Elbow APTA (2) Flashcards
1
Q
If a pt has varus instability, which structure is primarily compromised?
A
- RCL
2
Q
What are the 3 primary scenarios that could generate varus instability?
A
- simple or complex dislocation
- varus elbow stress
- iatrogenic causes
3
Q
What are 2 potential causes of varus instability that could result from relative repetitive stress?
A
- chronic overuse due to significant weightbearing through the UE; e.g., crutch use
- postural deformity; cubitus varus deformity. Could occur following childhood fx or be congenital
4
Q
Is corticosteroid injection concerning for generating varus instability?
A
- yes
- there are cases of posterolateral rotational instability that followed lateral epicondylitis treatment managed with injection
5
Q
What is the typical cause of a varus posteromedial rotary instability?
A
- elbow subluxation that avulses portions of the RCL, or the RCL in its entirety from the lateral epicondyle and fractures the anteromedial tip of the coronoid.
6
Q
A pt presents with lateral elbow pain following a traumatic subluxation. What may be of concern?
A
- varus posteromedial rotary instability, or RCL avulsion
7
Q
What is a standard presentation for pts with long-standing varus posteromedial rotary instability?
A
- clicking/popping with flexion/extension
- aggravation of symptoms with attempts to abduct the arm
8
Q
What is preferred management for varus posteromedial rotary instability?
A
- surgery; usually ORIF
- typically poor outcomes with nonoperative management
9
Q
What are the general rehab considerations post-op stabilization for varus posteromedial rotary instability?
A
- stability and alignment are key to successful outcomes
- shoulder abduction should be avoided for at least the first 4 weeks
- should be careful with force transmission through the elbow at >60* flexion to support the healing of the coronoid px
10
Q
What is the expected mechanism of injury for a posterolateral rotary instability?
What is happening anatomically?
A
- combination of axial compression, valgus stress, and supination
- the ulna supinates or ER away from the trochlea, subluxing the humeroulnar and humeroradial joints, rather than a radial head dislocation
11
Q
What is the typical pt presentation with a posterolateral rotary instability?
A
- vague elbow discomfort, lateral elbow pain
- clicking/snapping/clunking with supination
- “something not right” with elbow extension with supination
- giving way with loaded elbow flexion with supination
12
Q
What is the common differential dx with a posterolateral rotary instability?
A
- RCL insufficiency
- lateral epicondalgia/tendinopathy
- radial tunnel syndrome
- cervical spine referral
13
Q
What are common dx that may be secondary to a posterolateral rotary instability?
A
- lateral tendinopathy
- neural inflammation
14
Q
What are primary considerations to nonoperative management of posterolateral rotary instability?
A
- hinged elbow brace with forearm in supination to protect healing structures (more likely w/ acute injury) for 4-6 weeks
- avoidance of shoulder abduction and IR when performing elbow flexion/extension exercise
- little literature support for strengthening exercise, although conceptually it makes sense to strengthening secondary supports
15
Q
What are typical causes of ulnar (medial) collateral ligament insufficiency?
A
- traumatic valgus stress (FOOSH)
- insidious onset/overuse (overhead throwing athletes)
16
Q
What portion of the UCL is most vulnerable to valgus loading?
A
- anterior portion
17
Q
Valgus force is greatest at the elbow during which phases of the throwing motion?
A
- cocking/late cocking to the acceleration phase
18
Q
What test is appropriate to screen for varus posteromedial rotary instability? How is it performed?
A
- Gravity assisted varus stress test
- seated/standing w/ shoulder in 90* active abduction. Pt actively flexes/extends elbow. Positive with reproduction of symptoms such as clicking/grinding/popping, or pain
19
Q
What is a major drawback for the lateral pivot shift test?
A
- pts usually need to be under anesthesia. This is a dumb test.
20
Q
What does the lateral pivot shift test for? What is the general sequence of motions?
