MS1: Affectations of Elbow Flashcards
describe the elbow
modified hinge joint or trochoid ginglymus
stability allows little compensatory adjustments = prone to injury or overuse
what are the 3 joints of the elbow complex
humero-radial
humero-ulnar
proximal radioulnar
describe the joint capsule
thin and transparent
under tension when extended and relaxed when flexed
30-35 ml at 80 degrees flexion; fully distended
what is the functional ROM of the shoulder
supination - 81
pronation - 71
flex/extend - 150
what is the normal carrying angle
normal valgus:
5-10 degrees - males
10-15 degrees - females
diminishes w flexion
compare cubitus varus and valgus
varus: forearm towards midline
valgus: forearm away from midline
describe cubitus varus
decrease in carrying angle
due previous history of trauma - supracondylar fracture
what is gunstick deformity
most common type of varus - 3-57 %
cosmetic problem - no functional disability
describe cubitus valgus
increase in carrying angle
most common cause is lateral condylar fracture of humerus
usually asymptomatic but can develop tardy ulnar nerve palsy
what is tardy ulnar nerve palsy
possible effect of cubitus valgus
more lateral deviated = tension on ulnar nerve
describe the ulnar collateral ligament
from anterior inferior 2/3 of medial epicondyle to to proximal ulna
most important ligament against valgus stress
what are the bundles of the ulnar collateral ligament
anterior:
- strongest and stiffest = most common injured at media side
- main stabilizer against valgus stress
posterior: primary restraint in max elbow flexion
tranverse: cooper’s lig; least role in staibility
what comprises the lateral collateral ligament complex
annular ligament - winds the radius and ulna together
lateral ulnar collateral
radial collateral
accessory collateral
describe the lateral ulnar collateral ligament
from posterior lateral condyle to proximal ulna
restraints against varus and external stress during full arc of elbow motion
what is lateral ulnar collateral ligament injury
associated w dislocation from falling on supine arm with valgus stress
SSx:
- pain or clicking in elbow extension or pushing using arm
- tenderness
- varus instability
how to test for lateral ulnar collateral ligament injury
lateral pivot shift test: pt lies supine w forearm overhead and supinated; valgus stress applied while elbow moes from extension to 40 degrees flexion
x-ray to show dislocations and rule out fractures
what is the treatment for lateral ulnar collateral ligament injury
non-operative: casting 5-7 days with elbow flexed at 90 degrees
what is medial ulnar collateral ligament injury
anterior band microtrauma from repetitive valgus stress - valgus instability in adults
occurs in cocking phase or bwelo
common in athletes that do overhead throwing; little leaguer’s elbow
what are the symptoms lateral ulnar collateral ligament injury
SSx:
- pain or clicking in elbow extension or pushing using arm
- tenderness
- varus instability
what are the symptoms of medial ulnar collateral ligament injury
SSx:
- medial elbow pain
- decrease effectiveness in throwing
- tenderness along elbow at MCL origin
- limited ROM
what is the treatment for what is medial ulnar collateral ligament injury
rest for 6 weeks then therapy to strengthen pronation and flexors
for high level throwers - surgery
what is nursemaid’s elbow
radial head subluxation or pulled elbow
radial head slips through annular ligament
sudden longitudinal traction applied to the hand w elbow extended and forearm pronated or by a fall
what is the epidemiology nursemaid’s elbow
most often at ages 1-4 but can happen until 6-7; more common in women
what are the symptoms of nursemaid’s elbow
SSx:
- refuse to affected limb
- holds elbow in slight flexion and forearm pronated
- pain and tenderness
- full flexion and extension padin
- pain during supination
what is the treatment of nursemaid’s elbow
close reduction of annular ligament subluxation
what are the types of aseptic bursitis
acute hemorrhagic and chronic bursitis
common in football and hockey
describe acute hemorrhagic and chronic olecranon bursitis
acute: due to direct blow to olecranon
chronic: due to repetitive microtrauma; initial period of swelling that becomes into permanently thickened bursa with intrabursal bands
