PC Elbow Flashcards
Dynamic stabilizers of the elbow
Surrounding muscles: biceps, brachialis, BR, triceps, anconeus
Varus stabilizer of elbow
Articular congruency
Valgus stabilizers of elbow
MCL — primary stabilizer at 90 deg
Anterior joint capsule
Osseous articulation in extension
Primary status stabilizers of the elbow
Ulnohumeral joint
Medial collateral ligament (anterior, posterior, transverse bundles)
Lateral collateral ligament (RCL, LUCL, accessory collateral ligament, annular ligament)
If posterior bundle of MCL is contracted, what motion is lost?
Flexion is limited
Primary restraint to valgus stress in the elbow during functional ROM
Anterior band of the MCL
Primary restraint to valgus stress in the elbow in MAX flexion
Posterior band of MCL
Primary restraint to varus stress in the elbow
LUCL
Secondary static stabilizers of the elbow
Radiocapitellar joint
Capsule
Origins of the flexor and extensor tendons
Static stabilizers of the elbow
- Osseous articulation
- Capsule
- Lateral collateral ligaments
- > radial
- > ulnar: Primary stabilizer to PLRI
- Lateral collateral ligaments
- Medial collateral ligament (anterior, posterior, transverse bands)
- Annular ligament
Most common complication of elbow arthroscoy
Transient ulnar nerve palsy
Nerve injury from proximal anterolateral portal in elbow arthroscopy:
PIN injury (loss of digit extension)
Mechanism of injury triceps tendon:
Eccentric contraction (eg. Bench press)
Compliations of triceps tendon repair:
Failure of repair
ULNAR NERVE injury
Most common complications of distal biceps repair:
Lateral antebrachial cutaneous nerve
Synostossi
Hardware failure
Lateral epicondylitis pathophysiology:
Degenerative process of ECRB & EDC
Functional elbow range of motion
E 30
F 130
S 50
P 50
Spiral groove of humerus location
13 cm proximal to articular surface of trochlea
Attachment of anterior bundle of medial ulnar collateral ligament
Sublime tubercle of ulna
Bald spot of the radial head
Lateral 120 degrees contains no cartilage
Opitimal elbow position for arthrodesis
90 degrees flexion; 0-7 deg valgus; neutral pro/sup
Treatment of chronic Essex-Lopresti injury
–Interosseous ligament reconstruction –Radial head implant –Ulnar shortening osteotomy –Sauve-Kapandji procedure –Distal ulna resection (Darrach) –Creation of one bone forearm
Neurovascular structures at risk in a proximal anteromedial elbow scope portal:
MABC
Ulnar nerve
Median nerve
Brachial artery
Neurovascular structures at risk in a proximal anterolateral elbow scope portal:
Radial nerve
PIN
How to test for posterolateral rotatory instability:
Pivot shift test: –Supination –Axial compression –Valgus stress –Full extension to ~ 40° flexion
Treatment of PLRI
LUCL repair/advancement vs. reconstruction with tendon autograft vs allograft
Surgical technique associated with lowest complication rate and best patient outcome for reconstruction of elbow ulnar collateral ligament?
Splitting of flexor-pronator mass, docking graft fixation (suture anchor) into medial epicondyle and transosseous at the sublime tubercle of ulna
Structures released during elbow contracture release
Flexion: POSTERIOR BAND OF MCL and posteromedial joint capsule
Extension: Anterior joing capsule
Medial UCL is under most strain during what phases of throwing?