A
- tests for posterolateral rotary instability
- pt in supine, shoulder flexed past 90, elbow in extension. Therapist axially compresses towards humerus, provides valgus/supination force while flexing elbow. Elbow subluxes at ~40-70, then reduces with further flexion
21
Q
What are 3 tests other than the lateral pivot shift that are appropriate to screen for posterolateral rotary instability?
A
- push-up sign
- chair sign
- press up maneuver
22
Q
What test is appropriate to screen for RCL insufficiency? How is it performed?
A
- varus stress test
- Elbow in full extension, then flexed between 5-30*. Therapist applies varus force at varying angles. Positive if increased laxity compared to contralateral side.
- not sensitive enough for posterolateral rotary instability. Really only sensitive enough to pick up stage II disruption or > of the RCL
23
Q
When would it be expected to begin rehab for post-op posterolateral rotary insufficiency repair?
A
- probalby not earlier than 2 weeks. First two weeks the elbow is immobilized.
- however, can still do shoulder isometrics, manual work, or modalities
24
Q
What angle would the elbow be immobilized in for the first two weeks following post-op posterolateral rotary insufficiency?
A
- 45-90* flx in neutral or slight pronation
25
When can a pt expect to get rid of their brace following posterolateral rotary instability repair?
- ~8 weeks. Will be progressively increasing extension from week 2-8. Brace typically has a block for extension.
26
When can a pt expect to begin strengthening exercise at the elbow following posterolateral rotary instability repair?
- ~10 weeks, depending on pt's symptoms
| - may wait until week 16.
27
When can a pt expect to return to sports following posterolateral rotary instability repair?
- 16 weeks at the earliest. May be up to 9 months.
28
When is normal ROM expected following posterolateral rotary instability repair?
- ~8 weeks
29
What are the primary movements to avoid/be careful with during posterolateral instability repair recovery?
- extension and supination
30
What is standard differential dx for UCL insufficiency?
- medial tendinopathy
- posteromedial impingement by ulnohumeral compression
- radiocapitellar overload syndrome
- elbow OA
- ulnar neuritis
31
Would a pt w/ UCL insufficiency describe more instability in pronation or supination?
- pronation; flexors relatively become lax, so lose a bit of secondary stability
32
How long is the elbow immobilized following RCL repair?
- typically up to 2 weeks
33
When can a pt expect to start AROM following RCL repair?
- ~4 weeks
34
Can joint mobs be done 4 weeks out following RCL repair?
- yes, per this protocol; but only grade I or II for pain. I wouldn't.
35
When is a pt expected to have normal ROM following RCL repair?
- by 12 weeks
36
When can strengthening at the elbow begin following RCL repair?
- 12 weeks; initially the elbow flexors with the forearm in pronation for the first 2 weeks
37
When can a pt expect to return to sport following RCL repair?
- 16 weeks to 9 months
38
What is the mechanism that creates valgus extension overload syndrome?
- compression of the olecranon against the humerus with valgus stress, generating a posteromedial impingement
- associated with "tremendous" forces acting on the elbow especially into hyperextension
- often associated with throwing athletes
39
What can a clincian expect for presentation with valgus extension overload syndrome for:
- PROM
- AROM
- PROM: limited extension, flexion contraction and painful combined pronation, valgus force, and extension
- AROM: painful extension
40
What complications may be associated with a valgus extension overload syndrome?
- locking/catching
| - suggestive of chondromalacia, osteophytes, or loose bodies
41
What is appropriate management for valgus extension overload syndrome?
- rest, NSAIDs, initially
- then correction of throwing mechanics; shoulder, core, etc
- local strengthening may target eccentrics for elbow flexors, and progressive power for triceps
42
What syndrome may occur as a result of UCL insufficiency?
- radio-capitellar overload syndrome (lateral compression injury)
- chronic abutment of radial head against the capitellum
43
What is typical presentation for a pt w/ a lateral compression injury?
- TTP at radial head or tip of distal lateral humerus
44
What is a potential complication from a chronic lateral compression injury?
