Elbow Pathology Flashcards
What are the concave/convex components of the HumeroUlnar Joint?
Concave: trochlear notch of the ulna
Convex: trochlea of humerus
Which joint has a carrying angle + norms?
The HU joint: 11-14 men, 13-16 women
What is the resting position of the HU joint?
70 degrees elbow flexion, 10 degrees of supination
What is the closed pack position of the HU joint?
full elbow extension and supination
What is the capsular pattern of the HU joint?
flexion, extension
What are the concave/convex partners of the HumeroRadial joint?
Concave: head of the radius
Convex: Capitulum of the humerus
What is the resting position of the HR joint?
full elbow extension and supination
What is the closed pack position of the HR joint
Elbow flexed to 90 deg and supinated to 5 deg
What are the concave/convex partners of the proximal radioulnar joint
Concave: ulna
Convex: head of the radius
What is the resting position of the proximal RU jont
70 deg flexion 35 deg supination
What is the closed pack position of the proximal RU joint
5 deg supination
What is the capsular pattern of the prox. RU joint
pronation and supination equally limited
What are the medial ligaments of the elbow?
Ulnar Collateral Ligament w/anterior, transverse, and posterior bundle
Which bundle of the UCL is the primary restraint against valgus stress?
Anterior bundle
What are the lateral ligaments of the elbow?
Annular ligament
Lateral Radial Collateral Ligament
Lateral Ulnar Collateral ligament
Which lateral ligament wraps around the radial head?
Annular ligament
Which lateral ligament is associated w/ECRB and supinator
Lateral Radial collateral ligament
What are the primary flexors of the elbow?
Biceps, bracialis, bracioradialis
What are the weak flexors of the elbow?
PT
FCR
FCU
ECRL
What are the extensors of the elbow?
Triceps and anconeus
Where is the common extensor/supinator insertion?
Lateral epicondyle
Where is the common flexor/pronator insertion?
Medial epicondyle
List some pathologies that can occur at the lateral elbow
Lateral epicondylitis
Posterior interosseous nerve syndrome
Radial Tunnel Syndrome
Osteochondritis dissecans
panners disease
Osteochondral degenerative changes
Lateral collateral ligament injury
Synovitis & bursitis
Capitellum fracture
Radial head fracture
Cervical origin (C6-7)
What is the mechanism of injury for Lateral Epicondylitis
Overuse/insidious onset from manual labor actiities (could be due to a repetitive microtrauma)
What would you hear in the history to make you think Lateral Epicondalgia
Pain over lateral epicondyle
Pain with gripping
Occasional night pain or neck and shoulder pain
What are the special tests for lateral epicondalgia
Cozens, Mills and Middle Digit Extension Test
What are the examination findings that would indicate lateral epicondalgia
Full PROM of the elbow, limited wrist flexion - especially with pronation and elbow extension
Pain with resisted extension & RD, weak and painful grip strength
Tenderness at lateral epicondyle
What PT Interventions should be used for lateral epicondalgia?
Education
PREs (for chronic tendonosis not tendonitis)
Prox. forearm strap
Addressing proximal mm strength
manual therapy
What condition should you be mindful of when examining for lateral epicondalgia?
Radial tunnel syndrome
What are the possible areas of compression for Radial Tunnel Syndrome?
1 - Fibrous bands connecting brachialis to brachioradialis
2 - Vascular leash of henry (BV at radial neck)
3 - Medial leading edge of teh ECRB
4 - Fibrous bands at proximal and distal edge of supinator
What is the clinical presentation of Radial Tunnel Syndrome
- Diffuse aching in forearm
- Aggravated by repetitive pronation & supination
- Pain with resisted supination
- No sensory/motor changes
- tenderness over radial tunnel
- worsened w/forearm strap
What are the special tests for Radial Tunnel Syndrome
Pain w/resisted middle finger extension
What Interventions should be used for Radial Tunnel Syndrome?
