The Elbow Flashcards
What is the purpose of the condyles in the elbow?
- Tendon attachment points
- Supinators attach to the lateral condyle
- pronators attach to the medial condyle
What are the two articulations in the elbow? What are their functions?
- ulnohumeral: flexion/extension
- radioulnar: pronation/supination
What is the primary functional component of the elbow?
Flexion
What is the purpose of the olecranon fossa?
Provide stability for the elbow from varus and valgus along with the collateral ligaments.
What are the three main ligaments involved in stability of the elbow?
- Lateral epicondyle: radial collateral ligament - stability in extension, prevent varus and valgus
- Medial epicondyle: ulnar collateral ligament - stability in extension, prevent varus and valgus
- Annular Ligament - stability of the radial head
Which muscles and nerve(s) are responsible for supination of the forearm?
- Muscles: biceps, supinator
- Nerves: C5-6
Which muscles and nerve(s) are responsible for pronation of the forearm?
- Muscles: pronator quadratus, pronator teres
- Nerves: C6-8, T1
What is the typical ROM for pronation/supination?
- Pronation: 70 degrees
- Supination: 85 degrees
Which views are commonly used in elbow radiography?
AP, Lateral, Oblique
What is the sail sign?
Fat pad sign, showing effusion (blood) in the joint capsule. Suggests occult supracondyllar fracture in kids or occult radial head fracture in adults.
Lateral Epicondylitis
- “Tennis Elbow”
- Likely a degenerative process instead of inflammatory
- “Inflammation” of the extensor origin at their insertion onto the lateral epicondyle
- May present as a dull ache on the outer aspect of the elbow that increases with grasping, twisting and resisted extension of the wrist or fingers.
Lateral Epicondylitis Physical Exam
- Point tenderness over insertion of extensor tendon on lateral elbow
- Increasing pain with resisted extension/supination of wrist
Lateral Epicondylitis Treatment
- Rest, avoidance of aggravating activities like gripping
- Ice if due to acute trauma or repetitive injury (2-3 days)
- PT, iontophoresis/friction massage
- Compression, possible ace wrap?
- Anti-inflammatories
- NSAIDs
- +/- steroid injection and marcaine or lidocaine (2-3 max)
- Surgery: lateral epicondylectomy
Medial Epicondylitis
- AKA golfer’s, pitcher’s, or bowler’s elbow
- microtrauma to the flexor carpi radialis tendon insertion on the medial epicondyle
- Physical Findings:
- tender to palpation on the medial epicondyle
- increased pain with resisted flexion and pronation of the wrist
Medial Epicondylitis Treatment
- Rest, avoid aggravating activity
- +/- ice
- NSAIDs
- PT for iontophoresis, etc.
- Referral for resistant cases
- Use caution when considering injection - ulnar nerve
Olecranon Bursitis
- Inflammation, swelling and +/- pain over the olecranon process
- Causes:
- trauma
- infection - puncture wounds, microscopic (not clinically evident) wounds
- inflammation - gout, pseudo-gout, rheumatoid arthritis, uremia in renal failure
Olecranon Bursitis Risk Factors
Diabetes
Chronic alcohol abuse
Occupation/hobbies
Gout
Immunocompromised
Olecranon Bursitis Diagnosis
x-ray if trauma or suspicion of foreign body and +/- gout
CBC if suspicion of significant infection
ESR, CRP and serum uric acid if suspicion of gout
Aspiration is controversial, consider specialist consult
Olecranon Bursitis Treatment
- First line for non-infectious is nothing
- Rest - avoid direct trauma, elbow padding may help
- NSAIDs if pain is present (or APAP)
- Aspiration (specialist)
- Gram stain & culture
- > 5000 WBC/mL indicates infection
- If infection present, staph aureus is most common pathogen
- Do NOT inject steroids unless positive there is no infection
- Typically resolves in 2-4 weeks
- Consider close follow-up after steroid injections
Ulnar Nerve Entrapment Syndromes Basics
- May be from acute trauma such as a fracture or dislocation
- Initial treatment requires prompt reduction
