Elbow/Forearm Common Presentations Flashcards
What is heterotopic ossification?
- Mature lamellar bone integration in non-osseous tissues
- Asymptomatic -> painful -> progression to ankylosis (loss of motion at joint)
Common MOI of Radial head fracture and dislocations?
FOOSH
Because radial head fractures can be isolated to radial head, proximal forearm, or combined complex, what should we check for?
- Check for concomitant injury at the wrist & upper arm
- Check for concomitant neurovascular compromise
T/F Patient commonly presents to PT following a reduction of their radial head fractures/dislocations
True, might experience - Closed reduction & immobilization vs. ORIF/ replacement/ resection
Symptomology of radial head fracture/dislocation:
- Local pain
- Comminution: More than 2 segments
- Check pulse/sensation
Physical examination of radial head fracture/dislocation:
- Local swelling & tenderness
2. Limited/ painful ROM (active & passive), painful/ weak resistance testing (if administered)
With a radial head fracture/dislocation monitor for what type of complications?
- neurovascular compromise
- healing failure
- incision infection
T/F Early mobilization for radial head fracture/dislocation okay in tolerable ranges
True
What type of interventions for radial head fracture/dislocation? How progress?
Isometrics (initiate around 3 weeks) -> resistive training (5-6 weeks)
What is a monteggia fracture?
Dislocation of the proximal radius (anterior, posterior, or lateral) & ulna fracture
Common MOI of monteggia fracture?
Arm positioned in hyperextension or hyperpronation with direct trauma or FOOSH
What concomitant neurovascular structures should be checked with a monteggia fracture?
- posterior branch of radial nerve
- anterior interosseous nerve
- ulnar nerve
- Light touch sensation, pin prick sensation, and eventually motor
T/F Patient with monteggia fracture commonly present following ORIF (open reduction internal fixation).
True
Symptomology of monteggia fracture:
Local Pain
Physical examination of monteggia fracture:
- Local swelling & tenderness
- Limited/ painful ROM (active & passive)
- Painful/ weak resistance testing (if administered)
Typical intervention management of monteggia fracture:
- Arom initiated ~ 4 weeks post-op
- extension > 90 degrees usually held until ~4-6 weeks post-op
Common MOI of olecranon fractures:
trauma involving triceps contraction with flexion moment on elbow (fall on elbow, FOOSH) = avulsion
Symptomology of olecranon fracture:
- Local elbow pain
- Pain provoked with UE use during daily activities
Physical examination of olecranon fracture:
- Local swelling, tenderness, palpable gap at olecranon
2. Absent/ significant limitations with elbow extension (AROM, resistance)
Non-displaced management of olecranon fracture:
- Immobilized
- Maintain triceps function
- Early (tolerable) ROM (pronation/ supination after 2-3 days, flexion/ extension at ~ 2 weeks with limitations on flexion x ~2 months)
ORIF/excision & repair management of olecranon fracture:
- Pending surgeon restrictions, though early ROM
What is nursemaid’s elbow?
Dislocation of proximal radial head (slips through annular ligament)
Incidence of nursemaid’s elbow in children? Sex?
Incidence: 3% children < 8 y/o
Boys > Girls
Common MOI of nursemaid’s elbow:
- Traumatic injury
- traction on the pronated/ extended forearm
Symptomology of nursemaid’s elbow:
Pain in forearm, wrist, and/or elbow
Physical examination of nursemaid’s elbow:
Painful, flaccid arm in pronated position
What is panner’s disease?
- Growth plate injury
- Osteochondritis
- osteonecrosis (bone dies) of epiphysis
MOI of panner’s disease:
- direct trauma
- vascular changes
Common age of panner’s disease? Sex?
- 5-16
- Males (90%)
Symptomology of panner’s disease:
Lateral elbow pain
Physical examination of panner’s disease:
- Local swelling & tenderness
- Limited/ painful ROM (active & passive)
- possibly hard end-feel with fragmentation
- Painful/ weak resistance testing (if administered)
Management of panner’s disease:
- Activity modification, possibly splinting
2. ROM/ resistive progression based on pt tolerance
What is Osteochondritis Dessecans Capetellum?