- Conservative: immobilizations, NSAIDs, PT, and activitiy modification
- Sx (wide success range 10-95%): to decompress radial nerve
What is the clinical presentation of Posterior Interosseus Nerve Syndrome
- Lateral forearm/elbow pain
- Weakness of finger extension
- Thumb extension causes lateral epicondyle pain
- No sensation loss
- Motor symptoms (Impaced mm: EDM, ECU, ED, ECRb, EI, EPL, EPb, APL, Supinator - SPARED MM: Triceps, anconeus, brachiorad & ECRL)
What is capitellar osteochondritis dissecans (OCD)
Separation of a localized area of articular cartilage and subchondral bone
What are the signs and symptoms of capitellar osteochondritis dissecans
- Difficulty extending elbow - often 5-23 degree flexion contracture
- tenderness over lateral epicondyle
- lateral/antereior elbow/forearm pain
- Pain w/Weight bearing
What are the special tests for Osteochondritis Dissecans
Active compression test (Extended elbow w/pronation and supination)
Treatment of OCD
Depends on severity & compliance
- early: conservative 4-6 months
- Late/if needed: Sx (remove loose bodies, microfractures, OATs)
What is Panners disease
Focal osteonecrosis of the entire capitellum
A. OCD vs B. Panners
1. Age
2. History/onset
3. Locking and catching?
4. Duration of symptoms
1A. 10-21 yo vs B. 7-12 yo
2. Repetitive trauma overuse vs B. insidious
3A. locking and catching present vs B. not
4A. 5-6 mo, B. 2-24 mo
MOI for RCL sprain
Trauma, FOOSH, or axial compression w/ER and force
What does radiohumeral bursitis present similarly to?
Lateral epicondylitis
What are possible pathologies of the medial elbow?
Medial epicondylitis
Flexor/pronator strain
UCL sprain
Ulnar neuritis
Coronoid Fracture
CFCS
What two muscles are most affected with medial epicondyalgia
FCR and PT
MOI for medial epicondyalgia
Insidious onset or overuse (more common in golfers, tennis players, and overhead throwers)
Which decade of life is common onset for medial epicondyalgia
4th to 6th
What other condition should you be mindful of if you are thinking medial epicondyalgia?
UCL pathology in OH athletes or an ulnar nerve pathology
What population is a UCL sprain common in?
Baseball pitchers and gymnasts
What is MOI of UCL sprain?
Cummulative microtrauma from valgus + ER at HU jt or FOOSH
What portion of the UCL is affected most in a sprain?
anterior band of anterior oblique ligament
What are the signs/symptoms of UCL sprain
- point tenderness at insertion (1 inch distal to medial epi)
- pain/laxity w/valgus testing
- flexor muscle soreness
What are the special tests for UCL sprain?
Valgus stress test
Milking maneuver
Moving valgus stress test
Non-Sx MGT of UCL Sprain
- period of rest to preserve ROM
- Start w/ROM, PREs of wrist flexors + other surrounding
- Also treat other neighbouring joints, including the trunk/hip
What is little leaguer’s elbow?
Not a diagnosis itself, but is from valgus overload from repetitive throwing
What are possible pathologies from little leaguers elbow?
- medial apophysitis/avulsion fx
- Panners or OCD
- olecranon apophysitis
- posteromedial impingement
What is the best treatment for Little League elbow?
PREVENTION!!
- pitching < 8 mo in the year + adherence to pitching counts
- general LE and UE strength/conditioning
- other sports played too
What is treatment for a small little league lesion?
- rest
- resistance training avoided until full ROM without pain (2-3 weeks)
- no throwing for 6-12 weeks
- total body conditioning
What is Cubital Tunnel Syndrome
Ulnar Neuritis from compression of the medial head of triceps, anconeus, or between FCU
What is the most commonly effected nerve in the elbow?
Ulnar nerve
What are the signs and symptoms?
