Download Elbow

Elbow/ Forearm Anatomy
• Bones
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Humerus
Ulna
Radius
Bony Alignment
• Arthrology and
Movements
– Humeroulnar Humeroradial
– Proximal & Distal
Radioulnar
Elbow/Forearm Anatomy
• Ligaments and Capsule
– Joint Capsule
– Ulnar Collateral (UCL)
• 3 bundles
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Lateral Ulnar Collateral (LUCL)
Radial Collateral (RCL)
Annular
Interosseus Membrane
Anterior, Transverse, and Posterior Bundles
Elbow Movements
• Which muscles accomplish these?
– Flexion
– Extension
– Supination
– Pronation
Elbow/Forearm Anatomy
• Musculature
– Elbow Flexor/Pronator Group
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Biceps brachii
Brachialis
Brachioradialis
Pronator Teres/Quadratus
• Forearm Flexors - Common Flexor Tendon
» Medial epicondyle
– Flexor carpi radialis
– Flexor carpi ulnaris
– Flexor Digitorum
– Palmaris Longus
Elbow/Forearm Anatomy
• Musculature
– Extensor/Supinator Group
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Triceps Brachii
Anconeus
Supinator
Extensor carpi radialis longus
• Forearm Extensors - Common
» Lateral epicondyle
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Extensor carpi radialis brevis
Extensor carpi ulnaris
Extensor digitorum
Extensor digiti minimi
Extensor Tendon
Elbow/Forearm Anatomy
• Bursae
– Bicipital
– Olecranon
• Subcutaneous and
Subtendinous
• Blood supply
– Brachial, Radial, and Ulnar
arteries
• Nerve
– Radial, Ulnar, and Median
Nerves
Elbow Observation
• Anatomical
– Carrying Angle
– Cubitum Varum
– Cubitum Valgum
– Cubitum Recurvatum
Common Mechanisms of Injury
Indirect
Direct
Bursitis
– Etiology
• Superficial location makes it extremely susceptible to injury
(acute or chronic) --direct blow
– Signs and Symptoms
• Pain, swelling, and point tenderness
• Swelling will appear almost spontaneously and w/out usual
pain and heat
– Management
• In acute conditions, compression for at least 1 hour
• Chronic cases require superficial therapy primarily
involving compression
• If swelling fails to resolve, aspiration may be necessary
– Tends to fill up again
• Can be padded in order to return to competition
Elbow Injuries
• Bursitis
Elbow Injuries
• Muscle Strains
– Etiology
• MOI is excessive resistive motion (FOOSH), repeated microtears
• Hyperextension – torn anterior capsule
• Rupture of distal biceps is most common muscle rupture of the
upper extremity
– Signs and Symptoms
• Active or resistive motion produces pain; point tenderness in
muscle, tendon, or lower part of muscle belly
– Management
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RICE and sling in severe cases
Follow-up w/ cryotherapy, ultrasound and exercise
Tape for athletic competition
If severe loss of function encountered - should be referred for Xray (rule out avulsion or epiphyseal fx
• Forearm Compartment Syndrome
– Impaired circulation and neural function
Elbow/Forearm Injuries
Musculature/Tendinitis
• Medial Epicondylitis - chronic
“Pitcher’s, Golf, Javelin Elbow”
– MOI: repeated flexion (common flexor tendon), valgus
stresses, faulty biomechanics
– Special Tests: Epicondylitis tests (Flexor/Pronator)
• Tx: RICE (emphasize rest), NSAIDs,
strengthening
Elbow/Forearm Injuries
• Lateral Epicondylitis - chronic
“Tennis Elbow”
– MOI: overuse of extensor/supinator muscles, faulty
biomechanics (common extensor tendon)
• faulty backhand, too much topspin, too small or
large grip
– Special Tests: Epicondylitis tests (extensors)
– Tx: RICE (emphasize rest), NSAIDs, strengthening,
biomechanics correction
Elbow Injuries
• Bony/Articular
– Osteochondrosis/Osteochondritis
• Loose bodies (joint mice) – locking and clicking
– Little League Elbow (valgus overload or overstress injury
to the medial elbow )
• Apophysitis, stress fractures, avulsions usually at
medial epicondyle
• Onset is slow, very progressive pain
– Throwing distance is affected
• Tx: RICE (emphasize rest), NSAIDs
Nerve Injuries
• Ulnar nerve trauma
– The “funny bone”
– Tinel’s sign
• Radial tunnel syndrome
– Resembles lateral
epicondylitis
– Long finger test
• Pronator Teres Syndrome
– Median Nerve
– Pinch test
Elbow/Forearm Injuries
• Fractures - Humerus, Radius, Ulna
• MOI:
– Direct contact
– FOOSH
• Tx:
– Immobilize
– Referral
– Monitor pulse and circulation
Elbow Injuries
• Dislocations
– S/S:deformity, pain, limited ROM,
swelling.
