Elbow Forearm Surgeries - Dr. Davies Flashcards
Patient Management Model - APTA (8 items)
- Examination
- Evaluation
- Diagnosis
- Prognosis
- Interventions
- (Re-evaluation)
- Outcomes
- Long term outcomes, i.e. 2 years)
Exam Techniques are predicated on (4)
- Clusters of s/s
- Critical pathways
- Clinical Practice Guidelines
- Clinical Decision making
Lateral epicondylitis is
Acute inflammation of the tendon with inflammatory cells
lateral epicondylitis is
(I think maybe it was supposed to say epicondylosis)
non-inflammatory necrotic tissue
Angiofibroblastic hyperplasia
scar tissue
Lateral epicondylalgia
pain at the lateral epicondyle
slang for lateral epicondylitis/osus
Tennis elbow
Slang for Medial epicondylitis/osus (2 names)
Golfer’s Elbow
Little Leaguer’s Elbow
What is the most common pathology we will see in the elbow?
Lateral Epicondylitis
What is the success rate for PT with Lateral epicondylitis?
90-95% success
Rehab for lateral epicondylitis (3 bullets)
- PT
- Eccentric Exercises (for angiogenesis, collagen synthesis, realignment)
- Counterforce braces
What is the most common thing surgeons do for the elbow?
Scopes
Why must we understand anatomy for radiographs?
because imaging studies are all predicated on anatomy
if you see something that looks like an opening in a child’s x-ray, what could it be and what should we do?
It could be many things, including an avulsion fracture or just the epiphysial line.
Look in a book that shows when each growth plate closes (we don’t have to know on hand)
OCD
Osteocondritis Dissicans
what is Osteocondritis Dissicans
I think Dr. Davies said sort of like a bone bruise.
From AAOS:
Osteochondritis dissecans (OCD) is a condition that develops in joints, most often in children and adolescents. It occurs when a small segment of bone begins to separate from its surrounding region due to a lack of blood supply. As a result, the small piece of bone and the cartilage covering it begin to crack and loosen.
The most common joints affected by osteochondritis dissecans are the knee, ankle and elbow, although it can also occur in other joints. The condition typically affects just one joint, however, some children can develop OCD in several joints.
In many cases of OCD in children, the affected bone and cartilage heal on their own, especially if a child is still growing. In grown children and young adults, OCD can have more severe effects. The OCD lesions have a greater chance of separating from the surrounding bone and cartilage, and can even detach and float around inside the joint. In these cases, surgery may be necessary.
http://orthoinfo.aaos.org/topic.cfm?topic=A00610
What are the top three most common elbow surgeries from most common to least common?
- Scopes
- Surgical Debridement: 5-10%
- UCL
what is the percentage of elbow surgeries that is surgical debreidment?
Surgical Debridement: 5-10%
why can a minor cut be a problem?
infection
- itis
acute inflammation
chronic
(don’t understand this card second time around)
- osus
chronic degenrated tissue
- algia
painful
Which muscles does lateral epicondylitis/osus/algia often involve and which is almost always the culprit?
ECRB (main culprit - almost always involved)
ECRL (usually involved)
ECRB = extensor carpi radialis brevis
ECRL = extensor carpi radialis longus
mechanism of injury: epicondylitis/osis /algia
over and over leads to itis
microtearing
osus
Rehab for lateral epicondylitis/osis/algia
Eccentric exercisis (angiogenesis, collagen synthesis, realignment)
counterforce braces
What is a counterforce brace?
It is a band around a body part close to a joint that changes the “attachment” and changes the pull of the muscle direction.
It distributes force over a larger area
What besides PT, Eccentric exercises, & Counterforce bracing can PTs do for lateral epicondyle pathology?
stretching (hand flex & extension)
TERT if pt has fibrotic tissue-necrotic tissue and needs to be stretched
When should PT do TERT on epicondyle pathology?
TERT if pt has fibrotic tissue-necrotic tissue and needs to be stretched
What does TERT stand for?
Total End Range Time
Modalities for Lateral Epicondylitis/osus /algia
Graston
A-stim
From internet: Astym® (A-stim) treatment sets the standard for soft tissue therapy. It regenerates healthy soft tissues (muscles, tendons, etc.), and removes unwanted scar tissue that may be causing pain or movement restrictions. Astym® treatment has helped countless patients by restoring movement, getting rid of pain, and giving back their lives. Here are some of their stories. http://astym.com/Main
What does Graston do and not do?
does not realign collagen. It loosens it. The active resistive exercises is what realigns
What is the Tyler Twist good for?
lateral epicondylitis
What is the Tyler Twist
From Theraband Website
TheraBand FlexBar® Tyler Twist for Tennis Elbow
This eccentric exercise for the wrist extensors was shown to be effective for tennis elbow pain
Instructions:
A. Grasp FlexBar® exerciser in front of you with the injured side and extend your wrist.
B. Grasp the upper end of the bar with your other hand facing away from you
C. Twist the bar with the top hand as you stabilize with the bottom hand
D. Hold both wrists steady as you extend both elbows in front of you. The wrist on your injured side should be extended and the other wrist flexed.
