Forearm And Elbow Pathologies Dr. Mark Davies Sjsu, Spring 2008


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  • Forearm And Elbow Pathologies Dr. Mark Davies Sjsu, Spring 2008

    1. 1. Elbow and Forearm Pathologies Mark R. Davies, MD Center for Shoulder and Sports Disorders Kaiser Permanente Medical Group Santa Teresa Medical Center San Jose, CA
    2. 2. Dr. James Andrews Birmingham, Alabama Over 900 “ Tommy John” surgeries American Sports Medicine Institute Birmingham, AL
    3. 3. Elbow and Forearm Pathologies <ul><li>Elbow ligamentous sprains </li></ul><ul><li>Epicondylitis </li></ul><ul><li>Disorders of the capitellum </li></ul><ul><li>Rupture of distal biceps tendon </li></ul><ul><li>Olecranon bursitis </li></ul><ul><li>Neurologic injury </li></ul><ul><li>Elbow dislocations </li></ul><ul><li>Fractures </li></ul>
    4. 4. Elbow Ligamentous Sprains <ul><li>Medial (ulnar) collateral ligament injury </li></ul><ul><li>Lateral (radial) collateral ligament injury </li></ul>
    5. 5. Ulnar Collateral Ligament (UCL) <ul><li>UCL is the main medial stabilizer of the elbow </li></ul><ul><li>Anterior bundle is the primary structure involved in throwing </li></ul>
    6. 6. UCL History <ul><li>Pain or instability with throwing </li></ul><ul><li>What phase of throwing? </li></ul><ul><li>85% of throwers with medial elbow instability complain of pain in the acceleration phase of throwing </li></ul>
    7. 8. UCL Injury <ul><li>History: </li></ul><ul><li>- Acute medial pain </li></ul><ul><li>- Onset during throwing, inadequate warmup </li></ul><ul><li>- “Pop” heard or felt </li></ul><ul><li>- Can be one pitch or can be insidious </li></ul>
    8. 9. UCL Injury <ul><li>Physical exam: </li></ul><ul><li>- Medial elbow ecchymosis </li></ul><ul><li>- Ulnar nerve symptoms </li></ul><ul><li>- Tender at anterior bundle </li></ul><ul><li>- Difficult exam: </li></ul><ul><li>+/- instability </li></ul>
    9. 10. Milking Maneuver
    10. 11. Palpation of UCL Palpate in flexion to move flexor-pronator mass anteriorly
    11. 12. <ul><li>Complete UCL tear on MRI </li></ul>
    12. 13. Normal UCL
    13. 14. <ul><li>Bone tunnels are drilled </li></ul>“ Tommy John” Surgery
    14. 15. <ul><li>Graft is harvested – </li></ul><ul><li>Palmaris </li></ul><ul><li>longus </li></ul>Operative Technique
    15. 16. <ul><li>Graft is passed and crossed in a figure eight pattern </li></ul>Operative Technique
    16. 17. Results Return to Sport <ul><li>85 % of major league </li></ul><ul><li>professional baseball players </li></ul><ul><li>were able to return </li></ul>
    17. 18. Lateral Epicondylitis “ Tennis elbow”
    18. 19. Lateral Epicondylitis <ul><li>More common by 9:1 ratio than medial epicondylitis </li></ul><ul><li>Degenerative process: “tendinosis” </li></ul><ul><li>Extensor Carpi Radialis Brevis (ECRB) most commonly involved </li></ul>
    19. 20. Lateral Epicondylitis <ul><li>Palpate mobile wad while resisting active wrist extension </li></ul><ul><li>Pain at lateral epicondyle or over muscle mass usually present </li></ul><ul><li>No neurologic symptoms </li></ul><ul><li>Normal sensation </li></ul>
    20. 21. Lateral Epicondylitis Conservative Treatment <ul><li>Up to 90% of epicondylitis resolves spontaneously </li></ul><ul><ul><li>Rehab focus on stretching wrist extensors, eccentric wrist extensors </li></ul></ul><ul><ul><li>Activity modification </li></ul></ul><ul><ul><li>Anti-inflammatory medications </li></ul></ul><ul><ul><li>Counterforce bracing </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><ul><li>Injected </li></ul></ul></ul><ul><ul><ul><li>Topical –Iontophoresis / 24 Hr. patch </li></ul></ul></ul><ul><ul><li>Surgery </li></ul></ul>
