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The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
The Elbow - Anatomy, Injury, and Rehabilitation
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The Elbow - Anatomy, Injury, and Rehabilitation

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I delivered this talk to a group of hand and arm therapists. Find out more about hand and arm problems at http://www.noelhenley.com …

I delivered this talk to a group of hand and arm therapists. Find out more about hand and arm problems at http://www.noelhenley.com

Ozark Orthopaedic: Henley C Noel MD
3317 North Wimberly Drive, Fayetteville, AR 72703
(479) 521-2752 ‎

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  • 1. The Elbow Anatomy, Injury, andRehabilitation Implications C. Noel Henley, MD February 24, 2009
  • 2. Goals
  • 3. Goals• To review some elbow anatomy and relevance to surgical approach and therapy
  • 4. Goals• To review some elbow anatomy and relevance to surgical approach and therapy• To review some specific elbow disorders/ injuries
  • 5. Goals• To review some elbow anatomy and relevance to surgical approach and therapy• To review some specific elbow disorders/ injuries• To review some aspects of the stiff elbow
  • 6. Surgical Anatomy
  • 7. Surgical Anatomy• Approaches
  • 8. Surgical Anatomy• Approaches - posterior (“universal”)
  • 9. Surgical Anatomy• Approaches - posterior (“universal”) - medial/lateral
  • 10. Surgical Anatomy
  • 11. Surgical Anatomy• Posterior
  • 12. Surgical Anatomy• Posterior - midline posterior incision
  • 13. Surgical Anatomy• Posterior - midline posterior incision - circumferential access
  • 14. Surgical Anatomy• Posterior - midline posterior incision - circumferential access - leaves options open for future procedures
  • 15. Surgical Anatomy• Posterior - midline posterior incision - circumferential access - leaves options open for future procedures - lower chance for cutaneous nerve injury
  • 16. Surgical Anatomy
  • 17. Surgical Anatomy• Cutaneous nerves
  • 18. Surgical Anatomy• Cutaneous nerves - lateral antebrachial cutaneous nerve
  • 19. Surgical Anatomy• Cutaneous nerves - lateral antebrachial cutaneous nerve - medial antebrachial cutaneous nerve
  • 20. Surgical Anatomy• Cutaneous nerves - lateral antebrachial cutaneous nerve - medial antebrachial cutaneous nerve - posterior antebrachial cutaneous nerve
  • 21. lateral antebrachial cutaneous nerve
  • 22. medial antebrachial cutaneous nerve
  • 23. posterior antebrachialcutaneous nerve
  • 24. Surgical Anatomy
  • 25. Surgical Anatomy• Posterior approach
  • 26. Surgical Anatomy• Posterior approach - distal humerus fracture
  • 27. Surgical Anatomy• Posterior approach - distal humerus fracture - medial, lateral structures
  • 28. Surgical Anatomy• Posterior approach - distal humerus fracture - medial, lateral structures - may require a drain; more risk for seroma
  • 29. Surgical Anatomy• Posterior approach - distal humerus fracture - medial, lateral structures - may require a drain; more risk for seroma - several different ways of handling triceps - implications for therapy post-op!
