerve at arcade of Frohse (supinator syndrome)
Standard care for LET
Non operative management with NSAID’s, cross friction massage, electrical and thermal modalities, TE and bracing and race.
Possible joint mobilizations for elbow
- HU distraction: pain
- HU lateral glide: LET
- HR anterior glide: elbow flex
- HR posterior glide: elbow ext
- PRUJ glide: anteromedial supination, posteriorlateral pronation.
eccentrics for LET prescription
3x15 taking 4 seconds to complete with 30 second rest
Injections for LET
- provide high success rates within first 6-8 weeks but result in high pain recurrence rates and protracted recovery in long term
surgical intervention for LET
lateral epicondylar release
Lateral epicondylar release protocol first 7 days
Immediate goals: decrease pain and inflammation, improve ROM, minimize atrophy
pain-free AROM of shoulder, wrist (flex only), and fingers. AAROM into wrist ext with elbow flexed to 90, PROM into elbow flex/ext and pro/sup
Lateral epicondylar release protocol 2 weeks on
- AAROM/PROM progressed to AROM with goal of 80% ROM by 3 weeks
- sub max isometrics for grip, can add weight as patient can perform 30 reps pain free ( all exercises being performed at 90 degrees flexion)
- joint mobilizations introduced at week 3
- full recovery at 8-12 weeks
MET
golfers elbow
involves FCR, pronator teres with occational involvement of PL, FCU, FDS
- overuse injury
Presentation of MET
- medial elbow pain over flexor-pronator origin
- symptoms worsen with resisted wrist flexion, resisted pronation, passive wrist extension combined with passive forearm supination and elbow extension
DD for MET
- UCL injury or insufficiency
- medial elbow intra-articular pathology
- ulnar nerve entrapment or neuritis
- shoulder injury
- cervical spine nerve root impingement
- TOS
Bicipital tendinopathy
- occurs at radial tuberosity and is due to repetitive hyperextension of elbow with the forearm pronated or repetitive flexion combined with stressful pro/sup in athletic individuals over 35
complaints with bicipital tendinopathy
- elbow/forearm pain over radial tuberosity
- can be reproduced with resisted elbow flexion and forearm supination
4 phases of distal biceps tendinopathy in athlete
1: rest
2: stretching for scapular muscles, rotator cuff, and posterior GHJ capsule
3: eccentric strengthening of the elbow flexors and forearm supinators
4: progressive return to a throwing program
Avulsions of biceps tendon at elbow
- occurs exclusively in males
- most common being rupture of dominant elbow of muscular male in 50’s
- based on patient history (sudden pop) and PE alone (ecchymosis in distal arm and proximal forearm, flattening of distal contour of arm created by proximal forearm soon after injury
- MMT reveals weakness in flexion but mostly forearm supination depending on patient’s strength
- Hook test- 100% sn, sp.
- biceps squeeze- 96% sn
Biceps crease interval
distance between elbows antecubital crease and cusp of distal descent of biceps muscle (the point in which the distal curve of the biceps begins to turn most sharply toward the antecubital fossa
> 6cm has 92% SN, 100% SP
Distal BT repair early recovery
0-6 weeks
- focus on pain, protection of repair
- splint/brace immobilize elbow at 90 degrees flexion and in full supination worn at all times
- brace is unlocked for PROM from 30-full flexion (extension is progressed 10 degrees per week
- no active elbow flex or forearm supination
- cardiovascular exercises for LE early on
- next phase progression when no pain or swelling persists
Distal BT repair intermediate recovery
6-12 weeks
- iso triceps @ 6 weeks
- concentric triceps @ 8 weeks
- streengthening of shoulder girdle, wrrist flexors and extensors.
