pathology Flashcards
What muscles are important to target with medial instability?
- flexor carpi ulnaris because of it proximity to the MCL
2. flexor digitorum superficialis because of it proximity and size
What is the most common direction of elbow dislocation?
posteriorlateral rotation of the ulna
How can the redial head cartilage become irritated without a compressive force?
- the capitellum has insufficent cartilage on the posterior surface to accommodate the radial head in extreme hyper extension
- can mimic lateral epicondyalgia
What type of trauma can occur with hyper flexion injury of the elbow?
- coronoid process can jam into the coronoid fossa
2. smaller biceps are more prone to injury
What is the typical mechanism for anterior radial head dislocations?
- the biceps can pull the radial head out of the annular ligament in a flexed pronated elbow position
- in this position you have the least amount of static stability and the radius is fulcroming on the ulna
What redial head pathology is often mistaken for lateral epicondylgia?
carlitage irritation from boney contact of the radial head during hyper extension
Why are children more prone to pulled elbows?
- smaller radial heads
- relatively greater plasticity of cartilage
- immature annular ligaments
How does a “pushed” elbow effect elbow function?
- radial head comes in contact with capitellum prematurely limiting extension
- also have greater compression of the TFCC during supination because of further functional shortening of the radius
What are some common pathologies that disrupt the median nerve?
- fractures of the humerus and distal radius
- dislocations of the elbow or lunate
- laceration of the anterior wrist
- compression at ligament of streuthers, pronator teres, FDS, AIS, carpal tunnel
How does median nerve injury entrapement at the ligament of struthers manifest?
- symptoms; vague pain in the forearm
- motor: pronator teres, FCR, PL, FDS, FDP, FPL, PQ, lumbricals 1 and 2, OP AbPB FPB (Key is FCR)
- sensory: Palmar cutaneous, palmar digital cutaneous
What are some common cuase of pronator teres syndrome?
- lacertus fibriosis or thickening
- hypertrophied PT
- fibrous bands in the muscle
What are the symptoms of the pronator teres nerve entrapment
MEDIAN
1symptoms: vague pain in the forearm
2. motor: (pronator teres), FCR, PL, FDS, FDP, FPL, PQ, lumbricals 1 and 2, OP AbPB FPB
3. sensory: Palmar cutaneous, palmar digital cutaneous
What differential would you expect with pronator teres nerve entrapment?
weakness with pronation with the elbow flexed because you remove pronator teres which should be working fine
What are the clinical finding with anterior interossseus syndrome?
MEDIAN
- motor: (pronator teres, FCR, PL, FDS), FDP, FPL, PQ, (lumbricals 1 and 2, OP AbPB FPB)
- sensory:
- symptoms: proximal forearm pain and weakness
- signs: weak pinch, unable to pinch tip to tip, but collapses into pulp to pulp, weak pronation with elbow flexed
What might you expect to find with CTS?
MEDIAN
- motor: (pronator teres, FCR, PL, FDS, FDP, FPL, PQ), lumbricals 1 and 2, OP AbPB FPB
- senory:palmar digital cutaneous
What makes up the carpal tunnel?
- medially- pisiform and hook of hamate
- lateral- scaphoid tuberosity and crest of trapezium
- floor- lunate and capitate
- roof transverse carpal ligament and palamer carpal ligament that make up the flexor retiinaculum
What are the most common entrapement sites for the radial nerve?
- upper arm or brachial plexus
- posterior interosseus
- radial tunnel
- cheiralgia parasthetica
What clinical findings might you expect with an upper radial nerve injury?
- symptoms: weakness with wrist and elbow extension, loss of wrist stability and inability to grasp
- sensory: limited secondary to overlap with other nerves
- motor: treceps anconeus, brachioradialis, ECRL BRANCHES deep radial ECRB and supinator, post interosseous ED, EDM, ECU, AbPL, EPN, EPL, EI
What clinical finding would you expect with a posterior interosseus entrapment?
- symptoms: poor wrist stability and loss of grasp, wrist drop, inability to abduct thumb
- sensory: none
- motor: (triceps anconeus, brachioradialis, ECRL BRANCHES deep radial ECRB) and supinator, post interosseous ED, EDM, ECU, AbPL, EPN, EPL, EI
What clincal findings would you expect with radial tunnel syndrome?
- symptoms:lateral elbow pain and tenderness over the PIN
2. motor: decrease ECRB or positive long finder test
how do you differentiate between lateral epicondalgia and radial tunnel syndrome?
- tenderness: RTS extensor mass LE lateral epicondyle
- type of pain: RTS dull LE sharp
- resisted supination: RTS painful LE not painful
- response to steriod injection: RTS none LE good
What is the primary site for radial nerve sensory loss?
dorsal web space between first and second web space
What are some common compression sites for the ulnar nerve?
- snapping over medial head of triceps
- arcade of struthers
- cubital tunnel
- FCU
- tunnel of guyon
What is the arcade of Froshe?
band or tunnel in the supinator that PIN passes through
where is the arcade of struthers?
