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Diagnosis and Management > Orthopedics Elbow > Flashcards

Orthopedics Elbow Flashcards

1
Q

Normal Anatomy

A
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2
Q

PE General

  • The patient is in no acute ____, mood and affect are _____, alert and oriented times ____.
  • The patient is ambulating with a smooth and symmetric gait putting ____ weight on both lower extremities with good coordination and balance.
A
  • The patient is in no acute distress, mood and affect are appropriate, alert and oriented times three.
  • The patient is ambulating with a smooth and symmetric gait putting full weight on both lower extremities with good coordination and balance.
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3
Q

PE Inspection

  • Both elbows appear ______.
  • _____ is intact about both elbows without erythema.
  • Patients with elbow effusion generally hold the elbow flexed __-__degree (position of m______ capsular distention)
  • “____ness” of the elbow “_____ spot” (triangle formed by radial head, lateral epicondyle, and olecranon)
  • Olecranon _______?
A
  • Both elbows appear symmetric.
  • Skin is intact about both elbows without erythema.
  • Patients with elbow effusion generally hold the elbow flexed 70-80degree (position of maximum capsular distention)
  • “Fullness” of the elbow “soft spot” (triangle formed by radial head, lateral epicondyle, and olecranon)
  • Olecranon bursitis?
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4
Q

Tenderness to Palpation

  • Lateral ______? Medial ______? Radial H____? Ol______?
    • Radial head is best palpated with the forearm in what position?
A
  • Lateral epicondyle? Medial epicondyle? Radial head? Olecranon?
    • Radial head is best palpated with the forearm in supination
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5
Q

Range of Motion

  • Flexion/Extension: __ (extension)-___ (full flexion) (normal)
    • “_______” → 30-130 (like feeding themselves)
  • Pronation/Supination:
    • normal pronation: __
    • normal supination __
    • functional: __ pronation, __ supination
A
  • Flexion/Extension: 0 (extension)-140 (full flexion) (normal)
    • “Functional” → 30-130 (like feeding themselves)
  • Pronation/Supination:
    • normal pronation: 75
    • normal supination 85
    • functional: 50 pronation, 50 supination
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6
Q

Strength

  • Elbow as well as distally with ____ IP flexion, f______ abduction/adduction, and ______ extension.

Sensation

  • Intact to _____ touch distally without any focal (1) or (1).

Stability

  • V_____/V_____ Instability?
A
  • Elbow as well as distally with thumb IP flexion, finger abduction/adduction, and index extension.
  • Intact to light touch distally without any focal numbness or tingling.
  • Varus/Valgus Instability?
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7
Q

Common Conditions of the Elbow

(6)

A

Lateral epicondylitis (“tennis elbow”)

Medial epicondylitis (“golfer’s elbow”)

Ulnar neuropathy / Cubital tunnel syndrome

Olecranon bursitis

Nursemaid’s elbow

Radial head fracture

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8
Q

Lateral Epicondylitis “Tennis Elbow”

  • ____ common cause of elbow pain
    • Usually _______ arm
    • 1-3% of adults annually
    • __ - __ yrs-old
    • Men __ Women
  • Caused by over___
  • Can be associated with r_____ sports, but more commonly it is not
  • Etiology:
    • Inflammation of the _ _ _ _ tendon
    • Sometimes associated with “micro_____”
  • Many “treatments” aka none of them work well
    • Always (1)
  • BUT, it can take a _____ for the symptoms to resolve
  • Treatments help the symptoms and may accelerate pain resolution
A
  • Most common cause of elbow pain
    • Usually dominant arm
    • 1-3% of adults annually
    • 35 - 50 yrs-old
    • Men = Women
  • Caused by overuse
  • Can be associated with racquet sports, but more commonly it is not
  • Etiology:
    • Inflammation of the ECRB tendon
    • Sometimes associated with “microtears”
  • Many “treatments” aka none of them work well
    • Always self-limiting
  • BUT, it can take a year for the symptoms to resolve
  • Treatments help the symptoms and may accelerate pain resolution
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9
Q

