Lecture 5- Elbow

Question 1

Range of motion

Answer 1

• Carrying angle ➟ ≈ 60
  • Flexion ➟ ≈ 1400 – 1500
  • Extension➟ ≈ 00 – 100 (+ female)
  • Supination/Pronation ➟ ≈ 800
  Painful deficit in ROM:
• Effusion,
  • soft tissue swelling,
• bony impingement
• Locking: ➟ loose bodies
  • Pain in hyperextension: ➟ impingement
  • Crepitus: ➟ OA + ⬇ ROM all directions

Question 2

How will a patient hold his arm if there is effusion in the elbow joint ?

Answer 2

When effusion is present in the elbow joint, patient will often hold his elbow in a flexed position (700 – 800) (most capsular volume)

Question 3

ROM constraint

Answer 3

Constraint in flexion
1. Muscle contact
2. Radial impingement
3. Posterior capsule tension
4. Triceps tension
5. Radio-humerus contact
Constraint in extension
1. Olecranon impingement 2. Anterior capsule
3. Biceps tension

Question 4

What do we have to look for, feel for a move during an elbow examination?

Answer 4

• Look (observation)
Symmetry
Carrying
Palpation of the lateral recess for presence of effusion Tenderness of the common extensor region Inflammation or any other pain
Remote causes of
• Move (orthopaedics)
angle (anatomical position)
–
• Feel (palpation)
active; passive &
ROM
Effusion, color, contour
• • • •

Question 5

SYSTEMIC CAUSES OF ELBOW PAIN

Answer 5

• RHEUMATOID ARTHRITIS (RA)
• only 3% of cases present in elbow first but 50% of patient’s with RA for 3 years have elbow involvement
• 20% have associated rheumatoid nodules on the extensor surface of the olecranon and proximal ulna
• OSTEOARTHROSIS
• repeated minor trauma
• PSORIATIC ARTHROPATHY
• bilateral elbow involvement is common
• GOUT
• Though uncommon, can occur in severe cases
• HAEMARTHROSIS
• As seen in Hemophiliacs
• Elbow is the second most commonly affected joint in hemophiliacs, second to the Knee
• Repeated hemarthrosis destroys the synovium and joint surface

Question 6

Causes of lateral elbow pain?

Answer 6

MOST COMMON
Extensor tendinopathy Referred pain
• Cervical
• Upper thoracic
• Neuro-Fascial
LESS COMMON
Synovitis of the radiohumeral joint
Radiohumeral bursitis
Posterior interosseous nerve entrapment (radial tunnel syndrome)
NOT TO BE MISSED
Osteochondritis dissecans
• Capitellum
• Radius (adolescents)

Question 7

Causes of medial elbow pain

Answer 7

MOST COMMON 
Flexor/pronator tendinopathy Medial collateral ligament sprain 
• Acute
• Chronic
LESS COMMON 
Ulnar neuritis
Avulsion fracture of the medial epicondyle
Apophysitis 
NOT TO BE MISSED
Referred pain

Question 8

Elbow tendinopathy: Common wrist extensors originating on the lateral epicondyle

Answer 8

• Extensor carpi radialis brevis
• Extensor digitorum
• Extensor digiti minimi
• Extensor carpi ulnaris

Question 9

Elbow tendinopathy:Common wrist flexor originating on the medial epicondyle

Answer 9

• Pronator teres
• Flexor carpi radialis
• Palmaris longus
• Flexor carpi ulnaris
• Flexor digitorum superficialis

Question 10

Lateral epicondylitis

Answer 10

• The most common cause of elbow pain
• Tendinitis / tendinopathy / tendinosis of the ECRB
• Common in ages 35-50 years
• Can be acute, sub-acute (3m)
• Often recurrent

Question 11

What are the Tests for Lateral Epicondylitis

Answer 11

• Cozen’s (RIM) Test: looking for pain over lateral epicondyle
• Mill’s (stretch) Test: looking for pain over lateral epicondyle

Question 12

Treatment and Basic Rehabilitation Principles for the elbow

Answer 12

Standard Rx principles include
• Rest,
• NSAID’S,
• Manual therapy and
• Bracing
Bracing:
• Aim of a brace is to release tension on the ECRB by theoretically creating a new muscle origin just distal to the elbow
• Other bracing / strapping techniques aim at limiting wrist flexion / pronation (limiting stretch of the ECRB)

Question 13

Joint stability of the elbow

Answer 13

• The capsule is reinforce and thicken by both collateral ligament which contribute to lateral and medial stability
• The medial collateral ligament is reinforce by the Flexor Carpi Ulnaris
• This musculotendinous complex highly contribute to the joint stability
Alternatives include corticosteroid injection
• When would this be appropriate?
Autologous blood injections
• Platelet-richplasma
• Promotes rapid healing and tissue regeneration through the release of growth factors
• Also seen in the treatment of high hamstring injuries
• Controversialwhetherithaseffectiveoutcomes?
Surgical intervention – pros and cons?