- medial triceps border and intramuscular septum
2. 5-7 cm about the medial epicondyle
What clinical findings would you expect with a nerve entrapment at the arcade of struthers?
ULNAR
1.similar to cubital tunnel except you add FCU (flexion and ulnar deviation)
What are the differentials for cubital tunnel syndrome?
ULNAR
1. limited or painful elbow flexion, weakness in the hypothenar and interosseous muscles, claw hand, weak ulnar deviation and flexion, formet sign, sensory loss medial forarm and hand, AbDM DTR
What are the three zones of injury at the tunnel of guyon?
ULNAR
zone 1 before the tunnel motor and sensory
zone 2 after tunnel lateral motor only to interossseus
zone 3 after tunnel medially sensory only
What is ape hand deformity?
- thumb becomes extended and that hand flattens
- result of wast of the intrinsic muscles
- result of median and ulnar nerve injury (book says median)
What is claw hand deformity?
- during finger flexion you get extension of the MCP
- results from intrinsic muscle wasting and the stabilizing action of the wrist extensors during finger flexion
- can be a ulnar or median nerve problem (book says ulnar)
What is extension over load syndrome?
AKA throwing overload
- cubital valgus related syndrome
- during extension the olecranon glides medially to compress the medial edge of the fossa
- follow through further overloads the structures
- typically a throwing injury and they may complain of difficulty letting the ball go
What are the three classic criteria for lateral epicondalgia?
- pain on palpation
- pain with stretch
- pain with resistance to muscles
What histological changes occur with epicondyalgia?
cellular changes starting with
- tenocyte abnormalities
- ground substance breakdown
- neovascularization
- collagen breakdown
what motor changes have been noted with lateral epicondyalgia?
- increased ration times in the upper limbs
- dysfunctional activation of muscles of the forearm
- altered wrist posture with grip testing dropping into flexion instead of extension
- (B) ECRB tenderness
What are the different types of arthritis
- traumatic arthritis
- OA
- monarticular RA
- neuropathic arthritis- MTL
- OA with loose bodies
- osteochondrtis dissecens- necorosis of cartilage and bone
What is VOlkman’s ischemic contracture
contracture of the flexor muscles due to persistent spasm of the brachial artery following supracondylar humeral fracutres
What is synovial chondromatosis?
synovial villi become cartilagenous detach and calcify within the joint
What are some potential causes of loose bodies in joints?
- osteochondritis dissecans
- OA
- fractures with separtation
- synovial chondromatosis
OGI list 9 ROM based differentials for the elbow, what are the pathologies?
- OA
- traumatic arthritis
- RA
- loose bodies b/w olecranon and humerus
- osteoarthrosis
- loose bodies b/w coronoid process and humerus
- biceptial tendonitis
- pulled elbow
- PIN entrapment
How would you expect ROM to change with OA of the elbow?
capsular pattern of loss: 5-10 degree extension and 10-20 degree of flexion
How would you expect ROM to change with traumatic arthritis of the elbow?
capsular pattern of loss with slight flexion loss and marked extension loss
-usually no rotation restrictions unless radial head is fractured
How would you expect ROM to change with RA of the elbow?
Capsular pattern of loss with marked flexion loss and limited extension loss
How will the elbow ROM change with a loose body?
Single plane of restriction with pain and hard end feel
How would you expect ROM to change with bicepital tendonitis and PIN entrapment
- biceps- pain with full passvie pronation to squeeze the tendon against the ulna
- PIN- pain with active and passive supination, pain with pronation elbow flexed to 20 degrees
What structures can become pathologically loaded with cubital valgus?
- medial colateral ligament
- radial head is compressed
- secondary compression of the TFCC
How do you reduce a pulled elbow?
Compression with supination
What is patella-nail syndrome?
- Disease effecting body development of patella and finger nails as well as other parts of the body
- elbow deformities are common
How will a pulled elbow effect ROM?
1.extesnion limitations of about 20 degrees with rubbery end feel
What are some typical complications associated with a supracondylar fractures?
- median nerver injury
- mal-union with cubital varus deformity
- Volkman’s ischemic contracture
What complications typically occur with epicondylar fractures?
- boney inclusion into the joint
2. ulnar nerve injury
What complications are associated with olecranon fractures
fracture line nearly always falls through the joint line near the trochlear notch
When do coronoid fractures typically occur
With posterior elbow dislocations
What is one of the most common fractures among young adults?
Radial head
What is a Mantegga fracture?
1fractures of the proximal ulna with dislocation of the radial head
2.caused by a fall with forced pronation or direct blow on the back of the upper arm
What is neuropathic arthritis?
- repeated failure of protective mechanisms leads to instability and degeneration
- presents with swelling and feelings of weakness, absent pain and joint laxity
What is osteochondritis dissecans and how does it present at the elbow?
- necrosis fo articular cartilage and underlying bone by impaired blood supply
- elbow is the 2nd most effected joint and it nearly always involve with capitellum
- will ache after use and has intermittent swelling