- Early = sensory w/pain and paresthesia in medial elbow/forearm and ulnar distribution
- late = atrophy of ulnar musculature (FCU + ulnar half FDP, hypothenar eminence, 3rd & 4th lumbricals)
- clawing contracture of ring and little fingers
What muscles are most affected with cubital tunnel syndrome
FCU, ulnar half FDP, hypothenar eminence, 3rd and 4th lumbricals
What are the special tests for cubital tunnel syndrome
- biships deformity
- Tinels at elbow
- Wartenberg’s sign (pinky in)
- Froment sign (paper grip)
How to manage cubital tunnel syndrome?
- Avoid positions that provoke it
- Elbow pad
- Night splint 40-60 deg flexion
- Nerve glides
- possible sx decompression
What are possible MOI for chronic exertional compartment syndrome
- prolonged/repetitive gripping from muscle expansion during exertion while contained in an inelastic tissue envelope
- motorcross, rowing, gymnastics, hockey, WC athletics, climbing
- rarer in UE than LE
True or false: Compartment syndrome = Chronic exertional compartment syndrome
FALSEEEE
What are the signs/symptoms of CECS
- pain in forearm brought on by activity and resolved in periods of rest
- loss of grip strength
- altered senstaion in the hands that does not follow any specific nerve root
- bilateral
Management of CECS
- Non-operative: cessation of activities, PT, botox, taping
- Operative = open fasciotomy
What is Volkman’s Ischemia
Compartment syndrome of the elbow that causes permanent damage
T or F: CECS is permanent damage
False
What are the causes of volkmann’s ischemia
- arterial injury from open laceration
- arterial disruption secondary to severly displaced fractures or dislocations
What does prolonged ischemia to forearm muscles cause (like in Volkmann’s Ischemia)
- muscle necrosis and paralysis
- mm tissue replaced w/fibrous tissue
- severe deformities of hand and wrist
Mild Volkmann’s Ischemia
- 2-3 fingers contracted
- no limited/loss of feeling
Moderate Volkmann’s Ischemia
- all fingers flexed
- thumb stuck in palm
- wrist bent
- loss of some feeling in the hand
Severe Volkmann’s Ischemia
- all mm involved (finger flexors and extensors)
- severely disabiling
What are the S/S of Volkmann’s Ischemia
- purple/pale discoloration of the hand
- severe pain in forearm mm
- paresthesia as dysfucntion progresses
- pain on passive stretch
- swelling
What are the pathologies of anterior elbow pain
- Median nerve entrapment
- biceps strain
- distal biceps tendinopathy/tear
What are the common sites of median nerve entrapment
- Ligament of struthers (supracondylar process to medial epicondyle)
- Bicipital aponeurosis
- PT heads
- Fibrous arch of FDS
What are S/S of pronator syndrome
- pain in proximal anterior aspect of the forearm
- tenderness to PT
- weakness in median nerve distribution distal to PT
- paresthesia/numbness in median nn distribution
- lack of nocturnal symptoms
What mm are involved in pronator syndrome
FCR, PL, FDS, FPL, lateral FDP, PQ, thenar eminence
MGT of pronator syndrome
- rest/activity modification
- NSAIDS
- ICE
- restoration of flexibility/strength of wrist flexors/pronators
- STM
- splinting at 90 deg
What is AIN syndrome
Motor loss but no sensory loss for FPL, lateral half FDP, and PQ from compression at PT head
What are special test for AIN
Ok sign test
What leads to a biceps muscle strain
- strong elbow flexion force
- hyperextension force
- could lead to a rupture
What is MOI for distabl biceps tendon rupture
- eccentric load on lengthened biceps, common in middle-aged men
What are the tests for a distal biceps tendon rupture
- biceps squeeze
- hook test
When should Sx be completed for distal biceps tendon rupture
Soon after injury, but there is debate
S/S of bicipital radial bursitis
- visible/palpable enlargement
- pain in antecubital fossa
- tenderness to palpation at radial tub
- painful resisted movements of elbow flexion and supination
