Week 6 Elbow Instability Flashcards
Traumatic Elbow Injuries
FOOSH
Simple Dislocations
Elbow Fractures
Forearm Fractures
Traumatic Elbow Injury: A fracture and/or dislocation that occurs at or near the elbow injuring the (distal/proximal) humerus, (distal/proximal) ulna or radius, and/or the joints that comprise the elbow: humeroradial, humeroulnar, or proximal radioulnar joint.
FOOSH – Fall on an outstretched shoulder hand.
Foosh can lead to the things above ^^^
Any of those structures can be involved in a traumatic elbow injury.
distal; proximal
Elbow Complex: Osteology:
“Lock and Key” configuration is the primary stability
Ulnohumeral
Radiohumeral
Proximal Radioulnar Joint
Elbow has very congruent and irregular anatomic structure. Leads to a large amount of bony (mobility/stability). Because it has a lot of bony (mobility/stability), high forces from a trauma have a chance to wreak havoc through the joint.
stability; stability
Articular Configuration Adds to Stability
Trochlea groove is articulated by the ridge of the trochlear notch which gives good bony stability. Capsule surrounds all three joints holding them together. Capitulum and radial head have a good articulation.
Got it
From a bony standpoint in regard to the elbow, the closed pack position and the position of greatest stability is in (flexion/extension).
Closed pack position when it comes to soft tissue is (flexion/extension).
The anterior capsule is the most tense when in full (flexion/extension).
flexion; extension; extension
Medial capsule / lateral capsule – tight (in flexion and extension/throughout the range)
Anterior capsule – most tense in (flexion/extension)
Posterior capsule – most tense in (flexion/extension)
throughout the range; extension; flexion
The (brachialis/brachioradialis) is adherent to the anterior capsule. The elbow is the only joint in the body where we have nothing but muscle fibers crossing the joint adjacent to the capsule. When we have flexion contractures, it begs the question does the (brachialis/brachioradialis) have something to do with it?
brachialis; brachialis
LCL Complex
Yellow - _____ ligament
Blue - _______ ligament
Red - _______ ligament: This ligament will be important in posterior dislocation of the elbow
Annular; lateral collateral ; lateral ulnar collateral
Medial Collateral Ligament of the elbow:
Green - _____ band
Purple - ______ band
Yellow - ______ band: Attaches to 2 bony processes in the same bone
anterior; posterior; transverse
Annular ligament wraps around the radial head and the funnel shape limits the inferior translation of the radius.
______ elbow – happens in little children when parents lift them by their hands and wrists and swing them around in circles. Putting inferior distraction on the radial head and neck. Can slip down in the funnel of the _____ ligament and get stuck because in children they aren’t fully developed.
Nursemaids; annular
______ and _____ head act as a buttress to posterior deforming reaction forces imposed by the biceps, brachialis, and triceps.
You are landing on the outstretched hand and the things that get hit by the humerus are the _____ and the _____ head on impact. Forces imposed by the biceps, brachialis, and triceps are trying to stabilize. Muscles contract to try and bring stability to the joint and they force those bones together and you run the risk of fractures and further injury.
Coronoid and radial head; coronoid and the radial
Terrible Triad = (anterior/posterior) dislocation; fractures to ____ head and _____ process
(Anterior/Posterior) dislocation– radial head and coronoid process are in the way. Only way this dislocation occurs is if ulna and radius go inferior first and then pop out the back or the force causes a fracture at the radial head and ulna.
Direction the (forearm/humerus) goes is how the dislocation is named
Anterior dislocation – ______ process is at risk
Divergent – ulna and radius get split apart (messing up the ______ membrane)
posterior; radial; coronoid; Posterior; forearm; olecranon; interosseous;
Elbow Instability: 3 Stages of progression
Stage 1 – ____ head is subluxing meaning the (LUCL/Annular ligament) has failed. There is a level of movement that allows the radial head and ulna to drop down and slip out the back partially.
Stage 2 – closer to full (anterior/posterior) dislocation. The _____ process prevents full dislocation. This is not seen directly (physical exm) because it is hard for the elbow to rest on the coronoid process. This will slip back in place but in testing you can see how far it can go. Most likely under anesthesia to see that happening, not in your clinic.
The (MCL/LCLC) failed in this stage.
