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PHTY3120 > L14: Examination Elbow 1 > Flashcards

L14: Examination Elbow 1 Flashcards

1
Q

What are the 3 joints in the elbow (compound synovial joint complex)?

A
  1. Humeroulnar joint
  2. Radiohumeral joint
  3. Superior radio-ulnar joint
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2
Q

What are 4 characteristics of the humeroulnar joint?

A
  1. Articulation: trochlea of the humerus and trochlea notch of the ulna
  2. Stable bony arrangement
  3. Uni-axial hinge joint:
    • Flexion/extension
    • NB: Small amt of rotation and side to side motion due to asymmetry
  4. In the frontal plane, medial aspect of trochlea extends more distally than the lateral aspect
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3
Q

What is the close packed position and open packed postion humeroulnar joint?

A
  • Close packed position
    • extension and supination
  • Open packed position
    • 70º flexion, 10º supination
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4
Q

What is the carrying angle for the humeroulnar joint?

A

Accounts for carrying angle (valgus alignment)- In full extension and supination

  • Female > male
  • Between 10-15º in females
  • Between 5-10º in males

Looking for a loss or excessive carrying angle

  • Malunion (fracture)
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5
Q

What are 2 characteristics of the radiohueral joint?

A
  1. Articulation: capitellum (Ball shape) of the humerus and radial head (Cup shaped)
  2. Spherical joint
    • Flexion/extension
    • Pronation/supination
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6
Q

What is the close packed position and open packed postion radiohumeral joint?

A
  1. Close packed position
    • 90º flexion, 5º supination
  2. Open packed position
    • elbow extension, supination
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7
Q

What are 2 characteristics of the superior radioulnar joint?

A
  1. Articulation: convex rim of the radial head and concave radial notch of the ulna
  2. Pivot joint
    • pronation/supination
    • NB: Moves with the inferior RUJ
    • With affect joint at the other end
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8
Q

What is the close packed position and open packed postion superior radioulnar joint?

A
  1. Close packed position
    • 5º supination
  2. Open packed position
    • 35º supination, 70º elbow flexion
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9
Q

What is flexion for the HUJ and RHJ?

A
  • HUJ: ant glide of ulna on humerus
  • RHJ: ant glide of radial head on capitellum

AP for radiohumeral and AP for humero-ulnar joint

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10
Q

What is extension for the HUJ and RHJ?

A
  • HUJ: post glide of ulna on humerus
  • RHJ: post glide of radial head on capitellum
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11
Q

What is pronation for the HUJ and RHJ?

A
  • RHJ: med spin of radial head on capitellum
  • Sup RUJ: posterior glide of radial head

AP glide

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12
Q

What is supination for the HUJ and RHJ?

A
  • RHJ: lat spin of radial head on capitellum
  • Sup RUJ: anterior glide of radial head

PA glide

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13
Q

What are the 5 characteristics of medial collateral ligament?

A
  1. 3 bundles – ant, post, transverse
  2. Resists valgus stress
  3. Anterior bundle 1º restraint
    • taut through whole range
  4. Post bundle - taut at full flexion
  5. Transection of MCL: increased instability in pronation than supination during passive elbow flexion
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14
Q

What are the 5 characteristics of lateral collateral ligament?

A
  1. 3 bundles – radial collateral, accessory collateral, lateral UCL
  2. Resists varus stress
  3. LUCL (Below radial head) major contributor to prevention of posterolateral
  4. instability
  5. Uniform tension throughout range
  6. Transection of LCL: increased rotatory instability in supination than pronation during passive flexion
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15
Q

What are the 2 characteristics of annular ligament?

A
  1. surrounds neck of radius and attaches to radial notch of ulna
  2. Resists lateral subluxation and distal subluxation/dislocation

Often in children (grab on kids and pulling)

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16
Q

What are the 2 characteristics of interosseous membrane?

A
  1. Binds the radius to ulna
  2. Force transmission proximally through the upper limb

WB- force occurs at radiocarpal joint –> allow forces to be transmitted between ulnar and radius

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17
Q

What are 2 muscles in the anterior elbow?