E. Slowly release the bar with your injured side while maintaining tension with the uninjured side.
Repeat 10-15 times up to 3 times a day. Begin with the red FlexBar and progress to the next color when you can easily perform 3 sets of 15. Use ice or Biofreeze for any soreness.
Reference: http://www.thera-bandacademy.com/tba-exercise/FlexBar-Tyler-Twist-for-Tennis-Elbow
What do you do if PT fails in lateral epicondylitis?
corticosteroid injection.
Dry needling may also help to stimulate healing
What do you do if PT and injections don’t work on lateral epicondylitis
Debride the area (remove Angiofibroblastic hyperplasia)
Angiofibroblastic hyperplasia = scar tissue
What two ways can a lateral epicondyle debridement be performed?
Open
Endoscopic
Endoscopy
same as arthroscopy with a scope, but not inside the joint like arthroscopy is
Who often suffers from medial epicondilitis/osus/algia?
Kids playing overhead sports
When is there lots of traction forces on the medial epicondyle?
during overhead throwing
what are the forces doing at the medial and lateral epicondyles during overhead throwing?
medial: distractive forces
lateral: compression forces
little leaguer’s elbow can also be referred to as
epiphysiolysis
order of treatment attmpts for medial or lateral epicondilitis/osus/algia
- PT
- Corticosteroid injection after or with (not usually for children)
- Surgery - starting with debridement tech
VEOS Syndrome
Valgus Extension Overload Syndrome
Three things happen:
- Lateral Compression
- Medial Tension
- Posterior Shear
The three components of VEOS (more details on each)
Three things happen:
- Lateral Compression: compressive forces in radiocapitular joint
- Medial Tension: distractive forces - most common issue here is UCL tear
- Posterior Shear: overuse causes ostyophyte bone spur and fragments breaking of there and consequently some OCDs
Draw and explain VEOS
VEOS Three parts:
- Traction: distractive forces on medial side (most common issue here is UCL)
- Lateral Side: compressive forces in radiocapitular joint)
- Posterior Side: Overuse cause osteophyte bone spur and fragments breaking off there and consequently some OCDs Be able to draw and describe
AVN
Avascular necrosis
What is the most common injury on the medial side of the elbow?
UCL injury
What activity most commonly is the cause of UCL injury?
baseball
two MOI for UCL injury
Macrotrauma (dislocation)
Microtrauma tension injury
In a clinical trial, the MCL failed when _______.
Valgus torque > 33 Nm
What is the valgus force at 90 degrees when throwing?
64 Nm
How does MCL not fail in real life if Elbow valgus torque is 64 Nm during throwing but a clinical study showed MCL failure when valgus torque > 33 Nm? Why is this important?
Flexor Pronator group of muscles makes up the difference.
Make sure you rehab Flexor-pronator mass in rehab for medial epicondyle pathology!!
flexor/pronator group of muscles (superficial) (4)
Superficial -
- Pronator teres,
- flexor carpi radialis,
- palmaris longus,
- flexor carpi ulnaris
flexor/pronator group of muscles (intermediate) (1)
Intermediate - Flexor digitorum superficialis
flexor/pronator group of muscles (deep) (3)
Deep -
- Flexor Digitorum Profundus,
- Flexor Pollicis Longus,
- Pronator Quadratus
flexor/pronator group of muscles (all)
Superficial - Pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris
Intermediate - Flexor digitorum superficialis
Deep - Flexor Digitorum Profundus, Flexor Pollicis Longus, Pronator Quadratus
how many throws does it take to rupture the UCL?
as few as one
Tommy John Surgery
Ulnar Collateral Ligament Reconstruction
Common [elbow?] Surgeries (4?)
- Arthroscopy - diagonstic reasons
- Arthroscopy - Debridement/OCD
- Arthroscopy
- UCL
Elbow Arthroscopy indications (6) KNOW THIS!
- Diagnostic
- Removal of loose bodies
- Removal of bony osteophytes
- treatment - OCD
- Debridement of intra-articular adhesions with arthrofibrosis
- Debridement of synovitis
What joint is one of the most unforgiving?
elbow - it can be very hard to regain motion!
Elbow Arthroscopy contraindications (3)
- Bony anklyosis
- Severe arthrofibrosis
- Concurrent infections
UCL injury is extra-articular but surgeons usually ________ because
___________.
scope the joint
there is a lot of other things that could be going on in the joint besides just UCL tear
What usually happens to performance after any surgery?
can play again but not as well as previous level.
