Kin 191 B – Elbow And Forearm Pathologies

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  • 1. KIN 191B – Advanced Assessment of Upper Extremity Injuries Elbow and Forearm Pathologies
  • 2. Patholgies
    • Elbow ligamentous sprains
    • Epicondylitis
    • Rupture of distal biceps brachii tendon
    • Osteochondritis dissecans of capitellum
    • Neurological injury
    • Elbow dislocations
    • Fractures
    • Olecranon bursitis
  • 3. Elbow Ligamentous Sprains
    • Medial (ulnar) collateral ligament injury
    • Lateral (radial) collateral ligament injury
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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”
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. “ 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
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. Neurological Injury
    • Ulnar nerve
    • Median nerve
    • Radial nerve
    • Forearm compartment syndrome
      • Volkmann’s ischemic contracture
  • 17. 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
  • 18. Cubital Tunnel Syndrome
    • General term given to ulnar nerve injury or irritation
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. Elbow Dislocations
    • Posterior
    • Anterior
  • 23. 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
  • 24. Posterior Elbow Dislocation
  • 25. Anterior Elbow Disocation
    • Rare occurrences
  • 26. Fractures
    • Humerus
    • Ulna
    • Radius
  • 27. Humerus Fractures
    • Supracondylar fracture
    • Supracondylar fracture with posterior elbow dislocation
  • 28. 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
  • 29. 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
  • 30. Ulnar Fractures
    • Coronoid process fracture
    • May be associated with posterior elbow dislocation
  • 31. 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
  • 32. Olecranon Bursitis
    • Typically due to direct trauma
    • Usually easily treated with rest, modalities compression, and NSAIDs
    • If persists, may be aspirated – risk of infection