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Download Examination of the Elbow and Forearm
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ATTR 322 Krzyzanowicz- Spring ‘13 Understand bony and soft tissue anatomy of the elbow and forearm Understand movement relationships of the elbow and forearm Describe common injuries to the elbow and forearm Demonstrate the proper evaluation of the elbow and forearm to include ◦ Special tests ◦ Palpation ◦ MMT’s Utilize EBP principles' in evaluation techniques The link between powerful movements of the shoulder and fine motor control of the hand ◦ Often overlooked in injury evaluation Neurovascular structures ◦ Understanding anatomy is key Bony anatomy ◦ ◦ ◦ ◦ ◦ Medial epicondyle Trochlea Capitellum Lateral epicondyle Radial fossa Bony anatomy ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ 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’s tubercle 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 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 Radial Collateral Ligament Strong fan shaped ligament that runs from the lateral epicondyle of the humerus to the outer edge of the annular ligament Ulnar Collateral Ligament Three bands that pass between the medial epicondyle and the medial edge of the trochlear notch Annular Ligament Wraps around the head and neck of the radius Both ends of the ligament are attached to the ulna Medial View Lateral View The elbow is encased by a synovial capsule, which helps to lubricate the joint There are two main bursa in the elbow: Olecranon bursa lies between the olecranon process and the skin helps to cushion blows to the posterior aspect of the elbow Radial-humeral bursa lies anterior to the bicipital tuberosity helps to cushion the biceps tendon when the forearm is pronated Table 17.1 (p.712) ◦ Extensors originate on lateral epicondyle ◦ Flexors originate on medial epicondyle Three primary nerves cross the elbow ◦ Median Anterior elbow, same path as brachial artery Follow flexor digitorum superficialis Important in elbow dislocations (TAN) and carpal tunnel (wrist) Feeds the “W” ◦ Ulnar Medial, “funny bone”, impinged in throwers Feeds the 4th and 5th digits ◦ Radial Lateral Injury usually = motor loss Feeds the 1st and 2nd digits History ◦ Seasonal (golf, tennis) ◦ Cervical ◦ General medical health Neurovascular? ◦ Location Area and type of pain (sharp, dull, achy, etc) History ◦ Onset Acute vs. chronic ◦ MOI Throwing/weight lifting? FOOSH? Repetition? Throwing technique, ergonomics ◦ Table 17.2 (p.715) Possibly pathologies based on location of pain*** Inspection ◦ Functional observation 70 deg ◦ Anterior structures Carrying angle Cubitus valgus Cubitus varus Cubital fossa ◦ Medial structures Medial epicondyle Flexor muscle mass Inspection ◦ Lateral structures Alignment of the wrist and forearm Cubital recurvatum Extensor muscle mass Inspection ◦ Posterior structures Bony alignment Olecranon process and bursa Palpation of the anterior structures ◦ ◦ ◦ ◦ ◦ ◦ ◦ Biceps brachii Cubital fossa Brachioradialis Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Pronator quadratus Palpation of the medial structures 1. 2. 3. 4. 5. Medial epicondyle Ulna Anterior band UCL Posterior band UCL Transverse band UCL 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 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 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 Flexion Extension Neurologic testing ◦ Innervated by the brachial plexus Injury may disturb sensory or motor function in elbow, forearm, and hand ◦ Upper quarter screen Pathologies of the Elbow and Forearm MOI: axial force through forearm with elbow flexed ◦ Usually displaced posteriorly ◦ Extremely painful and obvious deformity Terrible triad ◦ Posterior dislocation, fx of radial head, fx of coronoid Medical Emergency ◦ Initiate EAP Do not relocate it yourself! ◦ Always check distal neurovascular function Pulse Sensation ◦ Splint and sling (if possible) Fractures of 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 Supracondylar fracture ◦ Almost always in adolescent athletes, direct fall on flex elbow or hyperextension Olecranon process fracture ◦ Falling on flexed elbow, P! with extension Radial head fractures ◦ FOOSH, P! with flex/ext and sup/pro Forearm