The Elbow - Anatomy, Injury, and Rehabilitation

The Elbow Anatomy, Injury, andRehabilitation Implications C. Noel Henley, MD February 24, 2009

Goals• To review some elbow anatomy and relevance to surgical approach and therapy

Goals• To review some elbow anatomy and relevance to surgical approach and therapy• To review some speciﬁc elbow disorders/ injuries

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

Surgical Anatomy

Surgical Anatomy• Approaches

Surgical Anatomy• Approaches - posterior (“universal”)

Surgical Anatomy• Approaches - posterior (“universal”) - medial/lateral

Surgical Anatomy

Surgical Anatomy• Posterior

Surgical Anatomy• Posterior - midline posterior incision

Surgical Anatomy• Posterior - midline posterior incision - circumferential access

Surgical Anatomy• Posterior - midline posterior incision - circumferential access - leaves options open for future procedures

Surgical Anatomy• Posterior - midline posterior incision - circumferential access - leaves options open for future procedures - lower chance for cutaneous nerve injury

Surgical Anatomy

Surgical Anatomy• Cutaneous nerves

Surgical Anatomy• Cutaneous nerves - lateral antebrachial cutaneous nerve

Surgical Anatomy• Cutaneous nerves - lateral antebrachial cutaneous nerve - medial antebrachial cutaneous nerve

Surgical Anatomy• Cutaneous nerves - lateral antebrachial cutaneous nerve - medial antebrachial cutaneous nerve - posterior antebrachial cutaneous nerve

lateral antebrachial cutaneous nerve

medial antebrachial cutaneous nerve

posterior antebrachialcutaneous nerve

Surgical Anatomy

Surgical Anatomy• Posterior approach

Surgical Anatomy• Posterior approach - distal humerus fracture

Surgical Anatomy• Posterior approach - distal humerus fracture - medial, lateral structures

Surgical Anatomy• Posterior approach - distal humerus fracture - medial, lateral structures - may require a drain; more risk for seroma

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!

Triceps Options

Triceps Options• Olecranon osteotomy• Triceps-reflecting• Triceps-splitting• Triceps-reflecting anconeus pedicle flap• Paratricipital

Triceps Options

Triceps Options• Olecranon osteotomy

Triceps Options• Olecranon osteotomy - pro: full visualization of articular surface

Triceps Options• Olecranon osteotomy - pro: full visualization of articular surface - con: more adhesions, nonunion, painful hardware

Triceps Options• Olecranon osteotomy - pro: full visualization of articular surface - con: more adhesions, nonunion, painful hardware - several hardware options

Olecranon Osteotomy

Olecranon Nail

Triceps Options

Triceps Options• Triceps-reﬂecting

Triceps Options• Triceps-reﬂecting - triceps repaired through drill holes in olecranon

Triceps Options• Triceps-reﬂecting - triceps repaired through drill holes in olecranon - must protect the repair for six weeks post-op

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

Triceps Options

Triceps Options• Triceps-splitting, triceps-reﬂecting anconeus pedicle, paratricipital approaches

Triceps Options• Triceps-splitting, triceps-reﬂecting anconeus pedicle, paratricipital approaches - all may compromise active resisted motion after surgery

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

Triceps-reﬂectingAnconeus Pedicle

Surgical Anatomy

Surgical Anatomy• Lateral approach (addressable injuries)

Surgical Anatomy• Lateral approach (addressable injuries) - radial head fracture

Surgical Anatomy• Lateral approach (addressable injuries) - radial head fracture - capitellum fracture

Surgical Anatomy• Lateral approach (addressable injuries) - radial head fracture - capitellum fracture - some coronoid fractures

Surgical Anatomy• Lateral approach (addressable injuries) - radial head fracture - capitellum fracture - some coronoid fractures - lateral collateral ligament complex injury

Surgical Anatomy

Surgical Anatomy• Kocher interval/approach (lateral)

Surgical Anatomy• Kocher interval/approach (lateral) - between ECU and anconeus

Kocher interval

Surgical Anatomy

Surgical Anatomy• Kocher interval/approach (lateral)

Surgical Anatomy• Kocher interval/approach (lateral) - designed to split the annular ligament anterior to the LUCL

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

a) Kaplan’s interval (EDC split)b) Kocher interval (ECU/anconeus)

PIN injury

PIN injury• Creates a wrist drop or inability to extend MCP joints and thumb IP joint

PIN injury• Creates a wrist drop or inability to extend MCP joints and thumb IP joint• May not involve dorsal hand numbness

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!

