Elbow - CHT

IN NURSEMAID'S ELBOW OR PULLED ELBOW SYNDROME, THE RADIAL HEAD SEPARATES FROM WHAT LIGAMENT AS A RESULT OF LONGITUDINAL TRACTION OF THE FOREARM?

Annular ligament

DEFINE AUTOLOGOUS INJECTION & PLATELET RICH PLASMA INJECTION

Autologous Injection: The patient's blood is taken from one part of the body and injected directly into another (the elbow for example). PRP Injection: The patient's blood which is first centrifuged to collect a concentration of platelets prior to injecting it. The theory is that the platelets will stimulate healing in the degenerative tendon.

DEFINE RADIAL TUNNEL SYNDROME

Compression of the radial nerve by anatomical structures inferior to the lateral epicondyle. 1. Dull achy pain over the extensor aspect of the forearm 2. Pain is absent upon waking but progressively worsens 3. tenderness oer the radial head/radial tunnel area 4. pain is reproduced with resisted extension of the fingers 5. Pain with resisted forearm supination with elbow extended 6. In advanced stage, weakness in the wrist, fingers and thumb extensors

DEFINE CUBITAL TUNNEL SYNDROME

Compression or trauma of the ulnar nerfe at the level of the medial aspect of the elbow. 1. Pain at the medial elbow 2. Sensory disturbances over the ulnar nerve distribution of the hand. 3. Weak intrinsic muscles 4. Palpable nerve that is more mobile than usual 5. Positive Tinel's at the cubital tunnel 6. Positive elbow flexion test 7. Positive Froment's sign in advanced stages

RECONSTRUCTION OF THE UCL TRAVERSES WHICH STRUCTURES IN THE ELBOW?

Coronoid - Medial Humeral Epicondyle Reconstruction of the UCL entails placing a ligament graft transosseously and spanning the medial humeral epicondyle to the coronoid.

WHICH MUSCLE ORIGIN IS MOST COMMONLY INVOLVED IN LATERAL EPICONDYLITIS?

ECRB

WHAT IS THE APPROPRIATE TREATMENT FOR A NON-DISPLACED, TYPE I RADIAL HEAD FRACTURE WHICH HAS NO ASSOCIATED LIGAMENT OR INTEROSSEOUS MEMBRANE INJURIES?

Intermittent use of a sling for comfort and begin early AROM to include elbow flexion, extension, supination, and pronation.

DESCRIBE THE ELBOW JOINT CAPSULE AND IT'S COMPONENTS

Ligaments of the elbow joint: 1. Medial (ulnar) collateral 2. Lateral (radial) collateral 3. Annular 4. Fat Pad 5. Olecranon Bursae

WHAT IS CONSIDERED FUNCTIONAL ROM OF THE ELBOW (MOTION NECESSARY TO DO THE MAJORITY OF ACTIVITIES OF DAILY LIVING) ?

Negative 30 degrees of extension 130 degrees of flexion 50 degrees of upination 50 degrees of pronation.

WHAT IS PANNER'S DISEASE?

Panner's disease, or osteochondritis of the capitulum, is a range of disorders from idiopathic osteochondritis to osteochondritis dessicans with a loose body formation.

WHICH PART OF THE ULNAR COLLATERAL LIGAMENT (UCL) OF THE ELBOW IS TYPICALLY INJURED IN THROWERS?

The Anterior Bundle

NAME THE TEST THAT IS PERFORMED BY RESISTED SHOULDER FLEXION WITH THE ELBOW HELD IN SUPINATION AND EXTENSION. A POSITIVE TEST IS INDICATIVE OF BICEP TENDINITIS

Speed's Test

TRUE OR FALSE? BOTH THE LONG HEAD AND THE SHORT HEAD OF THE BICEPS ORIGINATE ABOVE THE GLENOHUMERAL JOINT AND INSERT BELOW THE HUMEROULNAR AND HUMERORADIAL JOINTS.

True

DESCRIBE DISTAL HUMRAL FRACTURE TYPES A, B, AND C

Type A) extra-articular - they do not involve the joint surface. often called supracondylar or transcondylar. Type B) Intercondylar-articular fractures with one joint fragment in continuity with the shaft Type C) Intercondylar -articular fractures with articular fragments with no continuity with the shaft.

