Download Elbow, Radius, and Ulna Anatomy Annular ligament holds the

Elbow, Radius, and Ulna
Anatomy
-
Annular ligament holds the radius & ulna together
Humeroulnar joint is the true elbow joint
Innervation
o Median nerve
 Crosses elbow medially
 Passes through the 2 heads of the pronator teres
o Ulnar nerve
 Passes along medial arm & posterior to the medial epicondyle
 Through the cubital tunnel
o Radial nerve
 Descends the arm laterally, dividing into the superficial (sensory) branch & the deep (motor or
posterior interosseous) branch
 The deep branch passes through the arcade of frohse, where it is most susceptible to injury
History & PE
-
-
-
-
History most important
Inspection
o Expose the area! Actually look at the skin
o Carrying angle
 Normally 10-15 degrees
 Female > Male
 Valgus >15 degrees
 Varus <10 degrees
If not able to bend/extend elbow all the way, get an XR!
Grading muscle strength
o 0/5 no muscle movement
o 1/5 visible movement but not at the joint
o 2/5 movement at the joint but not against gravity
o 3/5 movement against gravity but not against added resistance
o 4/5 movement against resistance but less than normal
o 5/5 normal strength
Neuro Exam
o Tinel’s test:
 Tapping over a nerve to elicit pain/radiculopathy along the nerve
Diagnosis
o Flexor-Pronator Mass Syndrome
 Median nerve becomes trapped between heads of pronator teres muscle
 Repeated protation
 Resisted flexion of FDS tendon of middle/index finger
 Papal sign
o See below for rest of dx
SDLS
-
Room 1
o HPI = 2 y/o crying, refused to move right arm; brother yanked arm but denies trauma
o
-
-
-
-
-
Significant signs: No tenderness over shoulder, wrist, forearm; neuro signs normal; No flexion at
elbow/stuck in Extension and pain when testing ROM; No fracture
Dx = Nursemaid's elbow (Radial head Subluxation)
Tx = NSAIDs
o
o
Room 2
o HPI = 59 male RUE pain/swelling; was bowling when sudden pop in upper arm; has visible balled up
muscle/bruising
o Significant signs = Apparent pain but cooperative; Triceps/brachioradialis 2+/4 in right upper extremity;
No biceps reflex in right upper extremity; Muscle strength 3-4/5 in right arm with supination/flexion; 5/5
in left; Anterior soft tissue mass in right arm with tenderness and muscle guarding/patient is holding
arm at 90 degrees; Ecchymosis noticed on right upper arm; no Fx
o Dx = Right biceps tendon rupture
o Tx = naproxen and icing; considering OMM if needed; refer to surgery for complete rupture, PT for
partial rupture
Room 3
o HPI = 47 yo male with right elbow pain described as sharp/achy on inside part of right elbow that started
after he golfed; Tylenol has minimal benefit; moving aggravates pain; mild pain radiation towards wrist
but not encompassing hand
o Significant signs = Equal Deep tendon reflexes on both arms; with normal upper bilateral strength
without atrophy; pain in medial epicondyle that is aggravated with wrist abduction against resistance;
No pain on lateral epicondyle
o Dx = Medial epicondylitis with posterior radial head
o Tx = Naproxen; ME for posterior radial head/IO membrane release
Room 4
o HPI = 42 female with right elbow pain starting after racquetball; pain worse when extending arm/wrist
and improves with rest; mild radiation towards hand
o Significant signs = Equal Deep tendon reflexes on both arms; with normal upper bilateral strength
without atrophy; Normal flexion/extension at elbow/wrist; increased tenderness over lateral epicondyle
worsened with resisted supination and resisted extension of third finger in pronated position; Anterior
radial head
o Dx = Lateral epicondylitis, Anterior Radial head
o Tx = Naproxen; ME for anterior radial head/IO membrane release
Room 5
o HPI = 22 College pitcher with right elbow pain worsening over past month; constant aching pain when
he pitches/plays; 800 mg of Ibu not helping, rest helps slightly; occasional popping/catching/grinding
after 40+ pitches; medial elbow pain when gripping ball
o Sig Signs = Equal Deep tendon reflexes on both arms; with normal upper bilateral strength without
atrophy; maintains flex/ext and sup/pronation with only mild crepitus upon flex/ext; direct palpation
also elicits mild pain; valgus stress has mild gapping with proximal ulna pain; anterior radial head; No fx,
bone spurs, loose fragments
o Dx = UCL injury (possible tear); anterior radial head -> test with valgus/varus test by checking the
collateral ligaments (main stabilizers) at 30 degree flexion
o Tx = Naproxen 550, ME for ant radial head/IO membrane release
Room 6
o HPI = 48 male with right elbow pain without trauma after golfing; constant elbow pain, aching, nonradiating
o Sig Sings = swelling/redness at posterior elbow; Right upper extremity edema; erythema overlying right
olecranon; tender to palpation; decreased extension; Strength/DTR norm; Right shoulder/wrist and left
arm normal; no bony destruction
-
o Dx = Olecranon bursitis
o Tx = NSAID and potential aspiration/injection if no improvement; IO membrane release
Room 7
o HPI = 39 male has difficulty moving index/middle finger with weakness; difficulty bending IP joint in
thumb; Upper forearm pain radiating to elbow
o Sig signs = normal neuro; joints in thumb/index finger are straight instead of bent when pinching;
enveloped biceps tendon bursa upon US; no Fx
o Dx = Anterior Interosseous syndrome (compression of anterior IO nerve- branch of median nerve) ->
innervates Flexor digitorum profundus, Flexor pollicis longus, Pronator quadratus (Almost only motor
loss) **issue with DIP joint
o Tx = NSAID, steroids, rest, PT, surgery as last option