    21. 22. Medial Epicondylitis “Golfer’s Elbow”
    22. 23. <ul><li>Pain with resisted wrist flexion </li></ul><ul><li>Pain with resisted pronation </li></ul><ul><li>Tender either within muscle belly or directly over medial epicondyle </li></ul>Medial Epicondylitis Diagnosis
    23. 24. Medial Epicondyle Avulsion Fractures <ul><li>Result from extreme valgus loads or violent muscle contractions during the throwing motion </li></ul><ul><li>Commonly occur in adolescents as the medial epicondyle begins to fuse </li></ul><ul><li>May report a “pop” </li></ul><ul><li>Tender at medial epicondyle, ecchymosis present medially </li></ul>
    24. 25. Medial Epicondyle Avulsion Fractures
    25. 26. Medial Epicondyle Avulsion Fractures
    26. 28. Panner’s Disease <ul><li>Osteochondrosis of the capitellum </li></ul><ul><li>Elbow’s version of Legg-Calve-Perthes Disease </li></ul><ul><li>Presents with lateral elbow pain and perhaps stiffness in an active youngster </li></ul>
    27. 29. Panner’s Disease <ul><li>Usually seen in children less than age 10 </li></ul><ul><li>Fragmentation of the capitellum usually seen on xrays </li></ul>
    28. 30. Panner’s Disease
    29. 31. Panner’s Disease <ul><li>Treatment </li></ul><ul><li>Orthopedic referral appropriate as is MRI </li></ul><ul><li>Stop offending activities - typically throwing (baseball) or handsprings (gymnastics) </li></ul><ul><li>Rest elbow – may consider splinting for a few weeks </li></ul><ul><li>Typically symptoms will resolve in a few months and capitellum ossification will normalize within 2 years </li></ul><ul><li>Long term prognosis excellent in most cases </li></ul>
    30. 32. Osteochondritis Dissecans (OCD) of the Capitellum <ul><li>OCD is a localized lesion in which a segment of subchondral bone and articular cartilage separates from the underlying bone </li></ul><ul><li>Presents with lateral elbow pain and perhaps stiffness in an active youngster </li></ul><ul><li>Usually seen in children older than age 12 </li></ul><ul><li>Focal area of lucency in the subchondral bone in the anterior aspect of the capitellum </li></ul><ul><li>Prognosis worse </li></ul>
    31. 33. Osteochondritis Dissecans of the Capitellum
    32. 34. Osteochondritis Dissecans of the Capitellum <ul><li>Physical exam </li></ul><ul><li>Lateral elbow pain with tenderness directly over the capitellum </li></ul><ul><li>Small effusion may be noted. </li></ul><ul><li>Limited range of motion is typically observed with approximately 20° of extension loss </li></ul><ul><li>Crepitus may be present in the radiocapitellar joint with active or passive forearm rotation </li></ul><ul><li>May also complain of locking & catching, which may indicate a loose body </li></ul>
    33. 35. Osteochondritis Dissecans of the Capitellum <ul><li>Treatment </li></ul><ul><li>Orthopedic referral appropriate as is MRI </li></ul><ul><li>Stop offending activities - typically throwing (baseball) or handsprings (gymnastics) </li></ul><ul><li>Rest elbow – consider splinting for a few weeks </li></ul><ul><li>Treatment will depend on symptoms </li></ul><ul><li>Long term prognosis more guarded – may require surgery </li></ul>
    34. 36. Osteochondritis Dissecans of the Capitellum <ul><li>Surgical indications </li></ul><ul><li>Symptomatic loose bodies </li></ul><ul><li>Articular cartilage fracture </li></ul><ul><li>Displacement of the osteochondral lesion </li></ul><ul><li>Surgical management of OCD lesions </li></ul><ul><li>Excision of loose bodies or partially attached lesions </li></ul><ul><li>Abrasion chondroplasty or subchondral drilling. </li></ul><ul><li>Results of internal fixation of the loose fragment vary </li></ul><ul><li>New techniques to harvest cartilage from the knee and transplant into the elbow promising </li></ul>