- in adults, chondromalacia, cartilage/bony degeneration
| - in kids, osteochondritis dessicans
45
What is the biggest risk factor for child/adolescent development of "little leaguer's elbow"?
- number of pitches thrown
46
When is operative management of a UCL injury usually required?
- in conjunction with a displaced fx.
| - if non-displaced fx, usually managed non-operatively
47
What is the test with the best statistics when screening for UCL insufficiency?
- moving valgus stress test (spec: 1.0, sens: .75); others don't have validity research behind them
- pt upright with shoulder in 90* abduction and elbow maximally flexed. Add modest valgus torque to elbow until end range ER, then quickly extend to ~30* of elbow flexion
- positive if medial elbow pain is reproduced AND maximal pain is between 120-70* elbow flexion
48
What ROM should produce maximal provocation of symptoms during the moving valgus stress test?
- 120-70*
49
What is execution of the valgus stress test? What is it best for screening?
- elbow in full extension, then 5-30* flexion with modest valgus force. Assessing gapping/pain on the medial elbow. Compare laxity to CL side.
- best for assessing insufficiency of the anterior band of the UCL.
50
Why is the position of slight flexion used for varus/valgus stress tests?
- slight elbow flexion reduces the influence of bony stabilizers and the capsule for stability
51
What are the outcomes for pts with non-operative management of UCL rupture?
- fairly successful for non-athletes
- throwing athletes may not return to prior levels of competition depending on the severity of injury with non-operative management
52
In general, what is agreed upon as an important factor for elbow instability rehab?
- shoulder strengthening...sweet
| - another significant component mentioned throughout the chapter is core stability/integrated mechanics
53
What ROM limitation in baseball pitchers was associated with elbow symptoms?
- limited IR >25*. When addressed, improved elbow symptoms
54
A "Tommy Johns" surgery is a reconstruction of what ligament?
- UCL
55
What's the difference between a primary repair of the UCL and a reconstruction?
- primary repair uses the existing UCL
| - reconstruction is Tommy Johns, or updated variant using the flexor-pronator mass
56
What is the expectation for ROM immobilization following UCL reconstruction?
- likely first 2 weeks, with hinged brace to faciltiate gradual ROM increases afterward
57
How soon can a pt begin strengthening after a UCL reconstruction? When can they expect to begin throwing again? Return to sport?
- 4-6 weeks post-op
- interval throwing won't begin until at least 4 months post-op
- return to sport is 9-12 months post-op
58
The elbow is the _____ most commonly dislocated joint in adults.
- 2nd
59
What is the most common direction for elbow dislocation?
- posterolateral or posterior
60
What is the most common mechanism of elbow dislocation?
- FOOSH
61
What are some concerns to screen for with an elbow dislocation?
- fracture
| - nerve injury
62
What nerve(s) are most injured with a simple dislocation vs a complex dislocation?
- simple: ulnar and median
| - complex: radial
63
A pt comes in following what was dx'd as a simple elbow dislocation, which was reduced in the ED, but they're still having some discomfort. A recent radiograph shows a ulnohumeral distance of 5mm. Is this a concern?
- simple elbow dislocation is managed non-operatively, and typically reduced in the ED.
- an ulnohumeral distance of >4mm is indicative of continued elbow instability
64
What are the considerations for bracing vs mobilization following simple elbow dislocation?
- for a stable elbow joint, bracing would be inappropriate, and immediate functional mobility is recommended
- if unstable, a brace or cast could be appropraite, but immobilization for >14 days increases the risk of stiffness
65
For simple dislocations that are stable after reduction, what is the expected timeline for progression of activities?
- immediate mobilization is typically appropriate, with sling use as necessary
- aerobic exercise involving the UE can begin ~4 days later
- strengthening can begin 7 days later
- recommendations based on military population
66
With a disloaction where there is continued instability, what are the expectations for ROM?
- will limit elbow extension to ~60*, increasing by 10* each week
67
What would you want to see prior to beginning strengthening following a simple dislocation with instability?