Lateral Epicondylitis Diagnosis

History

  • Pain with ______ wrist _______
  • Pain with gr______ / decreased grip s______
A
  • Pain with resisted wrist extension
  • Pain with gripping / decreased grip strength
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10
Q

Lateral Epicondylitis Diagnosis

Physical

  • P_____ tenderness → _ _ _ _ at the lateral epicondyle
  • _______ grip strength (sometimes)
  • Normal se________ examination
  • Provocative tests:
    • Resisted _____ extension with elbow fully extended
    • Resisted extension of the long ______
    • Maximal _______ of the wrist
    • Passive wrist flexion in ___nation causes pain at the ______
A
  • Point tenderness → ECRB at the lateral epicondyle
  • Decreased grip strength (sometimes)
  • Normal sensory examination
  • Provocative tests:
    • Resisted wrist extension with elbow fully extended
    • Resisted extension of the long fingers
    • Maximal flexion of the wrist
    • Passive wrist flexion in pronation causes pain at the elbow
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11
Q

Lateral Epicondylitis Imaging

  • XR:
    • Usually ______
    • Sometimes ____cations in the extensor muscle mass
      • Up to 20% of patients
  • MR:
    • Necessary for diagnosis?
    • ECRB
      • Th_____, ed_____, tendon deg______
  • Ultrasound
    • Necessary for diagnosis? but most useful diagnostic tool in experienced hands
      • ECRB tendon appears thickened and _____echoic
A
  • XR:
    • Usually normal
    • Sometimes calcifications in the extensor muscle mass
      • Up to 20% of patients
  • MR:
    • Not necessary for diagnosis
    • ECRB
      • Thickening, edema, tendon degeneration
  • Ultrasound
    • Not necessary for diagnosis, but most useful diagnostic tool in experienced hands
      • ECRB tendon appears thickened and hypoechoic

Note: Hyechoic areas appear dark gray because they don’t send back a lot of sound waves. Solid masses of dense tissue are hypoechoic.

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12
Q

Lateral Epicondylitis Treatment

  • GOAL
    • Reduce pain / Restore function
  • Non-surgical
    • Rest
    • Activity modifications (1) Do things how?
    • Counterforce ______
    • NSAIDs (oral or topical) - _-_ weks, 2 weeks of non prn ______ __mg daily for 2 weeks then PRN , or more frequent ___mg _____TID then PRN
    • PT / Ultrasound
    • Injection
    • up to __% success rate with nonoperative treatment, but _______ is required
  • Surgery
    • ______ needed → De______ and R______ of ECRB
  • Refer → No improvement after full course of conservative options
A
  • GOAL
    • Reduce pain / Restore function
  • Non-surgical
    • Rest
    • Activity modifications
      • “Palm up” do things palm up to rest lateral muscle
    • Counterforce brace (strap) - 2nd pic
    • NSAIDs (oral or topical) - 2-4 weks, 2 weeks of non prn meloxicon 50mg daily for 2 weeks then PRN , or more frequent 400mg motrin TID then PRN
    • PT / Ultrasound
    • Injection
    • up to 95% success rate with nonoperative treatment, but patience is required
  • Surgery
    • Rarely needed → Debridement (taking away some of the inflammatory tissue) and release of ECRB
  • Refer → No improvement after full course of conservative options
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13
Q

Medial Epicondylitis “Golfer’s Elbow”

  • Much ____ common than tennis elbow
    • Usually ______ arm
    • __ - __ yrs-old (30 - 40 most common)
    • Men =__Women
  • Caused by ____use– can be associated with _____, but more commonly it is not
  • Etiology:
    • Inflammation of the f____-p_____ mass (pronator teres __ flexor carpi radialis)
    • Sometimes associated with “micro____”
  • Many “treatments” aka?
  • Usually resolves how?
    • BUT, it can take a ____ for the symptoms to resolve
    • Treatments help the symptoms and may accelerate pain resolution
A
  • Much less common than tennis elbow
    • Usually dominant arm
    • 35 - 60 yrs-old (30 - 40 most common)
    • Men = Women
  • Caused by overuse – can be associated with golf, but more commonly it is not
  • Etiology:
    • Inflammation of the flexor-pronator mass (pronator teres > flexor carpi radialis)
    • Sometimes associated with “microtears”
  • Many “treatments”
  • Usually self-limiting
    • BUT, it can take a year for the symptoms to resolve
    • Treatments help the symptoms and may accelerate pain resolution
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14
Q

