Elbow

Yes But! keep an eye on it...it may get infected.

Can you treat "Student elbow"?

True Osteochondritis dissecans: -Typically affects the lateral or central portion of the *capitulum*. -The radiographic appearance may include radiolucency of the capitulum, but it may also include loose body formation and secondary changes of hypertrophy of the radial head.

T/F: Some feel that Panner's and OCD are the *same* Dz at different points.

True

T/F: The "whipping" action of the throw causes lateral compression and resultant tension on medial supporting structures, particularly the *ulnar collateral ligament*.

B. <10

What age group is affected by Panner's Disease? A. <20 B. <10 C. <30 D. <40

C. Annular Ligament This occurs in this age group (1-3 years) due to the incomplete ossification of the radial head. *Rare* and *Very* painful in an adult.

With traction on the extended arm, the ________________ligament slides over the head of the radius into the joint space and becomes entrapped. A. Radial Collateral Ligament B. Ulnar Collateral Ligament C. Annular Ligament D. TFL

A. be inflamed by friction B. become seeded with bacteria

Bursae's can: (select all that apply) A. be inflamed by friction B. become seeded with bacteria

C. 1-3 years *F>M*

Nursemaid's Elbow: Common injury that is seen in children between the ages of: A. 3-6 years B. 6-9 years C. 1-3 years D. 9-12 years

B. 80-100 Any recurrence of symptoms necessitates cessation of throwing and a re-evaluation of the patient.

Return to throwing should be approached cautiously. A strength and flexibility exercise regimen should be rigorously adhered to, and pitch count should be limited to _______________pitches per week. A. 50-70 B. 80-100 C. 120-140 D. 100-120

A. Slightly flexed and pronated Child will be screaming at the top of their lungs! Tender, but there is *no swelling, redness, warmth, abrasions, or ecchymosis*.

A child with Nursemaid's Elbow will hold the affected arm in: A. Slightly flexed and pronated B. Slight extended and pronated C. Slight flexed and supinated D. Slight extended and supinated

Any *crepitus* means that a fracture or cartilage fragment was missed. -Open reduction, internal fixation indicated. Monitor neurovascular competency -Problems? ORIF (Open reduction internal fixation) If OK, rehab to get full extension back, flexion usually will return on its own. Brachialis likes to get MO after dislocations Medial and lateral instabilities may result if collaterals are trashed. -Tighten joint using palmaris longus.

Apres Reduction

B. Palpation C. Cozen's test D. Mill's test *Imaging* is not usually helpful except to R/O arthritis, unless its US.

How do you clinically diagnosis Tennis Elbow? (select all that apply) A. Imaging B. Palpation C. Cozen's test D. Mill's test

Hx of trauma Painful and limited ROM Pain on supination/pronation Tenderness Edema Tuning fork test historical, but unreliable Image if you suspect fracture

How does the Physical exam of a supracondylar fracture present?

C. 3-4mm Full thickness ulnar collateral ligament tears may necessitate reconstruction, often with a palmaris longus graft, the so-called "*Tommy John procedure*". In patients with OCD of the capitulum, the presence of a loose body within the joint is an indicator for surgery.

If apophyseal avulsions are displaced by ______________or greater, surgical reattachment is typically indicated. A. 1-2mm B. 2-3mm C. 3-4mm D. 4-5mm

Anterior and posterior bands of the medial and lateral collateral ligaments of the elbow Brachialis muscle Flexor-pronator muscle group Articular cartilage

In a posterior dislocation, what are the injured structures?

B. 10-16 Found in *young baseball pitchers*. -During the acceleration phase, the elbow assumes a valgus position which loads the capitulum.

OCD of the capitulum tends to occur in patients ___________years of age. A. 16-22 B. 10-16 C. 22-28 D. 28-34

B. 1-2 years During this time, symptoms gradually disappear, although the elbow may never fully straighten out.

Panner's Disease: How long does it take for the bone to slowly rebuild itself? A. 6 months to a year B. 1-2 years C. 1-6 months D. Never

B. Flexed, valgus This ligament is injured in sports that involve throwing. Initiation of the throwing motion places the ligament on tension.