Stage 3A: MCL - (anterior/posterior) band
Stage 3B: MCL - (anterior/posterior) band
FOOSH - This is the most common way that they’ll dislocate
With elbow extension you are in the (greatest/least) bony region of stability in terms of positioning.
Radial; LUCL; posterior; coronoid; posterior; anterior; least
Elbow Fractures
Represent 5-6% of all fractures
____ head most common fracture
LOM is a common sequelae following elbow trauma
Rates of stiffness after elbow trauma range from 5%-40%
Stiffness can occur any time during the healing process
(Pain/Stiffness) is the biggest problem after elbow trauma.
LOM – Loss of motion
Rates of stiffness – leaning more to 40% in all reality.
Radial; stiffness
Rehabilitation Guidelines for Simple Dislocations (went out the back and got put back in)
“Open reduction is where the fracture fragments are exposed surgically by dissecting the tissues. Closed reduction is the manipulation of the bone fragments without surgical exposure of the fragments.”
Therapy initiated within _ week post closed reduction
Ligament reconstructions are rare for a simple dislocation
Sling, Long Arm Orthosis, Hinge brace for immobilization between exercise sessions
A/AAROM for flexion/extension in (neutral rotation/supination) unless you know which side of the elbow is unstable (medial vs lateral)
Pronation/Supination performed in elbow (flexion/extension) because it is the most stable bony position
Closed reduction for 3 weeks or more vs. early mobilization
Evidence supports establishment of early mobilization following injury
Iordens, et al., 2017
Compared casting for 3 weeks to early mobilization
Results:
Early mobilization resulted in (earlier/later) recovery and work resumption
At 6 weeks better outcome measures (quick DASH, OES), better ROM
At 1 year – no difference between the groups
No residual instability, subluxation or secondary dislocations
The longer they wait for therapy, the more they muscle guard and increase the chance of a stiff elbow.
No (active/passive) stretching in the first _ weeks. Biggest mistake is to start (active/passive) stretching. Seems to be why we end up with so many stiff elbows. Try to get their ROM with (active/passive) motion. That is the way to go!
If we don’t start the ROM early, high chance of a stiff elbow (ROM – Active or active assisted )
1; neutral rotation; flexion; earlier; passive; 3 ; passive; active;
If you don’t know which side (medial/lateral) keep forearm in a neutral position.
Bony stability is in flexion so they’ll feel unstable in extension.
If LCL is the issue of instability, we want to put their forearm in a (pronated/supinated) position when they do active or active assisted elbow flexion/extension. Will put tension on supinator – help adds stability and limits the tension on the LCL.
If MCL is unstable, have them in (pronation/supination) when they do elbow flexion/extension so we don’t stress the MCL which occurs with (pronation/supination).
If both sides are an issue, stay in (pronation/neutral rotation).
pronated; supination; pronation; neutral rotation
Early Controlled Protected Ext/Flex
Protective Phase Overhead protocol (PROM/AROM)
Early controlled flexion/extension with arm flexed to _ degrees (doing flexion/extension against gravity) will help prevent drop sign. Gravity compresses the joints together and that is what we want.
AROM; 90
Ultimate Load To Failure
UCL w/o muscles intact has an ultimate failure load of 34Nm.
Torque on the elbow – There is a (valgus/varus) torque on the elbow as they start to throw and it is (higher/lower) than 34Nm. The motion itself is going to cause a 70Nm load and it will be (higher/lower) than the 34nm and you need muscular force to withstand it.
The muscle needs to be in place and functioning to prevent ultimate failure load of the UCL. Need muscles to provide the dynamic force.
valgus; higher; higher;
Clinical Examination
History Edema Palpation ROM – stiffness Joint Mobility Strength – elbow, total arm Function Wrist or Shoulder Exam? Complications- What is limiting resolution of impairments/function
Complications from surgery or rehab might cause problem.
Got it
Special Tests for the MCL
_____ Maneuver
Moving (Valgus/Varus) Stress Test
Traditional MCL Test - (Sufficient/Not sufficient) for throwers.
Milking maneuver – grab the thumb, support the elbow in a flexed position (don’t do this maneuver in abduction to prevent ER the shoulder too far). Supported for the thrower, like Lachman in the ACL.