- full ROM
68
With an RCL deficient elbow, ________ of the forearm should increase stability, while with a UCL deficient elbow, _______ of the forearm should increase stability.
- pronation for RCL deficient
| - supination for UCL deficient
69
How soon should you be worried about deficient ROM following a simple dislocation? What is recommended?
- would want to see normal ROM within 6 weeks
| - can use a hyperextension elbow brace for 9 months to a year at night
70
What is the focus of rehab following operative management of a simple dislocation?
- focus is to protect healing structures
| - ROM can begin w/in 7-10 days in protected postures
71
What are outcomes like following simple dislocation?
- typically very good. 95% return to previous occupations
72
What defines a complex elbow dislocation?
- extensive soft tissue injury in addition to a fracture
73
What is the "terrible triad" of a complex elbow dislocation?
- elbow dislocation
- radial head fx
- coronoid fx
74
What is standard treatment for a complex elbow dislocation?
- reduction
- fx fixation
- establishing a stable arc of motion (60*-full flx)
- if unable to establish the stable arc of motion, other procedures such as ligament repair/reconstruction need to happen
75
What 3 things would raise suspicion of elbow fx?
- hx of trauma
- fat pad sign (effusion over the posterior aspect of the elbow)
- inability to fully extend the elbow
76
With a complex fx, how quickly should the pt have surgery for fixation
- recommended w/in 24 hours
77
What is the general healing time for bones in an adult?
- 12-16 weeks
78
What are two considerations for post-op fx management for PT in terms of interventions?
- swelling management; manual lymphatic drainage or K taping
| - early ROM to prevent elbow stiffness
79
What are common complications of elbow fractures? (5)
- elbow stiffness
- instability
- non-union
- post traumatic arthrosis
- heterotopic ossifications
80
Olecranon fractures are common in which demographic?
- the elderly
81
What are characteristics of the most common type of olecranon fracture?
- displaced fracture where the UCL remains intact
- disrupts triceps function
- the displaced fracture is intraarticular
82
What are the two common surgical interventions for olecranon fx?
- bony fragment excision with triceps repair
- ORIF
- similar outcomes with both, but > potential for complications with the ORIF
83
Radial head fxs are more common in what demographic?
- female
| - 20-60 yo
84
What are the 3 common mechanisms for radial head fx?
- axial load on pronated forearm
- direct blow to elbow
- hyperflexion injury
85
A pt comes in after falling in a way where she felt like her elbow was bent too far. She's got significant TTP at the lateral elbow. What may be of concern?
- radial head fx
86
What are the 4 types of radial head fracture per the Mason Johnson classification?
- Type I: undisplaced fx
- Type II: large, displaced fx
- Type III: comminuted fx
- Type IV: fx associated with dislocation
87
What is the typical duration/position of immobilization if needed following a radial head fx?
- usually 3 weeks or less to avoid complications
| - full extension rather than flexion to improve ROM
88
Are outcomes for simple vs complex radial head fx managed with ORIF the same?
- not clear
- some research shows that complex will result in poorer outcomes, but another 11 year retrospective study didn't find a difference
89
When is radial head excision appropriate or not?
- if the UCL is intact, radial head excision will have little effect on stability
- if the UCL is not intact, it's not a good idea
- if going to excise, should occur within the first 24 hours to 10 days
90
When is radial head replacement indicated?
- Mason Johnson Type IV radial head fractures
- concurrent UCL or RCL dysfunction with instability
- coronoid fx with fragmentation involving >50% of the coronoid (Type III)
91
What's the common demographic/MOI for a capitellum fx?
- usually young male with high impact trauma or elderly with low/moderate impact
92
Are isolated coronoid fxs common? What is the proposed mechanism for an isolated coronoid fx?
- they are not common; part of the "terrible triad", or part of varus posteromedial instability
- theorized MOI is an axial load with 0-20* elbow flx; increased flx engages the radial head, which would likely be injured as well. These are high energy injuries
93
What should be avoided during early ROM for a complex coronoid fx following surgical stabilization?
What amount of elbow flexion can the pt expect to get back?