- Microtrauma over time (Pathomechanics poorly understood)
- Focal arterial injury f/b necrosis
- Possibly compression of humeroradial joint
- Commonly insidious onset
Symptomatology of Osteochondritis Dessecans Capetellum:
- diffuse lateral elbow pain/ “stiffness”
- Locking/ clicking/ popping/ catching
Physical examination of Osteochondritis Dessecans Capetellum:
- Tenderness humeroradial joint
- Diminished Extension ROM
- Painful pronation/ supination
- Pain with resistance testing
- Imaging: flattening of capitellum, loose bodies
MOI of elbow instability:
- acute trauma (FOOSH with/out rotary force)
- microtrauma (overhead throwers/ repetitive throwing)
Important history when diagnosing elbow instability:
- Prior elbow dislocation
- Repetitive throwing with stress during mid-flexion of elbow
Symptomology of elbow instability:
- Clicking/ popping/ clunk/ locking/ catching in extension AROM (supinated forearm)
Physical examination of elbow instability:
+ Moving Valgus Stress Test
+ Varus and/or Valgus Stress Test
Common MOI of MCL sprain:
Attenuation of valgus/ ER force (Tennis/ overhead throwing/ FOOSH)
Physical examination of MCL sprain:
- C/o medial elbow pain
- Tenderness MCL, local swelling
- Valgus stress testing: Painful/ excessive motion with testing
- Moving Valgus Stress Test
- Painful / limited elbow ROM
Common MOI of LCL sprain:
- Axial compression, ER, valgus force on elbow
Physical examination of MCL sprain:
- C/o lateral elbow pain
- Painful/ limited elbow AROM/ PROM
- Local swelling
- Tenderness LCL
- Varus stress testing: Painful/ excessive motion with testing
Hx of what can lead to olecranon bursitis?
Hx prolonged w/b through UEs or trauma/ fall onto elbow
Physical examination of olecranon bursitis:
- painful posterior elbow
- Observable focal swelling
- Pain with AROM elbow, passive flexion painful
T/F With patient with olecranon bursitis, important to monitor for signs of infection (septic bursitis).
True
Hx of what can be the cause of distal biceps tendinopathy?
Hx repetitive elbow hyper extension or repetitive flexion with stressful pronation/ supination
Physical examination of distal biceps tendinopathy:
- c/o pain anterior distal upper arm
- Tenderness to palpation
- A/PROM: pain end-range shoulder/ elbow extension
PROM – extension (flexion not so much)
AROM – flexion puts stress on biceps tendon - Resistive Testing: painful flexion and supination
Distal biceps tendinosis can progress to what?
Distal Biceps Tendon Rupture at the Musculotendinous junction or radial tuberosity
Incidence of Distal Biceps Tendon Rupture:
Sex?
Age?
- Most likely male
- Increased risk 5th decade
MOI of Distal Biceps Tendon Rupture:
- acute onset
- significant extension moment with elbow flexed 90 deg
- strong biceps contraction
Physical examination of Distal Biceps Tendon Rupture:
- Weakness/ pain with active/ resisted elbow flexion &/or forearm supination
- Pain with PROM & AROM of elbow ext - Ecchymosis (bruising) distal biceps insertion
- Palpable defect/ tenderness
- Biceps Squeeze Test
Hx of what can lead to triceps tendinopathy?
Hx repetitive elbow extension (microtrauma)
Physical examination of triceps tendinopathy:
- Posterior elbow pain
- A/PROM: painful flexion at end-range
- PROM extension probably not so painful - Resistive testing: painful extension
- Tender locally
T/F Triceps rupture is rare, but can be caused by sudden strong triceps contraction with elbow flexion motion (FOOSH)
True
What is lateral epicondylopathy?