Medial Epicondylitis Diagnosis

History

  • Pain with resisted wrist ______
  • Pain with ______ / _____ motion

Physical

  • ______ tenderness → 5-10 mm _____ and ______ to the medial epicondyle
  • Provocative tests:
    • Pain with resisted ______ and ______
  • Flexion _______ in chronic cases
A

History

  • Pain with resisted wrist flexion
  • Pain with gripping / elbow motion

Physical

  • Point tenderness → 5-10 mm distal and anterior to the medial epicondyle
  • Provocative tests:
    • Pain with resisted flexion and pronation
  • Flexion contracture in chronic cases
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15
Q

Medial Epicondylitis Imaging

  • XR:
    • Usually normal
    • Sometimes ca_______ in the __/__ muscle mass
      • Up to 25% of patients
  • MR:
    • More to (1) ligament injury, rupture of flexor/pronator origin
  • Ultrasound
    • Not necessary for diagnosis, but sensitive diagnostic tool in experienced hands
      • ____echoic/__echoic areas of focal degeneration
A
  • XR:
    • Usually normal
    • Sometimes calcifications in the flexor/pronator muscle mass
      • Up to 25% of patients
  • MR:
    • More to rule-out ligament injury, rupture of flexor/pronator origin
  • Ultrasound
    • Not necessary for diagnosis, but sensitive diagnostic tool in experienced hands
      • hypoechoic/anechoic areas of focal degeneration
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16
Q

Medial Epicondylitis Treatment

  • GOAL
    • Reduce pain / Restore function
  • Non-surgical
    • Rest
    • Activity modifications (1)
    • Counterforce (1)
    • NSAIDs (oral or topical)
    • PT / Ultrasound
    • Injection
  • Surgery
    • Rarely needed → D_______ of pronator teres and flexor carpi radialis
  • Refer → No improvement after full course of conservative options
A
  • GOAL
    • Reduce pain / Restore function
  • Non-surgical
    • Rest
    • Activity modifications “Palm down”
    • Counterforce brace (strap)
    • NSAIDs (oral or topical)
    • PT / Ultrasound
    • Injection
  • Surgery
    • Rarely needed → Debridement of pronator teres and flexor carpi radialis
  • Refer → No improvement after full course of conservative options
17
Q

Ulnar Neuropathy/Cubital Tunnel Syndrome

  • ________ neuropathy of the ulnar _____ caused by anatomic compression in the medial elbow
  • 2nd most common compression neuropathy of upper extremity
  • Males __ Females
  • Incidence increases with ___ in both men and women
A
  • Compressive neuropathy of the ulnar nerve caused by anatomic compression in the medial elbow
  • 2nd most common compression neuropathy of upper extremity
  • Males > Females
  • Incidence increases with age in both men and women
18
Q

Cubital Tunnel Syndrome Diagnosis

History

  • ________ of (3) parts of the hand**
  • Exacerbating activities include
    • Cell _____ use (excessive flexion)
    • Occupational or athletic activities requiring repetitive _____ flexion and _____ stress
  • Night symptoms
    • Caused by ______ with arm in _______
A
  • Paresthesias of small finger, ulnar half of ring finger, and ulnar dorsal hand
  • Exacerbating activities include
    • Cell phone use (excessive flexion)
    • Occupational or athletic activities requiring repetitive elbow flexion and valgus stress
  • Night symptoms
    • Caused by sleeping with arm in flexion
19
Q

