Elbow

Question 1

Tests for lateral tendinopathy

Answer 1

Cozen’s sign: resisted wrist ext with fingers flexed
Mill’s passive wrist flexion
Mandly’s 3rd finger extension with wrist in neutral
Hand shake test

Question 2

Tendinopathy surgical candidates

Answer 2

Pain with functional limits not resolved after multiple cortisone shots
Failure of rehab with symptoms >1 year
Constant pain
Associated intraarticular pathology

Question 3

What are the 3 groups of surgery For lateral tendinopathy?

What is post-op protocol?

Answer 3

Open
Percutaneous
Arthroscopic (can involve tendon release and/or debridement)
AROM day 1 with full extension AROM by day 10
Need full ROM and strength to return to sport

Question 4

What are tests for distal biceps tendon rupture?

Answer 4

Biceps squeeze test
Hook test
Biceps crease interval test
Muscle testing of supination and elbow flexion

Question 5

What causes varus instability of the elbow?
What causes varus Posteromedial instability of the elbow?
What is treatment?

Answer 5

Varus instability: RCL insufficiency maybe caused by elbow dislocation, varus stress
Varus Posteromedial instability: elbow subluxes and avulses part of the RCL, history of trauma a and popping/clicking
Treatment: operative management preferred and post-op shoulder ABD avoided for 4 weeks

Question 6

What is posterolateral rotary instability?
MOI?
Symptoms?
Avoid?

Answer 6

MOI: combination of axial compression, valgus stress, and supination force that produces rotation at humeroulnar joint
Symptoms: vague elbow discomfort, clicking, worse with sup
void: shoulder ABD/IR to avoid varus opening

Question 7

What is Valgus instability of the elbow?

MOI?

Answer 7

UCL insufficiency

MOI: FOOSH or throwing

Question 8

What are the phases of throwing?

Answer 8

Wind-up
Stride
Arm Cocking
Arm acceleration
Arm deceleration
Follow-through

Question 9

What is elbow valgus extension overload syndrome?
MOI?
What should we train?

Answer 9

Compression of olecranon against humerus with valgus stress generating Posteromedial impingement
MOI: force on elbow, especially into hyperextension
Training: eccentric biceps and forceful triceps

Question 10

What is little leaguer’s elbow?

Answer 10

Medial elbow pain secondary to apophysitis that can progress to avulsion fracture

Question 11

What is the post-op protocol for UCL reconstruction?

Answer 11

Week 2: decrease ROM
Strength @ 4-6 weeks
throwing @ 4 months
Return to sport 9-12 months

Question 12

What is the “terrible triad” of the elbow

Answer 12

Elbow dislocation
Radial head fracture
Type I Coronoid fracture

Question 13

What is the most common direction of elbow dislocation?
What radiographic signs will show dislocation?
What are post-reduction protocols? What could slow this down?
How long should immobilization happen for?

Answer 13

Direction: posterior or posterolateral
Radiographic drop sign = ulnohumeral distance > 4mm
Start UE movement day 4 and strength at day 7
If presence of instability, immobilization but if immobilization >14 days, increases stiffness

Question 14

Why would you need operative management of simple elbow dislocation?
What is post-op protocol?

Answer 14

If there is persistent instability, lack of congruency, or median n entrapment
ROM at day 4 and strength at day7

Question 15

What is considered complex elbow dislocation?

Goals for rehab

Answer 15

Involves soft tissue injury of fracture of radial head and/or Coronoid
Want to stabilize and heal fracture (60 deg of flexion to full flexion to decrease stress) before ROM

Question 16

Why would you suspect elbow fracture?
How would you diagnose?
What is healing time?
What are potential complications?

Answer 16

Suspect if: history of trauma, fat pad sign, instability to elbow extension
Diagnosed via radiograph
Healing time: 12-18 weeks
Complications elbow stiffness, instability, non-Union, post traumatic arthritis, HO

Question 17

What is the MOI for radio head fx?

What is the Mason Johnston classification for radial head fx?

Answer 17

MOI: axial load on probated forarm, direct blow to elbow, hyper flexion injury
Classifications:
I undisplaced
II large, displaced fragment
III comminuted
IV fracture with elbow dislocation

Question 18

Who are surgical candidates for radial head fracture?
What are the effects of radial head excision?
When is a radia head replacement needed?

Answer 18

If >30% of radial head involvements
Rotation ROM limited by mechanical block instead of pain
Excision affects the IOM
Replacement is Mason Johnston IV, UCL/RCL dysfunction and therefore instability, fracture of >50 of Coronoid process

Question 19

What causes elbow stiffness?
What is treatment for elbow stiffness?
What should surgery become a consideration?

Answer 19

• can be extrinsic of intrinsic but is oftentimes with thickened anterior and posterior capsule
• want gentle passive manipulation; aggressive can cause capsular tearing with hemorrhage and loss of ROM
• operative consideration if contracture >12 mo
• final ROM can occur in up to 6 months post-op

Question 20

What causes HO?
Where is it usually in the elbow?
What is treatment?

Answer 20

Caused after trauma up to 2 months
Occurrence at brachialis and anterior capsule or Posteromedial triceps and posterior capsule
Treatment: CPM/AAROM in pain free to decrease inflammation

Question 21

Where can the ulnar nerve become entrapped?
What is treatment of Cubital tunnel syndrome?
What are post-op rehab protocols?

Answer 21

Cubital tunnel, medial inter muscular septum, arcade of struthers, Cubital tunnel, fascia of FCU
Treatment: night splint at 30-45 flex and full sup for 4-6 weeks
- avoid elbow flexion >90 activities, excessive wrist and finger flexion, excessive valgus
- PROM during day to prevent stiffness
Post-op: 1-3 immobilization with avoiding wrist extension and supination
At 3 weeks start ROM with light exercise

Question 22

What are common median nerve entrapment sites?

How do you differentially diagnose between Pronator Teres, CTS, and AIN

Answer 22

Ligament of struthers, Lacertis fibrosis, Pronator Teres, FDS, carpal tunnel
AIN: motor only, no sensory - test OK sign for FPL and FDP of 2nd and 3rd digit
Pronator Teres: lacks + Tinnel sign at carpal tunnel and no ROS with wrist flexion

Question 23

What are radial nerve compression sites?

How do you differential diagnose PIN and RTS?

Answer 23

Radial tunnel bands, vessels of leash of Henry, leading edge of ECRB, Arcade of Froshe, fibrous edge of supinator
PIN vs RTS
RTS - only pain, deep ache distal to lateral epicondyle, no motor/sensory loss, Pain with brachioradialis, supinator, repetitive wrist flexion
PIN: lateral forearm/elbow pain, weak extensors, wrist extension with radial deviation, thumb extension causes pain at elbow

Question 24

What is Panier’s disease?

What causes OA Of elbow?

Answer 24

Panier’s: epicondyle apophysitis

OA of elbow: not decreased joint space but osteophytes and joint capsule contracture

Question 25

What is the ROM expected after TEA?

What is rehab protocol for unconstrained TE?

Answer 25

15-130 ROM

Unconstrained avoid 30-0 for 4 weeks