Late cocking/early acceleration
Origin and insertion of anterior oblique ligament of the ulnar MCL
Medial epicondyle to sublime tubercle
Nearly isometric
Strongest and most significant stabilizer to valgus stress
Most sensitive and specific test for elbow MCL injury
Moving valgus stress test
Abduct shoulder to 90
Apply valgus stress while ranging the elbow through full arch of flexion & extension
Positive test is subjective apprehension, instability or pain at the MCL origin between 70 and 120 degrees
100% sensitive, 75% specific
First line treatment for elbow MCL injury
Rest & PT
6 wks rest from throwing
Then, initial PT for flexor-pronator strengthening and improve throowing mechanics
Progressive throwing program
Failed PT, what’s next for elbow MCL injury
MCL anterior band ligament reconstruction
Indications: high-level throwers that wanto continue competetive sports; failed nonop tx
Strongest fixation for MCL reconstruction in humerus?
Humeral docking is biomechanically stronger than figure of 8 and interference screw fixation
Also has better patient outcomes and lower complication rate
Postop rehab courst after elbow MCL reconstruction
early
early active wrist, elbow, and shoulder range of motion
strengthening exercises beginning four to six weeks post-op
mid-term
initiate a progressive throwing program at four months
avoid valgus stress until 4 months post-op
return to competitive throwing at 9-12 months post-op
Pathophysiology of pitcher’s elbow
repetitive stress of pitching leads to
excessive shear forces on medial aspect of olecranon tip and olecranon fossa
lateral radio-capitellar compression
posterior extension overload
medial tension at MCL
pathologic biomechanics leads to
cartilage injury from repetitive impaction of olecranon into olecranon fossa
osteochondral lesions of the capitellum
osteophyte formation (posteromedial humerus and olecranon)
loose bodies from fragmentation
MCL can become attenuated with repetitive strain
Potential complication of arthroscopic debridement of pitcher’s elbow
Take too much olecranon and caus valgus instability
Risk factors to develop Little League Elbow
Greater than 80 pitches per game
More than 8 months of competitive pitching per year
Fastball speed > 85mph
Continued pitching despite arm fatigue/pain
Participating in showcases
Treatment of olecranon stress fracture in throwing athlete:
Nonoperative
short-term administration of NSAIDS, rest +/- temporary splinting
indications: first-line treatment
modalities
initial 4-6 weeks of rest or splinting
progressive ROM exercises
avoiding valgus loading forces (e.g. throwing)
electrical bone stimulation may also be considered
Operative
open internal fixation
indications
delayed fracture union
modalities
large compression screw
tension band wire
Lateral pivot shift test for LUCL injury
patient lies supine with affected arm overhead; forearm is supinated and valgus stress is applied while bringing the elbow from full extension to 40 degrees of flexion
Indications for LUCL repair
- osteochondral fragment or soft tissue preventing concentric reduction
- Complex dislocation
- Acute instability
Location of partial distal biceps avulsion
Primarily on the radial side of the biceps tuberosity footprint
Risk factors for distal biceps avulsion
anabolic steroids
smoking has 7.5x greater risk than nonsmokers
hypovascularity
intrinsic degeneration
mechanical impingement in the space available for the biceps tendon
Short vs long head of the biceps — insertions & which is better at flexion vs supination
Short head - attaches distally on radial tuberosity — better flexor
Long head - attaches proximally on radial tuberosity — better supinator because attahement is furthest from axis of rotation (attaches at apex of radial tuberosity)
Most sensitive test for distal biceps tear
Ruland biceps squeeze test — akin to the Thompson test for Achilles
Squeeze a slightly pronated forearm in mid-flexion and look for supinatoin
Function lost in nonoperatively treated distal biceps tear
50% supination
30% flexion
15% grip
Complications of distal biceps tendon repair
Single incision – LABCN most common; Radial nerve/PIN most severe
Double incision — Synostosis; Heterotopic ossification
Risk factors for triceps rupture
