UE Lab Flashcards
A 2-year-old male presents with left elbow pain of 2-hours duration. Dad was holding his left hand while they were walking. The child tripped and Dad attempted to pull him up to keep him from hitting the ground. The child suddenly cried and pulled his left arm into his side. He now refuses to move the elbow.
ddx?
Buckle or greenstick fracture of the distal humerus
Growth plate injury (Salter Harris fracture) of the distal humerus or proximal radius
Elbow dislocation
Avulsion fracture
Nursemaid’s elbow
Ortho exam left elbow:
No significant swelling or deformity palpated around the elbow.
Will not cooperate with medial/collateral ligament testing.
Unable to illicit pinpoint tenderness-screams with everything.
Mild tissue texture changes noted over the radial head.
nursemaid’s elbow
Nursemaid’s Elbow mechanism of injury
Axial traction
Immature radial head slips through annular ligament
Recoil traps annular ligament
Radial head subluxation
Pain results from trapped annular ligament
Management of nursemaid’s elbow
Reduce the subluxation – usually child begins using arm again almost immediately. May need to be distracted. Use your creativity with peds!
Sedation – usually not required
Splinting – usually not indicated
Meds – may give OTC acetaminophen, but frequently unnecessary. If stronger med needed, suspect other diagnoses
Rehab – usually none
Parent education. Do you suspect child abuse?
OMT Goals beyond reduction of the radial head
Once the elbow is fixed, need to think long-term and preventive care
Use OMT to restore OPTIMAL function (not just reduce dysfunction) with goal of preventing/reducing future injury
May not tolerate at initial visit. May need to bring the child back in 48-72 hours for treatment.
Fascial chains
Long fascial connections Myofascial strains tend to re-occur during growth spurts Look for - radial head dysfunctions, - fascial strain in the --- upper extremity --- ribs --- upper thoracic spine --- Cervical soine
Correction of Nursemaid’s elbow
Treatment consists of manipulating the child’s arm (closed reduction) so that the annular ligament and radial head return to their normal anatomic positions. Traditionally, the manipulation consists of forearm supination and elbow flexion, as follows:
This is accomplished by immobilizing the elbow and palpating the region of the radial head with one hand.
The other hand applies axial compression at the wrist while supinating the forearm and flexing the elbow.
As the arm is manipulated, a click or snap can be felt at the radial head.
Glenohumeral joint BLT
Correction is made with the patient seated, the physician standing on the side of lesion, facing him. The operator’s hands reach around the humerus with the fingers as superior a contact on the humerus into the axilla as possible. Caution about placement as the brachial plexus is vulnerable to compression. Change your hand placement if tingling in the arm occurs.
Leverage is placed with the humerus toward the chest and the fingers on the medial humerus pulling laterally.
The patient reaches the hand of the involved side across his chest to the distal third of the opposite clavicle and holds that shoulder.
The patient is instructed to move his uninvolved shoulder posteriorly, carrying with it the hand of the lesioned side. This draws the lower end of the humerus across the chest in order that the leverage over the fulcrum provided by the physician’s hand disengages the head of the humerus.
Balanced ligamentous tension is then established by gently internally or externally rotating the humerus (see Figure 20). A slight superior motion may also help engage the entire joint capsule.
This position is held until there is a change in tissue tension.
Respiratory cooperation may be employed to correct the lesion.
Scapulothoracic joint BLT
Get yoru fingers/ thumb anterior to posterior axillary fold, find edge of scapula, balance the scapula on the fingers (hand-in-glove technique)
ask the patient to lean into fingers
Scapulothoracic joint BLT- Modification for a child
Use only one finger in the scapulothoracic space
Give them a toy to play with to keep the hand more midline and humerus more internally rotated
Posterior radial head - dx
During dynamic motion testing, the radial head resists anterior motion and supination (position of ease is pronation with radial head preferring posterior motion).
Posterior radial head Still Technique
Initial position: The sensing hand gently contacts the radial head and supports elbow. The patients arm should be relaxed. The operating hand encircles the patients’ wrist. The forearm is brought into pronation until tissue balance is sensed at the radial head.
Final position: A gentle axial force is put through the distal radius to the radial head. Maintaining that compression, the forearm is brought into supination. Release the compression to recheck motion
Anterior radial head Diagnosis:
During dynamic motion testing, the radial head resists posterior motion and pronation (position of ease is supination with radial head preferring anterior motion).
Anterior radial head Still Technique
Initial position: The sensing hand gently contacts the radial head and supports elbow. The patients arm should be relaxed. The operating hand encircles the patients’ wrist. The forearm is brought into supination until tissue balance is sensed at the radial head.
Final position: A gentle axial force is put through the distal radius to the radial head. Maintaining that compression, the forearm is brought into pronation. Release the compression to recheck motion
Other conditions in which to think about these techniques…
Shoulder injuries
- Baseball/softball pitchers
- Hockey players
- Lacrosse players
- Swimmers
Elbow injuries
- Medial and lateral epicondylitis
Shoulder dystocia, arm presentation babies