How is performance after UCL repair different than most surgeries?
can get ALMOST back to premorbid performance (other surgeries this is much worse usually)
In real life what do people often think about post UCL performance
that UCL repair improves performance (this is incorrect!!)
Why is it called Tommy John surgery?
Dr. Jobe repaired Tommy John’s UCL this way and he went on to pitch many more years after surgery - highly successful repair
Do you need to harvest a tendon to use in Tommy John Surgery?
Yes (usually take palmaris longus or Gracilis)
what are is the most common tendons to harvest to use in Tommy John surgery?
palmaris longus Gracilis
Which side of the body does the surgeon usually harvest a tendon from in Tommy John surgery?
Ipsilateral side
Sometimes patient has more pain ______ during Tommy John surgery than at the UCL site.
from the knee where Gracilis is harvested
What is always done during surgery before UCL is repaired in Tommy John surgery?
arthroscope; scope the joint capsule first
Who is the leading surgeon for Tommy John surgeries in the world?
Dr. Andrews
Who is the second leading surgeon in the world for UCL surgeries?
Dr. Altchek
What is the difference between True Tommy John Surgery and Docking Technique?
Tommy John: tunnel through sublime tubercle–> figure 8 -> 2 tunnels in medial epicondyle –> secure ends together
Docking: Tunnel through sublime tubercle –> no figure 8 –> through one tunnel in medidal epicondyle –> suture ends of tendon to bone posterior to medial epicondyle
Why is using the sublime tubercle in UCL repair so important?
only place that allows isometricity of the new tendon
What options do you have with the ulnar nerve during a UCL repair (since it is often involved with VEOS)?
Leave it alone (what Dr. Altchek does if no distal symptoms)
Transposition:
- Subcutanious - not great because still exposed to compression
- Subfacial (as a subfacial sling; what Dr. Andrews always does)
- Submuscular - not great because –> entrapment
What kind of brace is necessary after UCL surgery?
ROM-limiting brace
What is the post UCL repair brace protocol?
KNOW THIS!
- Week 1: locked 90 OR AROM 90-60 degrees
- Increase AROM ~10 degrees in flex & ext each week
- Full ROM at ~6 weeks. Don’t wait longer because ROM is VERY difficult to regain in elbow)
Why is it important to palpate the supracondylar line?
fractures common
Neurovascular triad is also vulnerable here
How many kinds of elbow fractures are there and what can be done with them
Lots of kinds
closed or open reductions
ORIF
Open reduction with internal fixation
Where is the most common place in the whole body for Myositis Ossificans to occur?
at elbow
(also happens in quadriceps for football players, but not as much as elbow)
Myositis Ossificans
bone/calcium deposited within muscle
usually macrotrauma
5 more Common Elbow-area and forearm problems
- Supracondylar Fracture - many types
- Myositis Ossificans - elbow most common place
- DJD Injuries
- Elbow Dislocation
- Radial Head Dislocation - traction injury
5 Common Forearm Problems
- Forearm “splints”
- Forearm Fractures - nightstick fracture (ulna)
- Compartment Syndrome
- Colles Fracture
- Smith Fracture (reverse Colles)
Forearm “splints”
like shin splints
problem is in interosseous membrane
Common in:
- people who use jack hammers
- gymnasts (pommel horse)
Elbow Dislocation
almost always goes posteriorally
Concern for neurovascular triad
Treatment: reduce it
Radial Head Dislocation
Children
Traction injury
mills manipulation to try to fix or reduce
A common forearm fracture
“Nightstick Fracture” Ulna
Nightstick fracture
ulnar fracture like when trying to block a nightstick over head
could also involve radius
ORIF
Open reduction with internal fixation
Treatment of fractures (4)
- Closed reduction
- Open reduction with internal fixation
- Open reduction with external fixation
- Open reduction with internal and external fixation
Comminuted fracture
broken in 3 or more pieces
Acute Compartment syndrome
a major medical emergency
could result in amputation if not treated immediately
(chronic compartment syndrome happens in runners - not the same)
Colles Wrist fracture
The most common fracture of the wrist FOOSH on extended wrist
Reverse is Smith’s (reverse fracture) not as common - FOOSH on Flexed wrist
Smith’s Fracture
Reverse Colles Fracture (but not as common)
FOOSH on flexed wrist
Colles Fracture clinical Presentation (4 things)
KNOW THIS!
- Dinner (silver) fork deformity
- Swelling
- Obvious jog just proximal to wrist
- Post-displacement and post-tilt of distal radial fragment
Does Colles fracture need a closed or open reduction?
could be either: Closed reduction or ORIF
T/F: can have many different types of distal radial fractures
True
What is the most common fracture in the distal forearm?
colles fracture
what is the most common carpal fracture
scaphoid