  • 30. Triceps Options
  • 31. Triceps Options• Olecranon osteotomy• Triceps-reflecting• Triceps-splitting• Triceps-reflecting anconeus pedicle flap• Paratricipital
  • 32. Triceps Options
  • 33. Triceps Options• Olecranon osteotomy
  • 34. Triceps Options• Olecranon osteotomy - pro: full visualization of articular surface
  • 35. Triceps Options• Olecranon osteotomy - pro: full visualization of articular surface - con: more adhesions, nonunion, painful hardware
  • 36. Triceps Options• Olecranon osteotomy - pro: full visualization of articular surface - con: more adhesions, nonunion, painful hardware - several hardware options
  • 37. Olecranon Osteotomy
  • 38. Olecranon Osteotomy
  • 39. Olecranon Nail
  • 40. Triceps Options
  • 41. Triceps Options• Triceps-reflecting
  • 42. Triceps Options• Triceps-reflecting - triceps repaired through drill holes in olecranon
  • 43. Triceps Options• Triceps-reflecting - triceps repaired through drill holes in olecranon - must protect the repair for six weeks post-op
  • 44. Triceps Options• Triceps-reflecting - triceps repaired through drill holes in olecranon - must protect the repair for six weeks post-op - no active extension against resistance for six weeks
  • 45. Triceps Options
  • 46. Triceps Options• Triceps-splitting, triceps-reflecting anconeus pedicle, paratricipital approaches
  • 47. Triceps Options• Triceps-splitting, triceps-reflecting anconeus pedicle, paratricipital approaches - all may compromise active resisted motion after surgery
  • 48. Triceps Options• Triceps-splitting, triceps-reflecting anconeus pedicle, paratricipital approaches - all may compromise active resisted motion after surgery - critical to know details of triceps repair/ approach to guide limitations after surgery
  • 49. Triceps-reflectingAnconeus Pedicle
  • 50. Surgical Anatomy
  • 51. Surgical Anatomy• Lateral approach (addressable injuries)
  • 52. Surgical Anatomy• Lateral approach (addressable injuries) - radial head fracture
  • 53. Surgical Anatomy• Lateral approach (addressable injuries) - radial head fracture - capitellum fracture
  • 54. Surgical Anatomy• Lateral approach (addressable injuries) - radial head fracture - capitellum fracture - some coronoid fractures
  • 55. Surgical Anatomy• Lateral approach (addressable injuries) - radial head fracture - capitellum fracture - some coronoid fractures - lateral collateral ligament complex injury
  • 56. Surgical Anatomy
  • 57. Surgical Anatomy• Kocher interval/approach (lateral)
  • 58. Surgical Anatomy• Kocher interval/approach (lateral) - between ECU and anconeus
  • 59. Kocher interval
  • 60. Surgical Anatomy
  • 61. Surgical Anatomy• Kocher interval/approach (lateral)
  • 62. Surgical Anatomy• Kocher interval/approach (lateral) - designed to split the annular ligament anterior to the LUCL
  • 63. Surgical Anatomy• Kocher interval/approach (lateral) - designed to split the annular ligament anterior to the LUCL - posterior interosseous nerve (PIN - radial nerve motor branch) at risk, especially if radial neck/head plated
  • 64. a) Kaplan’s interval (EDC split)b) Kocher interval (ECU/anconeus)
  • 65. PIN injury
  • 66. PIN injury• Creates a wrist drop or inability to extend MCP joints and thumb IP joint
  • 67. PIN injury• Creates a wrist drop or inability to extend MCP joints and thumb IP joint• May not involve dorsal hand numbness
  • 68. PIN injury• Creates a wrist drop or inability to extend MCP joints and thumb IP joint• May not involve dorsal hand numbness• You may be the first to recognize this!
  • 69. Surgical Anatomy
  • 70. Surgical Anatomy• Medial approach (addressable injuries)
  • 71. Surgical Anatomy• Medial approach (addressable injuries) - coronoid fracture
  • 72. Surgical Anatomy• Medial approach (addressable injuries) - coronoid fracture - medial collateral ligament injury
  • 73. Surgical Anatomy• Medial approach (addressable injuries) - coronoid fracture - medial collateral ligament injury - an uncommon, but sometimes necessary approach
  • 74. Surgical Anatomy• Medial approach (addressable injuries) - coronoid fracture - medial collateral ligament injury - an uncommon, but sometimes necessary approach - several ways of splitting/elevating muscles
  • 75. Medial Approach
  • 76. Medial Approach
  • 77. Specific Injuries
  • 78. Distal Humerus Fractures
  • 79. Distal Humerus Fractures
  • 80. Distal Humerus Fractures • 90-90 plating concept
  • 81. Distal Humerus Fractures • 90-90 plating concept - historically recommended technique
  • 82. Distal Humerus Fractures • 90-90 plating concept - historically recommended technique - some problems with distal nonunions
  • 83. Distal Humerus Fractures
  • 84. Distal Humerus Fractures • near-parallel plating technique
  • 85. Distal Humerus Fractures • near-parallel plating technique - offers improved stiffness/ stability
  • 86. Distal Humerus Fractures • near-parallel plating technique - offers improved stiffness/ stability - better stability with varus/ shoulder abduction stress
  • 87. Distal Humerus Fractures • near-parallel plating technique - offers improved stiffness/ stability - better stability with varus/ shoulder abduction stress - allows earlier motion
  • 88. Distal Humerus Fractures
  • 89. Distal Humerus Fractures • Rehabilitation
  • 90. Distal Humerus Fractures • Rehabilitation - splinted x 2-3 days (usually extended)
  • 91. Distal Humerus Fractures • Rehabilitation - splinted x 2-3 days (usually extended) - A/AAROM
  • 92. Distal Humerus Fractures • Rehabilitation - splinted x 2-3 days (usually extended) - A/AAROM - PROM may promote ectopic ossification (EO) - debated!