A
  1. biceps- Shoulder flexion, elbow flexion and supination
  2. brachialis
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18
Q

What are 2 muscles in the posterior elbow?

A
  1. triceps
  2. anconeus

Elbow extension

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19
Q

What are 4 muscle group in the lateral elbow?

A
  1. Wrist E: ECRL, ECRB, ECU
  2. Finger E: ED, EDM- Common extensor tendon
  3. Supinator
  4. Elbow F: brachioradialis

Common extensor tendinopathy : tennis elbow

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20
Q

What are 3 muscle group in the medial elbow?

A
  1. Wrist F: FCR, FCU
  2. Finger F: PL
  3. Pronator teres

Common flexor tendinopathy (golfers elbow)

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21
Q

What are the 3 factors limiting normal elbow movements for flexion?

A
  1. soft tissue approximation anteriorly
  2. radial head and coronoid process opposition
  3. tension in posterior capsule, and triceps
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22
Q

What are the 2 factors limiting normal elbow movements for extension?

A
  1. olecranon opposition
  2. Tension in anterior capsule, ant portion of MCL, and the elbow flexors
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23
Q

What are the 2 factors limiting normal elbow movements for pronation and supination?

A
  1. Reciprocal stretch of antagonist muscles
  2. Quadrate ligament
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24
Q

What are 3 peripheral nerves in the elbow?

A
  1. Median
  2. Ulnar
  3. Radial
    • Posterior interosseus (PIN)- Motor branch
    • Superficial radial- Sensory branch
  • Consider path and potential sites of compression
  • Consider symptoms
    • Mechanosensitivity
    • Sensory / motor loss
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25
Q

What are 2 characteristics of the median nerve?

A
  1. at the elbow
    1. Cubital fossa = nerve medial to biceps tendon
  2. Innervates most flexors in forearm, thenar muscles in hand
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26
Q

What are 2 common sites of compression of the median nerve?

A
  1. Distal humerus under the ligament of Struthers
  2. Elbow joint between 2 heads of pronator teres
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27
Q

What are 3 characteristics of the radial nerve?

A
  1. at the elbow
    1. anterior to lateral epicondyle
    2. anterior to radiohumeral joint
  2. Divides into superficial branch of the radial nerve and the posterior interosseous nerve (PIN)
  3. PIN innervates wrist and finger ext, thumb ext and abd muscles
28
Q

What is a common sites of compression of the radial nerve?

A

PIN: intramuscular tunnel in the supinator = arcade of Frohse

  • Repetitive supination and pronation of forearm
29
Q

What are 2 characteristics of the ulnar nerve?

A
  1. At the elbow
    • posterior to medial epicondyle in cubital tunnel
    • Passes between humeral and ulnar heads of FCU
  2. Innervates FCU, medial 1/2 of FDP, most intrinsic muscles in hand
30
Q

What is a common site of compression of the ulnar nerve?

A

Cubital tunnel

31
Q

What are the 4 purposes of the patient interview?

A
  1. Formulate a hypothesis
  2. Determine severity and irritability of problem
  3. Understand cause and contributing factors
  4. Understand patient’s problem and functional limitations
32
Q

What are 4 characteristics for the history in the patient interview?

A
  1. Mechanism of injury
    • Acute
      • Impact injury- Varus or valgus force?
      • Acute/unaccustomed overload- Initial swelling?
    • Overuse
      • What repetitive activities involved (sport, occupation, leisure)- Increase in frequency, load, change in equipment
      • Any recent change in duties/training?
  2. Course since onset
  3. Investigations / Consultations
  4. Previous Injury- Susceptible to re-injury
33
Q

What is the diagnostic hypotheses for the acute injurt/specific mechanism?

A
  1. Fracture
  2. Dislocation
  3. Ligament sprain/rupture
  4. Muscle, tendon strain/rupture
  5. Bursitis
    • Inflammation from landing
  6. Joint overload (landing on FOOSH)
    • Acute inflammation
34
Q

What is the diagnostic hypotheses for the insidious onset?