Cubital Tunnel Syndrome Diagnosis

Physical

  • Diagnosis is made clinically with presence of s_______ changes to the (2) finger, intrinsic muscle ____ness and a positive ______ sign (tap nerve near elbow and feel sensation) over the cubital tunnel.
  • Inspection and palpation
    • Interosseous and first web space ______
    • Ring and small finger ____ing
    • Observe ulnar nerve ________ over the _______ epicondyle as the elbow moves through a flexion-extension arc
A
  • Diagnosis is made clinically with presence of sensory changes to the ring and little finger, intrinsic muscle weakness and a positive tinel’s sign (tap nerve near elbow and feel sensation) over the cubital tunnel.
  • Inspection and palpation
    • Interosseous and first web space atrophy
    • Ring and small finger clawing
    • Observe ulnar nerve subluxation over the medial epicondyle as the elbow moves through a flexion-extension arc
20
Q

Cubital Tunnel Syndrome Diagnosis

Physical

  • Sensory
    • _______ sensation in ulnar 1-1/2 digits
  • Motor
    • loss of the ulnar nerve results in _______ of intrinsic muscles (adductor pollicis, deep head FPB, interossei, and lumbricals 4 and 5) which leads to weakened gr____ and weak p______
    • Froment’s sign =
A
  • Sensory
    • Decreased sensation in ulnar 1-1/2 digits
  • Motor
    • loss of the ulnar nerve results in paralysis of intrinsic muscles (adductor pollicis, deep head FPB, interossei, and lumbricals 4 and 5) which leads to weakened grasp and weak pinch
    • Froment’s sign → compensatory thumb IP flexion (AIN, a branch of the median nerve)
21
Q

Cubital Tunnel Syndrome Imaging/Studies

  • Imaging:
    • Often _____/ ___-diagnostic
  • EMG/NCS:
    • Helpful in diagnosis and to tease out (1) from cubital tunnel syndrome in certain cases
A
  • Imaging:
    • Often normal/ non-diagnostic
  • EMG/NCS:
    • Helpful in diagnosis and to tease out C8 radiculopathy from cubital tunnel syndrome in certain cases
22
Q

Cubital Tunnel Syndrome Treatment

  • GOAL
    • Reduce pain / Restore function
  • Non-surgical (~50%)
    • Rest
    • NSAIDs (oral or topical)
    • Elbow extension _____ at (____ time)
  • Surgery
    • Ulnar nerve _________
      • Cubital tunnel _______ (release fascial structures superficial to nerve along medial aspect of elbow)
  • Refer?
    • No improvement after full course of conservative options
A
  • GOAL
    • Reduce pain / Restore function
  • Non-surgical (~50%)
    • Rest
    • NSAIDs (oral or topical)
    • Elbow extension splinting (night)
  • Surgery
    • Ulnar nerve decompression
      • Cubital tunnel release (release fascial structures superficial to nerve along medial aspect of elbow)
  • Refer?
    • No improvement after full course of conservative options
23
Q

Olecranon Bursitis

  • Bursa = a th__, _____-filled sac that acts as a _____ and _____ structure between bones and soft tissues
  • Located at the boney ___ of the elbow (the ______)
  • Normally what shape?, but if it becomes irritated or inflamed, more ____ will _______ in the bursa and bursitis will develop.
A
  • Bursa = a thin, fluid-filled sac that acts as a cushion and lubricating structure between bones and soft tissues
  • Located at the boney tip of the elbow (the olecranon)
  • Normally flat, but if it becomes irritated or inflamed, more fluid will accumulate in the bursa and bursitis will develop.
24
Q

Olecranon Bursitis Diagnosis

History

  • Causes:
    • Tr______
    • Prolonged ______ (sitting at _____)
    • In______
    • Associated conditions (2)
  • Symptoms (3)
A
  • Causes:
    • Trauma
    • Prolonged Pressure (sitting at desk)
    • Infection
    • Associated conditions (RA, gout)
  • Symptoms:
    • Swelling, Pain, Redness/Warmth
25
Q

Olecranon Bursitis Diagnosis

Physical

  • Sw_____ / “_____ _____”
  • W______
  • __________ ROM
  • Constitutional symptoms are?
A
  • Swelling / “golf ball”
  • Warmth
  • Decreased ROM
  • Constitutional symptoms (rare)
26
Q