describe septic bursitis
due to localized or systemic infection
SSx:
- edema, erythema and hyperthermia
- systemic symptoms of infection
what is treatment for aseptic bursitis
mild: AIF and therapy
severe: remove fluid
what is treatment for septic bursitis
aspiration of fluid for lab analysis
w/ systemic symptoms:
IV antibiotics
w/ localized symptoms: oral antibiotics
incision and drainage if doesnt improve from meds
what is the epidemiology lateral epicondylitis
common in > 35 yo; 40-50 yo
more common in male in tennis only
from excessive repetitive stress on lateral forearm musculature
what is the pathophysiology of lateral epicondylitis
degenerative and not inflammatory; misnomer
micro tears on common extensor muscles at their origin on lateral epicondyle
mostly affects ECRB and EDC; rarely ECRL and ECU
what are the symptoms of lateral epicondylitis
SSx:
- pain lateral elbow during gripping, repetitive wrist extension
- point tenderness over lateral epicondyle
- + cozen and mills
what is the differential diagnosis for lateral epicondylitis
xray: might reveal punctate calcifications
MSUS: reveal partial and complete tears
rule out lateral collateral ligament sprain and radial nerve impingement
what is the treatment for lateral epicondylitis
rest
cryotherapy
AIF
PT: heating and ultrasound (deep heat)
how is the cozen’s test done
stabilize pt’s elbow and ask to pronate and extend and radially deviate wrist against manual resistance of clinician
how is the mill’s test done
palpate pt’s lateral epicondyle while pronating forearm while fully flexing the wrist and elbow extended
pain in are = + test
what is the epidemiology of medial epicondylitis
occurs 3-7x less frequent than lateral epicondylitis
excessive repetitive stress on medial forearm musculature
what are the symptoms of medial epicondylitis
tenderness over the medial epicondyle
pain on making a fist, wrist flexion, forearm pronation and supination
what is the pathophysiology of medial epicondylitis
degenerative
involves tendinopathy affecting the common flexor origin
frequently pronator teres and FCR origins; less frequent FCU and FDS
what is the differential diagnosis of medial epicondylitits
xray and MSUS to rule out:
- medial ulnar collateral ligament injury
- ulnar nerve entrapment
what is the treatment for medial epicondylitis
rest
cryotherapy
AIF
PT: heating and ultrasound (deep heat)
what is the epidemiology of distal bicep tendonitis
not common
eccentric overload of the distal biceps during deceleration of follow through phase of throwing
what is the symptoms of distal bicep tendonitis
pain in antecubital fossa during elbow bending
pain with resisted elbow flexion
tenderness over distal biceps tendon
what is the treatment of distal bicep tendonitis
rest
cryotherapy
AIF
PT: heating and ultrasound (deep heat)
what is the epidemiology of distal bicep tendon rupture
betw 30-50 yo
M > F
what is the pathophysiology of distal bicep tendon rupture
injury usually occurs during heavy lifting w elbow at 90 degrees flexion
involves the dominant side
distal biceps tendon avulses from radial tuberosity
what are the signs of distal bicep tendon rupture
acute pain and popping sensation in the antecubital fossa
ecchymosis, erythema, edema in the antecubital fossa
deformity of the biceps muscle belly
proximal retraction of the biceps tendon is apparent - popeye sign
what is the treatment of distal bicep tendon rupture
nonoperative: only for elderly, sedentary patients who do not require strength and endurance in forearm flexion and supination
operative: for confirmed distal biceps tendon ruptures
- partial tears that fail to respond to nonoperative treatment
what are distal humerus fractures
2% of all fractures; 1/3 of all humeral fractures
2-column concept:
- medial column
- lateral column
- betw is coronoid fossa ant and olecranon fossa post
has supracondylar, transcondylar, intercondylar
describe supracondylar fractures
55-75% of all pediatric elbow fractures
FOOSH
treatment: casting/splinting, CR w percutaneous pinning, ORIF
describe intercondylar fractures
most common distal humeral fracture in adults
comminution is common
force is directed against the posterior aspect of an elbow flexed >90 degrees; driving the ulna into the trochlea