  • 93. Distal Humerus Fractures • Rehabilitation - splinted x 2-3 days (usually extended) - A/AAROM - PROM may promote ectopic ossification (EO) - debated! - functional arc: 30°/130°, 50°/50°
  • 94. Distal Humerus Fractures
  • 95. Distal Humerus Fractures • Rehabilitation
  • 96. Distal Humerus Fractures • Rehabilitation - flexion returns first (within 2 months)
  • 97. Distal Humerus Fractures • Rehabilitation - flexion returns first (within 2 months) - extension maximized at 4-6 months
  • 98. Distal Humerus Fractures • Rehabilitation - flexion returns first (within 2 months) - extension maximized at 4-6 months - supination/pronation minimally affected
  • 99. Distal Humerus Fractures • Rehabilitation - flexion returns first (within 2 months) - extension maximized at 4-6 months - supination/pronation minimally affected - 25% of patients may have exertional pain
  • 100. Cubital Tunnel
  • 101. Cubital Tunnel
  • 102. Cubital Tunnel• Conservative management
  • 103. Cubital Tunnel• Conservative management - splinting
  • 104. Cubital Tunnel• Conservative management - splinting - padding
  • 105. Cubital Tunnel• Conservative management - splinting - padding - activity/ergonomic modification, education
  • 106. Cubital Tunnel• Conservative management - splinting - padding - activity/ergonomic modification, education - 89% of patients with mild/ moderate symptoms will improve (studies)
  • 107. Cubital Tunnel
  • 108. Cubital Tunnel• Patient education
  • 109. Cubital Tunnel• Patient education - motions and positions that contribute to stretching, compression of the nerve
  • 110. Cubital Tunnel• Patient education - motions and positions that contribute to stretching, compression of the nerve - analyze daily tasks for these aggravating factors
  • 111. Cubital Tunnel
  • 112. Cubital Tunnel• Splinting
  • 113. Cubital Tunnel• Splinting - usually in 40-70° flexion, neutral rotation, neutral wrist position
  • 114. Cubital Tunnel• Splinting - usually in 40-70° flexion, neutral rotation, neutral wrist position - may need to allow room for an elbow pad or at least build a “bulge” in the medial elbow portion
  • 115. Cubital Tunnel
  • 116. Cubital Tunnel• Splinting - elbow pad during the day; reverse it at night
  • 117. Cubital Tunnel
  • 118. Cubital Tunnel• Nerve gliding exercises
  • 119. Cubital Tunnel• Nerve gliding exercises - nerves may not respond to being stretched, especially if already irritated
  • 120. Cubital Tunnel• Nerve gliding exercises - nerves may not respond to being stretched, especially if already irritated - effectiveness is debated
  • 121. Cubital Tunnel• Nerve gliding exercises - nerves may not respond to being stretched, especially if already irritated - effectiveness is debated - as always - listen to the patient!
