The Elbow Flashcards by Marc McShane

List 3 non-neuromusculoskeletal conditions that may refer pain to the elbow.

Acute Myocardial Infarction
Pancoast’s Syndrome (lung cancer causes damage to thoracic inlet / brachial plexus)
Esophageal Motor Disorders

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What are 3 symptoms of esophageal motor disorders? Why is this relevant when assessing upper extremity pain?

difficulty swallowing
heartburn
chest pain
- esophageal motor disorders can cause referred elbow pain

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What is Pancoast’s Syndrome? Why is this relevant in assessing upper extremity pain?

malignant neoplasm (lung cancer) causes damage to thoracic inlet / brachial plexus
Pancoast’s Syndrome can refer pain to the elbow

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How much elbow flexion is needed to bring food to the mouth?

115°-123°

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From which epicondyle of the humerus does the pronator teres muscle originate?

medial epicondyle

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From which epicondyle of the humerus does the supinator muscle originate?

lateral epicondyle

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What attaches to the lateral border of the ulnar tuberosity & what is its function?

the oblique cord (thickening of supinator fascia that connects the ulnar tuberosity distally to the radial tuberosity)
assists in limiting supination

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List 3 muscles that attach to the olecranon process

triceps brachii
anconeus
flexor carpi ulnaris (FCU)

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Why is the radial head considered essential to elbow stability? Under what circumstances would this be especially true?

contributes to all planes of motion
resists valgus forces
if collateral ligament is damaged/injured & the distal radioulnar joint is unstable, the humeroradial articulation is even more important for keeping the elbow stable

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What is the optimal ROM for the radioulnar articulation?

70° pronation & 80° supination

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When does the peak strain to the interosseous membrane between the ulna & radius occur?

during neutral forearm rotation

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How does tension on the Triangular Fibrocartilage Complex (TFCC) change with radioulnar motion?

in full pronation (~70°), the anterior/volar ligament of the TFCC is taut
in full supination (~80°), the posterior/dorsal ligament of the TFCC is taut

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In what ROM is the elbow capsule least tensioned?

70°-90° of flexion

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List the 3 ligaments of the Ulnar Collateral Ligament complex

anterior
posterior
transverse

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How does the structure of the anterior part of the UCL affect elbow joint stability through the full range of elbow motion?

has two bands: anterior & posterior
anterior band is taut from full extension to 60° of flexion
posterior band is taut from 60° to 120° of flexion

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Which soft tissue structure is the greatest restraint to valgus stresses at the elbow?

anterior portion of Ulnar Collateral Ligament complex

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At what angle is the posterior portion of the UCL most taut?

90° of flexion

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What is Cooper’s ligament? What role does it play in elbow stability?

transverse (or oblique) part of the UCL

- contribution to stability is limited (it’s variably present & often indistinguishable from the capsule)

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List the 4 structures that make up the Radial Collateral Ligament complex (RCL)

annular ligament
radial portion
ulnar portion
(variably present) accessory portion

Which soft tissue structure plays the primary role in elbow stabilization? Which other two structures play secondary roles in elbow stability?

the Radial Collateral Ligament complex

- elbow joint capsule & common extensor origin play secondary roles

Which component of the UCL complex was originally implicated as playing the primary role in Posterolateral Rotatory Instability (PLRI)? What are its attachments?

ulnar portion

- medial epicondyle to the crest of the supinator on the ulna (blends with fibers of the annular ligament)

Describe the Elbow Extension test & its general sensitivity/specificity.

patient actively fully extends elbow

- excellent specificity (97%) for elbow fracture, okay sensitivity (69%)

Which 2 clinical tests would you use to determine dislocation and/or gross instability of the elbow?

Active Floor Push-Up Sign & Chair Sign (100% sensitivity with both)

If a patient presents with elbow pain and an exaggerated bony prominence, effusion, and an appearance of an elongated forearm, what might you suspect

dislocation

What is an example of a benign neoplasm of the elbow?

osteoid osteoma

What is an example of a malignant neoplasm of the elbow? In which population are they most common?