– Management
• Immobilize in position found
• Do Not Reduce
• Monitor distal pulse and
neurological signs
Elbow Injuries
• Volkmann’s Contracture
– result of serious elbow/forearm
injury
– S/S: 4 P’s
1.
2.
3.
4.
loss of pulse
pallor
paralysis
pain w/ passive finger extension
Elbow Injuries
• Ligament Sprains
– Lateral Collateral
Ligament (Radial)
• Not as common as MCL
sprain.
• Special tests:
– Varus Test
– Annular Ligament
• Special Test:
– Radioulnar test
– Lateral ulnar collateral
ligament
• Posterior instability test
– Management
• Conservative treatment
begins w/ RICE and
NSAID’s
LUCL
What about the ulnar collateral
ligament?
• The Throwing or Overhead motion
Throwing Motion
• Early cocking
– Abduction/ER - Supraspinatus very active
• Late Cocking
– Anterior shld. Stretched/medial elbow valgus
– Scapula must be stable
– Valgus stress on elbow
• Acceleration
– Stable scapula/Large muscle groups to IR
– Valgus stress on elbow
• Deceleration - ECCENTRIC
– Teres Minor/Infraspinatus espec. active to slow
down
– Biceps Brachii to slow elbow extension
• Follow-Through
– Scapula protracts(abducts) - Serratus anterior
– LHB tendon stabilizes
Tensile stress
Acceleration:
Extension occurs at a rate of up to
2500º per second and continues to
20º of flexion. Forearm lags behind
the upper arm and generates
valgus stress (> 60 Nm), The
valgus force can overcome the
tensile strength of the UCL and
cause either chronic microscopic
tears or acute rupture.
Ulnar (Medial) Collateral
• At 90º of flexion, it provides 55% of the
resistance to valgus stress at the elbow.
– UCL is composed of 3 bands: anterior, posterior, and
transverse
• Etiology
– Injured as the result of a valgus force from repetitive
trauma
– Can also result in ulnar nerve inflammation, or wrist
flexor tendinitis; overuse flexor/pronator strain,
ligamentous sprains; elbow flexion contractures or
increased instability
Ulnar (Medial) Collateral
• Signs and Symptoms
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Pain along medial aspect of elbow; tenderness over MCL
Associated paresthesia, positive Tinel’s sign
Limited extension and supinatioin
Pain w/ valgus stress test at 20 degrees; possible end-point
laxity
– X-ray may show marginal osteophytes; calcification w/in MCL;
loose bodies in posterior compartment
• Management
• Conservative treatment begins w/ RICE and NSAID’s
OR
• Surgical intervention may be necessary (Tommy John procedure)
Elbow Injuries
• Ruptured Medial
Collateral Ligament
– “Tommy John” Surgery
– Use palmaris longus to
replace the ligament
– valgus stress avoided
for 4-6 months
– 1 to 1 ½
years to recover
Posterolateral rotatory instability
• Tear in Lateral Ulnar Collateral Ligament
– Humeroradial joint in instable
– Radius and ulna “rock away” from humerus
with extension
– Special Test:
• Posterolateral rotatory instability test
• May occur alone or along
with ulnar collateral tears
Prevention of Elbow Injuries
• Protective Equipment
– Pads, counterforce braces
• Physical Conditioning
– Don’t forget the muscles
• To support MCL and
flexor carpi ulnaris and flexor digitorum
superficialis
– Fist pumps and Rice bucket
• Proper Skill and Technique
Elbow Problem Solving
Putting it together with
Case studies
Recognition and Management of
Injuries to the Elbow
• Subject to injury due to broad range of motion,
weak lateral bone structure, and relative
exposure to soft tissue damage
• Many sports place excessive stress on joint
• Locking motion of some activities, use of
implements, and involvement in throwing motion
make elbow extremely susceptible
History
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What is the cause of pain?
