Elbow Flashcards
Articulations of elbow
Humeroradial
Ulnohemeral
Superior radioulnar
Humeroradial joint
Formed by radial head and capitellum of the humerus
Ulnohermeral joint
Ulnar notch and trochlea of the humerus
Ossesous anatomy provides stability in ___ and ___ of flexion
<20°
> 120°
Stable joint due to
Strong fibrous synovial capsule
Collateral ligaments
Muscular attachments
Lateral epicondylitis - in general
AKA - tennis elbow
An irritation, tendinosis and inflammation of the musculotendinous attachments of the long extensor muscles of the wrist and hand at the lateral epicondyle
The extensor carpi radialis brevis M. is most often involved
Most common cause of adult elbow pain
Lateral epicondylitis - RF
Smoking
Obesity
40-50yo
Repetitive movements for at least 2h daily
Forceful activity - managing physical loads over 20kg
Lateral epicondylitis - exam
Swelling over lateral elbow
Localized tenderness over the lateral epicondyle and proximal wrist extensor muscle mass
Pain with resisted wrist extension with the elbow in full extension
Pain with passive terminal wrist flexion with the elbow in full extension
Lateral epicondylitis - tx
Observation - s/s may last 6 months to 2 yrs
Activity modification / biomechanics
Counter force bracing - wear 6-10 cm distal to elbow joint
Splints to reduce wrist flexion / extension
PT / OT
NSAIDs - oral / topical
Steroid injection
Platelet-rich plasma injection
Lateral epicondylitis - management
Over 90% of cases can be managed non-operatively
X-ray to r/o bony abnormality or calcification
Lateral epicondylitis - when to refer to ortho
Severe pain or marked dysfunction > 6 months
Failure of conservative management, including PT/OT
Requested
Medial epicondylitis - in general
AKA - golfer’s elbow
Less common
An irritation, tendinosis and inflammation of the musculotendinous attachments of the long flexor muscles of the wrist and hand at the medial epicondyle
Medial epicondylitis - exam
Localized tenderness over the medial epicondyle and proximal wrist flexor muscle mass - not the MCL
Pain with resisted wrist flexion with the elbow in full extension
Pain with passive terminal wrist extension with the elbow in full extension
Olecranon bursitis - etiology
Direct injury or trauma
Prolonged pressure
Overuse or strenuous activity
Crystal-induced arthropathy - longstanding or tophaceous gout
Inflammatory arthritis such as RA or spondyloarthritis
Infection (septic bursitis) - this can occur due to transcutaneous transit of bacteria from penetrating injury or microtrauma (most commonly) or hematogenous seeding (less commonly)
Hemorrhage
Olecranon bursitis - exam
Obvious swelling and inflammation
Possibly warmth and erythema
Pain (or not)
Look closely for overt abrasion or puncture wound
Olecranon bursitis - imaging
Not necessary unless you suspect a foreign body
Olecranon bursitis - aspiration and analysis
Palpable fluid R/o infection Dx microcrystalline d/o examine the fluid and note color, thickness and sediment Gram stain Anaerobic / aerobic culture Cell count Crystal ID Fungal and mycobacterium in immunosuppressed pts, gardeners and fishermen
Olecranon bursitis - tx
If high suspicion of infection, begin abx
- >80% are S. aureus and other G+ organisms, but Gram stain is (+) only ub 50-66% of cases
Olecranon bursitis - tx (mild)
Clindamycin
Doxycycline
Bactrim
Olecranon bursitis - tx (severe)
Hospitalization
IV vancomycin + Zosyn or Ancef
Olecranon bursitis - indications for sx
Inability to adequately aspirate Recurrent bursitis Presence of foreign body Adjacent skin/soft tissue infection Ill pt
Distal Biceps Tendon
Attaches to the radial tubercle just distal to radial head
Major function is to supinate the forearm and also a secondary elbow flexor
Distal Biceps Tendon Rupture - MOI
Usually forceful lifting
Distal Biceps Tendon Rupture - presentation
Sudden pain in AC fossa
May have felt a pop
Swelling and ecchymosis in the AC fossa
Distal Biceps Tendon Rupture - exam
Tenderness over the radial tubercle, deep in the AC fossa
Pain / weakness with resisting flexion and supination of the forearm
May have Popeye sig, but less reliable than a proximal tear
Squeeze test
Hook test
Squeeze test
Firm squeeze of biceps muscle belly causes forearm supination
Hook test
The pt flexes the affected elbow to 90° with the forearm fully supinated