  • 122. Cubital Tunnel
  • 123. Cubital Tunnel• Conservative management - problems
  • 124. Cubital Tunnel• Conservative management - problems - splints poorly tolerated
  • 125. Cubital Tunnel• Conservative management - problems - splints poorly tolerated - elbow pad reversal may not be effective (too soft)
  • 126. Cubital Tunnel• Conservative management - problems - splints poorly tolerated - elbow pad reversal may not be effective (too soft) - anecdotally poor results
  • 127. Cubital Tunnel
  • 128. Cubital Tunnel• Surgery - current trends
  • 129. Cubital Tunnel• Surgery - current trends - move toward less extensive surgery
  • 130. Cubital Tunnel• Surgery - current trends - move toward less extensive surgery - in situ decompression, simpler transpositions
  • 131. Cubital Tunnel• Surgery - current trends - move toward less extensive surgery - in situ decompression, simpler transpositions - earlier ROM, return of function
  • 132. Cubital Tunnel
  • 133. Cubital Tunnel• Surgery - what I do
  • 134. Cubital Tunnel• Surgery - what I do - in situ decompression
  • 135. Cubital Tunnel• Surgery - what I do - in situ decompression - subcutaneous anterior transposition
  • 136. Cubital Tunnel
  • 137. Cubital Tunnel• Post-op rehabilitation
  • 138. Cubital Tunnel• Post-op rehabilitation - remove dressing in five days
  • 139. Cubital Tunnel• Post-op rehabilitation - remove dressing in five days - unlimited ROM
  • 140. Cubital Tunnel• Post-op rehabilitation - remove dressing in five days - unlimited ROM - progressive resumption of activity
  • 141. Cubital Tunnel• Post-op rehabilitation - remove dressing in five days - unlimited ROM - progressive resumption of activity - unusual to need formal outpatient visits
  • 142. Tennis Elbow
  • 143. Tennis Elbow
  • 144. Tennis Elbow• What is it?
  • 145. Tennis Elbow• What is it? - a tendinosis/tendinopathy = “failed reparative process”
  • 146. Tennis Elbow• What is it? - a tendinosis/tendinopathy = “failed reparative process” - no inflammatory cells in biopsy specimens
  • 147. Tennis Elbow• What is it? - a tendinosis/tendinopathy = “failed reparative process” - no inflammatory cells in biopsy specimens - involves ECRB origin
  • 148. Tennis Elbow
  • 149. Tennis Elbow
  • 150. Tennis Elbow
  • 151. Tennis Elbow• Treatment
  • 152. Tennis Elbow• Treatment - nonoperative
  • 153. Tennis Elbow• Treatment - nonoperative • therapy
  • 154. Tennis Elbow• Treatment - nonoperative • therapy • splinting
  • 155. Tennis Elbow• Treatment - nonoperative • therapy • splinting • injection
  • 156. Tennis Elbow• Treatment - nonoperative • therapy • splinting • injection • most studies show some short-term benefit but no difference between treatments long-term
  • 157. Counterforce Bracing
  • 158. Counterforce Bracing
  • 159. Counterforce Bracing• How does it work?
  • 160. Counterforce Bracing• How does it work? - ECRB compression transfers contraction force away from origin
  • 161. Counterforce Bracing• How does it work? - ECRB compression transfers contraction force away from origin - creates a “second origin” for the ECRB further distal
  • 162. Counterforce Bracing• How does it work? - ECRB compression transfers contraction force away from origin - creates a “second origin” for the ECRB further distal - limits full expansion; may limit force of contraction on the origin
  • 163. Counterforce Bracing
  • 164. Counterforce Bracing• Effectiveness data is mixed
  • 165. Counterforce Bracing• Effectiveness data is mixed - some studies show improvement
  • 166. Counterforce Bracing• Effectiveness data is mixed - some studies show improvement - others show no significant advantage over therapy alone
  • 167. Tennis Elbow