    35. 37. Distal Biceps Rupture <ul><li>Usually dominant extremity </li></ul><ul><li>Male (often weight lifters) Steroids?!? </li></ul><ul><li>Mean age of 50 (reported 18 to 72) </li></ul>
    36. 38. Biceps Rupture - Mechanism <ul><li>Often a single traumatic event </li></ul><ul><li>Unexpected eccentric extension force applied to an arm at 90 degrees of flexion </li></ul>
    37. 39. “ Popeye” muscle
    38. 40. Rupture of Distal Biceps Tendon <ul><li>AROM/PROM may be WNL but RROM limited due to pain with elbow flexion and forearm supination </li></ul><ul><li>Almost always treated surgically followed by progressive ROM and strengthening program </li></ul>
    39. 41. Olecranon Bursitis <ul><li>Typically due to direct trauma </li></ul><ul><li>Usually easily treated with rest, modalities compression, and NSAIDs </li></ul><ul><li>If persists, may be aspirated – risk of infection </li></ul>
    40. 42. Neurologic Injury <ul><li>Ulnar nerve </li></ul><ul><ul><li>At elbow (cubital tunnel) or wrist </li></ul></ul><ul><li>Median nerve </li></ul><ul><ul><li>At elbow or wrist (carpal tunnel) </li></ul></ul><ul><li>Radial nerve </li></ul><ul><ul><li>Least involved with overuse </li></ul></ul>
    41. 43. Sensory Examination <ul><li>Radial </li></ul><ul><ul><li>First dorsal webspace of hand </li></ul></ul><ul><li>Ulnar </li></ul><ul><ul><li>Pad of pinky finger </li></ul></ul><ul><li>Median </li></ul><ul><ul><li>Pad of index finger </li></ul></ul>
    42. 44. Tinnel’s Test <ul><li>Gentle percussion of the ulnar nerve above or within the cubital tunnel should not elicit pain in the normal elbow </li></ul><ul><ul><li>Pain or paresthesias into the ring and small fingers with tapping over the ulnar nerve in the cubital tunnel is considered a positive test </li></ul></ul>
    43. 45. Elbow Dislocations <ul><li>Typically results from hyperextension, trochlea levered over coronoid process </li></ul><ul><li>Vast majority are posterior with most common direction being posterolateral </li></ul><ul><li>Involve injury to most ligamentous structures, and potential for injury to neurovascular structures – if stable post-reduction, treat conservatively and if unstable, treat surgically </li></ul>
    44. 46. Posterior Elbow Dislocation
    45. 47. Fractures <ul><ul><li>Humerus </li></ul></ul><ul><ul><li>Radius </li></ul></ul><ul><ul><li>Ulna </li></ul></ul>
    46. 48. Humerus Fractures <ul><li>Supracondylar fracture </li></ul><ul><li>Supracondylar fracture with posterior elbow dislocation </li></ul>
    47. 49. Humerus Fractures <ul><li>Most common in children/adolescents from fall on flexed elbow or hyperextension mechanism </li></ul><ul><li>Deformity present if displaced, often missed on initial evaluation if nondisplaced </li></ul><ul><li>Often requires surgery if displaced </li></ul>
    48. 50. Ulnar Fractures <ul><li>Olecranon process fractures </li></ul><ul><ul><li>If stable/nondisplaced, short immobiliazation period (45-90 degrees of flexion) </li></ul></ul><ul><ul><li>If displaced, ORIF with longer immobilization period and early ROM if tolerated </li></ul></ul>
    49. 51. Radial Fractures <ul><li>Radial head fracture </li></ul><ul><li>Radial neck fracture </li></ul><ul><li>Most treated non operatively </li></ul>
    50. 53. Thank you!!!