Elbow Lecture Flashcards
History indicates insidious onset; Pt complains of weakness and pain. What should you do?
Screen the cervical spine
Include extremity joint assessment, reflexes, and/or myotome assessment).
If there is pain while leaning on the “point” of the elbow, what is indicated?
Olecranon bursitis
What elbow pathology is more likely in a younger Pt than older?
Radial head dislocation
Falling forward FOOSH has an increased risk of _____________ fracture than falling backward FOOSH which has an increased risk of a _________ fracture.
Forward FOOSH -> Radial head fx
Backward FOOSH -> Olecranon fx
With locking or catching in the elbow, what may be present?
Loose bodies
What two pathologies are a possibility if the elbow is unable to fully extend (elbow extension test)?
Synovitis
Fracture
What is elbow synovitis?
Inflammation of the synovial membrane surrounding the elbow
A “pop” with pain and swelling medially may mean a ___________.
MCL sprain
How are conditions at the elbow commonly described?
by their location
E.g lateral epicondalgia, radial tunnel syndrome…
Identify 3 medial impairments of the elbow:
Golfer’s elbow
Little Leaguer’s elbow
Cubital tunnel syndrome
Identify 2 anterior problems of the elbow:
Biceps tendonitis / -osis
Biceps bursitis / tumor
Identify 4 posterior problems of the elbow:
Olecranon bursitis
Olecranon fracture
Triceps tendonitis / osis
Left-arm / elbow pain
Identify 2 mechanisms that could lead to cubital fossa pain:
Tear of brachialis muscle at MT junction
Biceps brachii lesion
When left arm / elbow pain is precipitated by physical exertion and relieved by rest, what is a likely symptom?
Angina
When a fracture is suspected, what can be done during screening?
Use of a tuning fork + stethoscope
If sounds are diminished or absent from injured limb compared to uninjured = positive.
During an isolated muscle test of the biceps, the forearm should be in ________.
Supination
During an isolated muscle test of the brachialis, the forearm should be in ________.
Pronation
During an isolated muscle test of the brachioradialis, the forearm should be in ________.
Neutral
During an isolated muscle test of the common flexors, the forearm should be in ________.
Supination
_____ is the strongest wrist flexor.
Flexor carpi ulnaris
During an isolated muscle test of the common extensors, the forearm should be in ________.
Pronation
______ is the strongest wrist extensor.
Extensor carpi ulnaris
What nerves may be involved if the common flexors are impaired?
Ulnar (C8-T1)
Median (C6-7)
What nerve root may be involved if the common extensors are impaired?
C6-8 nerve root
If there is pain in the common extensors resisted test, what else is likely?
Possible lateral elbow pain / epicondylalgia
If there is pain with the common flexors resisted test, what else is likely?
Possible medial elbow pain / tendinopathy
When there is pain during resisted elbow flexion, what are 4 structures that could be lesioned?
Biceps brachii
Brachialis
Brachioradialis
Wrist extensors
When there is pain during resisted elbow extension, what are 2 structures that could be lesioned?
Triceps
Anconeus
When there is pain during resisted forearm supination, what are 4 structures that could be lesioned?
Biceps brachii
Wrist extensors
Radial nerve
Supinator
When there is pain during resisted forearm pronation, what are 4 structures that could be lesioned?
Wrist flexors
Median nerve
Pronator teres
Pronator quadratus
When there is pain during resisted wrist extension, what are 2 structures that could be lesioned?
Wrist extensors
Radial nerve
When there is pain during resisted wrist flexion, what could be lesioned?
Wrist flexors
Osteokinematics refers to ______.
ROM
Arthrokinematics refers to _______.
Joint play/mobilizations
Which tendon of the biceps is more likely to rupture?
The long head of the biceps tendon
What is the MOI for the distal biceps tendon to rupture?
With a large eccentric load, usually with fatigue
What event is the most common cause of trauma at the elbow joint?
FOOSH
Identify 3 things that may fracture due to a traumatic event in the elbow:
Olecranon
Capitellum
Radial head
Identify 2 neural issues that may be caused after a traumatic event:
Neuritis
Ulnar nerve subluxation
Overuse syndromes are most likely to primarily include the following (3):
Lateral epicondylopathy
Medial epicondylopathy
Triceps tendon enthesopathy
Traumatic pathologies are most likely to include the following
(4):
Partial or total tendon rupture
Ligament rupture
Fracture
Dislocation
Inflammatory disorders are most likely to include the following (2):
Bursitis
Intra-articular effusion
Entrapment neuropathies are most likely to include the following (2):
Cubital tunnel syndrome
Radial tunnel syndrome
A medial collateral ligament sprain is also known as what?
Ulnar collateral ligament sprain
The MOI for an elbow MCL sprain is VALGUS/VARUS force.