what is the indication for non-operative treatment for intercondylar fractures
if nondisplaced fractures
elderly with displaced and severe osteopenia
significant comorbid conditions precluding operative management
cast immobilization and traction with an olecranon pin; bag of bones
what is the operative treatment for intercondylar fractures
ORIF:
- for displaced reconstructible fractures
- restore articular congruity
- interfragmentary screws and dual plate fixation
total elbow arthroplasty:
- for comminuted fractures
- in osteoporotic bone
what is montaggia fracture
proximal 1/3 ulnar fracture w associated radial head dislocation/instability
rare in adults; common in 4-10 yo
what is galleazi fracture
distal 1/3 radius shaft fx and associated DRUJ
due to direct wrist trauma at dorsolateral aspect
FOOSH w pronation
what is elbow dislocation
due FOOSA in posterolateral region
associated with disruption of collateral ligaments of the elbow
- periarticular and intraarticular fractures
- brachial artery or median, ulnar and radial nerve injuries
what is treatment of elbow
CR - sling or long arm splint for 2-3 days followed by progressive ROM
- cryo and AIF
indication for surgery:
- disrupted ulnar collateral ligament
- disrupted flexor pronation musculature
- chronic recurrent elbow instability
full return in 8 weeks
90% restoration by 3 months post injury
what is volkmann’s ischemic contracture
untreated necrotic muscle and nerved are replaced with fibrous tissue
what is the etiology of volkmann’s ischemic contracture
supracondylar fractures of humerus in children
brachial artery held by lacertus fibrosus may get impinged on sharp proximal fragment
deficit in circulation causes ischemia to muscles and affect nerve function
what are other causes of VIC
crush injuries
prolonged external compression
internal bleeding: hemophilia
burns
what are the tolerance of tissues in VIC
muscle: 2-4 hrs
nerve: 30 min
what are the symptoms VIC
pain
paresthesia
pulsenessness
pallor/cyanosis
paresis
describe the mild deformities in VIC
mild:
- deep flexors semi involved; FPD
- 2 or 3 fingers; no limited loss of sensation
- pronation contracture involving either pronator teres or quadratus
describe the moderate deformities in VIC
- involves most of FDP, FPL and part of FDS
- neurological deficit involving the median nerve more than ulnar
- deformity is intrinsic minus hand
- diminished sensations in median and ulnar nerve zones
describe the severe deformities in VIC
- all the flexors and extensor muscles are involved
- neurological deficit is severe
- joint contractures are marked
- wasting of forearm muscles
how to diagnose VIC
pressure monitoring or ICP measurement
> 30 mmHG may be an indication for surgery
how to treat VIC
explore deeply until FDP and FPL
necrotic muscle must be excised
median nerve freed beneath the lacertus fibrosus
ulnar nerve is freed and transplanted anteriorly
brachial artery must be inspected and decompressed
surgical wound is left open for secondary closure later when swelling subsides
extremity supported w splint in functional position
how to treat VIC
explore deeply until FDP and FPL
necrotic muscle must be excised
median nerve freed beneath the lacertus fibrosus
ulnar nerve is freed and transplanted anteriorly
brachial artery must be inspected and decompressed
surgical wound is left open for secondary closure later when swelling subsides
extremity supported w splint in functional position
what is the cubital tunnel syndrome
ulnar nerve lies w/in the postcondylar groove where it is covered by a fibrous roof going from medial humeral epicondyle to the olecranon
2nd most common nerve entrapment in UE
what are the symptoms of CTS
paresthesia of the ulnar 1 1/2 digits
intrinsic muscle weakness and atrophy
clawing of ulnar digits is a severe late finding of ulnar neuropathy
how to test of CTS
froment’s
wartenberg
tinel sign
elbow flexion test
EMG-NCV
what are the treatments of CTS
non operative:
- activity modification
- night splints - elbow held at 45 degrees flexion
- NSAIDs
operative treatment:
- failed conservative treatment for 3 months
types:
- in-situ decompression
- ulnar nerve transposition
- medial epicondylectomy