The examiner then attempts to “hook” the distal biceps tendon with their index finger and pull it forward
Distal Biceps Tendon Rupture - imaging
MRI of elbow
Distal Biceps Tendon Rupture - tx
Referral to ortho ASAP
Most require sx unless low demand pt
Elbow dislocation - in general
Classified according to the direction of the distal bone
Posterior dislocations are the most common type (80-90%)
Predominantly 10-20yo
Both collateral ligaments are disrupted
Elbow dislocation - MOI
Axial force applied to the extended elbow
Elbow dislocation - presentation
Shortened extremity
Elbow in slight flexion
Elbow dislocation - imaging
Obtain pre- and post-reduction radiographs
Elbow dislocation - exam
Always check NV status before and after reduction
Watch for compartment syndrome
Elbow dislocation - tx
Elbow should be splinted in flexion and pronation after reduction
Early immobilization is important to prevent muscle contractures
Refer to ortho to r/o more complex injuries
Cubital tunnel syndrome - definition
An ulnar neuropathy caused by compression at the cubital tunnel along the medial elbow
Cubital tunnel syndrome - MOI
Swelling from trauma or PG
Osteophytes about the elbow
Arthritis
Repeated microtrauma or pressure
Cubital tunnel syndrome - Presentation
Numbness and tingling in the fourth and fifth digits
Medial elbow pain
Medial forearm pain
Nocturnal numbness and paresthesia
Worsening with elbow and/or repeated wrist flexion
Cubital tunnel syndrome - exam
May have weakness of the innervated muscles (interossei, adductor pollicis, the hypothenar eminence, and flexor carpi ulnaris.
Look for muscle wasting / atrophy.
May have a positive Tinel’s sign at the elbow
Elbow flexion test
Fell the medial elbow during flexion and extension for subluxing nerve
Sensation testing
Tinel’s sign at the elbow
Tapping over the tunnel causes / increases s/s
Elbow flexion test
Hyperflexion at elbow and put pressure on cubital tunnel
NCS
Externally applied stimuli and analysis for the consequent neurophysiologic responses of individual peripheral nerves
NSC are used to
Dx focal and generalized d/o of peripheral nerves
Aid in the differentiation of primary nerve and muscle d/o
Classify peripheral nerve conduction abnormalities due to
- axonal degeneration
- demyelination
- conduction block
Tracks progression regarding clinical course and efficacy of tx
NCS - goals in Cubital tunnel syndrome
Localized the lesion to the ulnar N at the elbow
Determine the character and severity of the injury
Aid in prognosis
Examine for the presence or absence of alternative dx
Cubital tunnel syndrome - tx (non-operative)
PT/OT
Protective pad
Night splint
Nerve glide exercises
Cubital tunnel syndrome - tx (sx)
Convincing clinical weakness, sensory loss
NCS evidence of moderate to severe degree
Moderate to severe progressive s/s for 6m despite conservative measures
Olecranon fx - MOI
Bimodal - high energy injuries in young
Low energy fall in the elderly
A direct blow or as an avulsion injury with a forceful triceps contraction
Olecranon fx - presentation
Pain
Swelling
Ecchymosis
Pain with elbow extension
Olecranon fx - exam
May feel palpable defect
Inability to extend elbow - loss of extensor mechanism
Olecranon fx - imaging
X-ray (best viewed on lateral)
CT by ortho if sx is planned
Olecranon fx - tx
Immobilization if the fx is non-displaced and the extensor mechanism is still intact
ORIF
Radial head fx - MOI
Most commonly from longitudinal loading from a fall on an outstretched arm
Radial head fx - imaging
If fx not apparent, look for fat pad or sail sign on radiograph
Radial head fx - the Mason classification
Type I - non-displaced
Type II - single, large displaced fragment
Type III - comminuted
Type IV - fx associated with an elbow dislocation
Radial head fx - tx
Type I - non-sx with early motion
Type II, with near normal motion: <2mm displacement, no other injuries, non-sx
Type II, with any associated injuries or mechanical block - ORIF
Type III - fragement excision or radial head prosthesis
Type IV - follows above guidelines
Nightstick fx - in general
An isolated ulna shaft fx
Usually from contact, not a fall
Nightstick fx - tx
Non-operative casting if - <50% displacement - <10% angulation - no radial head dislocation - located within the distal 2/3 of ulna Refer