- Document neurovascular status before and after reduction
Cubital Tunnel Syndrome
- AKA “truck driver’s elbow”
- Chronic pressure on the ulnar nerve where it passes between bone, tendons and ligaments at the elbow
- Can also be entrapment of the nerve from hypertrophy of the triceps or the flexor/pronator musculature
- May be remote result of trauma
Tardy Ulnar Palsy
ulnar neuropathy remotely after an injury at the condylar groove
Ulnar Nerve Entrapment Syndromes Symptoms
- paresthesias in the ring and small fingers
- weakness of the intrinsic muscles of the hand
- weakness of abduction of 5th digit
- chronic entrapment –> Pope’s Blessing Sign
- Positive Froment’s sign
Ulnar Nerve Entrapment Syndromes Diagnosis & Treatment
- Diagnosis:
- Clinical
- EMG
- Treatment:
- Splinting, NSAIDs, Surgery
Radial Nerve Palsy
- AKA Saturday Night Palsy
- wrist drop and loss of sensation in dorsal web space between thumb and index finger
- cock-up splint for wrist
- orthopedic follow-up
- occupational therapy
- claw hand in non-resolving cases
- painless loss of ability to extend the wrist and fingers
Radial Tunnel Syndrome
- Actually posterior interosseous nerve in forearm
- Use caution with tennis elbow straps
- Loss of motor function
Nursemaid’s Elbow
- Subluxation of radial head
- non-calcified radial head is pulled out from under the annular ligament
- usually pt is around 2 years old, peak age 1-4
- About 20% of all upper extremity injuries in children
- Sudden longitudinal pull on arm with forearm pronated
- Arm usually held in slight flexion and pronation
- Child will not want to use arm to grap anything
- Xray first if question of fracture
- Reduction technique - supinate the forearm and flex the elbow. feel over radial head for click
- Re-examine in about 10 min
Nursemaid’s Elbow Follow-up
- sling for pain for 1-2 days
- APAP or ibuprofen for pain
- generally the child will begin using the arm immediately but will be sore for 3-5 days
- educate parent on mechanism and what to avoid
Elbow Dislocation
- Most commonly posterior dislocation
- Associated with fall on nearly extended elbow or other similar energy applied to joint
- If ulnohumeral joint is dislocated there is often an injury to the radial head too
- Flexion and extension are extremely painful. Pronation and supination will be painful if radial head is also injured.
Elbow Dislocation Management
- Initial Management:
- immobilize in sling, posterior splint or pillow splint, narcotic analgesics
- Evaluation:
- X-rays
- Physical exam: document neurovascular exam
- Reduction:
- IV conscious sedation, stabilize upper arm, in line traction of lower arm, flexion of elbow, push toward hand on olecranon, long arm posterior splint, post-reduction xrays, record CMS in hand, specialist referral
Fracture of Radial Head
- Mechanism:
- FOOSH
- Radial head driven into capitellum
- Symptoms:
- Elbow pain, +/- swelling
- Physical Exam:
- Tenderness over radial head
- Limitation of motion, especially in extension and pro-supination
- Diagnosis:
- AP, lateral and oblique xray series
- Radial head views if needed
- Positive fat pad sign - fluid in the anterior joint capsule
- Treatment:
- Sling for comfort
- Ice for swelling, pain
- Analgesics, avoid NSAIDs in fractures
- Encourage early AROM
- Follow xrays week 1,3,6
Elbow Fractures
- Fall backward on partly extended elbow
- Be suspicious for vascular compromise, especially brachial artery
- Be suspicious for nerve injury of median, ulnar or radial nerve
- Not a primary care fracture
- Treatment:
- initial - closed reduction or ORIF
- Complications:
- loss of ROM/joint contracture
- post-traumatic arthritis if articular surface is disrupted
- non-union of fx site
- infection
- tardy ulnar palsy
- nerve or vascular injury
Elbow Arthritis
- Post Traumatic:
- most common
- arthroplasty is becoming better but not a great option
- injection technique is difficult
- Rheumatoid:
- best managed with DMARDs