Distal BT repair late recovery
12-16 weeks
- bicep isometrics
- light bicep concentric at week 16
Distal BT repair final stage
16+ weeks
- biceps strengthening advanced to side curls
Distal triceps tear
- occurs in less than 1%
- happens when deceleration force occurs during elbow extension or with an uncoordinated contraction of triceps while eccentrically resisting elbow flexion force
common findings of distal triceps repair
inability to extend arm overhead against gravity and loss of overall elbow extension strength
Non op approach for partial triceps tear
- immobilization for 3 weeks followed by gradual progression of ROM and strength
Distal triceps repair Immediately post op
- patient is in cast of 45 flexion, no weightbearing
-wrist extension/flexion with light dumbbell. shoulder pendulum
Distal triceps repair 2-6 weeks
- elbow ROM brace locked 0-90
- avoid PROM flexion past 90 and any elbow ext
- AAROM elbow ext is allowed with shoulder at 90 abd
- active supination/pronation, elbow flexion, light iso elbow flexion
- initial elbow extensor strength
Distal triceps repair 6-12 weeks
ROM is increased until full ROM
Distal triceps repair 12+
return to work/sports
aseptic olecranon bursitis
- injury from direct trauma or sustained pressure/vibration over bursa
- sling to reduce symptoms
- aspiration to analyze fluid to rule out infection or gout only when diagnosis is uncertain
- ice, compression, bandaging, NSAIDs
Septic olecranon bursitis
- redness, heat, tenderness
Chronic olecranon bursitis
- prolonged or repetitive injury to bursa or secondary to comorbidities such as DM, gout, pseudo-gout
- if no comorbidities, tis easy to treat through education about not irritating bursa
- corticosteroid injections may be warranted to manage recalcitrant chronic bursitis once diagnosis of infection has been excluded.
DD of olecranon bursitis
- acute fracture
- RA
- gout
- synovial cysts
comorbidities leading to peripheral nerve trunk injury
- DM
- hypothyroidism
- hereditary neuropathy
- immune deficiency syndromes
- RA
- alcoholism
nerve injury recovery
- 2mm-3mm per day in proximal segments
- 1mm- 2 mm per day in distal segments
Neuropraxia Sunderland gr I
focal, but transient, segmental demyelination without wallerian degeneration
Axonotmesis Sunderland gr II
axon is damaged with intact endoneurium. Wallerian degeneration occurs
Axonotmesis Sunderland gr III
axon and endoneurium are damaged with intact perineurium. regenerating axons may not innervate to original end organs
Axonotmesis Sunderland gr IV
axon, endoneurium and perineurium damaged with intact epineurium
Neurotmesis Sunderland gr V
complete nerve transection. surgical intervention is usually required
double crush syndrome
serial compromise of axonal transport within the same nerve fiber, causing a subclinical lesion at the distal site to become symptomatic
splinting for injury to median nerve
to enhance thumb opposition while also providing some assistance to finer flexion
splinting for injury to ulnar nerve
to prevent clawing of the hand by blocking MCP hyperextension
splinting for radial nerve injury
to provide wrist stability while also providing some assistance to MCP extension
cubital tunnel syndrome nerve and DD
ulnar
cervical radiculopathy
TOS
cubital tunnel syndrome diagnosis
found in throwers, due to the extreme valgus stress placed upon the elbow
people with sustained flexed elbow positions
pronator syndrome nerve and DD
Median
cubital tunnel syndrome
cervical radiculopathy
TOS
AIN syndrome
pronator syndrome diagnosis
differentiated from carpal tunnel syndrome by using tinel test at the wrist or the provocation of symptoms throw prolonged wrist flexion- neither of which should produce symptoms from pronator syndrome
AIN syndrome nerve and DD
median
cervical radiculopathy
brachial neuritis
rupture of flexor pollicis longus
pasonage-turner syndrome
AIN syndrome diagnosis
to help rule out brachial neuritis and parsonage-turner syndrome, you should determine whether the patient has any history of transient shoulder pain, viral infection, or recent immunization
PIN syndrome nerve and DD
radial
RTS
RTS nerve and DD
radial
LET
PIN syndrome
RTS diagnosis
only nerve compression syndrome in which signs and symptoms are note based on its distribution
- main clinical feature is localized tenderness over radial tunnel
- resisted supination of the forearm with the elbow fully extended should also reproduce pain
- pain can become more severe when increased traction is applied to the nerve by extending the elbow, pronating forearm, and flexing wrist
exercises for median nerve
thumb opposition
precision grip
strength in involved fingers
exercises for ulnar nerve
key pinch
power grip
coordination
exercises for radial nerve
MCP extension
thumb abduction
wrist extension
cubital tunnel syndrome treatment
activity modification with protection over cubital tunnel with elbow pad placed on medial-posterior aspect
-limiting repetitive extreme elbow flexion
- night splinting at 40-60 degrees of elbow flexion
-exercises must not reproduce distal symptoms
pronator syndrome treatment
- gentle massage along the fibers to aid in breaking adhesions
AIN syndrome treatment
- period of rest and observation
- splinting elbow near 90 of flexion
PIN syndrome treatment
- cock up splint combined with soft tissue techniques (active release techniques in conjunction with neural gliding
- regular gentle stretching of the wrist extensor muscles with elbow in full flexion is initiated after spontaneous recovery
radial tunnel syndrome treatment
- education to avoid provocative positioning of the arm into forceful extension and supination of the wrist and forearm with splinting used
when is surgery indicated for nerve pathologies
3-4 months of conservative care with muscle atrophy, persistent sensory changes, or persistent symptoms
5 items for classifying elbow instabilty
- timing (acute, subacute, chronic)
- articulation involved ( HU or PRUJ)
- direction of displacement ( varus, valgus, anterior, or posterolateral rotatory)
- severity (subluxation or dislocation)
- presence or absence of associated fractures.
