Elbow Upper Eval Test

Median nerve pathology

1.Most injuries occur at distal forearm 2.Pronator teres syndrome- in ability to pinch the tips of the thumb and index fingers together 3. carpal tunnel syndrome

Forearm (ulnar & radius)

1.Open or closed 2. Degree of angulation, rotation or displacement

Milking Sign/Maneuver

1.Puts a stress on the UCL 2.Position of patient: sitting, shoulder at 90, elbow flexed to 90 3.One hand stabilizes at the elbow, opposite grasps the thumb of the injured hand and go in a circle or pulling straight back, thus creating a valgus force 4.Positive: laxity and pain

Radial Dislocation

Almost always in pediatrics, longitudinal compression MOI: FOOSH

Falling directly onto the elbow is a common MOI for:

Olecranon bursitis

Which way does the olecranon commonly go when dislocated?

Posterior

Reflex C7

Radial nerve (triceps tendon)

Observation

Swelling Muscle Bulk (flexors and extensors) Deformity Cubital Fossa Discoloration Medial epicondyle Carrying angle Lateral epicondyle Gun stock deformity Alignment Hyperextended elbow (cubital recurvatum) Olecranon process and bursa Both sides

Palpation

Temperature Sensation Painful Areas Deformities Pulses: brachial and radial

Epicondylalgia

Tennis Elbow Tests: 1. Passive Tennis elbow test 2. Mill's test 3.Chair pick-up 4. Resistive Tennis Elbow Test 5. Cozen's Test Golfer's Elbow Test: 1. Passive test of golfers elbow test 2. Chair pick-up

The Resistive Tennis Elbow Test is done seated with the elbow bent

True

What does Tommy John surgery fix?

UCL tear

The Valgus Stress Test is looking for a ____________ pathology, whereas the Varus Stress Test is looking a(n) ___________ pathology.

UCL, RCL

What pathology can be detected by having the patient perform a pushup or push out of a chair?

Ulnar collateral ligament tear

Whartrenbert's sign is testing for ___________. You test it by ______________.

Ulnar nerve pathology; passively spread fingers apart and actively bring fingers together.

What does Cozen's Test test for?

Lateral Epicondylagia

What is medial epicondylitis known as in young throwers?

Little League Elbow

UCL Sprain

MOI: hyperextension or valgus force S/S: pain on medial aspect of elbow, compression of radial nerve Special Tests: Posterolateral Rotatory instability, moving valgus stress test (do a push up)

Osterochondritis Dissecans of the Capitellum

MOI= increased valgus loading Presents: may happen with orthopedic conditions: osteochondral fracture, avascular necrosis, detached bony fragments Treatment: rest and rehab Typically in adolescent throwers

Golfer's elbow is also known as

Meidal epicondylitis

Injuries that are most common in children?

Nursemaid's elbow, Little League elbow, Panner's disease

What is a positive test for the posterior rotary instability test?

clunk and/ or extra movement

What phase of throwing puts the most stress on the elbow joint?

cocking

What muscle does not flex the elbow

coracobrachialis

Which muscle inserts on the olecranon process of the ulna?

triceps brachii

a patient with jersey finger is unable to flex their DIP joint (T/F)

true

A UCL tear is often associated with what neuropathy?

ulnar

Cubital Tunnel syndrome is an entrapment of which nerve

ulnar

What nerve passes through the cubital tunnel?

ulnar

Valgus elbow stability depends mainly on the integrity of which structure?

ulnar collateral ligament

You suspect a patient to have an ulnar collateral ligament sprain. They complain of numbness and tingling on the inside of their hand (4th and 5th digits). What might be damaged with their UCL sprain?

ulnar nerve

What is the carrying angle for women and men

women: 10 to 15, men: 5 to 10

You are testing for lateral epicondylitis when you perform the golfer's elbow special test.

False

Which tunnel or canal allows passage to the ulnar nerve and ulnar artery into the hand?

