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Physical Exam > Elbow and Forearm > Flashcards

Elbow and Forearm Flashcards

1
Q

Extensors vs. Flexors insertion

A
  • Extensors insert on lateral epicondyle

- Flexsors insert on medial epicondlye

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2
Q

Location of an elbow effusion?

A

-Always at the antecubital fossa

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3
Q

What does normal ROM exclude?

A

-Intra-articular pathology

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4
Q

What is the primary complaint of an intra-articular process?

A

“I can’t straighten my elbow”

***Loss of smooth elbow motion in athletes is suspicious for osteonecrosis (osteochondritis dissecans) of the humerus

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5
Q

Inspection

A
  • swelling over the olecranon–> olecranon bursitis
  • “popeye” deformity in upper arm–> ruptured biceps tendon
  • Signs of inflammation or effusion
  • Carrying angle: 5-10 degrees men, 10-25 degrees women
  • “Gunstock deformity”–> cubitus varus deformity
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6
Q

Referred pain to the elbow

A
  • Cervical radiculopathy (esp C5)–> elbow pain
  • Rotator cuff can cause referred pain to the elbow
  • **85% of cervical radics involve c6 and c7–> refer to the hand
  • **Key element in the history is that elbow movement would have no effect on pain complaints.
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7
Q

How to assess the Ulnar Collateral Ligament?

A
  • Valgus Stress test
  • Moving valgus stress test
  • Milking maneuver
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8
Q

Moving Valgus Stress Test

A
  • Also assesses UCL, may be more sensitive
  • Shoulder abducted, arm externally rotated, elbow flexes maximally
  • Examiner provides constant valgus force while elbow is quickly extended from this position
  • Positive test is reproduction of medial elbow pain which is worse from 120-70 degrees of elbow flexion
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9
Q

Valgus Stress test

A
  • apply valgus stress with elbow at full extension and 20-30 degrees of flexion
  • positive test is medial elbow pain or increased laxity

***positive test in full extension implies more extensive injury (i.e. ligament and capsular involvement).

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10
Q

Milking maneuver

A
  • Also assesses UCL
  • elbow flexed, valgus force applied to elbow by supporting the elbow and pulling back on the thumb
  • positive test is medial elbow pain
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11
Q

How to assess the Radial Collateral Ligament?

A
  • Varus stress test

- Lateral pivot shift test

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12
Q

Varus stress test

A
  • Assesses radial (or lateral) collateral ligament
  • Apply varus stress with elbow at full extension and 20-30 degrees of flexion
  • Positive test is reproduction of lateral elbow pain or increased laxity compared to the other side

***Injury to the RCL is rare.

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13
Q

Lateral pivot shift test

A
  • Assesses for posterolateral rotorary instability or injury to the ulnar part of radial (lateral) collateral ligament
  • Pt supine, arm is extended overhead and supinated (palm down when over head)—> examiner then provides valgus and axial force while flexing the elbow.
  • Positive test is feeling of apprehension or impending dislocation
  • Under general anesthesia may produce “clunk” from subluxation at around 40 degrees of elbow flexion
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14
Q

Tinnel Sign

A
  • “tapping” over the medial epicondylar groove
  • positive test is radiation of pain into the 4th and 5th digits imply ulnar neuropathy
  • high false positives
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15
Q

Pinch Grip Test

A
  • “make an okay sign”

- inability to do so signifies AIN syndrome–> weakness of the FPL and FDP

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16
Q

Lateral Epicondylosis

A
  • “Tennis elbow”
  • Overuse of the extensor/supinator muscles in forearm
  • Thought to be tendinosis of the ECRB
  • Exam findings: tender over or just distal to lateral epicondyle and positive Cozen test
  • May cause neurologic symptoms radiating to forearm/hand due to irritation of sensory brach of radial nerve (controversial)
17
Q

What test do you use for lateral epicondylosis?

A

Cozen Test

  • elbow extended, hand pronated–> have patient resist wrist
  • positive test is lateral elbow pain
  • **can also do resisted supination

-pt may also have pain with passive wrist flexion and report pain when trying to hold a heavy book when hand is pronated, pain with hand shake, etc.

18
Q

Medial Epicondylosis

A
  • Golfer’s elbow
  • Overuse injury of flexor/pronator muscles in forearm, occasionally related to acute injury
  • exam findings: pain over or just distal to medial epicondyle, pain with resisted wrist flexion/pronation, may have pain with passive wrist extension
  • **Less common than lateral epicondylitis
  • **Ulnar nerve symptoms reported in up to 50%

BUT with ulnar neuropathy you get CONSTANT numbness!

19
Q

Radial Tunnel Syndrome

A
  • controversial
  • compression of radial nerve near elbow– generally weakness is not present
  • some overlap with lateral epicondylosis- coexist in ~5% of patients
  • tenderness is 4-5cm DISTAL to lateral epicondyle, pain reproduced with resisted middle finger extension and/or resisted supination
20
Q

PIN Syndrome

A

PIN- pure motor branch of the RADIAL nerve that arises near the elbow joint

  • patient presents with WEAKNESS of radial nerve muscles
  • always spares the brachioradialis and the ECRL, usually spares the ECRB and supinator
21
Q

What is arcade of frohse?

