Download ADduction of wrist

10- Exam of Elbow, Radius, Ulna
Most are overuse injuries: all treatments conservative
Uniaxial hinge Joint:
Multifaceted articulation
Capitellum and trochlea of the distal end of the humerus combine with:
◦ Radial head and olecranon of the proximal radius and ulna
Annular ligament holds the radius and ulna together
Humeroulnar joint is the true elbow joint
Capsule reinforced and thickened (Lateral: radial and medial: ulnar= most important)
Stabilize in flexion and extension
Median Nerve
◦ Crosses the elbow medially
◦ Passes through the two heads of the pronator teres
Ulnar Nerve
◦ Passes along the medial arm and posterior to the medial epicondyle
◦ Through the cubital tunnel
Radial Nerve
◦ Descends the arm laterally, dividing into the superficial (sensory) branch and the deep
(motor or posterior interosseous) branch
◦ The deep branch passes through the Arcade of Frohse, where it is most susceptible to
injury
History and PE: History, Inspection, Palpation, ROM, Muscle/Neuro testing, Specific tests
History: age, occupation, type injury, pain, alleviate/relieve, previous injury, OLD CARTS/PQRSTA
 Provocative or Palliative-What causes the symptom? What makes it better or worse? What have
you done to get relief?
 Quality or Quantity-What is the character of the symptom, i.e., pain: is it crushing, piercing, dull,
sharp?
 Region or Radiation-Where is the symptom? Does it spread?
 Severity-How does the symptom rate on a severity scale of 1-10 with 10 being the most intense
pain the patient (subjective) has ever had.
 Timing-When did the symptom begin? How long does it last? How often does it occur? Is it
sudden or gradual?
 Associated signs and symptoms of the chief complaint.
Examine Joint above and Joint below
Inspection: expose, compare bilaterally, joint alignment, previous injury, muscle imbalances, functional
Carrying angle: Normally 10-15 degrees (female>male)
Cubitus valgus: >15 (forearm deviating outwards)
Cubitus varus: <10 (forearm deviating towards midline)
10- Exam of Elbow, Radius, Ulna
Palpation: TART
ROM: flexion, extension, pronation, supination
Muscle Strength
0/5 No muscle movement
1/5 Visible movement but not at the joint
2/5 Movement at the joint but not against gravity
3/5 Movement against gravity but not against added resistance
4/5 Movement against resistance but less than normal
5/5 Normal strength
Neuro: C5=Biceps; C6=Brachioradialis; C7=Triceps
Tinel’s test: tapping over a nerve to elicit pain along nerves
Elbow Extension Test: inability to extend suggests need for Xray
Milking Maneuver: elbow flexed to >55, hand supinated, patient/DO may pull down own thumb
Pain=positive test
Moving Valgus Test: patient experiences reproduction of symptoms in an arc as the elbow goes from
120 degrees flexion to 70 degrees extension
10- Exam of Elbow, Radius, Ulna
Injuries
Anterior:
Biceps Tendon Rupture: weakness of supination and flexion; tender to palpation
Deformity as muscle belly contracts (avulsion fragment from radial tuberosity)
Risk: male, >30, steroids
Posterior:
Triceps Tendonitis: tenderness around insertion of the triceps (posterior elbow)
Pain with resisted extension of the elbow
Olecranon bursitis (miners/students elbow): Relatively painless posterior swelling (no
erythema/temp change)
Septic bursitis: infection (aspirate/culture); protection
Medial:
Epicondylitis: Golfers elbow (overuse of wrist flexors)
Microtears to the tendon at medial epicondyle
Increased pain with resisted wrist flexion and forearm pronation
Epicondylitis: Rest, Ice, Anti-inflammatories, steroids
Ulnar Collateral Sprain (MCL): pitchers= tenderness over humeroulnar joint; repetitive valgus
stress (20-130 degrees)
May have ulnar nerve irritation
Pain increases by manual valgus stress; milking maneuver
Medial Apophysitis: Any tension stress may partially or completely tear off the medial
epicondyle
Either fast or gradual onset of pain, with swelling/bruising
Pitchers: treat via education, biomechanics, limiting pitches, rest, NSAIDs, Rehab
Cubital Tunnel Syndrome: 2nd most common compression neuropathy behind CTS(carpal)
Mechanical compromise of ulnar nerve: Direct insult, excessive traction/compression
Positive Tinel’s test: weakness of intrinsic hand muscles
Flexor-Pronator Mass Syndrome: purely sensory syndrome (median n. becomes trapped)
Resisted flexion of FDS rtendon of index/middle finger
Anterior Interosseous Syndrome: mostly motor syndrome: minimal or no sensory loss
Weakness or loss of flexion of DIP joint of thumb index finger
Lateral:
Nursemaids elbow: pull childs arm, axial traction on extended/pronated arm
Pulls radius distally (supinate and pronate and it pops back into place)
Epicondylitis: tennis elbow (overuse of wrist extensors)
Microtears of the tendon at lateral epicondyle
More common than medial
Ache over lateral epicondyle (difficulty with wrist extension: ie pick up cup)
General treatment for all: Rest, Ice, OMM, splint, rehab, steroid, Surgery last resort
SP Always write: OMM, meds, labs, xrays, followup, patient voices understanding and agrees with the
above treatment