Guyon's canal

what is inured in a pseudo-boutonniere deformity?

rupture of the solar plate

What does the "chair pick-up test" test for?

lateral and medial epicondylalgia

Dermatome C6

lateral elbow and forearm to thumb and index finger

The forearm extensors attach where?

lateral epicondyle

What is the isosceles triangle in the elbow?

medial and lateral epicondyle, and olecranon process

Dermatome T1

medial elbow to just below axilla region

Which nerve innervates the biceps brachii muscle?

musculocutaneous nerve

What is responsible for the hard end feel of elbow extension

olecranon process

A 14 y/o pitcher presents to you with lateral elbow pain. He says that it hurts most when he is cocking and feels like it's locking up during his follow-through. What might he have?

osteochondritis dissecans

lalgia

pain in the region

which nerve innervated the triceps brachii muscle

radial

Aconeus

same as triceps

supinator

shake hands and resist supination

pronator quadratus

shake hands with elbow flexed, resist pronation

pronator teres

shake hands with elbow flexed, resist pronation

Dermatome C4

shoudlers and clavicle region

Myotomes C5

shoulder abduction

Myotomes C4

shoulder shrug

What lifestyle choice predisposes patients to distal biceps tendon ruptures?

smokers

Hypertrophy of what muscle causes radial nerve irritation?

supinator

Compression of this nerve at the elbow can result in drop wrist syndrome

radial nerve

Muscle Palpations

-Triceps: 3 heads long: proximal/medial aspect of humerus medial: distal aspect of humerus lateral: lateral aspect -Biceps brachii: to radial tuberosity -Brachioradialis: lateral supracondylar ridge to styloid process -Brachialis -Extensors: Extensor carpi radialis longus Extensor carpi radialis brevis Extensor carpi ulnaris -("Mobile wad of three" = Extensor carpi radialis longus, extensor carpi radialis brevis, and brachioradialis -Flexors: Palmaris longus Flexor carpi ulnaris Flexor carpi radialis Pronator Teres Finger flexors Finger extensors Thumb muscles Both sides

Humerus Palpations

-medial epicondyle: MCL and forearm flexor attachment -lateral epicondyle: LCL and forearm extensor attachment -medial supracondylar ridge: flexor attachment -lateral supracondylar ridge: extensor attachment -capitellum: (lateral condyle) articulates with radius -[trochlea: (medial condyle) articulates with ulna] -olecranon fossa: depression in humerus -medial collateral ligament: ulna to humerus, medial to trochlear notch (groove) -lateral collateral ligament: radius to humerus -ulnar nerve (ulnar notch): passes thru cubital tunnel formed by the flexor carpi ulnaris and ulna -Cubital fossa

Ulna Palpations

-olecranon process: proximal end of ulna: triceps -olecranon bursa: proximal end of ulna -ulnar collateral ligament

Radius Palpations

-radial head -annular ligament -radial collateral ligament

Medial epicondylagia

1. Degenerative tendinosis of proximal tendon of wrist flexors MOI= snapping of the wrist and pronation of the forearm S/S: pain over medial epicondyle, decreased grip strength, pain with gripping

Mobility Tests

1. Elbow Joint Play 2. Valgus Stress Test 3. Moving Valgus Stress Test 4. Milking sign/Maneuver 5. Varus Stress Test 6. Hyperextension Test 7. Posterolateral rotary instability test (pivot shift)

History

1. How did you do it? 2. What is the type of pain? 3. When did you do it? 4. What is the duration of pain? 5. Where does it hurt? 6. Have you had x-rays? 7. What did you do? 8. Have you taken any medications? 9. Have you had a previous Injury? 10. Which is your dominant hand? 11. Did you hear any sounds or sensations? 12. Was it supported or protected?

Which tests have a positive test for pain?