- Tendinopathy of the common wrist extensor tendon
- Most common ECRB, ECRL, ECU, EDC origin
AKA:
1. “Tennis Elbow”
2. Lateral Epicondyalgia (pain)
3. Lateral Epicondylitis (acute)
T/F Lateral epicondylopathy is 7x more likely than medial epicondylopathy.
True
Most common age group for lateral epicondylopathy?
35-50
Patient interview for lateral epicondylopathy:
- Lateral elbow pain
- MOI: Microtrauma, repetitive grasping/ throwing
- Aggravation with gripping/ carrying/ grasping
Physical examination for lateral epicondylopathy:
- Tenderness bulk of extensor muscle bellies, common extensor tendon
- Painful tensile loading of extensor units (wrist flexion/ fist, elbow extension)
- Resistive testing painful wrist/ finger extension (especially 3rd digit), radial deviation
- Cozen’s Test
- Resisted Tennis Elbow Test
- Passive Tennis Elbow Test
What is medial epicondylopathy?
- Tendinopathy common flexor tendon of wrist
AKA “Golfer’s Elbow”
Patient interview for medial epicondylopathy:
MOI: Microtrauma (f/b infiltration of fibrotic tissues)
Physical examination for medial epicondylopathy:
- Tenderness common wrist flexor tendon, FCR, pronator teres (radial head), PL, FCU, FDS
- Painful A/PROM wrist extension/ supination
- Resistive testing: painful wrist flexion & pronation
What is cubital tunnel syndrome?
Entrapment of the ulnar nerve as it runs between:
- Medial epicondyle and the olecranon (capsule and medial band of the MCL)
- Cubital retinaculum or between the two heads of FCU
Hx of what can lead to cubital tunnel syndrome?
- swelling
- arthritic changes
- trauma
- job requiring prolonged elbow flexion
- elbow varus or valgus deformity
- overhead throwing athletes
Cubital tunnel syndrome can cause weakness in what muscles?
- FCU
- ulnar half of the FDP
- adductor pollicis hypothenar muscles (only thumb muscle)
- interossei
- 3rd and 4th lumbricals
Cubital tunnel syndrome can cause pain/paresthesia in what areas?
- medial elbow and forearm
2. 5th digit and medial half of 4th digit
Pain/paraesthesia caused by cubital tunnel syndrome will worsen with what motion at the elbow?
Worsens with elbow flexion (space for nerve decreases by 55%)
Physical examination of cubital tunnel syndrome:
- tinel’s sign at the elbow
- Pressure provocation test
- Elbow Flexion Test
4; “claw-hand posture”: MP joints are hyperextended and the IP joints are flexed
- Elbow Flexion Test
Hx of what can lead to ulnar nerve entrapment as it passes through guyon’s canal?
- ulnar artery aneurysm or thrombosis
- carpal ganglia
- hamate fracture
- blunt trauma
- long distance cyclist
- use of pneumatic jack hammers
- use of crutches
Entrapment of ulnar nerve in guyon’s canal can cause weakness in what muscles?
- hypothenar muscles
- adductor pollicis
- interossei
- medial 2 lumbricals (more distal – won’t effect FDP, FCU)
Entrapment of ulnar nerve in guyon’s canal can cause sensory changes to what areas?
5th and medial ½ of the 4th digit
What is pronator teres syndrome? Hx of what can lead to it? Age? Sex?
- Median Nerve compression at lacertus fibrosus, pronator teres or FDS
- Pain in proximal anterior forearm
- Hx repetitive exertion grasping work
- 5th decade; women 4x> men
pronator teres syndrome can cause weakness in what muscles?
