Elbow
the lateral collateral ligament complex consisted of...
1. radial collateral ligament - runs longitudinally to radius near radial head 2. lateral (ulnar) collateral lig (LUCL) - runs obliquely to ulan
Normal Carrying Angle
10-18 degrees (> Females)
what is the region specific ROS
cardiovascular
Cubital Valgus
Excessive > 30 degrees
Why is ECRB clinically significant to test?
Lateral epicondyle tendinopathy / lateral epicondylitis, ECRB attaches at the lateral epicondyle BUT ECRL attaches at lateral supracondylar ridge
compound or simple joint?
compound synovial joint •Modified Ginglymus (Hinge) Joint
"Gunstock" (Varus) Deformity
deformity that occurs due to an improperly aligned healed supracondylar fracture. Rare in the U.S.
imaging for Acute Injury -R/O Fracture OR Chronic Injury
Plain Radiographs
Tinel's (Ulnar Nerve) Cubital Tunnel
Positive Test = Paresthesia in the ulnar distribution
Elbow Flexion Test tests what
Ulnar Nerve •Shoulders adducted •Scapula depressed •Elbows fully flexed •Wrist extended •Fingers extended •Hold for 60 seconds Positive Test = Recreation of Ulnar nerve symptoms
what restrains radial head dislocation?
annular lig
what is the primary restraint to valgus of the elbow?
anterior bundle
when do the physes fuse and when do they unite?
fuse at yr 6 unite 12 -20 yoa
Functional Elbow ROM
flex/ext = 30 -130 degrees (100 deg total) supination/pronation = 50 deg - 50 deg (100 deg total)
3 joints of the elbow
humeroulnar, humeroradial, proximal radioulnar
Acute Elbow Dislocation
instead of olecranon bursitis but the "bump" will be hard.
T or F: the elbow physes close early in growth but the lateral epicondyle is the last physis in the elbow to close.
false the medial closes last girls 14+ boys 17+ even 20 yoa (think about baseball pitchers and this not being mature enough for the stressed placed on it
T or F: Synovial fluid communicates with all 2 articulations only, the ulnohumeral and radiohumeral joints
false! Synovial fluid communicates with all 3 articulations
T or F: the anconeus is an elbow extensor
false, its more of an elbow stabilizer
larger MEDIAL lip of the trochlea, why?
medial instability biomechanically so we need a stronger guide rail on that side
what deficits are apparent in Radial nerve/PIN entrapment
motor deficits only of the EI, EDC, EDM, APL, EPL, EPB, EI, ECU. Commonly confused with Lateral Epicondylitis.
Fat Pad ("Sail") Sign means...
normally fat pads "tucked away" in the olecranon and coronoid fossa of the elbow. Swelling within the joint capsule (typically due to a fracture) pushes the fat pads out of the fossae making them visible on plane radiograph.
Moving Valgus Stress Test tests more anterior or posterior bundle?
posterior bundle when flexed the valgus stress test in extension targets the anterior bundle
Valgus Stress Test tests what
primarily testing the anterior bundle of the MCLC. tensioning the medial elbow but COMPRESSING the lateral elbow. Lateral Pain May Suggest Radiohumeral Pathology
Maudsley's Test, more sensitive or specific?
sensitive Good at Ruling Out LET when negative
what deficits are apparent in Pronator Teres Syndrome
sensory deficits in a Median N. distribution but may cause weakness of the FPL, FDP, and PQ (AIN innervated mm).
what deficits are apparent in Ulnar Nerve Compression or Entrapment
sensory disturbances along the Ulnar nerve distribution
the interval of the extensors demarcates what 2 mm?
separates ECRL and brachioradialis from ECRB ECRL and BR attach to the supracondylar ridge where ECRB attaches at the lateral epicondyle
what makes the elbow stable distally?
the radius
lateral ligaments of the elbow
the radius is lateral radial collateral lig and annular lig the lateral ulnar collateral ligament (LUCL) runs obliquely
what makes the elbow stable proximally?