Olecranon Bursitis Imaging

  • Imaging
    • Often _____/ ___-diagnostic
    • Associated with bone _____
    • Sometimes associated with a f_____ b____
  • Aspiration / Fluid Analysis:
    • If (2) suspected
A
  • Imaging
    • Often normal / non-diagnostic
    • Associated with bone spur
    • Sometimes associated with a foreign body
  • Aspiration / Fluid Analysis:
    • If infection or gout is suspected
27
Q

Olecranon Bursitis Treatment

  • GOAL
    • Reduce pain / Restore function
  • Non-surgical (~50%)
    • Rest
    • Activity changes / elbow ____
    • NSAIDs (oral or topical)
    • _______(usually only recommended after 3 - 6 weeks of symptoms) + ______
  • Surgery
    • _______ (rarely needed)
  • Refer?
    • No improvement after full course of conservative options and/or suspicion of _______ (red/warm/pain out of proportion/severe ROM limitation)
A
  • GOAL
    • Reduce pain / Restore function
  • Non-surgical (~50%)
    • Rest
    • Activity changes / elbow pad
    • NSAIDs (oral or topical)
    • Aspiration (usually only recommended after 3 - 6 weeks of symptoms) + steroid
  • Surgery
    • Bursectomy (rarely needed)
  • Refer?
    • No improvement after full course of conservative options and/or suspicion of infection (red/warm/pain out of proportion/severe ROM limitation)
28
Q

Nursemaid’s Elbow

  • “_____ elbow” → Radial _____ sub______
    • Subluxation =
  • Very common (very little force)
    • __ - __ yrs most common
      • But can be 0 - 7
  • Mechanism of injury
    • Sudden, longitudinal ______ applied to the hand with the elbow _______ and forearm _____nated
    • May also be caused by a _____
A
  • “Pulled elbow” → Radial head subluxation
    • Subluxation = partial dislocation
  • Very common (very little force)
    • 1 - 4 yrs most common
      • But can be 0 - 7
  • Mechanism of injury
    • Sudden, longitudinal traction applied to the hand with the elbow extended and forearm pronated
    • May also be caused by a fall
29
Q

Nursemaid’s Elbow History

  • History
    • A _____ may be heard or felt by the person pulling the child’s arm
  • Symptoms
    • Child ______ to use the affected limb
    • Holds the elbow in slight ______ and the forearm ______
A
  • History
    • A click may be heard or felt by the person pulling the child’s arm
  • Symptoms
    • Child refuses to use the affected limb
    • Holds the elbow in slight flexion and the forearm pronated
30
Q

Nursemaid’s Elbow PE

  • P____ and _______ness localized to the _____ aspect of the elbow
  • Range of motion
    • _____ flexion and extension
    • Pain with _____nation
A
  • Pain and tenderness localized to the lateral aspect of the elbow
  • Range of motion
    • Full flexion and extension
    • Pain with supination
31
Q

Nursemaid’s Elbow Imaging

  • XR:
    • Not required in the setting of the ______ presentation:
      • History of _____ injury
      • Child _____ years or younger
      • Consistent clinical exam
      • When obtained, elbow radiographs are usually _____
      • Obtain (1) if there is any in______
  • ______
    • Helpful to confirm diagnosis “when necessary”
      • When the mechanism of injury is not evident
      • When physical examination is inconclusive
A
  • XR:
    • Not required in the setting of the classic presentation:
      • History of traction injury
      • Child 5 years or younger
      • Consistent clinical exam
      • When obtained, elbow radiographs are usually normal
      • Obtain xray if there is any inconsistency
  • Ultrasound
    • Helpful to confirm diagnosis “when necessary”
      • When the mechanism of injury is not evident
      • When physical examination is inconclusive
32
Q