A
  • formed from proximal tendinous origin of supinator muscle

- MC site of PIN compression

22
Q

What is a Monteggia fracture?

A
  • fracture of proximal 1/3 of ulna with associated dislocation of radial head
  • may be associated with PIN syndrome
23
Q

What are the exam findings of PIN syndrome?

A
  • Radial deviation with wrist extension (KNOW THIS!)
  • May have pain over lateral epicondyle or more distally near arcade of Frohse
  • Weakness of thumb/finger extension at MCP joint, also weakness of wrist extension due to involvement of ECU (radial n.)

Injection options:
-PIN block- If patient has pain may inject 3 cm proximal to wrist joint and 1 cm ulnar to Lister’s tubercle

24
Q

Why do you get radial deviation with wrist extension in PIN syndrome?

A
  • Because ECRL and ECRB come off in the same area–> spared!!
  • Therefore, you get radial deviation due to unopposed action.
25
Q

What is Monteggia fracture associated with??

A

ALWAYS think PIN syndrome–> high incidence!

26
Q

Ulnar (or medial) Collateral Ligament Injury

A
  • Usually in throwing athletes, esp pitchers.
  • Assessed by valgus stress, moving valgus stress, or milking maneuver
  • > 2mm separation in valgus stress radiographs c/w injury, however, MRI is test of choice

-Tommy John surgery: UCL reconstruction

27
Q

Little Leaguer’s Elbow

A
  • repetitive microtrauma to the medial epicondyle leading to medial epicondyle apophysitis or medial epicondyle fragmentation
  • Usually seen with repetitive VALGUS stress in adolescents (pitchers)
  • Exam usually reveals pain with valgus stress test and no instability, tenderness over medial epicondyle
  • Treatment: conservation vs. surgical (if avulsion >3-4 mm)
28
Q

Panner’s Disease

A
  • Osteochondrosis or AVN of elbow (capitellum) seen in young boys (age 5-12), usually <10 years
  • Exam- tenderness and swelling of lateral aspect of elbow, limited elbow extension (typically lack 20-30 degrees from full extension)
  • Treatment: immobilation followed by gradual ROM
29
Q

What disease should you think of in a boy <10 years old who can’t fully straighten the elbow?

A

Panner’s disease–> AVN of the elbow

30
Q

What disease should you think of in a boy 10-16 years old who have elbow pain?

A

Osteochrondritis dissecans (OCD)

31
Q

Nursemaid’s Elbow

A
  • Subluxation of the radial head usually seen in pre-school age children
  • MC ortho injury in children <2 years, girls>boys
  • Usually caused by swinging the child
  • Typically hold arm in flexion/pronation across the body and the child will not use the arm
  • Reduced by supination/elbow flexion and /or hyperpronation
32
Q

Olecranon Bursitis

A
  • located at the tip of the elbow/olecranon process- may be affected by gout, RA, sepsis, or trauma (usually repetitive from leaning on elbows/laying carpet, etc.)
  • Dx by identifying cystic swelling over the olecranon process
  • KEY: Elbow ROM is preserved!!!
  • Aspiration may be performed
  • Rx: give elbow pad
33
Q

Ulnar Neuropathy

A

MC site of entrapment is at the elbow/cubital tunnel

Exam findings:

  • Elbow flexion test: pt holds arm in >90 degrees elbow flexion, supination, and wrist extended–> reproduction of pain/paresthesias in <60 sec is positive
  • positive tinel’s at the elbow (false positives)
  • Atrophy of FDI/weakness of ulnar innervated muscles
  • Wartenberg sign (inability to adduct 5th digit)–> wallet sign!
  • Froment’s sign (inability to do lateral pinch grip)
34
Q

What borders the Cubital tunnel?

A
  • bordered by the medial epicondyle, olecranon

- aponeurosis of FCU and Osborne’s ligament form the roof of the tunnel

35
Q

AIN Syndrome

A
  • pure motor branch of median nerve
  • Innervated the FPL, 2ng and 3rd digits of FDP, and pronator quadratus
  • Patient unable to make “okay” sign–> positive pinch grip test
36
Q

What are the sites of AIN compression?

A
  • Pronator teres (deep head)- MC
  • Thrombosed radial or ulnar artery
  • Fascial band at origin of FDS
  • Gantzer’s muscle (accessory head to FPL)
  • Other (enlarged bicipital tendon bursa, other aberrant accessory muscles)
37
Q

Triceps Tendonitis

A
  • overuse injury 2/2 repetitive arm extension
  • posterior elbow pain with tenderness at insertion of triceps tendon
  • pain with resisted elbow extension (activates the triceps)
38
Q

Distal biceps tendonitis

A
  • Overuse injury due to repetitive elbow flexion or supination vs. eccentric overload injury
  • may lead to ruptured biceps tendon- “popeye deformity”
  • Pain in antecubital fossa, pain with resisted elbow flexion or supination

Physical Exam (7 decks)

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