Elbow Flashcards
elbow functional assessment
Most ADL performed between 30 and 130 deg of flexion and between 50 deg of pronation and 50 deg of supination
reflexes
biceps (C5-C6)
brachioradialis (C5-C6)
Triceps (C7-C8)
peripheral nerves
- lower lateral cutaneous nerve of arm (radial)
- medial cutaneous nerve of forearm
- medial cutaneous nerve of forearm
- lateral cutaneous nerve of forearm (musculocutaneous)
- posterior cutaneous nerve of forearm (radial)
peripheral nerve injuries about the elbow
median nerve (C6-C8, T1)- ant interosseous syndrome, pronator syndrome, ligament of struthers
Ulnar nerve (C7-C8, T1)- cubital tunnel
Radial nerve (C5-C8, T1)- canal of Frohse
Lateral epicondylitis sy/sx
PROM-full wrist flex with ulnar deviation, full pronation, and elbow ext
resisted wrist ext with elbow extended
joint play-WNL and not painful
palpation over lateral epicondyle or muscle substance
Lateral epicondylitis tests
grip strength
cozen test
mills test
third finger resistance test
Lateral epicondylitis DDX
C5 nerve root px
radial nerve entrapment
radial head involvement/annular ligament sprain
Lateral epicondylitis
Most commonly involved ECRB
Attach to the lateral collateral lig, annular lig, and epicodyle, Runs over radial head in ext/pro
ECRL and brachioradialis attach above the epicondyle-papate above condyle for tenderness
Due to fatigue and micro-trauma
More tendinosis than tendinitis
Medial epicondylitis
tendinitis vs tendinosis
wrist flx and pronation mechanism (golf, throwing)
involved pronator teres and flexor carpi radialis. Occasionally FCU and FD superficialis
Ulnar nerve compression in ulnar groove-can produce similar symptoms
Medial instability
response to excessive valgus force
can be acute of chronic
overhead throwing a common mechanism
presents with medial elbow pain
tenderness distal to medial epicondye of humerus
Valgus stress test (straight and at 70 deg)
bracing.surgical repair
Medial tension overload
medial tendinosis, instability, tension (traction), lateral elbow compression
symptoms medial initially and eventually can be lateral as well
ligament, muscle/tendon, bone/epiphyseal pate, nerve
Myositis ossificans
result of fracture, dislocation, direct bow, also seen in individuals with neurologic px
ectopic bone growth. calcium deposits in muscle
may be palpated, seen on xray
noted as stiffness, pain, and firm mass on palpation
do not use heat
no resistance exercises involving muscle
typically, brachialis
can develop while in cast over 3-6 weeks
Nerve entrapment
r/o cervical spine and brachial plexus
ulnar, median, ant interosseus, and radial and post interosseus nerve
ulnar nerve
damaged with supracondylar and epicondylar fractures, fracture callus
behind med epicodyle usceptile to trauma and direct injury
friction syndromein ulnar groove or intermuscular septum. Can sublux in groove
can become involved with medial instability
fromet’s sign: adductor pollicus (can’t hold aper between thumb and first finger)
wartenburgs sign: weakness of 5th finger ADD
sensory changes along inervation of ulnar hand (little finger and lateral hand)
Triceps tendinitis
sudden snapping of the elbow towards extension
pain with resisted elbow EXT
Differentiate from post impingement (synovial capsule/tissue pinched between olecranon fossa)
Radial head fractures
type I- undisplaced ( no immobilization or little 2-3 wks, can be full rom if no pain)
type II-displaced. Usually single fragment displaced more than 3 cm
type III- comminuted. Radial head in multiple frag. (II and III-ORIF, brief immob, 30 deg rom lost)
type IV- with dislocation of elbow (usually involve capsule, lig, and capitulum. Usually will not regain full EXT-need to prevent myositis ossificans)
Olecranon fractures
direct blow or hyper-extension which leads to dislocation
soft tissue sweling posteriorly
can have avulsion of olecranon/triceps tendon
distal humerus fracture
common to children
50-60% of all elbow fx in children
98% with arm-wrist EXT
Must be reduced, traction
check neurovascular
malunion common, with varus deformity (lose carrying angle)
Capsular tightness
mobilization
prolonged positioning
Ice after ROM is common
AROM before PROM
strengthening
surgical intervention
Median nerve
injured with post dislocation
can be involved with callus formation
can be entrapped under lig of struthers
usually presents as neurpraxia
dx with EMG, NVC
Anterior interosseus nerve
branch of median nerve
between two heads of pronator teres, fracture, or fracture callus
can cause “pronator teres syndrome”
deficit purely motor (no pain)-FPL, FDP, PQ
surgical release is common tx
radial
mid shaft fractures at spiral groove
direct trauma to brachioradialis, extensor carpi radialis
motor nerve
enters the supinator muscle (arcade of Frohse) between two heads
ECRB and fibrous edge of supinator
radial tunnel syndrome
Posterior interosseus
motor nerve
enters te supinator muscle (arcade of Frohse) between two heads
ECRB and fibrous edge of supinator
radial tunnel syndrome
mimics lateral epicondylitis
doe not resolve with standard tx
weakness and pain on resist wrist ad finger EXT/ esp middle
pain on passive stretch
tender over radial nerve
Bursitis
trauma
inflamm dis/gout
repet micro trauma
infection/cellulitis
sometimes can see capsular pattern
tx-injection, padding, rest
Lateral ligament injury
radial collateral lig is primary restrain to varus forces
common extensor tendon, pot capsule, capsule/annular lig are secondary restraints
PLRI has been noted to develop following steroid injection in the lateral elbow
physical exam may appear normal, except post lat instab test (pivot shift). symptoms vague
push sign can provoke-push up with forearms supinated
apprehension is a positive finding
Lateral ligament injury mechanisms of injury
elbow dislocation
varus elbow stress
iatrogenic (related to tx uch as a fracture)
Lateral ligament injury rehab
no evidence favoring particular program
rehab should include protection and reloading of the injured muscles
hinged elbow brace with forearm in pronation for 4-6 weeks
avoidance of shoulder abduction/IR with elbow exercise
following surgery, jt is immobilized for 1-2 weeks, with ROM gradually introduced
protect healing structures with post surgical rehab
Posterior elbow dislocation
if fracture or unstable before 60 deg FLX= surgical mobilization
reduction and immobilization (90 deg with a post splint) for 4 days
days 4-2 weeks hinged elbow brace
by 6 weeks, should have full FLX
can begin low-load prolonged stretching for EXT at 6 weeks
Radial head dislocation
FOOSH, MVA, direct blow, pulling on arm
posterior dislocation most common. can have recurrent dislocations.
divergent-adius seperate from ulna and humerus
rx: neurovascular, alignment, stability
if uncomplicated-excellent results