systemic illness (hyperparathyroidism, renal osteodystrophy, OI, RA, type I DM) anabolic steroid use local steroid injection fluoroquinolone use chronic olecranon bursitis previous triceps surgery Marfan syndrome
Mechanism of lateral epicondylitis
Eccentric overload at origin of common extensor tendon –> leads to tendinosis and inflammation at the origin of the ECRB
Pathohistology seen in lateral epicondylitis
Angiofibroblastic hyperplasia
Deorganized collagen
Condition associated with lateral epicondylitis
Radial tunnel syndrome — 5% of time
Complications of ECRB debridement for lateral epicondylitis
Iatrogenic LUCL injury — do not resect beyond equator of radial head — leads to PLRI
Test for medial epicondylitis
Pain with resisted FA pronation and wrist flexion
First line treatment for medial epicondylitis
rest, ice, activity modification (stop throwing x 6-12wks), PT (passive stretching), bracing, NSAIDS
Risk factors for developing elbow OCD
Repetitive overhead and upper extremity weight bearing activities — seen in gymnasts & throwing athletes
Panner’s disease
osteochondrosis of the capitellum
typically presents in first decade of life (<10 years old)
usually benign self-limiting course
same mechanism of injury as OCD
surgery is contraindicated for Panner disease (unlike OCD elbow)
Pathophysiology of elbow OCD
theorized to result from repetitive compression-type injury (overhead or upper extremity weight bearing activities) of the immature capitellum causing:
vascular insufficiency
repetitive microtrauma
Treatment of stable OCD with intact cartilage
Nonop
Treatment of elbow OCD with bony collapse or loose fragment
Small and stable lesion: microfracture
Large and incompletely displaced: fixation
Unstable: debridement and exision
Large and unstable: OATS
Indications for arthroscopic debridement and capsular release in elbow arthritis
mechanical symptoms from loose bodies
stiffness related to capsular contracture
stiffness related to bony block to motion
preferred in patients with >90° of motion
Indications for ulnohumeral distraction interposition arthroplasty in elbow arthritis
young, high demand patients with END STAGE arthritis (OA, RA, post-traumatic arthritis who would otherwise have received TEA if they were older)
Indications for total elbow arthroplasty
- older patients >65 years with severe elbow arthritis (Larsen stage 3-5)
- complex distal humerus fracture in elderly with poor bone stock
- distal humerus nonunion or malunion in elderly, lower demand
- post-traumatic arthritis
Culprit if elbow contracture and < 90-100 flexion
posterior band of MCL
Indications for static splinting for elbow contractures
Failed PT with:
Elbow flexion contracture > 30 OR
Elbow flexion less than 130
Operative treatment for elbow flexion contracture
Capsular release +/- posterior band of MCL
Indications for operative treatment of elbow flexion contracture
Extrinsic capsular contratures with normal joint surface congruency
Risk of posteromedial portal in elbow arthroscopy
Injury to ulnar nerve
Contraindicaitons to elbow arthroscopy
Prior trauma
Surgical scarring
PREVIOUS ULNAR NERVE TRANSPOSITION
Complications after elbow arthroscopy
Nerve palsy — transient ulnar nerve palsy most common
HO
Infection (sinus tract from posterolateral portal)
Best total elbow survivorship in?
Rheumatoid arthritis
Contraindicaitons to total elbow arthroplasty
absolute
active infection (arthrodesis favored)
Charcot joint
relative
poor neurologic control of affected extremity
active patient younger than <65 years old
olecranon osteotomy
Total elbow replacement design with best results
Semi-constrained or linked components
Key components of postop care in total elbow
Early period of immobilizaiton (5-10 days) — early motion after TEA is associated with wound complications, instability, and hardware loosening — typically immobilize for 4 weeks after surgery
Lifelong weightlifting restriction of less than 5-10 lbs
Most common compliations after total elbow
Aseptic loosening (17%) Infection (8%) Instability (10%) Bone loss, bushing wear, wound healing difficulty, ulnar neuropathy, triceps insufficiency Periprosthetic fx
Principals of fixation of periprosthetic total elbow fractures
Think of them exactly like Vancouver classification of fxs
Near joint & nondisplaced — nonop, immobilize
Near joint & displaced — ORIF w suture vs tension band
Along stem — revise to long stem
Distal to prosthesis — OIRF like regular fx