Surgical Anatomy

Surgical Anatomy• Medial approach (addressable injuries)

Surgical Anatomy• Medial approach (addressable injuries) - coronoid fracture

Surgical Anatomy• Medial approach (addressable injuries) - coronoid fracture - medial collateral ligament injury

Surgical Anatomy• Medial approach (addressable injuries) - coronoid fracture - medial collateral ligament injury - an uncommon, but sometimes necessary approach

Surgical Anatomy• Medial approach (addressable injuries) - coronoid fracture - medial collateral ligament injury - an uncommon, but sometimes necessary approach - several ways of splitting/elevating muscles

Medial Approach

Speciﬁc Injuries

Distal Humerus Fractures

Distal Humerus Fractures • 90-90 plating concept

Distal Humerus Fractures • 90-90 plating concept - historically recommended technique

Distal Humerus Fractures • 90-90 plating concept - historically recommended technique - some problems with distal nonunions

Distal Humerus Fractures • near-parallel plating technique

Distal Humerus Fractures • near-parallel plating technique - offers improved stiffness/ stability

Distal Humerus Fractures • near-parallel plating technique - offers improved stiffness/ stability - better stability with varus/ shoulder abduction stress

Distal Humerus Fractures • near-parallel plating technique - offers improved stiffness/ stability - better stability with varus/ shoulder abduction stress - allows earlier motion

Distal Humerus Fractures • Rehabilitation

Distal Humerus Fractures • Rehabilitation - splinted x 2-3 days (usually extended)

Distal Humerus Fractures • Rehabilitation - splinted x 2-3 days (usually extended) - A/AAROM

Distal Humerus Fractures • Rehabilitation - splinted x 2-3 days (usually extended) - A/AAROM - PROM may promote ectopic ossiﬁcation (EO) - debated!

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°

Distal Humerus Fractures • Rehabilitation

Distal Humerus Fractures • Rehabilitation - ﬂexion returns ﬁrst (within 2 months)

Distal Humerus Fractures • Rehabilitation - ﬂexion returns ﬁrst (within 2 months) - extension maximized at 4-6 months

Distal Humerus Fractures • Rehabilitation - ﬂexion returns ﬁrst (within 2 months) - extension maximized at 4-6 months - supination/pronation minimally affected

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

Cubital Tunnel

Cubital Tunnel• Conservative management

Cubital Tunnel• Conservative management - splinting

Cubital Tunnel• Conservative management - splinting - padding

Cubital Tunnel• Conservative management - splinting - padding - activity/ergonomic modiﬁcation, education

Cubital Tunnel• Conservative management - splinting - padding - activity/ergonomic modiﬁcation, education - 89% of patients with mild/ moderate symptoms will improve (studies)

Cubital Tunnel

Cubital Tunnel• Patient education

Cubital Tunnel• Patient education - motions and positions that contribute to stretching, compression of the nerve

Cubital Tunnel• Patient education - motions and positions that contribute to stretching, compression of the nerve - analyze daily tasks for these aggravating factors

Cubital Tunnel

Cubital Tunnel• Splinting

Cubital Tunnel• Splinting - usually in 40-70° ﬂexion, neutral rotation, neutral wrist position

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

Cubital Tunnel

Cubital Tunnel• Splinting - elbow pad during the day; reverse it at night

Cubital Tunnel

Cubital Tunnel• Nerve gliding exercises

Cubital Tunnel• Nerve gliding exercises - nerves may not respond to being stretched, especially if already irritated

Cubital Tunnel• Nerve gliding exercises - nerves may not respond to being stretched, especially if already irritated - effectiveness is debated

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!

