Download Chapter 16 - Elbow and Forearm Pathologies

Chapter 16
Elbow and Forearm Pathologies
Copyright © 2015. F.A. Davis Company
Clinical Anatomy
 Bony anatomy
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Medial epicondyle
Trochlea
Capitellum
Lateral epicondyle
Radial fossa
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Clinical Anatomy
 Bony anatomy
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Ulna
Semilunar notch
Olecranon process
Olecranon fossa
Coronoid process
Coronoid fossa
Radial notch
Proximal radioulnar joint
Radial head
Bicipital tuberosity
Radial shaft
Radial styloid process
Lister tubercle
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Clinical Anatomy
 Articulation and ligamentous
anatomy
 Humeroulnar joint
 Flexion and extension
 Modified hinge joint
 Humeroradial joint
 Flexion and extension
 Pronation and supination
 Modified hinge joint
 Proximal and distal radioulnar
joints
 Pronation and supination
 Syndesmotic joint
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Clinical Anatomy
 Articulation and
ligamentous anatomy
 Ligamentous support
 Ulnar collateral
ligament (UCL)
 Anterior, transverse,
and posterior bundle
 Lateral collateral
ligament
 Radial collateral
ligament (RCL)
 Annular ligament
 Accessory lateral
collateral ligament
 Interosseous membrane
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Clinical Anatomy
Elbow flexor and supinator group
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Elbow extensor and pronator
group
Clinical Anatomy
Nerves
 Median nerve
 Anterior interosseous
nerve
 Ulnar nerve
 Arcade of Struthers
 Tunnel of Guyon
 Radial nerve
 Superficial branch
 Deep branch
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Bursa
 Subcutaneous olecranon bursa
 Subtendinous olecranon bursa
Clinical Evaluation of the Elbow
and Forearm
Past medical history
 Previous history
 Seasonal pain
 Cervical injury
 General medical health
 Vascular, neurological, or
systemic conditions
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History of the present
condition
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Location of the symptoms
Onset of the symptoms
MOI
Technique
Associated sounds and
sensations
Clinical Examination of the Elbow
and Forearm
 Inspection
 Functional observation
 Anterior structures
 Carrying angle
 Cubitus valgus
 Cubitus varus
 Cubital fossa
 Medial structures
 Medial epicondyle
 Flexor muscle mass
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Cubital Fossa
The cubital fossa is a triangular area demarcated by the brachioradialis
muscle laterally and the pronator teres medially. The brachial artery and
its two subdivisions (the radial and ulnar arteries), the median nerve,
and the musculocutaneous nerve pass through this fossa.
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Clinical Examination of the Elbow
and Forearm
 Inspection
 Lateral structures
 Alignment of the wrist
and forearm
 Cubital recurvatum
 Extensor muscle mass
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Clinical Examination of the Elbow
and Forearm
 Inspection
 Posterior structures
 Bony alignment
 Olecranon process and
bursa
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Clinical Examination of the Elbow
and Forearm
 Palpation of the
anterior structures
1.
2.
3.
4.
5.
6.
7.
8.
Biceps brachii
Cubital fossa
Brachioradialis
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor carpi ulnaris
Pronator quadratus
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Clinical Examination of the Elbow
and Forearm
Method of approximating the superficial muscles of the flexor forearm.
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Clinical Examination of the Elbow
and Forearm
 Palpation of the
medial structures
1.
2.
3.
4.
5.
