Elbow and FA- Sprains thru Ulnar n. Entrapment Flashcards
How does valgus stress overload happen?
- Trauma (FOOSH)
- Overuse/repetitive stress with overhead sports
What structures are involved with valgus stress overload?
3 portions of UCL
What does the Anterior portion of the UCL do? Where is it?
- primary stabilizer
- medial epicondyle to coronoid, anterior to ulnar nerve
Where is the posterior portion of the UCL?
Medial epicondyle to olecranon
Where is the transverse portion of the UCL?
Olecranon to coronoid
What does the transverse portion of the UCL do?
Provides varus stability and prevents valgus stress
What would be signs of UCL sprains?
limited and painful ROM in extension, creates more valgus position
What are some signs of valgus stress overload?
- ROM painful and limited with extension
- Stress tests positive with distraction and relief with compression
- Positive stability tests
What stability tests are positive with a valgus stress overload?
- Valgus stress test at 0 and 90 degrees
- UCL instability
What other conditions must we differentiate valgus stress overload from?
Medial epicondyle apophysitis and tendiopathy
What is the mechanism of Varus stress overload?
Same as UCL but with Varus stress
What structure is involved with varus stress overload?
RCL
What shape is the RCL?
Triangular
What does the RCL do?
Provides lateral stability and prevents varus stress
Where does the RCL run?
Lateral epicondyle to annular ligament to lateral radius
What are some specific S&S for varus stress overload?
ROM more pain and limitation with flexion
Positive stability tests (varus stress test at 0 and 90 degrees)
What is the general Rx for Sprains?
POLICED
-possible brief period of immobilization
- bracing and taping PRN
-MET
What is MET for sprains ultimately for?
Tissue integrity and stabilization
What is the MD rx for UCL?
- Direct repair vs. reconstruction with palmaris longus graft
- Reconstructive surgery known as Tommy John sx
How long is the ideal recovery from UCL surgeries?
12-18 months
Why is a palmaris longs graft repair of the UCL successful?
Both are made of the same collagen type so that they both resist tension
What is a pushed dislocation?
When the radial head goes proximal or is pushed into a subluxation/dislocation
What is the mechanism of a pushed dislocation?
Falling on an outstretched hand (FOOSH), usually on thenar eminence which shoves radial head proximally
What are some complications of a pushed dislocation?
may also cause a fx of distal radius and ulna aka Colle’s fx
What is a pulled dislocation?
Radial head distal or pulled subluxation/dislocation - forceful traction through lateral forearm
What structures are involved with a pulled subluxation?
Radioulnar articulations held together by:
- annular ligament
- interosseous membrane
Where does the annular ligament run?
Attaches anteriorly and posteriorly on radial notch, encompasses radial head and holds It against ulna
What does the Interosseous membrane do?
Keeps radius and ulna together, serves as a muscle attachment for forearm and wrist muscles
What are some complications of a humeroulnar dislocation?
- the three nerves around elbow: radial, ulnar, median
- Brachial artery emergency referral
- fractures of radial head
- frequent loss of terminal extension
Why can humeroulnar dislocations result in a loss of terminal extension?
Due to intimate bony congruency of deep joint, immobilization makes it hard to get the extension back
What is the Rx for subluxations/dislocations?
Like ligamentous sprains for worse case hyper mobility/instability
How many sets and reps for acute dislocations?
1-2 sets of 10-15 with light resistance
What is a supracondylar fracture?
Distal humeral segment is fractured and displaced
What is an intercondylar fracture?
Fracture within the humeral condyles
What are some complications with the brachial artery along with condylar fractures?
- Volkmann’s ischemic flexion contracture
** EMERGENCY REFERRAL
What are the 3 types of radial head fractures?
- Nondisplaced
- Displaced
- Comminuted
What can be difficult after an olecranon fracture?
Regaining full extension
What are typical S&S of fractures?
Multiple planes of limitation and weakness, won’t like distraction or vibration
What are special tests after trauma / fracture?
- lack of pronation (highest LR)
- lack of supination
- lack of extension ROM - high sens
- Other motions restricted - high spec
When does PT begin after a fracture?
When clinical union occurs - between 4-8 weeks
What is pain from fracture typically NOT from?
Bone
What is PT for fractures focused on?
Consequences of prolonged immobilization where every tissue is negatively influenced
Why is elbow extension difficult after fractures/surgery?
Elbow is immobilized in flexion after all fractures / surgeries making the regaining of full extension difficult
What is the 2nd most common compression neuropathy seen by hand surgeons?
ulnar nerve entrapment
Where can ulnar nerve entrapment happen?
- cubital tunnel at elbow
- FCU heads in proximal forearm
- Guyon’s canal in hand
What is the etiology of ulnar nerve entrapment?
- Trauma (FOOSH)
- Overuse/repetitive stress with elbow/hand
- Age related joint changes/ RA at elbow/wrist
What two nerve roots make up the ulnar nerve in the cubital tunnel?
C8 and T1
What are some symptoms of cubital tunnel syndrome?
- Medial hand/finger paresthesias
- Weak grip
What are signs of cubital tunnel syndrome with ROM?
- possible limitation with elbow flexion and paresthesias and radial deviation
- Possible limited ext at end range
What are some signs of cubital tunnel syndrome found in resisted testing?
Possible weak wrist and 4th and 5th digit flexion, thumb abduction, and grip
What are some neurological signs of cubital tunnel syndrome?
- possible diminished sensation over ulnar nerve distribution
- positive ulnar nerve dural mobility test
What are some special tests for cubital tunnel syndrome?
- elbow flexion test
- Tinel’s ( Tap test)
- Wartenberg’s sign
Where can we palpate for cubital tunnel syndrome? Why?
Over ulnar nerve
- Provocation with ulnar nerve pressure up to 60 seconds
- May be able to sublux ulnar nerve
What are some specific S&S for flexor carpi ulnaris ulnar nerve subluxation?
- ROM - elbow WNL
- ONLY Wartenberg special test positive
- NO provocation or ulnar nerve subluxation in cubital tunnel with palpation
- Provoked at FCU heads
What are some specific S&S for Guyon’s canal ulnar nerve subluxation?
- ROM: elbow WNL
- Resisted testing - hand but NO wrist weakness
- ONLY Wartenberg special test positive
- Palpation: No paresthesias or ulnar nerve subluxation in cubital tunnel; Provocation at guyon’s canal
Where is Guyon’s Canal?
Hook of hamate at wrist
What is the Terminal nerve branch injury Rx?
- POLI (NO C) ED - when compression is the cause
- Bracing/splinting to assist with eliminating compression
- MET with optimal stresses
What is the MET prescription for terminal nerve branch injury?
MET with optimal stresses to create neural motion/flossing and elimination of compression
** want movement without undesirable symptoms