fractures ◦ Common in athletics; can compromise neurovascular structures in wrist and hand Very common in athletics ◦ Radial collateral ligament (varus) Not as common due to varus forces being protected by the body Varus special test ◦ Ulnar collateral ligament (valgus)** “Tommy John Injury” Common in throwers, racquet sports Valgus special test Valgus Varus UCL is stressed secondary to valgus loading ◦ Occurs during overhand pitching motion Force generated is too great, UCL cannot handle tension on it’s own Must rely on triceps brachii, wrist flexor-pronator muscles and anconeus for dynamic stabilization When forces generated during the cocking and acceleration phases of throwing are greater than the tensile strength, tearing occurs Presentation ◦ P! on medial aspect of elbow that increases with motion Compression of radial nerve may produce radicular p! Tensile forces on the ulnar nerve can cause paresthesia in distal ulnar nerve distribution patterns Swelling my be present and in most cases the anterior oblique section of the UCL is traumatized Tenderness is noted along it’s length from med. Epi to coronoid process Elbow flexed past 60 degrees the pos. oblique band may be involved Special tests ◦ Moving valgus stress test ID’s UCL instability between 120 and 70 deg Similar to late cocking and early acceleration phases of throwing ◦ Valgus stress test ID’s UCL instability Always perform at 0 and 20-30 degrees Valgus extension overload ◦ Weakness of ant. bundle leads to valgus ext. overload Collection of tensile, shear and compressive forces that result from UCL laxity Tensile stresses on UCL and ulnar nerve; compressive and shear forces on radial head and post. Medial olecranon process These all create bone spurs, loose bodies, “joint mice” Posterolateral rotatory instability ◦ Tears of the lateral UCL cause a rotational subluxation of the radius and ulna on the humerus Causing external rotation of the radius and ulna, and valgus opening of the elbow. Won’t want to push out of a chair or fully extend elbows with the forearms supinated Chronic overload ◦ Pitchers, overhead athletes Chronic p! medially, overuse Lose IR of shoulder and gain excessive ER to compensate for elbow p! Can lead to kinetic chain issues, shoulder pain, don’t just treat the pain, find the cause of the pain! Valgus force Pitch Count Curve balls? Why not softball? Origin ◦ Both lateral and medial epicondyles serve as origin for muscles acting on wrist and fingers Epicondylitis- does not accurately capture most conditions at these origins Chronic pathology is more likely a degenerative tendinosis than an actual true inflammatory condition The term epicondylalgia is a better encompassing term Inflammation or repetitive stress ◦ Irritates common attachment of wrist extensor group Any or all muscles may be involved, extensor carpi radialis brevis is most commonly affected though Very broad origin Repeated, forceful eccentric contractions of wrist extensor muscles result in accumulation of degenerative forces at the attachment site Small area of attachment = greater force load applied to bone More prevalent in racquet sports ◦ “Tennis elbow” Most common in patients over 40 y/o, p! over lateral condyle, decreased grip strength, p! with gripping Racquet sports- increased p! during backhand strokes Swelling, active wrist extension increases p! Tennis elbow test TX Avoiding activity, NSAIDS, biomechanical analysis Increase grip size MOI: ◦ “Golfer’s elbow” Activities involving swift, powerful snapping of the wrist and pronation of the forearm load the medial epicondyle Pt tenderness at origin of pronators and flexors Pronator teres ◦ TX “Little league elbow”- avulsion of tendon from med. Epi. Same as lateral epicondylalgia Biceps tendon ruptures most common in males older than 40 ◦ Usually proximal (short head of biceps) Distal tears are not as common Tendon and its aponeurosis degrade with time, resulting in spontaneous rupture MOI: Eccentric loading of biceps brachii when elbow is flexed to 90 degrees Complete or partial tears Signs and symptoms ◦ Loss of strength during elbow flexion and supination Immediate p!, hearing a “pop” Swelling and ecchymosis in cubital fossa Palpable defect may be noted ROM may remain normal, MMT’s will be decreased “Hook Test” TX