LIST THE TYPES OF RADIAL HEAD FRACTURES

Type I: Nondisplaced fracture Type II: Displaced Type III: Comminuted Type IV: Complex instability

WHEN CAN A PATIENT INITIATE TRICEPS ISOTONIC CONCENTRIC EXERCISES FOLLOWING A DISTAL TRICEPS REPAIR

Typically around 12 weeks post-operatively.

WHEN CONSIDERING PINNING ON THE MEDIAL SIDE AFTER CLOSED REDUCTION OF A SUPRACONDYLAR FRACTURE, A PHYSICIAN MUST BE CAREFUL WITH WHICH NEUROVASCULAR STRUCTURE?

Ulnar Nerve

WHAT IS CONSIDERED NORMAL RANGE OF MOTION FOR THE UNINJURED ELBOW?

0 degrees of extension 145 degrees of flexion 75 degrees of pronation 85 degrees of supination

MUSCLES OF ELBOW FLEXION

1. Biceps brachii 2. Brachialis 3. Brachioradialis - assists 4. Pronator teres - assists

MATCH THESE MUSCLE GROUPS WITH THEIR CERVICAL NERVE ROOT: C5. C6, OR C7 1. TRICEPS, WIRST FLEXION AND FINGER EXTENSION 2. ECRL, ECRB, BRACHIORADIALIS 3. BICEPS

1. C7 2. C6 3. C5

THE MAIN ELBOW FLEXORS ARE THE BICEPS AND BRACHIORADIALIS. LIST THE ACCESSORY ELBOW FLEXOR MUSCLES

1. FCR 2. supinator 3. Pronator teres

DESCRIBE A DISTAL BICEPS RUPTURE

1. Injury occurs with forceful flexion 2. "Popeye" deformity - bulging biceps mid-humerus 3. Near complete loss of supination and flexion strength

A PATIENT IS REFERRED 1 DAY FOLLOWING AN ORIF (OPEN REDUCTION INTERNAL FIXATION) OF AN OLECRANON FRACTURE. WHAT ARE APPROPRIATE GOALS FOR THE FIRST TWO WEEKS OF TREATMENT?

1. Pain and edema control 2. long-arm orthosis positioning the elbow in 70 degrees of flexion 3. Initial AROM/AAROM of the elbow and forearm.

THE CLINICAL MANIFESTATION OF COMPARTMENT SYNDROME INCDLUDES THE 4 Ps. WHAT ARE THEY?

1. Pain with passive stretch 2. Pallor 3. Pulselessness 4. Paresis Crush injuries are especially prone to develop compartment syndrome.

AT WHAT TIME CAN AN ATHLETE RETURN TO A THROWING PROGRAM AFTER REPAIR OF A TORN UCL OF THE ELBOW?

4 Months

AFTER AN OPEN RELEASE FOR MEDIAL OR LATERAL TENDINOSIS, WITH THE CONSIDERATION OF NO SECONDARY COMPLICATIONS, THE ATHLETE CAN EXPECT TO RETURN TO COMPETITION IN WHAT TIME SPAN?

5-8 Months

IN WHICH AGE GROUP IS NURSEMAID'S ELBOW MOST COMMON?

6 months to 3 years. As the radius grows and becomes more ossified, pulled elbow syndrome is less common.

MUSCLES OF FOREARM PRONATION

1. Pronator teres 2. Pronator quadratus

MUSCLES OF FOREARM SUPINATION

1. Supinator 2. Biceps Brachii with elbow flexion

NAME THE TWO BASIC COMPARTMENTS OF THE FOREARM AND THEIR CONTENTS.

1. Volar Compartment: Flexors and Pronators 2. Dorsal Compartment: Wrist and finger extensors

WHERE DOES A BICEPS TENDON RUPTURE TYPICALLY OCCUR?

At the Elbow -- radial tuberosity

WHAT MUSCLE IS THE MOST POWERFUL SUPINATOR OF THE FOREARM?

