Download 1 – OMM Landmarks

10 – Exam of Elbow, Radius and Ulna
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Elbow
o Uniaxial hinge joint
o 50% plus injuries sports/recreational related
o Non-traumatic/overuseinjuries equal or exceed traumatic occurrences.
Multifaceted articulation
o Capitellum and Troclea of distal end of Humerus combine with:
 Radial Head and Olecranon of proximal radius and ulna
 Anular ligament holds the radius and ulna together
 Humeroulnar joint is TRUE elbow joint
 Capsule is reinforced and thickened by lateral and medial collateral
ligaments
 Resists and prevents excessive AB and AD duction
 Does not impede supination of pronation
o Ulnar Collateral Ligament
 Fan shaped – most important stabilizer
 Full extension  provides 30% of stability 54% in 90degree flexion,
possible up to 70%
 Radial head is an important secondary stabilizer in flex/ext – 30-33%
of stability
Innervation
o Median Nerve
 Crosses elbow medially – passes through two heads of pronator teres
o Ulnar Nerve – medial epicondyle  Passes along medial arm and posterior to the medial epicondyle
through the cubital tunnel
o Radial Nerve – lateral epicondyle
 Descends arm laterally, divides into superficial (sensory) branch and
deep (motor or posterior interosseus) branch. Deep Branch passes
through Arcade of Frohse where it is most susceptible to injury
H&P examination
o History  Inspection  Palpation  ROM  Muscle/Neuro Testin 
Specific tests
o PQRSTA
 Provocative or Palliative – what causes, what helps?
 Quality or Quantity – Character of symptom – dull, sharp?
 Region or Radiation – where, spread?
 Severity – 1-10
 Timing – when did it begin? How long does it last? How often?
Sudden/gradual?
 Associated signs and symptoms of chief complaint
o Always examine joint above and below
o Cardinal signs of inflammation
 Rubor
 Swelling
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 Heat
 Pain
 Loss of function
o Inspection
 Bilateral comparison – asymmetry
 Carrying angle – normal = 10-15 degrees of valgus
 Cubitus Valgus = Cubitus angle > 15 degrees
o Results in forearm ab duction
 Cubitus Varus = Cubitus angle < 10 degrees
o Results in forearm ad duction
o Palpation
 TART – Tissue/Texture changes – Asymmetry – Restricted ROM –
Tenderness
 Check joint above and below!
Muscle Strength Grading
o 0/5 – No muscle movement
o 1/5 – visible movement but not at the joint
o 2/5 – movement at joint but not against gravity
o 3/5 – movement against gravity, but not added resistance
o 4/5 – movement against resistance but less than normal
o 5/5 – Normal strength
Neuro Exam
o C5 – Biceps
o C6 – Brachioradialis
o C7 – Triceps
o Tinel’s test – tapping over a nerve to elicit pain/radiculopathy along the nerve
Inability to extend suggests need for elbow x-ray
Valgus/Varus Test
o Collateral ligaments
o Main stabilizers
 Medial collateral ligament – AKA ulnar collateral ligament
o Test at 30 degrees flexion
Milking Test
o Elbow flexed to 55, hand supinated, pull down on thumb, induces valgus
stresses. Pain = positive.
Moving Valgus
o Elbow maximally flexed
o Modest valgus torque applied until shoulder reaches its limit of external
rotation
o Elbow is quickly extended
o Positive test = reproduction of symptoms in an arc as the elbow passes from
120 to 70 of extension
Elbow Regions
o Anterior
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Pain = biceps tendinitis – excessive elbow flexion and supination
activities – anterior elbow pain with flexion and supination, weakness
secondary to pain
 Biceps Tendon Ruptur
 Popeye – 97% are proximal, weakness of supination and
flexion
o Posterior
 Triceps tendonitis – repetitive extension of the elbow – throwing,
hammering – pain in posterior elbow, tenderness around insertion of
triceps
 Pain with resisted extension of elbow
 Olecranon Bursitis – miner’s or student’s elbow – relatively painless
posterior swelling
o Medial
 Medial Epicondylitis – golfer’s elbow
 Overue of wrist flexors.
 MCL Ulnar Collateral Sprain
 Most important stabilizer of valgus stresses – mainly from 20130 degrees
 Pitching or throwing, racquet sports
 Pain increases by manual valgus stress
 Medial Apophysitis
 Young children – growth plates still open
 Any tension stress may partially or completely tear off the
medial epicondyle.