- avoid varus forces during early ROM
| - ~110* flx can be expected
94
What are the more common complications following elbow trauma? (6)
- elbow stiffness
- heterotopic ossificans
- complex regional pain syndrome
- neural injury
- arterial injury
- compartment syndrome
95
What is the differentiation between intrinsic and extrinsic elbow stiffness?
- extrinsic is due to any tissue that is outside of the joint (skin, muscle, capsule, ligaments, heterotopic ossificans)
- intrinsic would be any intraarticular structures, joint congruency, and articular surface degeneration
- most elbow stiffness would be a combination of both
96
What is the typical presentation for elbow stiffness?
- loss of extension w/ mild/moderate pain
- likely supination/pronation are affected, but can remain intact in some cases
- ulnar neuritis is a commonly associated diagnosis
97
With treatment for elbow stiffness, when trying to improve PROM, what is a primary concern?
- stretching/mobs should be gentle
- potential to develop heterotopic ossificans with more aggressive stretching
- aggressive manipulation may cause capsular tearing and increased loss of motion
98
What are useful adjuncts to manual therapy when treating elbow stiffness?
- splints, braces, etc to improve ROM (e.g., turn-buckle, or dynamic hinge brace)
99
When is surgical release appropriate for elbow stiffness/loss of ROM?
- with chronic symptoms for up to 12 months with loss of functional ROM
100
Following release for elbow contracture (elbow stiffness), how long can a pt expect to make gains to ROM?
- can make gains for up to 6 months post-op
101
For most elbow surgeries, what nerve is most likely impacted with complications?
- ulnar n.
102
Is heterotopic ossificans (HO) more likely at the hip or the elbow?
What is the rate of HO with fracture/dislocation at the elbow?
- more frequently reported at the hip, however the elbow is at greater risk to develop HO
- rates reported as high as 56% following elbow fx or dislocation
103
What are the most common locations for HO to develop in the elbow?
- between the brachialis and anterior capsule
| - between the triceps and posterior capsule
104
What is the standard presentation for heterotopic ossificans?
- pain with progressive loss of ROM
105
How early can HO be picked up in imaging?
- 5th week with plain films
| - 2nd week with bone scan
106
What is often in the differential for HO at the elbow?
- septic arthritis
- infection
- thrombophlebitis
- CRPS
107
What is the primary aim of PT management for HO at the elbow?
- prevention of a permissive environment for HO development; i.e., decreasing risk of excessive inflammation
- interventions like CPROM, AAROM, education re: avoiding pain during activities
108
What is the predominant feature of CRPS?
- pain that is disproportionate to the injury
| - Also, autonomic, sensory, and motor impairments that develop through the course of CRPS
109
What age/genders are more likely to be dx'd w/ CRPS? Is is more likely in the UE or the LE?
- more likely in females, typically ~40yo
| - ~2x more likely in the UE
110
What is the difference between CRPS I and II?
- CRPS I is associated with a minor injury such as sprain, strain, fx, or surgery
- CRPS II is associated with a known nerve injury prior to onset of symptoms
111
What is the theorized pathophysiology behind CPRS?
- not well understood
- thought to be multifactorial, with dysfunction in the sympathetic nervous system, somatic sensory nervous system, an exaggerated inflammatory response, hypoxia in the integumentary system, and potential psychosocial overlay
112
What are the 3 stages of CRPS?
- they all overlap, but:
- acute inflammation
- dystrophy
- atrophy
113
What is the presentation for CRPS? What can be expected?
- intractable pain in a nonperipheral nerve distribution
- edema with sensory and motor changes in the area
- hyperalgesia, hyperpathia, and allodynia may be present
- may have increased hair or nail growth
- glossy, thin appearance to skin (dystrophic stage)
- skin becoming thin, dry, and cyanotic (atrophic stage)
114
What are some key interventions for CRPS?
- desensitization
- graded motor imagery
- isometric exercises
- postural correction
- ROM
- intervention must be individually tailored