A
  1. Bursitis
  2. Tendinopathy (common)
  3. Chronic instability (esp. MCL)
  4. Neural entrapments
  5. Referred pain (from spine or shoulder)
  6. Chronic overload (repetitive compression)
  7. Stress fractures
35
Q

What are 4 characteristics of pain when “determining the exact location” in the patient interview?

A
  1. Localised or widespread?
    • Dermatome, nerve route or due to central sensitisation
  2. Multiple pain sites?
    • Most common lateral epicondyle
  3. Description of pain
    • i.e. type / depth
  4. Severity (pain VAS)
36
Q

What are 4 characteristics of other symptoms in the patient interview?

A
  1. Clicking, snapping, locking, catching
    • Intra-articular
  2. Giving way
    • laxity, instability
  3. Weakness or heaviness
    • Muscle
    • Nerve-related
  4. Pins, needles or numbness
    • Nerve-related
37
Q

What are 3 features of pain in the patient interview?

A
  1. Determine the exact location
  2. Easing and aggravating factors
    • Positions/movements/functional tasks
    • Time to ease/aggravate
  3. 24-hour pattern
    • Morning
    • Night/sleep
    • Throughout day
38
Q

What are 3 characteristics in determining activitoes that are limited (functional limitations) in the patient interview?

A
  1. Occupational
    • Computer work
    • Using tools (i.e. pliers, spanner, etc…)
  2. Recreational
    • Golf, Tennis- (eg. tennis or golfer’s elbow)
    • Throwing – what phase, what symptoms
  3. Daily living
    • Using a can opener
    • Turning a door knob

Establish Patient Specific Function Scale (PSFS)

39
Q

What is the Patient Specific Functional Scale?

A

Patient identifies up to 3 important activities they are unable to do or have difficulty with as a result of their elbow problem.

40
Q

What are 3 conclusions at the end of the interview?

A
  1. Nominate primary hypothesis
  2. Nominate an alternative hypothesis
  3. Plan your physical examination- Keep in mind patient’s irritability and sensitivity
    • Select examination techniques to confirm primary hypothesis
    • Select examination techniques to rule out alternative hypothesis
    • Select techniques and order with consideration of severity and irritability
41
Q

What are the 3 purposes of the physical examination?

A
  1. Confirm or negate hypothesis
  2. Determine and measure impairments
    • Articular
    • Musculotendinous
    • Neural
  3. Establish and measure functional limitation
42
Q

What are 4 observations in the physical examination for elbow?

A
  1. Swelling or bruising
  • Localised = bursitis or collateral ligament injury
  • Diffused= intraarticular pathology
  • Esp. acute injury
  1. Deformity
  2. Posture
    1. Neck and trunk
    2. Shoulder and scapular position
  3. Elbow
    1. Carrying angle (arm in anatomical position)- Loss or excessive angle = suggestive of pathology
    2. Amount of flexion/extension at rest
      • Acute = in some flexion (opens joint space for swelling); chronic = contractures
    3. Muscle atrophy/hypertrophy between sides
43
Q

What are 3 movement exams in the physical examination for elbow?

A
  1. Functional activities (nominated in interview)
    • Computer work, gripping, lifting, throwing
  2. AROM
    • Measure any deficits in range
    • Can apply overpressure if full active range
  3. PROM
    • Measure any deficits in range
    • Determine end-feel
44
Q

What is an example of the movement exam in the physical examinations?

Your patient has limited elbow extension.

Determine structures involved if:

  • AROM < PROM
  • AROM = PROM
A

AROM < PROM

  • Weakness or pain inhibition

AROM = PROM

  • Bony block, joint stiffness, capsular tightness, muscle tightness = END FEEL can diifferentiate

What tests can be used to differentiate?

  • Bony = hard
  • Capsular/soft tissue = elastic
  • Glide
  • Length tests
45
Q

How can to differnetiate triceps VS anconeus?

A
  • Muscle test
  • Triceps (long) also extends shoulder
  • Can’t differentiate for other heads
  • Can just be more suggestive
46
Q

When do you use combined movements in movement exams?