Conservative vs. surgical MRI? Osteochondritis Dissecans of the capitellum ◦ Develops gradually due to increased valgus loading compressing the radial head and capitellum with overhead throwing Compressive and shear forces on the capitellum OCD develops secondary due to disrupted blood flow Usually results in bony fragments too Pt c/o Lateral elbow p! increases with activity, flexion contracture is usually present X-ray Emanate from brachial plexus ◦ Easily compromised by chronic or repetitive trauma Can be found in intramuscular fascia, tunnels beneath ligaments, bony tracts through which nerve passes Post injury scarring is common as well Ulnar nerve Median nerve Radial nerve All can cause dysfunction in wrist, hand and fingers, symptoms radiate distally, paresthesia, decreased grip strength Superficial ◦ Crossing the medial aspect of elbow’s jt line Predisposing it to concussive forces “funny bone” ◦ Sublux If nerve’s tunnel is unstable, nerve will sublux in and out Common in pitchers ◦ Traction forces During throwing increased traction force ◦ All can cause progressive inflammation Inflammation ◦ Increases in pressure, therefore increasing p! with elbow flexion and with wrist extension Signs and Symptoms ◦ Decreased sensory and motor function in the hand and fingers c/o increase in symptoms when elbow is flexed for prolonged periods (sleeping) Burning sensation in medial forearm, little and ring fingers Numbness on dorsal aspect of hand = elbow Numbness on palmar side of hand = tunnel of guyon Chronic neurological deficit ◦ Hand to deviate radially during flexion Clawhand Tinel’s sign Radial nerve most often injured by deep lacerations of the elbow ◦ Secondary to fractures of humerus or radius Posterior interosseous nerve (deep branch of radial nerve) dedicated to motor function of thumbs extensor’s, wrist extensors, finger extensor’s and supinators Injury to this nerve can be damaging to ADL’s Radial tunnel syndrome (RTS) ◦ Clinically resembles lateral epicondylalgia RTS symptoms more distally on forearm and can persist for more than 6 months Symptoms reproduced with resisted supination or during resisted extension of the middle finger Typically injured or compressed on the distal portion of the forearm ◦ Pressure in cubital fossa may compress nerve Carpal tunnel syndrome (chapter 18) Pronator teres syndrome Anterior interosseous nerve is compressed by the pronator teres Patient’s inability to pinch tips of the thumb and index fingers together Forearm contains three compartments ◦ Volar wad ◦ Dorsal wad ◦ Mobile wad Increased pressures within these compartments increases risk of compromising circulation and neurological function of the hand Usually due to hypertrophic muscles or fractures Signs and Symptoms ◦ Pressure in forearm, sensory disruption in hand and fingers, decreased strength Flexor digitorum profundus and flexor pollicis longus most commonly affected due to deepness in arm ◦ Volkmann’s ischemic contracture Chapter 18 ◦ Surgery is often needed to decrease pressures Always rule out fracture of forearm or dislocation of elbow first ◦ Position of arm Obvious deformity? ◦ Type of force Valgus, varus or FOOSH? Gross deformity? ◦ Alignment of forearm and wrist Are they same length bilaterally? ◦ Posterior triangle of the elbow Alignment of medial and lateral epicondyle and olecranon process Should form an isosceles triangle when elbow is flexed to 90 degrees If it does not, possible dislocation Posterior dislocation Olecranon process becomes prominent Quickly ◦ Alignment of elbow ◦ Collateral ligaments (UCL/RCL) ◦ Radius and Ulna Elbow dislocation ◦ Immobilize in position found Check distal pulse, capillary bed refill, neuro status Transport immediately to E.D. for reduction (911 if needed) Fractures ◦ Forearm fractures (radius and ulna) are very common Immobilize in position found Check distal pulse, capillary bed refill, neuro status Transport immediately to E.D. (911 if needed) Monitor for shock Knowing all anatomy (bony, ligament, muscle and nerve) is needed for proper evaluation and management of elbow/forearm injuries The UCL is a complex ligament bundle that causes major injury in patients Fractures are common when FOOSHing Neurological functioning can easily be altered with elbow/forearm injuries
