L12 Elbow Conditions Flashcards
ABCs of radiograph
alignmnet
bone
cartilage
soft tissue
Primary static constraints of elbow
ulnohumeral articulation
MCL
LCL
Secondary static constraints
radial head
common flexor and extensor origins
capsule
Dynamic stabilizers of elbow
anconeus
triceps
brachialis
Flexor pronator group
stabilizes against valgus stress when in supination
Extensor-supinator group
stabilizes against varus stress when in pronation
Flexion stability
abutment of radial head against capitulum
coronoid process against trochlea
osseous articulations contribute 1/3 jt stability in both flexion and extension
Extension stability
coronoid process impacts against the trochlea
olecranon process into olecranon fossa
osseous articulations contribute 1/3 jt stability in both flexion and extension
0° elbow extension valgus/medial resistance to stresses
(valgus stress)
MCL: 31%
Ant Capsule: 38%
Bony articulation: 31%
90° elbow flexion resistance to valgus/medial stresses
MCL: 54% (mainly ant portion)
Ant capsule: 10%
Bony articulation: 36%
0° elbow extension resistance to varus/lateral force stresses
LCL: 14%
Ant Capsule: 32%
Bony articulation: 55%
90° elbow flexion resistance to varus/lateral stresses
LCL: 9%
Ant capsule: 13%
Bony articulation: 75%
Biomechanics of elbow dislocation
- Ulnar portion of LCL is disrupted
- Remaining LCL structures, ant and post capsule disrupted
- MCL is partially disrupted, involving MCL only or is completely disrupted
Elbow dislocations
most frequent in children
second most frequent overall after shoulder
MOI: foosh with axial loading, supination of forearm
posterolateral is most common
Simple dislocation of elbow
absence of fractures
named for direction of dislocation
Complex dislocation
presence of fractures
Terrible triad
posterior dislocation with intra-articular fractures of radial head and coronoid process
Pt presentation of elbow dislocation
olecranon tip is prominent
shoulder, wrist, and hand involvementn possible
Neural and vascular complications of elbow dislocation
ulnar and median possible with simple dislocations
radial nerve with complex radial head injuries
Non-op management of simple elbow dislocation
Closed reduction
check stability and NV involvement
immobilize at 90° for 7-10 days
limit full extension if grossly unstable
Therapy for simple elbow dislocation
as soon as day 2
begin with AROM gripping, flex/ext
supervised AAROM in stable arm
limit full extension
do not immobilize for more than 3 weeks, you will lose extension
REturn to full activity based on soft tissue damage only
light use at 2 weeks
sports up to 3-4 months
Pronation makes ___ taut and stabilizes ____
supinators
varus
Good to excellent prognosis for dislocation
immediately reduced
no loss of NV
no fx
wrestlers
What decides future stability?
integrity of soft tissue
presence of fx
Little League Elbow definition
overuse injury due to repetitive valgus loading with throwing resulting in microtrauma to an immature skeleton
Tension overload in little league elbow
- medial epicondyle. Results in altered growth of epicondyle, traction apophysitis, stress fractures
- UCL anterior band
- Flexor pronator mass
Younger athletes are more likely to have
apophysitis or avulsion injuries instead of UCL sprains
Throwing causes
medial tension and lateral compression forces
S/S of Little league elbow
m elbow pain in throwing arm
decreased throwing speed, accuracy, distance
tenderness to palpation at medial elbow
pain with valgus stress
Differential diagnosis for Little League
Avulsion fx of medial epicondyle
UCL sprains or tears
Ulnar nerve neuropathy
Avulsion fx of medial epicondyle vs LL elbow
point tenderness and swelling over medial epicondyle, lack of full extension are clinical signs
Interventions for LL Elbow
relative rest
core strengthening
ROM and joint mobs
joint stabilization
biomechanical throwing analysis
progressive throwing program at 4-8 weeks of tx
Pitching over ____ innings in 1 calendar year increases risk of LL elbow by ____
100
3.5 times
limiting the # of innings pitched per year may reduce the risk of injury
Indications for Tommy John
(UCL ant band ligament reconstruction)
high level throwers that want to continue competitive sports
failed non operative management in pts willing to undergo extensive rehab
Technique for Tommy John Surgery
muscle splitting approach
in-situ ulnar nerve decompression
reconstruction: most usually with autograft
Valgus extension overload, pitcher’s elbow
condition characterized by pathology in poteromedial elbow
usually in competitive baseball pitchers
MOI: repetitive stress of pitching leads to excessive shear forces on medial aspect of lecranon tip and olecranon fossa and overload tension at MCL
Progression of Pitcher’s elbow
- chrondrolysis
osteophyte formation
loose bodies
MCL attenuated with repetitive strain
radio-capitellar compression
Pitcher’s elbow is a combination of
breakdown of lateral epicondyle (compression)
and breakdown of medial epicondyle (tension)
Lateral Tendinopathy, Tennis Elbow
overuse injury involving eccentric overload at origin of common extensor tendon
most common cause for elbow symptoms in pts with elbow pain
Demographics of tennis elbow
up to 50% of all tennis players develop it
1-3% of general pop
usually age 35 to 54
lasts from 6 mo to 2 years
resolves after 2 years regardless of interventions
Pathophys of lateral tendinopathy
eccentric overload to ECRB
repetitive pronation/supination with elbow extension
RF are tools heavier than 1 kg, loads hevier than 20 kg at least 10 times a day, repetitive movements for more than 2 hrs per say
Anatomy of tennis elbow
usually begins as a microtear of the origin of ECRB
may also involve microtears of ECRL
microscopic anatomy reveals angiofibroblastic hyperplasia and disorganized immature collagen
S/S of tennis elbow
pain with gripping activities
decreased grip strength
point tenderness ECRB at lateral epicondyle
decreased grip strength
weakness and pain with resisted wrist ext
Provocative Tests for tennis elbow
resisted wrist extension with elbow fully extended
resisted exntesion of middle finger
maximal passive flexion of wrist
all tell you HOW irritable the lateral elbow is
Differential diganosis from tennis elbow
Lateral elbow pain and loss of ROM can be:
elbow OA, radial head fx, osteochondritis of capitellum
Cervical involvement: radiating pain, neck pain, paresthesias, muscle weakness in myotomal pattern
Protected function phase of tx for tennis elbow
limit pain provoking activities
keep limb mobile
MWMs
modalities aren’t great
Total arm strength rehab phase of tx for tennis elbow
proximal stability before distal stability
serratus and lower trap
RC post cuff muscles
eccentric, endurance, stretching of forearm extensors
Return to activity phase of tx for tennis elbow
tolerance to resistance exercises in phase 2
strength
functional ROM
Radial tunnel syndrome
deep aching distal to lateral epicondyle
pain at belly of brachioradialis
pain with resisted supination
pain with repetitive wrist flexion or pronation
initiated and intensified by repetitive movements with pronation
uncommon in general pop
Distal radioulnar joint
concave ulnar notch of radius articulates with convex head of ulna
resting position is with the forearm supinated to 10°
treatment place is the articulating surface of radius, parallel to long axis of radius
Distal Radioulnar Dorsal/Palmar Glides
forearm on treatment table, begin in resting position and progress to end range pronation or supination
stabilize distal ulna by placing fingers of one hand on dorsal surface, thenar eminence and thumb on palmar surface. Other hand goes on radius
glide distal radius (concave) dorsally to increase supinsation or palmar to increase pronation