A
  • Nominated a task that requires combined movements
  • To clear a joint

Quality and quantity of movement

47
Q

When do you use repetitive movements in movement exams?

A

Repetitive movements, sustained movements, weight-bearing positions

  • Unable to bring on symptoms and want to load joint
48
Q

What are 2 characteristics of accessory glides for the movement exam in the physical exam?

A
  1. Consider all 3 joints
  2. Assess movement quality and quantity, resistance and end-feel between sides
  3. Clear adjacent joints
    • Neck, thorax, shoulder
49
Q

What are the accessory glides for HUJ, RHJ and SRUJ?

50
Q

What are 3 characteristics of the palpation in the physical examination?

A
  1. Pain
    • Underlying structures
    • Palpation depth varies with structure depth
  2. Muscle activity
    • Hypertrophy
    • Atrophy
    • Spasm
  3. Swelling
    • Heat
51
Q

What are 3 other tests (ligament integrity test) in the physical examination?

A
  1. MCL (valgus) stress test
    • What are the restraints to motion in full extension and slight flexion
  2. LCL (varus) stress test
    • What are the restraints to motion in full and slight flexion
  3. Condition specific tests
    • Treatment direction tests i.e. lateral elbow tendinopath
52
Q

What are 3 characteristics of resistance in muscle exam in the physical examination?

A
  1. Isometric
  2. Through ROM
  3. Tests for lateral /medial elbow tendinopathy?
  4. Tests for entrapment neuropathies?
53
Q

What are 2 characteristics of strength/endurance/power in muscle exam in the physical examination?

A
  1. Appropriate for patient
  2. Quantify where possible
54
Q

What are 5 features in muscle exam in the physical examination for elbow?

A
  1. Resistance
  2. Strength/endurance/power
  3. Muscle length
  4. Gripping
  5. Motor control
55
Q

What are 2 characteristics of gripping in muscle exam in the physical examination?

A
  1. Grip strength dynamometry
    • Pain-free grip strength- Less irritable
    • Maximal grip strength if not irritable
    • Calculate ratio (aff/unaff %)
    • For tennis or golfer’s elbow
  2. Spontaneous wrist posture during gripping
56
Q

What is a characteristic of motor control in muscle exam in the physical examination?

A

During functional tasks

  • E.g. gripping, lifting, throwing
57
Q

What is a characteristic of joint position sense for sensori-motor in the physical examination?

A
  1. Symmetrical between sides
  2. Appropriate for patient
58
Q

What are 3 features of neural exam in the physical examination?

A
  1. Sensation, power and reflexes
    • Compare between side
  2. Neurodynamic tests
    • Symptoms
    • Range of movement
    • Compare between sides
  3. Nerve palpation- More responsive to pressure
    • Symptoms
    • Ease of symptom production
    • Compare between sides
59
Q

What is a characteristic of sensation, power and reflexes for neural exam in the physical examination?

A

Compare between side

60
Q

What are 3 characteristic of neurodynamic tests for neural exam in the physical examination?

A
  • Symptoms
  • Range of movement
  • Compare between sides
61
Q

What are 3 characteristic of nerve palpation for neural exam in the physical examination?

A
  1. Symptoms
  2. Ease of symptom production
  3. Compare between sides

More responsive to pressure

62
Q

What are 3 conclusions at the end of the physical exam?

A
  1. Nominate a clinical diagnosis
  2. Nominate key outcome measures
  3. Plan your treatment
    • Determine treatment aims
    • Select interventions to achieve these aims
    • Select outcome measures to evaluate effectiveness
63
Q

What are 2 outcome measures from the interview?

A
  1. Pain or symptom VAS
  2. PSFS
64
Q

What are 3 outcome measures from the physical exam?

A
  1. AROM / PROM
  2. Pain-free grip strength
  3. Strength / endurance or power test
65
Q

What are 2 outcome measures from the questionnaires for elbow?

A
  1. DASH (Disabilities of the arm, shoulder and hand)
  2. PRTEE (Patient-Rated Tennis Elbow Evaluation)
    • Measures pain and disability

PHTY3120 (29 decks)

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