Valgus
In throwing athletes, what phase causes MCL sprain?
The wind-up phase
Two ways to diagnose an MCL sprain:
Valgus stress test is painful
Palpation over ligament is painful
How do you manage an MCL sprain?
Restrict ROM to 20-90 with gradual progression
Ice
anti-inflammatory modalities
Isometrics
(Rest)
What is the MOI for little leaguer’s elbow?
Forceful pitching
A stress fracture and partial avulsion of the medial epicondyle in children and adolescents is known as __________.
Little leaguer’s elbow
Two ways to diagnose little leaguer’s elbow:
Mobile epicondyle
Point tenderness
How do you manage little leaguer’s elbow?
Rest
Ice
Limit contraction of wrist flexors
Progressive ROM and strengthening
Limit pitch count
Miner’s elbow or Washwoman’s elbow refer to this condition:
Subcutaneous bursa over triceps tendon (olecranon bursitis)
What is the MOI for Miner’s elbow?
Repeated pressure on elbow
What is the MOI for Washwoman’s elbow?
Repeated elbow extension
What are 2 mechanisms of injury for olecranon bursitis?
Repeated pressure
Deposit of uric acid crystals (gout)
How is olecranon bursitis diagnosed?
Soft, fluid filled pouch, pain with pressure.
How do you manage olecranon bursitis?
Modalities, behavior modification, aspiration, compression.
Cubitus varus is also known as what?
Gunstock deformity
What is the cause of cubitus varus?
Malunion of medial supracondylar fracture. May have healed in an abnormal position
How is cubitus varus diagnosed?
Varus deformity
How do you manage cubitus varus?
Generally you don’t… but you can get an osteotomy (insert bone fragment to correct alignment).
A fragment in the joint space is termed what?
A loose body
A loose body can be _______, _________, ________, etc.
Bony, cartilaginous, soft tissue, etc
Identify 3 potential causes for loose bodies:
Osteochondritis dissecans
Acute trauma
OA
How do you diagnose a loose body (2)?
History of sudden locking
Fragments on radiograph
How do you manage loose bodies in a joint (2)?
High velocity low amplitude (HVLA)
Excision
When is an excision appropriate/likely to deal with loose bodies in a joint?
If manipulation and moving around to alleviate pain isn’t effective.
What two ligaments in the elbow are often injured together? Why?
The lateral collateral and annular ligaments due to the LCL being attached to the annular ligament.
What is the MOI for LCL and annular ligament sprain?
Excessive varus force
How do you diagnose a sprain of the LCL and annular ligament (2)?
Varus stress test
Tenderness
How do you manage a sprain of the LCL and annular ligament (3)?
Ice
Modalities
Friction massage (??)
Biceps tendinopathy at the distal attachment is LESS/MORE common than at the long head at the shoulder.
Less common
What is the MOI for Biceps tendinopathy?
Strong or repetitive elbow flexion
How do you diagnose biceps tendinopathy?
Resisted static contraction
How do you manage biceps tendinitis?
Similar to any tendinitis - Modalities, ice, gradual strengthening
Friction massage (??)
What is the MOI for distal biceps tendon rupture?
Forceful eccentric contraction
How do you diagnose distal biceps tendon rupture?
Weak, painless flexion during resisted isometric
How do you manage distal biceps tendon rupture?
Usually do nothing.
Surgical repair possible
A brachialis tear is managed in the same way as what other structure?
Distal biceps
Lateral epicondylitis is also known as _________.
Tennis elbow
According to Cyriax, the origin of the __________ was the primary site of injury for lateral epicondylalgia, but the ECRL and ECU are also indicated.
ECRB
___–___% of the population have lateral epicondylalgia?
1-3%
People who have lateral epicondylalgia are typically ___-___ years old.
35-50
What is the MOI for lateral epicondylalgia?
Overuse (micro) or a single forceful contraction (macro)
How do you diagnose lateral epicondylalgia?
Resisted static contraction, tenderness
How do you manage lateral epicondylalgia (7)?
Modalities, ice, stretching, modify activity, gradual strengthening, cuff/brace.
Friction massage (??)
Medial epicondylalgia is also known as what?
Golfer’s elbow
What is the MOI for medial epicondylalgia?
Overuse (micro) or a single forceful contraction (macro)
How do you diagnose medial epicondylalgia?
Resisted static contraction, tenderness
How do you manage medial epicondylalgia (7)?
Modalities, ice, stretching, modify activity, gradual strengthening, cuff/brace.
Friction massage (??)
T/F Medial and lateral epicondylalgia must be diagnosed and managed in ways unique to their side.
False, they are the same.
Histology shows that epicondylosis is often not inflammatory, but _________.
degenerative
Describe Nirschl’s stages of repetitive microtrauma stages I-IV:
Stage I: Injury is inflammatory, no associated pathologies, likely to resolve.
