Kin 191 B – Elbow And Forearm Pathologies

KIN 191B – Advanced Assessment of Upper Extremity Injuries Elbow and Forearm Pathologies

Patholgies
Elbow ligamentous sprains
Epicondylitis
Rupture of distal biceps brachii tendon
Osteochondritis dissecans of capitellum
Neurological injury
Elbow dislocations
Fractures
Olecranon bursitis

Elbow Ligamentous Sprains
Medial (ulnar) collateral ligament injury
Lateral (radial) collateral ligament injury

MCL/UCL Injury
Can be acute (traumatic valgus force) or chronic (e.g. - repetitive overhand throwing)
Anterior bundle most affected – primary stabilizer
Posterior bundle may be involved if elbow flexed beyond 60 degrees at time of injury

MCL/UCL Injury
Most common symptoms include:
Point tenderness, swelling (may be significant), neuro symptoms (ulnar and radial nerves), limited elbow and forearm ROM due to tension on ligaments and pain, laxity to valgus stress test
Mild and moderate injuries often treated conservatively with rest, NSAIDs, progressive flexibility and strengthening exercises
Severe injuries, especially in competitive athletes, typically treated surgically
“ Tommy John” injury/surgery
Usually use palmaris longus tendon as graft

LCL/RCL Injury
Much less common than MCL/UCL injury
When occur, typically due to varus force application – may injure LCL/RCL and annular ligament
May affect radial articulation with capitellum and/or proximal radioulnar articulation
Most common symptoms include:
Point tenderness, swelling, limited elbow and ROM and laxity to varus stress test
Almost always treated conservatively

Epicondylitis
Medial epicondylitis
Commonly referred to as “golfer’s elbow”
May present as “little leaguer’s elbow”
Lateral epicondylitis
Commonly referred to as “tennis elbow”

Medial Epicondylitis
Irritation of medial epicondyle from overuse of pronation and flexion muscles
May irritate ulnar nerve if significant – most common presentation is point tenderness, swelling at site and weakness to affected muscles

Medial Epicondylitis
“ Little leaguer’s elbow” is avulsion of flexor/pronator common tendon from origin at medial epicondyle
Typically treated conservatively with rest, NSAIDs, flexibility and strengthening exercise program

Lateral Epicondylitis
Irritation of lateral epicondyle from overuse of supination/extension muscles
Most commonly involves extensor carpi radialis longus and brevis
Most common presentation is point tenderness, swelling at site and weakness to affected muscles

“ Tennis Elbow” Test
Clinician palpates lateral epicondyle with elbow at 90 – resists extension of wrist
Positive if painful and/or weak at lateral epicondyle – ECRB involvement
If test replicated with elbow extended, indicates ECRL involvement

Rupture of Distal Biceps Tendon
Etiology is eccentric loading of tendon with elbow extended (hyperextension)
Often accompanied by “pop” at elbow
X-ray used to rule out avulsion fracture
Visible/palpable defect present, typically has considerable swelling/ecchymosis to cubital fossa

Rupture of Distal Biceps Tendon
AROM/PROM may be WNL but RROM limited to elbow flexion and forearm supination
Almost always treated surgically followed by progressive ROM and strengthening program

OCD of Capitellum
Etiology is repetitive valgus loads at the elbow compressing radial head on capitellum – overhead throwing
Gradual vs. acute onset of symptoms
Typical complaints of lateral elbow pain which worsens with activity – often accompanied by elbow flexion contracture

OCD of Capitellum
X-ray can reveal non-displaced defect or loose body in joint
If non-displaced, usually treated conservatively
If loose body, surgical removal is indicated
Atypical to return to prior activity and/or performance level

Neurological Injury
Ulnar nerve
Median nerve
Radial nerve
Forearm compartment syndrome
Volkmann’s ischemic contracture

Ulnar Nerve
Superficial orientation in cubital tunnel predisposes ulnar nerve to injury
May be contused via direct trauma, compressed by flexor/pronator mass, and/or sublux from cubital tunnel
Numbness/tingling to medial forearm, hand and ring/little fingers
Weakness to finger flexion, abduction and adduction
Evaluated with Tinel’s sign

Cubital Tunnel Syndrome
General term given to ulnar nerve injury or irritation

Median Nerve
Median nerve most commonly affected at wrist – may be compressed with pressure in cubital fossa
Branch of median nerve, anterior interosseous nerve, passes between heads of pronator teres – may be compressed there causing pronator teres syndrome
Inability to pinch together tips of thumb and index finger

Radial Nerve
Rarely injured unless associated with laceration, fracture or dislocation
Sensory deficit to dorsal aspect of hand (1 st dorsal webspace)
Motor deficit to wrist/finger extension and supination

Forearm Compartment Syndrome
Forearm compartments similar to leg
Increased pressure can occur from:
Muscle hypertrophy, fractures, dislocations
Neurovascular compromise can present with sensory and/or motor deficits – if severe, can present with decreased or absent radial and ulnar pulses
Volkmann’s ischemic contracture – flexion contracture of wrist/hand/fingers

Elbow Dislocations
Posterior
Anterior

Posterior Elbow Dislocation
Typically results from hyperextension, trochlea levered over coronoid process
Most common direction is posterolateral
Involve injury to most ligamentous structures, and potential for injury to neurovascular structures – if stable post-reduction, treat conservatively and if unstable, treat surgically
Most present with subsequent myositis ossificans

Posterior Elbow Dislocation

Anterior Elbow Disocation
Rare occurrences

Fractures
Humerus
Ulna
Radius

Humerus Fractures
Supracondylar fracture
Supracondylar fracture with posterior elbow dislocation

Humerus Fractures
Most common in children/adolescents from fall on flexed elbow or hyperextension mechanism
Deformity present if displaced, often missed on initial evaluation if nondisplaced

Ulnar Fractures
Olecranon process fractures
If stable/nondisplaced, short immobiliazation period (45-90 degrees of flexion)
If displaced, ORIF with longer immobilization period and early ROM if tolerated

Ulnar Fractures
Coronoid process fracture
May be associated with posterior elbow dislocation

Radial Fractures
Radial head fracture classifications (Mason)
Type I: nondisplaced
Type II: fracture with displacement, depression or angulation
Type III: comminuted fracture of head
Type IV: comminuted fracture associated with elbow dislocation

Olecranon Bursitis
Typically due to direct trauma
Usually easily treated with rest, modalities compression, and NSAIDs
If persists, may be aspirated – risk of infection

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Kin 191 B – Elbow And Forearm Pathologies

by JLS10 on May 28, 2009

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Kin 191 B – Elbow And Forearm Pathologies — Presentation Transcript