Milking ; Valgus; Not sufficient
Post-Op Rehabilitation Following UCL Repair
Hinge orthosis for early motion- 1st week: (protected AROM/no motion) 2nd week: _-_ degrees 3rd week: _-_ degrees By end of 6th week, (75% ROM/full motion)
No (valgus/varus) stress allowed.
Emphasize gradual progression
no motion; 30-100; 15-110; full motion; valgus;
Post-Op Rehabilitation Following UCL Repair Continued
Repair beyond 6-8 weeks-
Management of stiff elbow
Management of irritable scar: Medial elbow - (Radial/Ulnar) nerve runs right around the medial elbow so have to manage irritability around the scar.
(Isometric/Eccentric) total arm exercises
Progressive strengthening
Proprioception rehabilitation
Sports-specific training: Throwing intervals ~ _ months post-op
(-) months for Return to Play
Ulnar; isometric; 4; 12-18
Posterolateral Rotatory Instability (PLRI)
Disruption of the (LCL/MCL) Complex
Clinical Presentation-
Hx of recurrent painful clicking, snapping, clunking, locking
Mechanism- Occurs with (extension and forearm supinated/flexion and forearm pronated) Hx of “sprain” FOOSH Injury Prolonged Crutch Walking
No PT Management for instability?
If misdiagnosed; likely treated for tennis elbow and treatment fails; relative rest may reduce pain symptoms
LUCL Only has been stretched in stage (1/3)
Find out because they had an injury a while ago and had PT mismanagement.
Fracture was healed and potentially surgeon didn’t tighten anything up.
LCL; extension and forearm supinated; 1
Posterolateral Pivot Shift Test
Therapist Hands:
Apprehension test
Both examiner and patient think the radial head will sublux when it is positive
MD Hands:
Under anesthesia or local injection: full subluxation
The subluxation typically occurs with the elbow in - degrees of flexion
If it occurs further into flexion around 80-90 degrees suspect (anterolateral/posterolateral) capsule too, not just the LUCL.
Posterolateral pivot shift test –
If the LUCL cannot keep the ulna in a compressed position with the humerus, now the ulna will slide up the trochlea as you do the axial load. LUCL is the one we think is compromised.
20-40; posterolateral;
Posterolateral Rotatory Instability (PLRI)
Relocation Tests:
Table, Chair, Push-up
Clinical Wisdom
Patients with (acute/chronic) injury will not assume these positions due to apprehension.
Patients with (acute/chronic) hx will demonstrate it while providing the hx
Pain and apprehension drive patients willingness to perform these tests.
Before performing ask the patient to flex the elbow to 90 at their side, then ask them to actively extend the elbow.
If the patient is apprehensive about performing this active motion, refer them to an elbow surgeon
Creating the same force the therapist would be creating in the posterolateral pivot shift test.
acute; chronic
Instability Assessments
Joint Play-
Avoid if suspect (acute/chronic) injury
(Acute/Chronic) injuries can assess
Traditional Varus Stress Test-
Does not stress the (LUCL/Capsule), only the LCL and the (LUCL/capsule). So not good to test the (LUCL/capsule) with this test.
acute; chronic; LUCL; capsule; LUCL
LUCL Reconstruction
Typically start PT _ week post-op
Range - days post-op if sound reconstruction
Delayed referral to therapy (- weeks) if tenuous reconstruction suspected
Starting 1 week post op with all of these surgeries due to risk of stiffness if delayed.
1; 3-10; 2-4
Varus Imperative
The elbow must be able to perform in a (varus/valgus) environment
There is always a varus external force on our arm in the majority of things we do. Have to prevent the varus forces early on if issue is dealing with the (lateral/medial) elbow.
Lateral instability of the elbow – mostly what we do functionally puts the arm in a position where external forces cause a varus torque. This is not what we see in baseball pitchers. Essentially everything we do puts us at a varus torque.
varus; lateral
Prevent (varus/valgus) forces for PLRI. Need to think of shoulder (IR/ER), every time it is in (internal/external) rotation there is a (varus/valgus) force on the elbow.
MCL – avoid anything that puts them in a (varus/valgus) force. When the shoulder is (internally/externally) rotated you are getting a (varus/valgus) force on the elbow.
varus; IR; internal; varus; valgus; externally; valgus;