Cubital Tunnel

Cubital Tunnel• Conservative management - problems

Cubital Tunnel• Conservative management - problems - splints poorly tolerated

Cubital Tunnel• Conservative management - problems - splints poorly tolerated - elbow pad reversal may not be effective (too soft)

Cubital Tunnel• Conservative management - problems - splints poorly tolerated - elbow pad reversal may not be effective (too soft) - anecdotally poor results

Cubital Tunnel

Cubital Tunnel• Surgery - current trends

Cubital Tunnel• Surgery - current trends - move toward less extensive surgery

Cubital Tunnel• Surgery - current trends - move toward less extensive surgery - in situ decompression, simpler transpositions

Cubital Tunnel• Surgery - current trends - move toward less extensive surgery - in situ decompression, simpler transpositions - earlier ROM, return of function

Cubital Tunnel

Cubital Tunnel• Surgery - what I do

Cubital Tunnel• Surgery - what I do - in situ decompression

Cubital Tunnel• Surgery - what I do - in situ decompression - subcutaneous anterior transposition

Cubital Tunnel

Cubital Tunnel• Post-op rehabilitation

Cubital Tunnel• Post-op rehabilitation - remove dressing in ﬁve days

Cubital Tunnel• Post-op rehabilitation - remove dressing in ﬁve days - unlimited ROM

Cubital Tunnel• Post-op rehabilitation - remove dressing in ﬁve days - unlimited ROM - progressive resumption of activity

Cubital Tunnel• Post-op rehabilitation - remove dressing in ﬁve days - unlimited ROM - progressive resumption of activity - unusual to need formal outpatient visits

Tennis Elbow

Tennis Elbow• What is it?

Tennis Elbow• What is it? - a tendinosis/tendinopathy = “failed reparative process”

Tennis Elbow• What is it? - a tendinosis/tendinopathy = “failed reparative process” - no inﬂammatory cells in biopsy specimens

Tennis Elbow• What is it? - a tendinosis/tendinopathy = “failed reparative process” - no inﬂammatory cells in biopsy specimens - involves ECRB origin

Tennis Elbow

Tennis Elbow• Treatment

Tennis Elbow• Treatment - nonoperative

Tennis Elbow• Treatment - nonoperative • therapy

Tennis Elbow• Treatment - nonoperative • therapy • splinting

Tennis Elbow• Treatment - nonoperative • therapy • splinting • injection

Tennis Elbow• Treatment - nonoperative • therapy • splinting • injection • most studies show some short-term beneﬁt but no difference between treatments long-term

Counterforce Bracing

Counterforce Bracing• How does it work?

Counterforce Bracing• How does it work? - ECRB compression transfers contraction force away from origin

Counterforce Bracing• How does it work? - ECRB compression transfers contraction force away from origin - creates a “second origin” for the ECRB further distal

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

Counterforce Bracing

Counterforce Bracing• Effectiveness data is mixed

Counterforce Bracing• Effectiveness data is mixed - some studies show improvement

Counterforce Bracing• Effectiveness data is mixed - some studies show improvement - others show no signiﬁcant advantage over therapy alone

Tennis Elbow

Tennis Elbow• operative treatment

Tennis Elbow• operative treatment - many options (open, arthroscopic, percutaneous)

Tennis Elbow• operative treatment - many options (open, arthroscopic, percutaneous) - all focus on ECRB

Tennis Elbow• operative treatment - many options (open, arthroscopic, percutaneous) - all focus on ECRB - depending on post-op pain relief, more therapy may be necessary

The Stiff Elbow

The Stiff Elbow• Etiologic factors (post-op stiffness)

The Stiff Elbow• Etiologic factors (post-op stiffness) - immobilization

The Stiff Elbow• Etiologic factors (post-op stiffness) - immobilization • leads to capsular contracture

The Stiff Elbow• Etiologic factors (post-op stiffness) - immobilization • leads to capsular contracture - forced passive manipulation (increased risk for HO)

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

The Stiff Elbow

The Stiff Elbow• Etiologic factors (post-op stiffness)

The Stiff Elbow• Etiologic factors (post-op stiffness) - multiple procedures early on in treatment course

The Stiff Elbow• Etiologic factors (post-op stiffness) - multiple procedures early on in treatment course - burns

The Stiff Elbow• Etiologic factors (post-op stiffness) - multiple procedures early on in treatment course - burns - head trauma (as high as 90% risk)

The Stiff Elbow

The Stiff Elbow• Nonoperative treatment

The Stiff Elbow• Nonoperative treatment - gradual AAROM, modalities in therapy

The Stiff Elbow• Nonoperative treatment - gradual AAROM, modalities in therapy - splinting

The Stiff Elbow• Nonoperative treatment - gradual AAROM, modalities in therapy - splinting • dynamic spring/rubber band devices

The Stiff Elbow• Nonoperative treatment - gradual AAROM, modalities in therapy - splinting • dynamic spring/rubber band devices • static progressive splint (patient- adjustable)