Stage II: Associated with pathologic alterations (tendinosis, degeneration)
Stage III: Associated with pathologic changes and complete structural rupture.
Stage IV: Features of stage 2 and 4 as well as other changes
Which stage of Nirschl’s stages of repetitive trauma is most associated with overuse / overload?
Stage II
What two arteries does the brachial artery divide into at the elbow?
Radial and ulnar arteries
What is Volkmann’s ischemic contracture? What does it follow?
A permanent shortening of the forearm muscles that gives rise to a clawlike deformity of the hand, fingers and wrist. It follows a disruption of blood flow (i.e. fracture).
Describe the different grades of Volkmann’s ischemic contracture (mild-severe).
Mild: Flexion contracture of 2-3 fingers
Moderate: all fingers and thumb, some decreased sensation
Severe: Involves all muscles of the forearm and hand
How do you manage Volkmann’s ischemic contracture?
Splinting in functional hand position
What causes cubital tunnel syndrome?
Entrapment of the ulnar nerve in the cubital tunnel
Identify 4 S/S of cubital tunnel syndrome:
Numbness and/or weakness in ring and little fingers
Tenderness
Decreased coordination of hand
Ulnar nerve distribution
How do you manage cubital tunnel syndrome (2)?
Decrease pressure
Surgical release
Radial nerve palsy is also known as what?
Saturday night palsy
What are the causes of radial nerve palsy (4)?
Dislocation of the radial head
Entrapment in supinator
Repetitive twisting
Pressure
What are the S/S of radial nerve palsy?
No active extension of fingers, wrist
How do you manage radial nerve palsy (3)?
Relocation of radial head or release
Decrease pressure
Splinting
Median nerve palsy is sometimes referred to as what?
Pronator teres syndrome
What is the cause of median nerve palsy?
Entrapment in pronator teres
What are the S/S of median nerve palsy (2)?
Forearm pain
Decreased pinch
How is median nerve palsy managed (1)?
Soft tissue release (??)
What three regions refer pain to the elbow? “What should I screen to rule out my differential diagnoses?”
Shoulder
Wrist
Neck
Above and below and the part of the spine related to the area.
A supracondylar fracture occurs most often in this patient population:
Children
What are the MOIs for posterior displacement and anterior displacement supracondylar fractures?
Posterior displacement: FOOSH (can injure anterior neurovascular tissues as well).
Anterior displacement: Fall onto flexed elbow
What are the S/S of a supracondylar fracture?
Pain
swelling
S-shaped deformity
Fragments seen on radiograph
Management for a non-displaced supracondylar fracture:
Immobilization - probably casted
Return to activity
Management of a displaced supracondylar fracture:
Closed reduction or ORIF
Immobilization
Progressive ROM and strengthening
Transcondylar fractures are more common in this patient population:
elderly, osteoporosis
T/F the MOI and the management for a transcondylar and a supracondylar fracture are the same.
True
What is an ORIF?
Open reduction and internal fixation - a type of surgery used to stabilize and heal a broken bone.
What is required for a fracture to be considered complex?
The joint space must be disrupted
Intracondylar fractures are ALWAYS considered _________ fractures.
Complex
A vertical fracture between condyles is termed this:
Intracondylar fracture
What is the MOI for an intracondylar fracture?
Excessive force through olecranon (fall onto point of elbow, splits condyles apart)
What are the S/S for an intracondylar fracture (4)?
Short arm
Wide elbow
Mobile condyles
Fragments seen on radiograph (difficult to see non-displaced)
How do you manage an intracondylar fracture (3)?
ORIF
Gentle ROM
Isometrics - progress to isotonics
What movement is slow to return after an intracondylar fracture?
Extension
If a fracture may impact a growth plate, it is considered a __________________ fracture.
Complex
A Lateral condylar epiphysis fracture occurs in children under what age?
Under 16
MOI for a lateral condylar epiphysis fracture
FOOSH with supination and varus stress
(Stretches LCL, avulses lateral epiphysis)
S/S of lateral condylar epiphysis fracture (3)
Edema
Tenderness
Painful passive wrist extension
Management for lateral condylar epiphysis fracture (non-displaced and displaced):
Non-displaced: Immobilize, ROM, strengthening.
Displaced: ORIF, immobilize, etc.
Medial condylar epiphysis fracture is similar to ___________.
Little leaguer’s elbow
MOI for a medial condylar epiphysis fracture
FOOSH with wrist hyperextension
S/S for a medial condylar epiphysis fracture
Edema
Tenderness
Possible N/T in ulnar fingers
With a medial condylar epiphysis fracture, what nerve may experience pressure?
Ulnar nerve
The management of a medial condylar epiphysis fracture is the same as what?