pt hx for elbow instability
- recurrent painful clicking, snapping, clunking, or locking or elbow that occurs in the extension portion of arc of motion with forearm in supination
ulnar collateral ligament test
elbow is placed in 20-30 degrees of flexion and forearm supinated and valgus stress applied
positive when no firm endfeel or greater than 10 mm opening noted, or pain felt
SN 66%
SP 60%
radial collateral ligament test
patient sitting or standing, therapist places elbow in slight flexion between 5-30 and applies varus force
positive if the patient experiences pain or excessive laxity noted
valgus instability tests
valgus stress test
milking maneuver
moving valgus stress test
modified milking maneuver
varus instability clinical findings
- posterolateral- vague elbow discomfort or clicking or clunking that is worse with supination of forearm
- posteromedial- history of repetitive trauma and reports of clicking and popping with elbow flexion and extension
valgus instability clinical findings
- medial elbow pain and history of either trauma or overuse
- associated tendinopathy or another source of local inflammation
- more unstable when the forearm is in pronation than when the forearm is in supination
the most common type of elbow instability
posterolateral rotatory instability
posterlateral rotatory instability DD
varus posteromedial rotary instability
cervical pain referral
LET
RTS
valgus instability
posterolateral rotatory instability symptoms
- lateral elbow pain
- clicking
- recurrent subluxation when load is applied while elbow is in flexion and supination
lateral pivot-shift test
patient in supine, elevate arm over head with shoulder placed in full external rotation and forearm supination. a valgus, supinating, and axial force is applies as the elbow is slowly flexed
- a skin dimple can be seen proximal to radial head
- with increased flexion the dimple disappears as the radial head reduces
con- may have apprehension
in anesthetized patient, 100% SN
chronic cases of PLRI
do not have adequate tissue to repair and often require an open ligamentous reconstruction using autograft or allograft
post op protocol for PLRI
- immobilization device set to 45-90 elbow flexion with neutral or slight pronation with extension block for 8 weeks ( 60 at wk 2, 45 at wk 4, 30 at wk 6).
- week 2 can begin forearm pronation exercises with extension and active supination beyond 90 elbow flexion is allowed
- normal ROM is expected by 8 weeks and strength is initiated
- return to sport when strength is 85%-90% equal
posterior elbow impingement
common injury in throwers due to high amount of valgus torque and rapid extension occurs during pitching
can lead to compromise of integrity of UCL, producing a radiocapitellar overload syndrome and valgus extension overload
6 phases of throwing
wind up
early cocking
late cocking
acceleration
deceleration
follow through
acceleration phase of throwing
generates the most valgus force at the elbow
deceleration phase of throwing
the dissipation of the forces creates pathological forces in the posterior elbow , generating a reactive bone formation on the olecranon’s posteromedial tip.
- can lead to osteophyte development or the occurrence of loose bodies that may result in impingement.
most SN test for posterior impingement
moving valgus stress test
DD for posterior elbow impingment
LET
cubital tunnel syndrome
elbow instability
radiocapitellar synovial plica
what percentage of 7-18 YO baseball players experience elbow and shoulder pain?