Biceps brachii

A RELEATVE COINTRAINDICATION FOR ENDOSCOPIC CUBITAL TUNNEL DECOMPRESSION IS: A. EMG EVIDENCE OF DENERVATION B. CLINICAL EVIDENCE OF INTRINSIC MUSCLE ATROPHY C. PRE-OPERATIVE ULNAR NERVE SUBLUXATION D. ELBOW JOINT CONTRACTURE

C. Preoperative Ulnar Nerve Subluxation Decompressing a subluxed ulnar nerve will only destabilize the nerve further and lead to more symptoms. A transposition, which is performed in an open fashion, would be more appropriate.

STATE THE AGE AT WHICH THE FOLLOWING OSSIFICATION CENTERS OSSIFY ? CAPITULLUM MEDIAL EPICONDYLE RADIAL HEAD TROCHLEA OLECRANON LATERAL EPICONDYLE

Capitulum = 2 years Medial Epicondyle = 4 years Radial Head = 5 years Trochlea = 8 years Olecranon = 9 years Lateral Epicondyle = 10 years Remember: CMRTOL and 2,4,5,8,9,10

DESCRIBE THE ELBOW FLEXION TEST FOR ULNAR NEUROPATHY

Elbow are flexed at 90 degrees or greater, forearm supinated and wrists extended. Position is held up to 3 minutes. Test is positive with aching or paresthesia along the ulnar nerve distribution.

IN WHAT POSITION SHOULD THE ELBOW BE SPLINTED FOLLOWING ORIF OF AN OLECRANON FRACTURE?

Elbow at 90 degrees during the day and elbow in extension at night.

DISRUPTION OF THE INTEROSSEOUS MEMBRANE WITH PROXIMAL RADIAL MIGRATION AFTER FRACTURE OF THE RADIAL HEAD IS KNOWN AS WHAT?

Essex-Lopresti Lesion

TRUE OR FALSE? THE BICEP MUSCLE IS THE PRIMARY ELBOW FLEXOR WITH THE FOREARM HELD IN SUPINATION AS WELL AS PRONATION

FALSE Studies have demonstrated that during elbow flexion, at 90 degrees of flexion and forearm pronation, little or no activity was measured in the biceps with surface electrodes. The biceps is the primary flexor with the forearm held in supination not pronation.

TRUE OR FALSE? THE ELBOW JOINT IS A BIAXIAL JOINT, WITH 2 DEGREES OF MOTION, FLEXION/EXTENSION, AND SUPINATION/PRONATION.

FALSE The elbow joint is made up of two separate joints. The ulnohumeral joint resembles a hinge (ginglymus), which allows elbow flexion and extension. Axial rotation at the radiohumeral and proximal radiohumeral joint is a pivoting type of motion (trochoid) rendering joint articulation to be classified as a trochoginglymoid

TRUE OR FALSE? THE BICEP MUSCLE IS THE PRIMARY ELBOW FLEXOR WITH THE FOREARM HELD IN SUPINATION AS WELL AS PRONATION.

FALSE The biceps is the primary elbow flexor with the forearm held in supination NOT pronation.

THE PATIENT HAS BEEN DIAGNOSED WITH CUBITAL TUNNEL SYNDROME. TREATMENT IS TARGETED TO DECREASE COMPRESSION OF THE ULNAR NERVE AS IT PASSES THROUGH THE TENDON OF WHAT MUSCLE?

FCU

WHICH MUSCLE OVERLIES THE ANTERIOR BUNDLE OF THE UCL AND THEREFORE MAY HAVE PROTECTIVE VALUE FOR THIS VULNERABLE STRUCTURE?

FCU The FCU runs directly over the anterior bundle of the UCL. Selected strengthening of this muscle in throwers may protect against ligament injury.

WHICH ARE THE PRIMARY STRUCTURES INVOLVED IN MEDIAL EPICONDYLITIS?

FCU + Pronator Teres

DESCRIBE THE HUMERORADIAL JOINT OF THE ELBOW

Formed from capitulum of humerus and radial head of radius - responsible for pronation/supination as well as flexion/extension.

DESCRIBE THE HUMEROULNAR JOINT OF THE ELBOW

Formed from the trochlea of humerus and the trochlear notch of the ulna, responsible for flexion/extension.