Ewing's sarcoma in patients 4-15 years old

What are the 4 criteria for ruling out an elbow fracture?

1. tenderness of anterior forearm radial head? 2. tenderness of posterior/lateral radial head? 3. any bruising? 4. tenderness over olecranon or medial epicondyle? (100% sensitivity)

Desribe Maudley's test

- resisted 3rd digit extension (test for lateral epicondylalgia)

Decribe Cozen's test

- resisted wrist extension (test for lateral epicondylalgia)

Describe Mill's test

- passive stretch of wrist extensors (test for lateral epicondylalgia)

How do you know when to target the elbow and when to target the cervicothoracic spine for lateral epicondylalgia?

- pain-free grip strength deficit predominates: local treatment - pressure pain threshold deficit predominates: remote treatment (C/T, wrist)

What structures form the cubital tunnel?

medial epicondyle, flexor carpi ulnaris, and olecranon process (ulnar nerve travels through the tunnel)

What are 4 neurological tests for Cubital Tunnel Syndrome?

1. Tinel's sign 2. Pressure Provocation test 3. Elbow Flexion test 4. Upper Limb Tension test (Ulnar bias)

What is Tinel's sign? What is its general specificity/sensitivity?

- tapping over the ulnar nerve at the cubital tunnel reproduces symptoms along the ulnar nerve distribution - moderate sensitivity (0.7), excellent specificity (0.98)

Describe the Pressure Provocation test for the elbow. What is the general specificity/sensitivity?

- elbow in 20° of flexion - pressure applied to the ulnar nerve at the cubital tunnel for 60 secs - (+) test is reproduction of symptoms along ulnar nerve distribution - good sensitivity (0.89), excellent specificity (0.98)

Describe the Elbow Flexion test. What is the general specificity/sensitivity?

- bilateral active elbow flexion with wrist extension, held for 3 minutes - (+) test is production of pain, numbness, or tingling along ulnar nerve distribution - moderate sensitivity (0.75), excellent specificity (0.99)

What is Little League Elbow Syndrome? Which tissues are involved?

- valgus overload or stress injury to the medial elbow as a result of repetitive throwing - ligament injury, but in more severe cases: apophysitis or stress fracture

Describe the Moving Valgus Stress test. What is the general specificity/sensitivity?

- pt is seated with shoulder abducted to 90° - starting with elbow in maximal flexion, apply a valgus torque until shoulder reaches max ER - maintain valgus torque & quickly extend elbow to ~30° of flexion - (+) test is reproduction of medial elbow pain, especially between 120° and 70° degrees - excellent sensitivity (1.0), moderate specificity (0.75)

Which condition commonly occurs concomitantly with Ulnar Collateral Ligament laxity?

Cubital Tunnel Syndrome

What is "Tommy John surgery"?

reconstruction of the anterior band of the ulnar collateral ligament complex with the palmaris longis (also anterior transposition of the ulnar nerve)

What is the role of conservative management vs surgery for patients with Ulnar Collateral Ligament laxity?

- conservative management for most | - Tommy John surgery for higher-level athletes (cost-effectiveness under question)

What 2 tests should be performed for a patient with suspected Ulnar Collateral Ligament insufficiency / Little League Elbow?

1. Valgus Stress test | 2. Moving Valgus Stress test

What motion of the shoulder is frequently limited in patients with UCL insufficiency / Little League Elbow?

internal rotation

List 3 common impairments in patients with non-specific elbow pain.

1. ROM 2. ULTT ROM 3. strength

List 4 neurological tests for Cubital Tunnel Syndrome

1. Tinel's sign 2. Pressure Provocation test 3. Elbow Flexion test 4. Upper Limb Tension Test 3 (Ulnar nerve bias)