The Stiff Elbow• Nonoperative treatment - gradual AAROM, modalities in therapy - splinting • dynamic spring/rubber band devices • static progressive splint (patient- adjustable) - better compliance

The Stiff Elbow

The Stiff Elbow• Nonoperative treatment

The Stiff Elbow• Nonoperative treatment • splinting (adjustable static type)

The Stiff Elbow• Nonoperative treatment • splinting (adjustable static type) - goal: plastic deformation of soft tissue through stress relaxation

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)

The Stiff Elbow

The Stiff Elbow• Heterotopic bone (ectopic bone)

The Stiff Elbow• Heterotopic bone (ectopic bone) - inappropriate formation of mature lamellar bone in soft tissue

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

The Stiff Elbow

The Stiff Elbow• Signs of HO

The Stiff Elbow• Signs of HO - swelling, warmth, tenderness

The Stiff Elbow• Signs of HO - swelling, warmth, tenderness - endpoints of ROM abrupt, solid

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.)

The Stiff Elbow

The Stiff Elbow• Treatment of HO

The Stiff Elbow• Treatment of HO - usually wait six months before resecting

The Stiff Elbow• Treatment of HO - usually wait six months before resecting• Start with therapy, splinting

The Stiff Elbow• Treatment of HO - usually wait six months before resecting• Start with therapy, splinting• Surgical excision, capsule release/excision

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

The Stiff Elbow

The Stiff Elbow• Stages of stiffness after surgery/injury

The Stiff Elbow• Stages of stiffness after surgery/injury - bleeding

The Stiff Elbow• Stages of stiffness after surgery/injury - bleeding • in minutes to hours

The Stiff Elbow• Stages of stiffness after surgery/injury - bleeding • in minutes to hours • joint capsule distension

The Stiff Elbow• Stages of stiffness after surgery/injury - bleeding • in minutes to hours • joint capsule distension • swelling of tissues

The Stiff Elbow• Stages of stiffness after surgery/injury - bleeding • in minutes to hours • joint capsule distension • swelling of tissues • pain, resistance to ROM

The Stiff Elbow

The Stiff Elbow• Stages of stiffness after surgery/injury - edema

The Stiff Elbow• Stages of stiffness after surgery/injury - edema • over hours, days

The Stiff Elbow• Stages of stiffness after surgery/injury - edema • over hours, days • inﬂammation vasodilation

The Stiff Elbow• Stages of stiffness after surgery/injury - edema • over hours, days • inﬂammation vasodilation • swelling, decreased compliance of soft tissues

The Stiff Elbow

The Stiff Elbow• Stages of stiffness after surgery/injury - granulation tissue

The Stiff Elbow• Stages of stiffness after surgery/injury - granulation tissue • over days to weeks

The Stiff Elbow• Stages of stiffness after surgery/injury - granulation tissue • over days to weeks • tissue is loose initially, then becomes solidiﬁed

The Stiff Elbow

The Stiff Elbow• Stages of stiffness after surgery/injury - ﬁbrosis

The Stiff Elbow• Stages of stiffness after surgery/injury - ﬁbrosis • granulation tissue matures

The Stiff Elbow• Stages of stiffness after surgery/injury - ﬁbrosis • granulation tissue matures • forms rigid scar tissue

The Stiff Elbow

The Stiff Elbow• Stiffness prevention after surgery

The Stiff Elbow• Stiffness prevention after surgery - CPM started on day one

The Stiff Elbow• Stiffness prevention after surgery - CPM started on day one • creates a “pumping effect” on edema ﬂuid in soft tissues

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

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

Case Example - HO

Case Example - HO• 37yo university professor

Case Example - HO• 37yo university professor• Sustained comminuted olecranon fracture

Case Example - HO• 37yo university professor• Sustained comminuted olecranon fracture• ORIF

Case Example - HO

Case Example - HO• Healed the fracture, started therapy

Case Example - HO

Case Example - HO• Began having wrist pain in therapy, limited forearm motion

Case Example - HO• Began having wrist pain in therapy, limited forearm motion• CT scan conﬁrms forearm synostosis

Case Example - HO

Case Example - HO• Eventually chose surgery

Case Example - HO

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http://www.orthopaedicprotocols.com	8
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The Elbow - Anatomy, Injury, and Rehabilitation

by C Noel Henley MD on Feb 26, 2011

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The Elbow - Anatomy, Injury, and Rehabilitation — Presentation Transcript