WHAT IS THE MOST COMMON COMPLICACTION FOLLOWING A TOTAL ELBOW ARTHROPLASTY (TEA)?

Infection

AN ULNAR SHAFT FRACTURE THAT IS ASSOCIATED WITH RADIAL HEAD DISLOCATION IS CALLED WHAT?

Monteggia Fracture

WHAT TEST WOULD YOU USE TO TEST THE ANTERIOR INTEROSSEOUS NERVE?

Pinch Grip test

WHEN TREATING LATERAL EPICONDYLITIS WITH INJECTIONS, WHICH HAS MORE LONG LASTING EFFECTS ON BOTH PAIN AND IMPROVED FUNCTION: CORTICOSTEROID INJECTION OR PLATELET-RICH PLASMA (PRP) INJECTION?

Platelet-rich Plasma (PRP) In recent randomized controlled trials, PRP was more effective than corticosteroid injection in terms of both pain relief and improved function with results that lasted up to 2 years.

WHEN SHOULD THERAPY BE INITIATED AFTER EITHER AN OPEN OR ARTHROSCOPIC ELBOW CONTRACTURE RELEASE?

Post-op day 1

WHICH NERVE IS PARTICULARLY AT RISK DURING ELBOW ARTHROSCOPY?

Radial Nerve The radial nerve is only 3mm away from the anterolateral portal in a cadaver study. Use of blunt cannula and instruments minimizes risk to the radial nerve during arthroscopy.

DESCRIBE THE PROXIMAL RADIOULNAR JOINT

Radial head glides in the radial notch of the ulna with pronation/supination.

How is Cozen's test performed?

Resisted wrist extension with proximal ECRB palpation

TRUE OR FALSE? HYPERTROPHY OF THE FCU CAN BE AN INDICATOR OF IMPROPER THROWING TECHNIQUES

TRUE

TRUE OR FALSE? THE LATERAL EPICONDYLE, MEDIAL EPICONDYLE, AND OLECRANON LINE UP IN FULL ELBOW EXTENSION.

TRUE

TRUE OR FALSE? A PATIENT WHO IS EXPERIENCING ELBOW PAIN MAY HAVE REFERRED PAIN FROM SHOULDER PATHOLOGY

TRUE Shoulder impingement, tendinitis, and associated rotator cuff pathology have pain that is manifested in the brachium.

WHERE IS RADIAL NERVE COMPRESSION IN THE FOREARM TYPICALLY LOCATED?

The arcade of Frohse within the supinator muscle.

DEFINE HETERATROPIC OSSIFICATION

The formation of mature bone in non-osseous tissue which can be the result of any traumatic elbow condition. Clinical presentation is pain, swelling, and warmth about the injured area.

DEFINE THE MOBILE WAD OF HENRY

The mobile wad of Henry consists of the: brachioradialis, ECRL, and ECRB. Some authors consider the mobile wad of Henry as a separate compartment and others include it in the dorsal compartment. The mobile wad of Henry is a surgical term used to describe the radial muscles of the posterior compartment of the forearm that flex the elbow. The group of muscles is relatively mobile as a unit and can be retracted in surgery.

DESCRIBE THE NIRSCHL HAND SHAKE TEST

The patient firmly shakes the hand of the examiner with the elbow extended and then supinates the forearm against resistance. Repeat the hand shake with the elbow at 90 degrees. If pain is less with the elbow at 90 degrees than it was with the the elbow extended, conservative management will most likely be successful.

WHICH CLINICAL SIGN INDICATES ULNAR NEURITIS AT THE ELBOW?

Tinel's Test over the cubital tunnel

WHAT IS ANOTHER NAME FOR COMPARTMENT SYNDROME OF THE FOREARM?

Volkmann's Ischemia

A COMPLETE DISTAL BICEP TENDON AVULSION INJURY IS MOST COMMON IN WHICH GENDER?

Well conditioned males The literature states that the majority (up to 80%) of avulsion ruptures occur in the right-dominant upper extremity in well- developed males. The mechanism of injury is a sudden extension force to the elbow when the elbow is in 90 degrees of flexion.