30-40%
little league elbow
- avulsion of the humeral medial apophysis in adolescents
- irritation of the origin of the flexor-pronator mass
- MET
- UCL injury due to fragmentation and avulsion of medial epicondyle
factors leading to little league elbows
- overuse, exacerbated by high pitch counts, poor technique and pitch type
clinical findings of little league elbow
- patient reports a sudden increase in volume or intensity of training
- steady increase in discomfort during throwing motion
- subsequent aching
- decreased throwing velocity and problems with accuracy due to diminished grip strength
medial epicondyle that is TTP and which may be enlarged, ROM exam reveals acute motion loss and pain with extremes of motion
management of acute little league syndrome
- rest and eliminating the offending activity for 2-3 weeks
Osteochondritis dissecans of the capitulum
- related to excessive repetitive valgus compression across the elbow joint in presence of immature articular cartilage
Stage 1 OCD
- hyperemic bone, edematous periarticular soft tissues are also found
Stage 2 OCD
epiphysis deforms, sometimes with fragmentation
Stage 3 OCD
necrotic bone is replaced by granulation tissue
best imaging for OCD
radiographs AP view with elbow in 45 degrees of flexion- very insensitive
MRI or CT often needed
OCD treatment
- smaller lesions without cyst like features heal with nonoperative treatment
- unstable lesions require osteochondral autologous transplantation surgery
- nonop approach lasts between 3-4 months and focuses on pain control, non abusive activity with biceps/triceps
Heterotropic ossification
- ectopic ossification of myositis ossificans
- bone formation at an atypical site
- can happen in any place at elbow but typically posterior, deep to triceps extending from either epicondyle to olecranon or anterior at brachialis
- direct elbow trauma or surgery is most common cause, can result from neural trauma, burns, or genetic disorders
most common characteristics for HO
- limited active and passive elbow flexion/extension
- weak and painful elbow flexion/extension
2 approaches to managing HO
- preventative strategies to avert or lessen the extent of the condition
- interventions to tackle the symptoms and address functional limitations (active and passive ROM, continuous passive motion, dynamic splinting and static splinting.)
- low dose radiation and NSAIDs
elbow dislocation
- 2nd most common dislocated joint of UE, 1/4 are associated with elbow fracture
simple dislocation
- soft tissue injuries and more common
complex dislocation
- involve ligament injuries and associated fractures of articular surfaces.
different types of acute elbow dislocations
- classified as posterior (most common), anterior, divergent
divergent dislocations
- displacement of the radius and ulna from each other and both are dislocated from ulna
radial head dislocation
most common associated with high force injury
Monteggia lesions
- rare, combination of injuries involving dislocation of the proximal end of the radius and fracture of the ulna
- Bado classification
Bado Classification type 1
- anterior dislocation of the radial head accompanied by a fracture of the proximal or middle third of ulna ( most common in children/young adults.
Bado classification type 2
- posterior dislocation of the radial head accompanied by a fracture of the proximal or middle third of ulna (most common in adults)
Bado classification type 3
- lateral dislocation of the radial head with fracture to ulnar metaphysis
Bado classification type 4
- dislocation of the radial head in any direction accompanied by a fracture of the proximal or middle third of ulna/radius
management of monteggia lesions
- children - closed reduction
- adults- surgery is required, open reduction of the radial head and internal fixation of ulna, internal fixation of ulna, or internal fixation of the ulna with excision of the radial head
Nursemaid elbow
- partial displacement of annular ligament
- hold will often have protuberant radial head and will protectively old their arm in extended and pronated fashion
olecranon fracture
- common especially in elderly, usually caused by a fall backward onto elbow.
olecranon fracture
- common especially in elderly, usually caused by a fall backward onto elbow.
how to classify olecranon fracture
- anatomical location (metaphyseal (most common), physeal, epiphyseal)
- fracture pattern (longitudinal, transverse, oblique)
- displacement (undisplaced/minimally displaced but stable OR displaced and unstable (85%))
- associated injuries of the elbow complex (radial head dislocation, radial neck fracture, lateral condyle fracture, supracondylar fracture)
coronoid fracture
- untypically isolated, most commonly part of a terrible triad (coronoid and olecranon fractures, head of radius dislocated posterolaterally)
types of coronoid fractures
type 1- tip of coronoid
type 2- more than tip but less than 50% of coronoid
type 3- involving greater than 50% of the coronoid
type B= dislocation
coronoid fracture presentation
history of hyperextension or twisting, hyperflexion with a sense of dislocation followed by spontaneous reduction
- no ROM if elbow is deformed
- light touch and 2 point discrimination and pulses
treatment of coronoid fractures
type 1- early motion
type 2 - ORIF
type 3 - ORIF or hinged fixator
medial epicondyle fracture
- involved avulsion injury of attachment of forearms common flexors.