1. Milking sign 2. Chair pick up 3.passive tennis elbow test 4.valgus/varus stress test

Elbow Fractures

1. Supracondylar fractures have higher incidence in adolescents 2. Olecranon fractures more common in skeletally mature patients. 3. radial head fractures: occurs with elbow dislocation MOI: 1.FOOSH 2.May cause gunstock deformity 3.Fall directly onto flexed elbow 4.Direct blow to elbow 5.Hyperextension (Supracondylar fx)

Neurological Tests

1. Tinel Sign 2. Pinch grip test 3.Elbow Flexion test 4. Whartenberg's Sign

Functional Tests of elbow

1. ball squeezes 2. chin-ups 3. push-ups 4. throwing motion 5. sport activity skills 6. grass drills 7. contact

Three things that can contribute to Little League Elbow:

1.) Skeletal immaturity 2.) Over-training 3.) Poor biomechanics

Elbow Joint Play

1.Assess the amount of mobility allowed by the joint capsule and ligaments Humeroulnar: i.Position of patient: supine, elbow flexed at 70 ii.Distract the elbow Radioulnar: iii.Position of patient: supine, elbow flexed at 70 and supinated to 35 iv.Anterior and posterior force Radiohumeral: v.Position of patient: supine, elbow extended, and supinated vi.Anterior and posterior force 2.Positive: hypomobility or hypermobility

Lateral epicondylagia

1.Degenerative tendinosis to common extensor tendon MOI:Stress on extensor carpi radialis brevis S/S: pain over lateral epicondyle, decreased grip strength, pain with gripping Special Test: Tennis Elbow pain worsens with backstroke

Biceps Tendon Rupture

1.Distal biceps brachii at its radial attachment most common muscle rupture in upper extremity 2.MOI: Eccentric loading of biceps brachii when elbow flexed to 90°, loss of strength in flexion and supination 3.common in males over 40 4. 7.5 times more likely in people who smoke S/S: pop, immediate pain in cubital fossa Special Test: hook test

Dislocations

1.Most common is ulna and radius being forced backward 2.MOI: FOOSH in hyperextension or slight flexion,Severe twist while in flexed position 3.May causes rupture/tear of stabilizing ligamentous tissue. 4. Must rule out the "terrible triad of the elbow"

Moving Varus stress test

1.Puts tensile forces on the UCL through elbow flexion and extension for dynamic elbow instability 2.Position of patient: sitting, shoulder abducted to 90, elbow flexed to end of ROM 3.One hand stabilizes the distal humerus, opposite grasps the ulnar side of the distal forearm, while applying valgus stress on the elbow, ER the humerus, then move elbow into flexion and extension with the valgus force 4.Positive: pain at medial elbow, apprehension, pain at 120 to 70 (cocking and acceleration phase of throwing), reproduction of pain in ROM during flexion and extension

Posterolateral Rotatory Instability

1.Tear to the LUCL 2.Causes ER and valgus opening 3.Commonly associated with posterior dislocation injury, especially the "terrible triad"

Chair pick-up (lateral)

1.Test lateral epicondylagia 2.Position of patient: picking up the chair 3.Grab chair elbows fully extended, hands pronated, pull the chair straight up 4.Positive: pain and inability to pick up the chair

Mills' test

1.Test lateral epicondylagia 2.Position of patient: seated, elbow extended at 90, pronated hand, 3.passive wrist flexion, active wrist extension will hurt 4.Positive: pain and weakness with passive wrist flexion

Passive tennis elbow test

1.Tests for lateral epicondylagia 2.Position of patient: seated, elbow flexed to 90, pronated (palm down) 3.Moving wrist into passive flexion, active wrist extension will hurt 4.Positive: pain and weakness with passive wrist flexion

Resistive tennis elbow test

1.Tests for lateral epicondylitis 2.Seated with arm rested on the table, elbow at 90, palm down, resist the third finger as they go into extension 3.Feel for the lateral epicondyle, resist as they extend 4.Positive: pain along the lateral epicondyle, clicking, muscle weakness

Chair pick-up (medial)

1.Tests for medial epicondylagia 2.Position of patient: picking up a chair 3.Grabbing chair, arms fully extended, supinated (palm up), pull the chair straight up 4.Positive: pain and inability to pick up the chair

Passive test or golfers elbow test

1.Tests for medial epicondylitis 2.Position of patient: sitting or standing, elbow flexed to 90, supinated 3.Palpate the medial epicondyle, passively extend their wrist, pain with active wrist flexion, check also for ulnar nerve 4.Positive: pain on the medial aspect of the elbow