- abductor pollicis brevis
- Oppens pollicis
- flexor pollicis brevis
- flexor pollicis longus
- FDP of 2nd and 3rd digits
- pronator quadratus
- FCR
pronator teres syndrome can cause loss of sensation in what areas?
lateral 3.5 digits and palm
Symptoms of pronator teres syndrome are reproduced with resisted:
- Pronation with forearm neutral and gradual ext of elbow (PT)
- Elbow flexion at 120-130 deg elbow flex and max supination (LF)
- PIPJ of 2nd digit (FDS)
Physical examination of pronator teres syndrome:
- Tinel’s: Pronator Teres <50%
2. Provocation with direct compression at pronator teres
What is ANTERIOR INTEROSSEOUS NERVE SYNDROME?
Compression deep head of the pronator teres, FDS, accessory head of the FPL, palmaris profundus origin, accessory lacertus fibrosus
Common clinical presentation for ANTERIOR INTEROSSEOUS NERVE SYNDROME:
- pain in proximal anterior forearm
- Motor = Weakness/ atrophy flexor pollicis longus, FDP of 2nd and 3rd digits, and pronator quadratus
- OK sign: Hyperextension of DIPJ 2nd finger (FDP) and use of lateral portion of the 1st IPJ with pinch grip (opponens)
- Direct compression: negative
ANTERIOR INTEROSSEOUS NERVE SYNDROME causes what sensation impairments?
NONE, motor nerve only
Hx of what can cause Carpal Tunnel Syndrome (CTS)?
- Provocation with wrist movements
- Symptoms increase at night (side lying position with elbow flexed and wrist flexed)
- Repeated shaking of hands improves hand paresthesia/ anesthesia
Carpal Tunnel Syndrome (CTS) affects sensation where?
Lateral 3.5 digits
Carpal Tunnel Syndrome (CTS) affects which muscles?
- abductor pollicis brevis
- Oppens pollicis
3, flexor pollicis brevis - lumbricals (lateral 2)
LOAF (Lumbricles Op, Abductor pb, Fpb)
Physical examination of Carpal Tunnel Syndrome (CTS) :
+ Tinel’s at the carpal tunnel
+ Phalen’s Test
+ Median Nerve Compression Test
Provocation with direct compression at carpal tunnel
What is ape hand deformity?
- Paralysis of the thenar muscles secondary to median nerve injury causes the EPL to drift the thumb medially and posteriorly
- Inability to perform opposition
- Recurrent branch of median nerve injury
What is bishop’s hand deformity?
- Ulnar nerve injury (opening hand - extensors lacking)
- median nerve (close hand - flexor lacking)
What is claw hand deformity?
- Ulnar and median nerve or inferior roots of brachial plexus injured
- Intrinsic weakness
- Long extensors hyperextend the MCPJs
- Long Flexors flex PIPJ and DIPJ
- Curvature of palm lost
What is saturday night palsy?
- Wrist drop
- Radial nerve compression in radial groove
What portion of brachial plexus affected in Erb’s palsy?
- Superior portions of the brachial plexus affected
- Area of convergence of C5 & C6
Loss of what muscles in Erb’s Palsy?
- shoulder lateral rotators & abductors
- elbow flexors
- hand extensors
Loss of sensation where in Erb’s Palsy?
Sensory loss lateral forearm
T/F Erb’s Palsy commonly associated with birthing (delivery) injury.
True, brachial plexus stretched due to traction
Why is Erb’s Palsy also called “waiter’s tip deformity”?
- Shoulder internally rotated & adducted
- Elbow extended
- Wrist flexed
What portion of brachial plexus affected in Klumpke’s Palsy?
- Inferior portions of the brachial plexus affected (intrinsic muscles mostly affected)
- Area of convergence of C8 & T1
Loss of what muscles in Klumpke’s Palsy?
- Loss of intrinsic hand musculature
- Loss of ulnar flexors of the wrist & fingers
Loss of what senses in Klumpke’s Palsy?
Sensory loss medial forearm & hand
What is another name for Klumpke’s Palsy?
Claw hand deformity
T/F Klumpke’s Palsy is associated with hyperabduction of shoulder (e.g. delivery injury).
True