the ulna
medial ligaments of the elbow
the ulna is medial 3 parts of the ulnar collateral ligament (anterior is shown, transverse*oblique, and posterior*up&down)
T or F: Annular Ligament is lined with cartilage to promote less friction.
true
T or F: fat pads are shown extra-synovial but intra-capsular
true
the arcade of Struthers entraps which nerve?
ulnar n
where does the brachialis attach?
ulnar tuberosity the main elbow flexor on the BIG proximal bone
medial ligaments mainly restrain what motion?
valgus forces - gap medially and compresses laterally
chronic elbow pain first imaging
x-ray
imaging Elbow Series
AP (Frontal) Lateral Oblique Coyle's View (Radial Head Fx)
what is the strongest bundle of ligaments?
(medial) anterior bundle
Sensory and proprioceptive innervation to the joint capsule is primarily from which 2 nerves?
1. Musculocutaneous N. 2. Radial N. (Hilton's Law) - where theres sensory into mm/tendons the same nerve innervating the skin above innervates the deeper joint capsule
what are the 1st and 2nd most common entrapments?
1. Carpal tunnel - median n 2. Cubital Tunnel Syndrome - ulnar n
Why is this important to know loose pack position?
1. if someone is carrying themselves there you know that is the most comfortable 2. leaves room for swelling, effusion, and laxity 3. laxity causes the capsule to fold and crease - we want to prevent contracture and adhesions
is the Moving Valgus Stress Test more sensitive or specific?
100% sensitive 75% specific
Mills test, more sensitive or specific?
100% specific - Good at Ruling In LET when Positive
Cozen's Test more sensitive or specific?
84% sensitive 0% specific Good at Ruling Out LET when negative
Ulnohumeral and Radiohumeral joints AAOS values
AAOS Values = 0-150 Up to 10 degrees hyperextension is considered normal
Proximal and Distal Radioulnar Joints AAOS values
AAOS Values = 80 Supination/Pronation [85 Supination; 75 Pronation is more accurate]
Regionally Relevant Questions
Age = (Open Physes?) •Traumatic or Overuse - High probability of overuse in this region •FOOSH Injury (Child or young male)? Elderly more likely to fracture distally. Younger hurt elbow more. •FUNCTION •Differentiate regional pathology from cervical radiculopathy (Double Crush Syndrome) •Tease out peripheral N. pattern from nerve root pattern (Can be hard!) •If local to the elbow, does it refer pain distally? •Hypomobility - Common •ROM limitation (extension primary limitation) •Sensory, motor, or both? Real MMT
Cubital Varus
Any varus is abnormal A few degrees of Varus and Valgus joint play is NORMAL and DESIRED for optimal function Not under Physiologic Muscle Control
Cozen's Test
Arm supported on the table! MMT for the ECRB with the elbow flexed to "take out" the ECRL. The fingers are flexed and the wrist is extended and radially deviated. The examiner applies a isometric force to flex and ulnar deviate the wrist.
cubital tunnel
Bwtn heads of FCU through the boney architecture
Extensor Digitorum MMT
C6,7,8 (PIN) common extensor tendon on lateral epicondyle-->extensor expansion 2-5 digits (extension across the MCP) - Position: neutral wrist, grab to stabilize metacarpals (lumbrical grip their hand), "make a claw hand": hyperextended MCP, PIP flexion Pressure: pressure on PIP down into extension
Pronator quadratus MMT
C8,T1; AIN *test makes distinction between muscle and nerve problem(s) Distal ¼ of anterior ulna-->Distal ¼ of anterior radius - Position: supine; full pronation, elbow completely flexed (shortened teres) - Pressure: hand at wrist, direct toward supination
common radial and deep radial innervation
Common Radial - Brachioradialis, ECRL Deep branch - ECRB, Supinator?? PIN- EI, EDC, EDM, APL, EPL, EPB, EI, ECU
imaging for Heterotopic Ossification and Unexplained Elbow Stiffness
Computed Tomography
Transverse Bundle aka
Cooper's Ligament Does NOT cross the elbow joint (Ulna to Ulna) Guides the weak medial side serves as protection
Ulnar Nerve Compression or Entrapment
Cubital Tunnel Syndrome Ulnar & humeral heads of FCU Arcuate ligament Arcade of Struthers - 70-80%
imaging for Chronic Epicondylitis, Tendon Injury, Bursitis, Collateral Ligament Tear, Nerve Injury
Diagnostic Ultrasound
What is the first muscle innervated by PIN?