  • 168. Tennis Elbow• operative treatment
  • 169. Tennis Elbow• operative treatment - many options (open, arthroscopic, percutaneous)
  • 170. Tennis Elbow• operative treatment - many options (open, arthroscopic, percutaneous) - all focus on ECRB
  • 171. Tennis Elbow• operative treatment - many options (open, arthroscopic, percutaneous) - all focus on ECRB - depending on post-op pain relief, more therapy may be necessary
  • 172. The Stiff Elbow
  • 173. The Stiff Elbow
  • 174. The Stiff Elbow• Etiologic factors (post-op stiffness)
  • 175. The Stiff Elbow• Etiologic factors (post-op stiffness) - immobilization
  • 176. The Stiff Elbow• Etiologic factors (post-op stiffness) - immobilization • leads to capsular contracture
  • 177. The Stiff Elbow• Etiologic factors (post-op stiffness) - immobilization • leads to capsular contracture - forced passive manipulation (increased risk for HO)
  • 178. The Stiff Elbow• Etiologic factors (post-op stiffness) - immobilization • leads to capsular contracture - forced passive manipulation (increased risk for HO) • gentle progressive PROM may be needed
  • 179. The Stiff Elbow
  • 180. The Stiff Elbow• Etiologic factors (post-op stiffness)
  • 181. The Stiff Elbow• Etiologic factors (post-op stiffness) - multiple procedures early on in treatment course
  • 182. The Stiff Elbow• Etiologic factors (post-op stiffness) - multiple procedures early on in treatment course - burns
  • 183. The Stiff Elbow• Etiologic factors (post-op stiffness) - multiple procedures early on in treatment course - burns - head trauma (as high as 90% risk)
  • 184. The Stiff Elbow
  • 185. The Stiff Elbow• Nonoperative treatment
  • 186. The Stiff Elbow• Nonoperative treatment - gradual AAROM, modalities in therapy
  • 187. The Stiff Elbow• Nonoperative treatment - gradual AAROM, modalities in therapy - splinting
  • 188. The Stiff Elbow• Nonoperative treatment - gradual AAROM, modalities in therapy - splinting • dynamic spring/rubber band devices
  • 189. The Stiff Elbow• Nonoperative treatment - gradual AAROM, modalities in therapy - splinting • dynamic spring/rubber band devices • static progressive splint (patient- adjustable)
  • 190. The Stiff Elbow• Nonoperative treatment - gradual AAROM, modalities in therapy - splinting • dynamic spring/rubber band devices • static progressive splint (patient- adjustable) - better compliance
  • 191. The Stiff Elbow
  • 192. The Stiff Elbow• Nonoperative treatment
  • 193. The Stiff Elbow• Nonoperative treatment • splinting (adjustable static type)
  • 194. The Stiff Elbow• Nonoperative treatment • splinting (adjustable static type) - goal: plastic deformation of soft tissue through stress relaxation
  • 195. The Stiff Elbow• Nonoperative treatment • splinting (adjustable static type) - goal: plastic deformation of soft tissue through stress relaxation - 21 hour program (morning, noon, night breaks)
  • 196. The Stiff Elbow
  • 197. The Stiff Elbow• Heterotopic bone (ectopic bone)
  • 198. The Stiff Elbow• Heterotopic bone (ectopic bone) - inappropriate formation of mature lamellar bone in soft tissue
  • 199. The Stiff Elbow• Heterotopic bone (ectopic bone) - inappropriate formation of mature lamellar bone in soft tissue - may be prevented by radiation or NSAID administration - controversial
  • 200. The Stiff Elbow
  • 201. The Stiff Elbow• Signs of HO
  • 202. The Stiff Elbow• Signs of HO - swelling, warmth, tenderness
  • 203. The Stiff Elbow• Signs of HO - swelling, warmth, tenderness - endpoints of ROM abrupt, solid
  • 204. The Stiff Elbow• Signs of HO - swelling, warmth, tenderness - endpoints of ROM abrupt, solid• May appear 2-12 weeks after initial event (trauma, surgery, burn, etc.)