Pinch Grip Test

1.Tests for the anterior interosseous nerve between the two heads of the pronator teres (innervates the pronator quadratus, flexor pollicis longus, 1st and 2nd components of the flexor digitorum profundus) 2.Position of patient: seated 3.Have them take their thumb and pointer and pinch them together, seeing if they can bring together 4.Positive: inability to touch the tips of the thumb and index finger together

Whartenberg's Sign

1.Tests for ulnar nerve 2.Position of patient: palm down on table, elbow extended 3.Passively abduct their fingers and then have them actively pull back in 4.Positive: when you put them in the position, are they unable to bring their pinky finger back in

Tinel's Sign

1.Tests for ulnar nerve entrapment 2.Position of patient: seated, elbow slightly flexed 3.Palpate the ulnar groove, go in the middle where the nerve is and tap it 4.Positive: numbness or tingling at the medial part of the 4th and the 5th finger

Elbow flexion test

1.Tests for ulnar nerve, cubital fossa syndrome 2.Position of patient: seated 3.Have patient maximally flex their elbows, hold for 3 to 5 minutes flexed, looking for the ulnar nerve problems since its entrapping the nerve 4.Positive: radiating pain into the median nerve distribution in the arm or hand (lateral forearm, tip of thumb, index and middle g=finger, lateral half of index finger), also ulnar nerve symptoms in the fifth digit and medial aspect of the fourth digit

Cozen's test

1.Tests lateral epicondylitis 2.Position: seated with arm resting on the table, pronate and radial deviate, and extend the wrist against resistance 3.Pushing them into supination and ulnar deviate them as you grab their hand like you are giving them a hand shake 4.Positive: pain along lateral epicondyle and muscle weakness

Hyperextension test

1.Tests the anterior capsule to see if you can put into full extension, could be a torn or stretched anterior capsule 2.Position of patient: sitting, arm in full extension, palm up 3.Have patient hyperextend their arm and try to apply a pressure down to see if they passively go farther 4.Positive: elbow extension is just beyond 0 degrees is considered hyperextension, goes past the 0 degrees

Varus stress test

1.Tests the integrity of the radial collateral ligament 2.Position of patient: sitting, elbow flexed to 20 to 30 degrees, palm up 3.One hand supports the lateral elbow, opposite grasps the distal forearm as you apply a varus force (medial, pushing out) 4.Positive: increase laxity, diminished, or no endpoint, compared with the opposite side, lateral elbow pain, or both

Valgus stress test

1.Tests the integrity of the ulnar collateral ligament, beyond 60 indicated posterior oblique fibers 2.Position of patient: shoulder at 90, sitting, humerus IR, elbow flexed 20-30 degrees 3.One hand supports the lateral elbow, opposite grasps the distal forearm as you apply a valgus force (laterally, push in) 4.Positive: increase laxity, or diminished or no end point compared with the opposite side, medial elbow pain, or both

Posterolateral rotary instability test (pivot shift)

1.Tests the posterolateral rotatory instability of the elbow and lateral collateral ligament; consists of extending the elbow with an axial load, valgus stress, and forearm supination, elbow subluxes at near full extension 2.Position of the patient: supine, elbow flexed to 90, forearm supinated 3.One hand grasps the proximal forearm, opposite grasps the distal forearm at the wrist, while applying a valgus stress and axial compression, elbow extended and forearm in supination (palm down), put a valgus stress on the elbow as you pull them into extension 4.Positive: elbow subluxes as it is extended and can be felt to relocate as it is flexed, pain in middle elbow, instability

Forearm compartment syndrome

1.Three compartments 2. May be exertional or acute 3.S&S: Pressure Sensory disruption Decreased muscular strength PROM - elongation of involved muscles Flexor digitorum profundus Flexor pollicis longus Decrease/absence radial and/or ulnar pulses Volkmann's Contracture

Cubital Tunnel Syndrome

1.Ulnar nerve entrapment at the cubital tunnel in the elbow. 2. MOI: traction injury from a valgus force, irregularities w/in the tunnel, subluxation of ulnar nerve, progressive compression of ligament on nerve 3. S&S:Pain on medial aspect of elbow usually referred distally. Tenderness over cubital tunnel, esp. with hyperflexion. Burning, tingling, loss of sensation, numbness, possible muscle atrophy over fourth and fifth fingers. Decreased strength 4. Tx: Rest, Immobilization, NSAIDS, Splinting ~ possible surgery, Avoid elbow hyperflexion and valgus stresses.