What are pathologies that cause posterior elbow pain
- olecranon tip stress fracture
- olecranon bursitis
- posterior impingement
- triceps tendonopathy
- ulnar neuritis
What is MOI of olecranon bursitis (Students elbow)
- direct trauma
- repetitive grazing
- prolonged WB
S/S students elbow
- slight to extreme distention
- decreased ROM or difficulty wearing a shirt
MOI of posterior impingement
repetitive injury/overuse from forced extension (throwing, swimming, boxing) that causes impingement of olecranon process in the fossa
What are the S/S of posterior impingement
- Posterior elbow pain locking, catching or crepitis worsened w/elbow extension
- limited full elbow extension
Onset of triceps tendonitis
Sudden severe strain as arm is fully extended or sudden sapping of elbow w/flexion force
Signs of triceps tendonitis
- pain with resisted elbow extension
- pain w/PROM of elbow flexion and shoulder flexion
What is the elbow imaging criteria
age > 14 yo
Less than 24 hours
Inability to actively extend the elbow
Adolescent Ossification Sequence at the elbow
C - Capitulum
R - Radial head
I - Internal (med.) epicondyle
T - trochlea
O - olecranon
E - external (lat.) epicondyle
What is the sail sign
- finding on a radiograph that suggests a fx of one or more bones on the elbow
1/3 of all elbow fx are …
at the radial head
MOI for radial head fx?
- axial load on pronated forearm
- direct blow to forearm
- hyperflexion injury
Radial head fx classification
I - non dispalced
II - large dispalced
III - comminuted
IV - Fx w/dislocation
What is MOI of Nursemaid’s Elbow
distraction force on elbow causing radial head to dislocate out of annular lig, common 2-3 yo
Sign of nursemaid’s elbow
Arm held at side + pronated
What technique to fix nursemaid’s elboq
closed reduction and manipulation w/forearm forcefully supinated + downward pressure on radial head
Capitellum Fx?
seen in young male w/blunt force trauma or elderly female w/low to mod force trauma
Coronoid Fx
Uncommon in isolation - more w/RCL instability or terrible triad of the elbow
Olecranon fx?
MOI: FOOSH or backwards fall
Common in elderly
What is a greenstick fx?
- incomplete fx of one or both forearms
What is a nightstick fx?
- ulnar fx in midportion of the bone
- consider pt safety
What is a Monteggia Fx
- radial head injury + prox ulnar fx + disolcation of radial head
MOI of monteggia fx
FOOSH w/ hyperextension/hyperpronation
What is a galeazzi fx?
fx of distal third of the radius accompanied w/dislocation of distal RU jt
What are common causes of elbow dislocation?
- falls, sports, physical assault from valgus moment w/axial load and supination
What is the 2nd most frequent dislocated major joint
Elbow
How are elbow dislocations named?
Direction of the ulna/radius
What injuries can occur from dislocations
Nerves!
Posterior/posteriolateral dislocation of elbow presentation
- sudden onset hx
- deformity of elbow: shorter forearm, disrupted anatomical triangle, dlbow in 45 deg flexion
What should you do if you see posterior/posteriolateral dislocation?
Immediate reduction + ortho consult for neurovascular assessment
What is the terrible triad of the elbow?
- posterior elbow dislocation
- radial head fx
- type I cornoid fx
What is a perched dislocation?
subluxation of humerus onto coronoid process that can lead to medial instability
RA at the elbow causes?
- loss of elbow extension
- local swelling and warmth
- large cysts along olecranon/prox ulna
OA at the elbow s/s?
- loss of terminal extension
- painful locking
- ulnar neuropathy
What causes myositis ossificans of the elbow?
- contusino to brachialis from posterior dislocation or suprachondylar fx
- too mch stretching post injury/immobilization
S/S of myositis ossificans
- pain w/elbow flexion and extension
- palpable area on mm that is warm to touch
- bony end feel
- limited ROM