Lateral condylar epiphysis fracture
MOI for olecranon fracture:
Direct trauma
S/S for an olecranon fracture (4):
Edema/effusion
Pain
Decreased ROM
If triceps torn (sometimes happens) - inability to extend elbow
Management of an olecranon fracture (non-displaced and displaced):
Non-displaced: Immobilization, ROM, strengthening.
Displaced: ORIF, immobilization, etc.
MOI for an avulsion fracture of the olecranon:
Pull of triceps (e.g. javelin throwers)
S/S of an avulsion fracture of the olecranon (1):
Unable to extend elbow against gravity
Managment of an avulsion fracture of the olecranon (2):
ORIF or fragment excision
reattachment of triceps
A radial head fracture is an _________ fracture.
impaction
MOI for a radial head fracture:
FOOSH
S/S for a radial head fracture (3):
Painful pronation
Painful supination
Radiograph shows vertical split, lateral displacement or shattering
Management of a radial head fracture (5):
Immobilization or ORIF then immobilization
ROM
Strengthening
Possible radial head excision
Possible radial head implant
If there is only a dislocation, with no fracture, what is this termed?
Simple dislocation
When there is a dislocation as well as a fracture, what is this termed?
Complex dislocation
The elbow is the ___ most commonly dislocated/subluxed joint in the body following the _________.
2nd; shoulder
With an ulnar dislocation, the ulna dislocates ANTERIORLY/POSTERIORLY. What else will often dislocate with it?
Posteriorly; the radial head
MOI for an ulnar dislocation:
FOOSH with elbow extended or hyperextended.
S/S for an ulnar dislocation (4):
Deformity
Pain
Swelling
Complications
Managment for an ulnar dislocation:
Closed reduction under anesthesia
Surgical repair of soft tissues
Immobilization, ROM, etc.
MOI for a radial head dislocation:
Swinging child by arms or yanking
S/S for a radial head dislocation (1):
Pain with supination
Management of a radial head dislocation:
Relocation with distraction, supination, and flexion.
What is the most common form of elbow instability?
Posterolateral rotary instability (PLRI)
Describe a Monteggia’s fracture:
Fracture of proximal third of ulna with anterior dislocation of the radial head
MOI for a Monteggia’s fracture:
Forced pronation
S/S for a Monteggia’s fracture (2):
Anterior angulation and shortening of forearm.
Radial head palpable in antecubital fossa
What is a possible complication after a Monteggia’s fracture?
Radial nerve injury
Management for a Monteggia’s fracture:
Closed reduction or ORIF, immobilization, ROM, strengthening.
What tissue damage is possible during an ulnar dislocation?
Tearing anterior capsule, brachialis
Overstretch of medial collateral, nerves, blood vessels.
T/F Osteoarthritis can affect any/all of the elbow joints.
True
Osteoarthritis of the elbow usually follows __________.
Trauma (unilateral)
How do you diagnose elbow OA (2)?
Capsular pattern
Radiography
Management of elbow OA:
ROM, isometrics, modalities, mobilization
May require arthroplasty
Describe rheumatoid arthritis
Systemic inflammation of tendons and ligaments leading to decreased stability of joints. Often can occur bilaterally.
Describe osteochondritis dissecans
A joint disorder in which a segment of bone and cartilage starts to separate from the rest of the bone after repeated stress or traum
What structure is often involved with osteochondritis dessecans?
The capitulum of the humerus
Osteochondritis dessecans often occurs in which 2 patient populations?
Adolescents and young adults
Management of osteochondritis dessecans:
Manipulation PRN to restore normal mobility.
excision in extreme cases
Night stick fracture tends to be _________ of the ulna. Monteggia is the ____________ of the ulna.
in the mid portion; proximal third.
Septic arthritis is more often seen in the ________ and ________.
Shoulder and wrist
What is the cause of septic arthritis?
A bacterial infection
S/S of septic arthritis (4 acute and 3 chronic):
Acute - increased temp, swelling, stiffness, pain at rest.
Chronic - muscle wasting, osteoporosis, bony erosion.
Management of septic arthritis:
Treat early on
Antibiotics, joint protection (e.g. splinting)
Compare and contrast OA vs RA
No cure for either
Both cause joint pain, stiffness, and swelling.
Symptoms tend to be worse in the morning
OA is unilateral, RA often bilateral.
OA is bone, RA is soft tissue
OA caused by wear and tear, RA is autoimmune
S/S of neuropathic arthritis (3)
Progressive weakness and instability
Loss of pain and temp sensation
Can lead to flail elbow
Treatment for neuropathic arthritis:
Splint in functional position
List 4 indications for an arthroscopy:
Diagnostic
Excision of loose bodies
Debridement
Occasionally collateral ligament repair
Minimally invasive!