ECRB
PREE (Patient-Rated Evaluation of the Elbow)
Elbow specific •Pain Subscale (5 Items) •Function Subscale (15 Items) 20 items total lower the score the better 0 = high function
Proximal Radioulnar Joint mob
Flex the elbow to 20 degrees Stabilize the ulna with the medial hand Grasp the proximal radial head with the lateral hand Apply either a dorsal or volar glide
Radiohumeral Joint Distraction
Flex the elbow to 70 degrees Stabilize the distal humerus Grasp the distal radius using a Lumbrical grip Apply a long axis distraction to the Radiohumeral Joint
Extensor Carpi Radialis Longus + Brevis MMT
Longus: C 6,7; radial n. and Brevis: C6,7; PIN - Longus: Lateral supracondylar ridge (humerus)-->Base of 2nd MC and Brevis: Lateral epicondyle of humerus--> Base of 3rd MC - Position (BOTH): sitting with arm pronated; fingers loose/off table, wrist extended, radial deviated - bend trunk forward for brevis (making ECRL actively insufficient) - Pressure: 60% toward wrist flexion and ulnar side
imaging for Mechanical Symptoms (locking, clicking, limited ROM), Suspected Occult Fx, Soft-Tissue Mass, Chronic refractory Epicondylitis, Suspected Ligament Tear, Suspected Biceps Tendon Rupture, Suspected Nerve Injury, Inflammatory Arthropathy
Magnetic Resonance Imaging (No Contrast)
what else can you test w/ Elbow Flexion Test
May also perform a ULTT (Ulnar N) Bias to help differentiate proximal origin
Maudsley's Test
Middle Finger Test - Tests for Lateral Elbow Tendinopathy •Hand on a table •Elbow slightly flexed (45 degrees) •Pronated Forearm •Wrist in neutral extension •Middle Finger Extended •Resisted Middle Finger
which test has the best specificity and sensitivity?
Mills test - 100% specific Maudsley's Test - 88% sensitivity
what are the limits of the posterior bundle?
Most taut in Flexion (60-120 deg) sail shaped one. Taut w/ valgus
Olecranon Bursitis
Must differentiate an infection from an inflammation - Aspiration if thought to be infected or unconfirmed gout Inflamed or Infected? <Doubt, refer OUT
Proximal and Distal Radioulnar Joints end feels
Normal End-feels Supination - Firm Ligamentous Pronation - Hard (jams bone)
Supinator MMT
PIN C 6 Olecranon, lateral epicondyle, radial collateral lig, annular lig --> Proximal radius (anteriorly) and Between radial tuberosity and pronator teres *Note* we take out biceps by shortening or lengthening them and making insufficient (active or passive) - Shortened Bicep: Supine; shoulder and elbow completely flexed; forearm fully supinated - Elongated Bicep: seated; forearm fully supinated; fully extend shoulder and elbow
Resisted Supination tests for what
PIN Entrapment Positive Test is Recreation of the patients pain (deep supinator pain).
what are the limits of the anterior bundle?
Primary restraint to valgus of the elbow. Most taut in extension (0-60 deg). FLOOR of ulnar groove - ulnar nerve sitting through here
Median Nerve Entrapment
Pronator Teres Syndrome Ligament of Struthers - 13%
Brachioradialis MMT
Radial n. C5,6 Lateral supracondylar ridge of humerus --> Styloid process of radius Not a break test. See if it's contracting. Unique elbow flexor that supinates and pronates too. - Position: supine; 70° elbow flexion, hand neutral (between pronation/supination) - Pressure: below thumb, on wrist, pulling towards you/the table. Free hand could go under the elbow to cushion from table pressure.
