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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

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

Published in: Health & Medicine
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The Elbow - Anatomy, Injury, and Rehabilitation

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

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