- common in adolescents and older children
- associated with elbow dislocation
- operative when valgus instability or ulnar nerve entrapment is suspected, when fracture is displaced into elbow joint, or displaced greater than 5 mm
Medial epicondylar ORIF what not to do for 4-6 weeks
- elbow joint mobilizations
- wrist flexor or pronator strengthening exercises
- wrist flexor or pronator stretching
- valgus stress to medial elbow
- lifting greater than 5 pounds
Lateral epicondyle fracture
- mostly in children, rare in adults
- classified by Jakob classification
- main complication is nonunion
Jakob stage 1
- fracture line goes through the capitellar ossification center, minimal displacement (<2 mm)
treatment
- cast immobilization in 90 flexion with the forearm pronated for 3-4 weeks
Jakob stage 2
- fracture line runs medial to the capitellar ossification center
- 2-4 mm displacement but intact articular surface
treatment
- immobilization or treated with closed reduction percutaneous pinning if there is questionable stability
Jakob stage 3
- fracture is completely displaced and rotated, leading to disruption of articular surface
treatment
- closed reduction percutaneous pinning or ORIF
compartment syndrome
- causes can be limb placement during surgery, use of tight dressings and plaster casts, bleeding, incresed capillary permeability, trauma, burns, intensive use of muscles, infection
acute compartment syndrome of forearm
- has 4 compartments, most common location of ACS
- both anterior compartments are at highest risk for developing ACS following trauma (deep is affected more)
findings for compartment syndrom
- palpation of a swollen and tense compartment with overlying skin that is often pink or red
- severe pain that may seem out of proportion to the injury and which is exacerbated by passive stretching of the muscles of the involved compartment
- sensory deficits or paresthesia occurs within 30 min to 2 hours of the initial development of ACS
- muscle weakness within 2-4 hours
- possible absence of radial and ulnar pulses at the wrist
normal pressure of compartments
- should be between 0-8 mmHg
- capillary blood flow becomes compromised when tissue pressure increases to within 25 mmHg to 30 mmHg of mean arterial pressure
chronic exertional compartment syndrome
- more common in female gymnasts and climbers
- symptoms occur with exercise but completely resolve between periods of exercise.
- definitive treatment is fasciotomy
complex regional pain syndrome
- intense burning pain, stiffness, swelling, discoloration that most often affects the hand but can affect hands, arm, and feet
- amplified pain responses, alterations in perspiration, vasomotor anomalies, trophic changes
- can be triggered by autonomic nervous system and immune system or genetic markers or psychological influences
type 1 CRPS
- occurs in absence of nerve trauma, following minor injury such as a strain or sprain or several other causes such as fracture, surgery, stroke, spinal cord injury
type 2 CPRS
- nerve trauma
warm CPRS
- inflammatory characteristics
cold CPRS
- autonomic features
stages of CPRS
- acute inflammation, dystrophy, atrophy
DD of CPRS
- RA, septic arthritis, gout, cellulitis, vasculitis, peripheral neuropathy, peripheral nerve entrapment, Raynauds, PVD
OA of elbow
- chronic MSK pain is the main symptoms
- stiffness, reduction in ROM, weakness, instability, decrease in quality of life
- capsular pattern with passive flexion most limited and pro/sup usually unaffected
total elbow arthoplasty
- most common indication is inflammatory arthropathies such as RA
- posttraumatic OA, acute distal humerus fractures, distal humerus non-nions, reconstruction after tumor resection
posttraumatic elbow stiffness definition
loss of more than 30 extension and less than 120 flexion
first line of treatment for post traumatic elbow stiffness
- static progressive stretching 3 times for 30 min per day in each direction
- lack of response, bony block, flexion contracture greater than 30 or elbow flexion less than 130 requires surgery.
when are re-ruptures most common in distal biceps repairs?
3-7 weeks but only 1-2% of patients