 Multifaceted Treatment
 Prevention, education, biomechanics, limiting pitches, rest,
NSAID’s, rehabilitation
 Medial Pain – Cubital Tunnel Syndrome
 2nd most common compression neuropathy behind Carpo
Tunnel Syndrome
 Mechanical compromise of ulnar nerve
o Direct insult, excessive traction, compression or
friction
o Clumsiness of hand
o Positive Tinel’s test
 Tx – night splint
o Lateral
 Nursemaid’s elbow – young children girls > boys.
 Axial traction on extended and pronated arm, also FOOSH.
 Pulls radius distally, slips through the annular ligament
 Arm is flexed at elbow and forearm pronated held close to body.
 Easily reduced in the exam room
 Supination and flexion
 Hyperpronation
 Sling
 Recurrence 26-39%
 Epicondylitis – Tennis Elbow
 Overuse of wrist extensors
 10X more common than medial
 Rest and ice, forearm splint, rehab, omm, steroid injection
- Flexor-Pronator Mass Syndrome
o Purely sensory syndrome
o Median Nerve becomes trapped between heads of pronator terres muscle
 Pain and parasthesia
o Mechanism
 Repetitive pronation
 Anomalous anatomy
o Resisted flexion of FDS tendon of index/middle finger
 Hand of the benediction
- Anterior Interosseous Syndrome
o Branch of the median Nerve
 Mostly motor syndrome – minimal or no sensory loss
 Weakness of loss of flexion of DIP joint or thumb index finger
LECTURE 10Lab
- Carrying Angle
o Adduction of Ulna will cause radius to be pulled proximal – results in AB
duction of wrist
o AB duction of ulna will cause radius to be pushed distal, this will result in
AD duction of wrist.
- Interosseous membrane
o Anterior Fibers
 Run obliquely distally and medially
o Posterior Fibers
 Run proximally and laterally
11 – Examination of Wrist and Hand
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Wrist Joints
o Radiocarpal, radioulnar, intercarpal – RC provides most flexion/extension
Hand joints
o Metacarpophalangeal MCP, proximal interphalangeal PIP, distal
interphalangeal DIP
Examination
o Look at thenar and hypothenar eminences
o Look for contractures of flexor tendons – dupuytren’s
o Palpate 8 carpal bones – MCP, PIP, DIP, squeeze MCP from both sides
between thumb and fingers
 PIP – RA or Bouchard’s nodes in DJD
 DIP – Heberden’s or psoriasis and base of thumb in DJD
Motion Testion and Maneuvers
o Wrist
 Adduction – ulnar deviation 30 degrees – FCU
 Abduction – radial deviation 20 degrees – FCR
 Flexion – 80-90 degrees
 Extension – 70 degrees
Finkelstein’s
o Patient grasp’s own thumb, then move wrist in ulnar deviation – de
Quervain’s tenosynovitis – inflammation of abductor pollicus longus and
extensor pollicus brevis tendons and sheaths.
Tinel’s Sign
o Tapping over coarse of median nerve
Phalen’s sign – hold wrist in flexion for 60 xeconds
Ganglion Cyst
o Soft Tissue Mass of hand wrist – most commonly the scapholunate joint
o Lining herniates out of ligamentous defect causing cyst
o Inflammatory process produces jelly like fluid
o Positive Transillumination – may be mistaken for bony prominence
Dupuytren’s Disease
o Fingers become progressively flexed at the MCP and PIP joints
 Diabetis, Smokers, Alcoholics
Kienbock’s Disease – idiopathic avascular necrosis – Lunate - MRI
o Repetitive compressive forces
o Vascular impairment
o Presents w/ vague aching wrist pain, stiffness
o Dominant wrist, men 20-40 y/o, women later in life
o Stages I-IV
 I – acute stage – indistinguishable from wrist pain, symptoms abate
 II – change in density of lunate, but size, shape, configuration are
normal; pain and swelling due to reactive synovitis
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III – increasing wrist stiffness, collapse of lunate, proximal migration
of capitate and disruption of carpal architecture
IV – further degenerative changes present in carpal
12 – OMT for Non-Surgical Forearm, Wrist and Hand Somatic
Dysfunctions
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Allen’s Test for Carpal Tunnel Syndrome
o Tests radial/ulnar artery insufficiency
 Pt rapidly open and lose fist then hold it closed
 Occlude ulnar and radial artery
 Open fist and release one artery –look for pink
 Positive is poor return of color.