Nursemaid’s Elbow Treatment

  • Reduction
    • _____nation → _____nation and then m______ ____ the elbow
    • _____ applies ______ over the radial head and a palpable _____ is often heard with reduction of the radial head
  • Aftercare
    • Child should begin to use the arm within _______ after reduction
    • I_________ is unnecessary after first episode
  • Refer
    • Recurrence?
    • Not reducible (surgery _____ required)
A
  • Reduction
    • Pronation → supination and then maximally flex the elbow
    • Thumb applies pressure over the radial head and a palpable click is often heard with reduction of the radial head
  • Aftercare
    • Child should begin to use the arm within minutes after reduction
    • Immobilization is unnecessary after first episode
  • Refer
    • Recurrence (does often recur)
    • Not reducible (surgery rarely required)
33
Q

Nursemaid’s Elbow Prevention

  • Once a nursemaid’s elbow has occurred, there is a high likelihood of?
  • Guidelines parents and caregivers can follow that may prevent the injury.
    • To safely lift a child, grasp gently _____ the arms. Do not lift children by holding their h_____ or a____.
    • Do not _____ a child by holding the hands or arms.
    • Avoid t_____ or pulling on a child’s hands or arms.
A
  • Once a nursemaid’s elbow has occurred, there is a high likelihood of recurrence.
  • Guidelines parents and caregivers can follow that may prevent the injury.
    • To safely lift a child, grasp gently under the arms. Do not lift children by holding their hands or arms.
    • Do not swing a child by holding the hands or arms.
    • Avoid tugging or pulling on a child’s hands or arms.
34
Q

Radial Head Fracture

  • Common injuries, occurring in about __% of all acute elbow injuries.
  • Many elbow d________ also involve fractures of the radial head.
  • Women __ Men, __ and __ years of age.
A
  • Common injuries, occurring in about 20% of all acute elbow injuries.
  • Many elbow dislocations also involve fractures of the radial head.
  • Women > Men, 30 and 40 years of age.
35
Q

Radial Head Fracture History

  • ____ on out______ hand
  • Elbow in ________ + forearm in _______
  • Most force transmitted from (1) to (1)
A
  • Fall on outstretched hand
  • Elbow in extension + forearm in pronation
  • Most force transmitted from wrist to radial head
36
Q

Radial Head Fracture Symptoms

  • Pain on the ____side of the elbow
  • Sw______ in the elbow joint
  • Difficulty in b___ing or st_____ning the elbow accompanied by pain
  • Inability or difficulty in t______ the forearm (palm up to palm down or vice versa)
A
  • Pain on the outside of the elbow
  • Swelling in the elbow joint
  • Difficulty in bending or straightening the elbow accompanied by pain
  • Inability or difficulty in turning the forearm (palm up to palm down or vice versa)
37
Q

Radial Head PE

  • Pain and tenderness ______ to radial head
  • Range of motion (mechanical _____ - can they fully pronate or supinate or is there a bone _______ blocking the full motion)
  • Be sure to palpate w____/d______ radius
A
  • Pain and tenderness localized to radial head
  • Range of motion (mechanical blocks - can they fully pronate or supinate or is there a bone fractureblocking the full motion)
  • Be sure to palpate wrist/distal radius
38
Q

Radial Head Imaging

  • XR:
    • Non-dis______ fractures are often hard to diagnose…
    • Check for ___ ___ sign indicating occult minimally displaced fracture
      • (1): always abnormal
      • (1): can be normal
  • CT:
    • ______ fracture delineation, usually for surgical planning
A
  • XR:
    • Non-displaced fractures are often hard to diagnose…
    • Check for fat pad sign indicating occult minimally displaced fracture
      • Posterior: always abnormal
      • Anterior: can be normal
  • CT:
    • Better fracture delineation, usually for surgical planning
39
Q

Radial Head Fracture Treatment

  • (1)
    • Sling
    • Usually just a few weeks (prevent stiffness)
  • (1)
    • Depends…
      • Displacement + mechanical block → ______
      • ORIF v. excision v. arthroplasty
  • Refer
    • Appropriate to refer all elbow _______
A
  • Non-displaced
    • Sling
    • Usually just a few weeks (prevent stiffness)
  • Displaced
    • Depends…
      • Displacement + mechanical block → surgery
      • ORIF v. excision v. arthroplasty
  • Refer
    • Appropriate to refer all elbow fractures

Diagnosis and Management (36 decks)

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