Ulnohumeral Joint mob
Stabilization of the Humerus is desired (Note Belt Fixation) The elbow is flexed to 70 degrees (unlock the Ulnohumeral joint - Loose Packed Position) Long-Axis Distraction along the line of the humerus
larger MEDIAL epicondyle compared to the lateral condyle, why?
Stronger wrist flexors insert on the medial condyle (more muscle mass)
Radial nerve entrapment
Supinator / Radial Tunnel Syndrome - Leash of Henry, or Arcade of Frohse
Elbow Joint Capsule
The articular capsule is thin but notorious for becoming thickened and hypomobile in the presence of trauma or immobilization (like in that loose packed position)
Arcade of Struthers separates...
Tissue band from med head of triceps to med intermuscular septum 7/10 people have it
Olecranon Bursitis cause
Trauma, repetitive compression, Gout, RA, infection, Kidney Disease
lateral ligaments mainly restrain what motion?
Varus of the elbow (less of a concern than valgus)
Olecranon Bursitis tx
Watchful neglect, aspiration (rarely), steroid injection, excision (rare)
the ligament of Struthers entraps which nerve?
median n
What is the last muscle innervated by the AIN?
pronator quadratus if pronator quadratus is working the AIN is working.
where does the biceps attach?
radial tuberosity the supinator on the BIG rotating bone
Loose Pack Position
•70 flexed •10 supinated
Muscles Primarily Acting on the Elbow Joint Complex
•Biceps - (Musculocutaneous) •Triceps - (Radial) •Brachialis - (Musculocutaneous [+ Radial]) •Brachioradialis - (Common radial) •ECRL (Common radial) and ECRB (Deep radial) •Supinator (Deep radial vs. PIN) •Pronator Teres (Median) •Pronator Quadratus (AIN) •Anconeus (Radial)
Outcome Measures
•DASH (Disability Arm Shoulder Hand) •Quick DASH •PREE (Patient-Rated Evaluation of the Elbow) Elbow specific
Muscle with Minimal Action on the Elbow Complex
•FCU (Ulnar) •FCR (Median) •ECU (PIN)
Valgus Stress Test
•Full Humeral ER to get the humeral condyles in a horizontal orientation •Elbow flexed 20 degree (unlock olecranon from the olecranon fossa •Proximal hand on distal lateral humerus •Distal hand on medial distal forearm •STARTING POSITION: Apply a SLIGHT VARUS force •Apply a relatively quick Valgus force •Assess joint play, end-feel, and pain
Varus Stress Test
•Full Humeral ER to get the humeral condyles in a horizontal orientation •Elbow flexed 20 degree (unlock olecranon from the olecranon fossa) •Proximal hand on distal medial humerus •Distal hand on lateral distal forearm •STARTING POSITION: Apply a SLIGHT VALGUS force •Apply a quick Varus force Assess joint play, end-feel, pain
Magnetic Resonance Imaging with Contrast for...
•Osteochondral injury
Moving Valgus Stress Test
•Start in full (150 degrees) flexion •Examiner applies a valgus force •Examiner passively extends the elbow while maintaining a valgus force •Positive pain/laxity from 120-60 degrees Thought to mimic functional instability in throwing athletes
Varus Stress Test tests what
•Tests LCLC •Pain WHERE? Lateral pain, but can medial side is compressed
Mill's Test
•Tests for Lateral Elbow Tendinopathy Elbow Extension •Forearm Pronation •Finger Flexion (fist) •Ulnar Deviation •Wrist Flexion (Slowly) •Palpation of lateral epicondyle at the insertion of the ECRB
Cozen's Test tests for what
•Tests for Lateral Elbow Tendinopathy Positive Test = Pain local to the lateral epicondyle at the insertion of the ECRB. Not specifically a "strength" test.