  • 205. The Stiff Elbow
  • 206. The Stiff Elbow• Treatment of HO
  • 207. The Stiff Elbow• Treatment of HO - usually wait six months before resecting
  • 208. The Stiff Elbow• Treatment of HO - usually wait six months before resecting• Start with therapy, splinting
  • 209. The Stiff Elbow• Treatment of HO - usually wait six months before resecting• Start with therapy, splinting• Surgical excision, capsule release/excision
  • 210. The Stiff Elbow• Treatment of HO - usually wait six months before resecting• Start with therapy, splinting• Surgical excision, capsule release/excision - CPM, early and frequent therapy
  • 211. The Stiff Elbow
  • 212. The Stiff Elbow• Stages of stiffness after surgery/injury
  • 213. The Stiff Elbow• Stages of stiffness after surgery/injury - bleeding
  • 214. The Stiff Elbow• Stages of stiffness after surgery/injury - bleeding • in minutes to hours
  • 215. The Stiff Elbow• Stages of stiffness after surgery/injury - bleeding • in minutes to hours • joint capsule distension
  • 216. The Stiff Elbow• Stages of stiffness after surgery/injury - bleeding • in minutes to hours • joint capsule distension • swelling of tissues
  • 217. The Stiff Elbow• Stages of stiffness after surgery/injury - bleeding • in minutes to hours • joint capsule distension • swelling of tissues • pain, resistance to ROM
  • 218. The Stiff Elbow
  • 219. The Stiff Elbow• Stages of stiffness after surgery/injury
  • 220. The Stiff Elbow• Stages of stiffness after surgery/injury - edema
  • 221. The Stiff Elbow• Stages of stiffness after surgery/injury - edema • over hours, days
  • 222. The Stiff Elbow• Stages of stiffness after surgery/injury - edema • over hours, days • inflammation vasodilation
  • 223. The Stiff Elbow• Stages of stiffness after surgery/injury - edema • over hours, days • inflammation vasodilation • swelling, decreased compliance of soft tissues
  • 224. The Stiff Elbow
  • 225. The Stiff Elbow• Stages of stiffness after surgery/injury
  • 226. The Stiff Elbow• Stages of stiffness after surgery/injury - granulation tissue
  • 227. The Stiff Elbow• Stages of stiffness after surgery/injury - granulation tissue • over days to weeks
  • 228. The Stiff Elbow• Stages of stiffness after surgery/injury - granulation tissue • over days to weeks • tissue is loose initially, then becomes solidified
  • 229. The Stiff Elbow
  • 230. The Stiff Elbow• Stages of stiffness after surgery/injury
  • 231. The Stiff Elbow• Stages of stiffness after surgery/injury - fibrosis
  • 232. The Stiff Elbow• Stages of stiffness after surgery/injury - fibrosis • granulation tissue matures
  • 233. The Stiff Elbow• Stages of stiffness after surgery/injury - fibrosis • granulation tissue matures • forms rigid scar tissue
  • 234. The Stiff Elbow
  • 235. The Stiff Elbow• Stiffness prevention after surgery
  • 236. The Stiff Elbow• Stiffness prevention after surgery - CPM started on day one
  • 237. The Stiff Elbow• Stiffness prevention after surgery - CPM started on day one • creates a “pumping effect” on edema fluid in soft tissues
  • 238. The Stiff Elbow• Stiffness prevention after surgery - CPM started on day one • creates a “pumping effect” on edema fluid in soft tissues • 24 hours/day is ideal
  • 239. The Stiff Elbow• Stiffness prevention after surgery - CPM started on day one • creates a “pumping effect” on edema fluid in soft tissues • 24 hours/day is ideal • lasts for 3-4 weeks
  • 240. Case Example - HO
  • 241. Case Example - HO• 37yo university professor
  • 242. Case Example - HO• 37yo university professor• Sustained comminuted olecranon fracture
  • 243. Case Example - HO• 37yo university professor• Sustained comminuted olecranon fracture• ORIF
  • 244. Case Example - HO
  • 245. Case Example - HO• Healed the fracture, started therapy
  • 246. Case Example - HO
  • 247. Case Example - HO• Began having wrist pain in therapy, limited forearm motion
  • 248. Case Example - HO• Began having wrist pain in therapy, limited forearm motion• CT scan confirms forearm synostosis
  • 249. Case Example - HO
  • 250. Case Example - HO
  • 251. Case Example - HO
  • 252. Case Example - HO
  • 253. Case Example - HO• Eventually chose surgery
  • 254. Case Example - HO
  • 255. Case Example - HO

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