Mechanism of injury?
Previous history?
Location, duration and intensity of pain?
Creptitus, numbness, distortion in temperature?
Sounds or sensations?
Technique changes?
Weakness or fatigue?
What provides relief?
Observation
– Deformities and swelling?
– Carrying angle
• Cubitus valgus versus cubitus varus
– Flexion and extension
• Cubitus recurvatum
– Elbow at 45 degrees
• Isosceles triangle (olecranon and epicondyles)
– Elbow at 0 degrees
• Straight line (olecranon and epicondyles)
Palpation - bony
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Humerus
Medial and lateral epicondyles
Olecranon process
Radial head
Radius
Ulna
Palpation – soft tissue
• Ulnar (medial), Radial and Lateral Ulnar collateral
ligaments
• Annular ligament
• Biceps brachii
• Brachialis
• Brachioradialis
• Pronator teres
• Triceps
• Anconeus
• Supinator
• Wrist flexors and extensors
ROM and Muscle Testing
– Active and Passive Range of Motion
• Flexion and Extension
• Supination and Pronation
– Muscle Testing
• Muscles of the elbow and those that serve as
wrist flexors, extensors, supinators, and
pronators
Circulatory and Neurological Function
– Circulatory
• Pulse should be taken at brachial artery and radial
artery
• Skin sensation should be checked - determine
presence of nerve root compression or irritation in
cervical or shoulder region
– Neurology
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Tinel’s sign
Elbow Flexion Test
Pronator Teres Syndrome Test
Pinch Test
Joint Stability
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Valgus Stress Test
Varus Stress Test
Radioulnar Joint Test
Posterolateral Rotatory Instability Test
Epicondylitis Tests
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Resisted Wrist Extension Test
Resisted Long Finger Extension Test
Wrist Flexion-Pronation Stretch Test
Resisted Wrist Flexion Test
Wrist Extension-Supination Stretch Test
Case Study #1
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A 24 year old woman comes to you
complaining of pain in her right elbow on
the medial side. The pain sometimes
extends into the forearm and is often
accompanied by tingling in to the little
finger and half of the ring finger. The pain
and paresthesia are particularly
bothersome when she plays recreational
volleyball. Describe your assessment
plan.
Case Study #2
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A 14 year old female gymnast comes to you
complaining of elbow pain. She explains she
was doing a vault and bent her elbow
backward (hyperextension) when she heard a
snap. The injury occurred 1 hour ago and there
is swelling. She is cradling her elbow in slight
flexion against her body and she does not
want to move the elbow. She has normal
sensation and vascularity in her hand.
Describe your assessment plan.
Case Study #3
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A 22 year old wrestler comes to you
complaining of posterior elbow pain. He
says that 10 days ago he banged his
elbow in practice and then later on his
car door. He has had posterior swelling
since then and increasing pain and
dysfunction. Describe your assessment
plan.
Case Study #4
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A 46 year old man comes to you complaining
of diffuse left elbow pain. He notes that when
he picks items up with his left hand to carry,
the pain increases dramatically. For example,
when he carries a briefcase for several
minutes, his elbow becomes stiff and sore. He
reports general physical activity including
gardening and work around the home. He has
a workshop and does some woodwork and
other crafts. Describe your assessment plan.