Volkmann's ischemia has signs and symptoms that include

1.discoloration 2. loss of temperature, 3. loss of wrist extension

Finger flexors

1.flexor digitorum superficialis = flexion of PIP joint (test individually) 2. flexor digitorum profundus = flexion of the DIP joint (test individually)

Which anatomical landmarks are located on the humerus (

1.medial epicondyle 2.olecranon fossa 3. lateral supracondylar ridge 4.trochlea

Normal carrying angle in females for the elbow is?

10 to 15 degrees

Myotomes C8

1st and 5th digit

Dermatome C7

3rd digit

Dermatome C8

4th & 5th digit to medial forearm

Pathology to the ulnar nerve would elicit numbness and tingling into which fingers?

4th and 5th

Little League Elbow commonly affects young overhead athletes aged....

8-10

popular dislocations in the forearm?

90% posteriorly

What mechanism is likely to cause a distal biceps tendon tear?

Biceps eccentric contraction at 90 degrees (moving toward extension)

Reflex C5

Biceps reflex

Which muscle originates on the lateral supracondylar ridge and inserts on the radial styloid process?

Brachioradialis

Reflex C6

Brachioradialis reflex

What is the mechanism of injury for a Boutonniere deformity

DIP extension, PIP flexion

how to splint a jersey finger?

DIP in flexion

What is the "terrible triad of the elbow"?

Elbow dislocation, radial head fracture, coronoid process fracture

Active ROM

Elbow flexion Elbow extension Supination: test with elbow flexed to avoid shoulder motion Pronation: test with elbow bent to avoid shoulder motion Wrist flexion Wrist extension Wrist radial deviation Wrist ulnar deviation Finger flexion Finger extension Thumb movements Both sides

Passive ROM

Elbow flexion Elbow extension Supination: test with elbow flexed to avoid shoulder motion Pronation: test with elbow bent to avoid shoulder motion Wrist flexion Wrist extension Wrist radial deviation Wrist ulnar deviation Finger flexion Finger extension Thumb movements Both sides

In throwers, osteochondritis is common in the medial aspect of the elbow joint. (specifically between the capitellum and radial head) True or False

False

Is mill's Test another name for the passive tennis elbow test

False

The MOI for mallet finger is forced flexion of the PIP joint

False

Valgus Extension Overload

a collection of tensile, shear, and compressive forces that result from mild UCL laxity

What is the carrying angle

a lateral deviation of the elbow, greater in women then men

Which ligament surrounds the head of the radius and anchors it to the radial notch of the ulna?

anular ligament

Triceps

arm extended

Dermatome C5

deltoid area (above elbow)

Myotomes C7

elbow extension

Myotomes C6

elbow flexion

Radial Tunnel Syndrome (RTS)

entrapment of the radial nerve resembles lateral epicondylagia except symptoms are more distally on the forearm S/S: reproduced with supination and extension of middle finger

Anconeus does what action?

extends the elbow

What AROM will be painful with lateral epicondylalgia?

extension

Finger extensors

extension of MCP joints of digits 2-5

Extensor carpi radialis longus and Extensor carpi radialis brevis

extension of the wrist toward the radial side

Extensor carpi ulnaris

extension of wrist toward the ulnar side

what muscle is associated with tennis elbow

extensor carpi radialis

Myotomes T1

finger abduction

What AROM will be painful with an ulnar collateral ligament sprain?

flexion

Flexor carpi radialis

flexion of the wrist toward the radio side (includes palmaris longus)

Flexor carpi ulnaris

flexion of wrist toward ulnar side

brachioradialis

forearm neutral

brachialis

forearm pronated

biceps brachii

forearm supinated

What is the difference between the medial and lateral chair pick up tests?

hand placement (pronation, supination)

The capitellum articulates with what?

head of radius

how to splint mallet and boutonnière

in extension

litis

inflammation of the epicondyle