Medial epicondyle
Ulna
Anterior band UCL
Posterior band UCL
Transverse band
UCL
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Clinical Examination of the Elbow
and Forearm
 Palpation of the
lateral structures
1. Lateral epicondyle
2. Radial head
3. Radial collateral
ligament
4. Capitellum
5. Annular ligament
6. Lateral ulnar
collateral ligament
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Clinical Examination of the Elbow
and Forearm
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Palpation of the
posterior structures
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Olecranon process
Olecranon fossa
Triceps brachii
Anconeus
Ulnar nerve
Extensor carpi ulnaris
Extensor carpi radialis brevis
Extensor carpi radialis
longus
Extensor digitorum
Extensor digiti minimi
Extensor pollicis brevis
Abductor pollicis longus
Radial tunnel
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Clinical Examination of the Elbow
and Forearm
 Joint and muscle function assessment
 Active range of motion (AROM)
 Flexion and extension
 Pronation and supination
 Manual muscle tests (MMT)
 Passive range of motion (PROM)
 Flexion and extension
 Pronation and supination
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Clinical Examination of the Elbow
and Forearm
 Passive range of motion
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Passive Range of Motion
 Elbow: Ulnohumeral and radiohumeral
joint capsular patterns and end-feels
 Capsular pattern: Flexion, extension
 Extension: Hard
 Flexion: Soft
 Elbow: Superior radioulnar joints
 Capsular pattern: Supination and pronation
equally
 Radioulnar supination: Firm
 Radioulnar pronation: Hard or firm
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Passive Range of Motion
 Forearm: Distal radioulnar joint
 Capsular pattern: Supination and pronation
equally
 Radioulnar supination: Firm
 Radioulnar pronation: Firm
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Clinical Examination of the Elbow
and Forearm
 Joint stability tests
 Stress testing
 Medial ligament laxity
 Lateral ligament laxity
 Joint play
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Valgus Stress Test
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Varus Stress Test
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Clinical Examination of the Elbow
and Forearm
 Neurological testing
 Innervated by the
brachial plexus
 Injury may disturb
sensory or motor
function in elbow,
forearm, and hand
 Upper quarter screen
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Pathologies and Related Special
Tests
 Elbow dislocations
 MOI: Axial force
through the forearm
with the elbow flexed
 Extremely painful
 Obvious deformity
 “Terrible triad of the
elbow”
 Swelling can be rapid,
masking deformity
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Pathologies and Related Special
Tests
 Fracture about the elbow
 Supracondylar fracture
 MOI: Hyperextension or
fall on flexed elbow
 Olecranon process fracture
 MOI: Falling on flexed
elbow
 Radial head fracture
 MOI: Longitudinal
compression (FOOSH)
 Forearm fracture
 Open or closed, simple
or complex, degree of
angulation, rotation or
displacement
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Pathologies and Related Special
Tests
 Elbow sprains
 Ulnar collateral ligament
 Valgus extension overload
 Elbow posterolateral rotatory instability
 Radial collateral ligament
 MOI: Varus force
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Selective Tissue Test: Moving
Valgus Stress Test
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Selective Tissue Test: Posterolateral
Rotatory Instability Test (Pivot Shift)
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Pathologies and Related Special
Tests
 Epicondylalgia
 Lateral epicondylalgia
 Inflammation or repetitive
stress at the lateral
epicondyle
 Swelling
 TTP
 Pain with active wrist
extension
 “Tennis elbow”
 Medial epicondylalgia
 TTP on medial epicondyle
 “Little Leaguer’s elbow”
 Neuropathy of the ulnar
nerve
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Selective Tissue Test: Lateral
Epicondylalgia (“Tennis Elbow” Test)
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Pathologies and Related Special
Tests
 Distal biceps tendon rupture
 Most common in males over 40 years of age
 MOI: Eccentric loading of the biceps brachii when the
elbow is flexed to 90
 Complete or partial
 Signs and symptoms
 Pain
 “Pop” within elbow
 Palpable defect
 Usually treated with a surgical repair
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Selective Tissue Test: Hook Test for
Distal Biceps Tendon Rupture
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Pathologies and Related Special
Tests
 Nerve pathology
 Ulnar nerve pathology
 Radial nerve
pathology
 Median nerve
pathology
 Forearm compartment
syndrome
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On-Field Evaluation of Elbow and
Forearm Injuries
On-field history
On-field inspection
 Position of the arm
 Type of force involved
 Alignment of forearm and
wrist
 Posterior triangle of the
elbow
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On-Field Evaluation of Elbow and
Forearm Injuries
On-field palpation
On-field joint and muscle
function tests
 Alignment of the elbow
 Collateral ligaments
 Radius and ulna
 AROM
 MMT
 PROM
On-field neurological tests
 Assessment of forearm and
hand
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On-Field Management of Elbow and
Forearm Injuries
 Elbow dislocations
 Management
 Activate EMS
 Immobilize in the position found in
 Monitor distal pulse
 Rule out injury to GH joint, proximal humerus, and
wrist
 Immediately transport athlete to medical facility for
further evaluation and treatment
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On-Field Management of Elbow and
Forearm Injuries
 Fractures about the elbow
 Management
 Monitor distal pulse
 Immobilize elbow, forearm, and wrist
 Treat for shock
 Immediately transport athlete to medical facility for
further evaluation and treatment
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