Question 14

Medial Epicondylitis

Answer 14

Forceful repetitive contractions stressing the common flexor tendon:
• Pronator teres
• FCR
• FCU
History & Physical Examination:
• Pain over medial epicondyle
• Pain with resisted wrist flexion
• Pain with passive wrist extension
• Pain with tight grip

Question 15

Myofascial Injury of the elbow

Answer 15

Rupture at the distal biceps tendon:
• Uncommon
• Typicallyeccentricinjury
• Risk factors: >30 yo, Male>Female, smokers +, steroid use +,
• 30% loss in elbow flexion and 40% loss in strength supination
• Signs/Sx: “pop”, swelling, ecchymosis, shortening of biceps with a palpable “popeye” deformity.
• Loss of active/passive extension
• Palpable gap

Question 16

Myositis Ossificans

Answer 16

Bone deposition within the muscle due to trauma
• Brachialis and triceps at risk in the upper extremity
• Frequent complication of fractures and blunt trauma
• Pain with decreased ROM
• May have a firm, palpable mass in the muscle

Question 17

Olecranon Bursitis

Answer 17

The olecranon bursa is superficial to the triceps tendon, over the olecranon
Cause
• Single trauma or Repetitive action
Signs and Symptoms
• Inflammatory reaction
• Variable amount of heat, erythema and swelling – can be large!

Question 18

Directed study for osteochondritis dissecans - examinable

Answer 18

http://emedicine.medscape.com/article/1253074-overview

Question 19

Why is medial elbow instability more common

Answer 19

…..?

Question 20

What test should you perform to assess medial stability of the elbow?

Answer 20

• Valgus stress test

Normal joint space open less than 3 mm with a firm end point.

Question 21

Elbow dislocation

Answer 21

Mechanism:
• fall on the outstretched supinated hand (backward fall) – “FOOSH”
Posterior dislocation most common
• Anterior dislocation is from similar MOI but more extreme hyperextension
• Associated fractures:
• radial head,
• coronoid process,
• epicondyles

Question 22

Peripheral neuropathy

Answer 22

Peripheral neuropathy is common
• Risk factors
• Superficial position
• Long course through an high risk area • Narrow path through a bony canal
• The most common nerve entrapment is carpal tunnel syndrome which has a general population prevalence of 3% and 5 – 15% in an industrial setting.

Question 23

Pathophysiology

Answer 23

There are three categories of nerve injuries
1. Neurapraxia: least severe, local damage of the myelin, has a limited course
2. Axonotmesis: more severe, injury to the axon itself, regeneration is possible but takes months, recovery is usually incomplete
3. Neurotmesis: complete disruption of the axon, regrowth is unlikely
Most nerve injuries result in neurapraxia or axonotmesis.

Question 24

Mechanism of injury to a nerve

Answer 24

1. Direct pressure
2. Repetitive microtrauma
3. Stretch or compression-induced ischemia
   The degree of injury is related to SEVERITY x TIME
   Peripheral neuropathy should be suspected when patients report pain, weakness, or paraesthesia not related to known bone, soft tissue, or vascular injury. Onset can be insidious or acute.

Question 25

Median nerve entrapment AKA pronator Teres syndrome

Answer 25

• Entrapment of the median nerve between the 2 heads of pronator teres
• Presents as CTS
• Test median nerve function:
• Motor
• Sensory (thenar eminence)
Check pronator teres

Question 26

Test for Pronator Teres Syndrome

Answer 26

Looking for reoccurrence of previous symptoms felt by the patient

Question 27

Racial nerve entrapment AKA radial tunnel syndrome

Answer 27

Radial tunnel begins where the deep branch of the radial nerve (DBRN) courses over the radiohumeral joint; ends where the DBRN becomes the PIN as it exits the distal edge of the superficial supinator.

Question 28

Structures commonly implicated in DBRN compression within the tunnel?

Answer 28

• Fibrous adhesions between the brachialis and brachioradialis
• The fibrous edge of the ECRB,
• The arcade of Fröhse, and
• Fibrous bands associated with the supinator muscle
Pain centrally in the forearm, distal to that of lateral epicondylitis (over the radial neck)

Question 29

Radial nerve entrapment - details

Answer 29

Radial Nerve entrapment (posterior interosseous nerve entrapment)
• Motor deficit only, no pain
PIN supplies all of extrinsic wrist extensors
except for the ECRL
Patient will present with generalized hand
weakness (digit ++++, wrist extension++

Question 30

Ulnar Nerve entrapment AKA cubital tunnel syndrome

Answer 30

Second most common nerve entrapment
Think of the symptoms you get when you knock your “funny bone” (back when you were a “lay-person”)
When the elbow flexes the cubital tunnel volume decreases.
Prone to acute contusion or chronic compression

Question 31

Causes of ulnar nerve entrapment

Answer 31

Causes include:
• Prolonged elbow flexion or pressure directly on the elbow
• Arthritis (bony spurs (OA) or swelling
In the case of ulnar nerve symptoms also check Guyon’s canal at the wrist (later)

Question 32

Symptoms of ulnar nerve entrapment

Answer 32

Symptoms
• Can present as an ache of the medial elbow, but most sx’s are in the hand (ulnar nerve symptoms)
• Loss of grip strength is a prominent feature
• May have paraesthesia in the 4th and 5th fingers
When present
• Weakdigitabduction
• Weak thumb abduction
• Weak thumb Index – Finger pinch • Powergrip⬇

Question 33

Test for ulnar nerve entrapment

Answer 33

Froment sign
• Weakness of the adductor pollicis (ulnar nerve)
• Patient compensate by using the flexor pollicis longus (FPL) (median nerve)

Question 34

Elbow disorders in children

Answer 34

PULLED ELBOW /NURSEMAID’S ELBOW
A significant distraction force leads to Radial head subluxation (partial dislocation) due to child’s under- developed radial head and weakness of annular ligament.
History of distraction, often accompanied by a “pop” and followed by pain & failure to move the arm. Arm is often held in flexion with the elbow held in pronation.