Rupture of the UCL usually occurs in the _________elbow with _____________stress. A. Flexed, varus B. Flexed, valgus C. Extended, varus D. Extended, valgus

True Another common mechanism is when the child is swinging while being held by the hands.

T/F: *Most commonly* it occurs when a child is falling and the individual holding the hand doesn't let go.

True

T/F: A frequent MOI is a FOOSH with the forearm internally rotated and the elbow flexed about 20 degrees.

True The child begins to complain of pain during activity. The pain eases with rest.

T/F: Affects the *dominant elbow* of children, mainly boys, between the ages of 5 and 10.

True Non-displaced Fx may be immobilized via sling, especially radial head Fx.

T/F: All displaced Fx should be immobilized via casting or stabilized via surgical pinning.

True

T/F: Anterior dislocation and any open fracture are commonly associated with disruption of the brachial artery and/or injury to the median nerve.

False May *not be* necessary if...

T/F: Imaging is necessary if the active range of motion of the elbow remains normal.

True

T/F: In *adolescents*, the immature apophysis of the medial epicondyle is often the weaker link, and injuries that affect this ossification center may thus predominate in the young thrower.

True

T/F: In *adults*, the repetitive valgus forces of throwing often result in chronic degeneration, microtears, or rupture of the ulnar collateral ligament.

True *Volkmann Contracture* Pertains to Supracondylar fractures.

T/F: In 1881, Richard von Volkmann published an article in which he attempted to ascribe irreversible contractures of the flexor muscles of the hand to ischemic processes in the forearm.

False *Valgus*

T/F: In the throwing athlete, the acceleration phase of the overhead throw causes extreme *varus* stress upon the elbow.

True

T/F: Males are more affected than females when it comes to Tennis Elbow.

True *Fragmentation is typically surgical.*

T/F: Panner's disease involves the entire epiphysis and is radiographically characterized by radiolucency and *fragmentation*, similar to Legg-Calve-Perthes disease of the hip.

True Typically, patients are 3-10 (6.5) years old. In the immature skeleton, the collateral ligaments and joint capsule are stronger than the bone. The opposite is true in the mature skeleton. Therefore, supracondylar fractures seldon occur in adults.

T/F: Supracondylar fractures are the *most* common elbow fractures in pediatric patients.

True

T/F: The ability to fully extended the elbow while supinated may be sufficient to obviate radiography. In such cases, patients may be advised to return in 7-10 days if their symptoms do not resolve.

False *MRI* findings!

T/F: The treatment approach in patients with little league elbow is often guided by the *X-ray* findings.

True Eccentric strengthening and flexibility of the FCU is key.

T/F: Treatment is the same as for Tennis Elbow, but with focus on the flexor group.

B. Weaker & Thinner Provides varus stability and is rarely stressed in the athlete. The anconeus muscle also contributes to joint stability.

The RCL complex is ___________and ___________than the UCL complex. A. Weaker & Thicker B. Weaker & Thinner C. Stronger & Thicker D. Stronger & Thinner

A. Anterior band B. Transverse band D. Posterior band

The ulnar collateral ligament is composed of three bands. What are they? (select all that apply) A. Anterior band B. Transverse band C. Oblique band D. Posterior band

A. Supinated & Flexed A *"click"* will be heard or felt with *reduction*. There is a relatively *high incidence* of recurrence.

Traditional Way: While supporting the radial head, the forearm is _________________& _________________at the same time. A. Supinated & Flexed B. Supinated & Extended C. Pronated & Flexed D. Pronated & Extended

Local tenderness over the lateral aspect of the elbow, most typically in the dominant arm. Swelling Intermittent locking that is worse with activity Crepitus on flexion and extension

What are the *early* findings of OCD?

Joint effusion More progressive limitations of elbow movement (loss of extension, usually 5-10 degrees) Crepitus with motion Muscle atrophy Catching and locking of the elbow (usually observed with separation of osseous/cartilaginous fragments).

What are the *late* findings of OCD?

Pain and/or burning along the lateral aspect of the distal humerus and proximal forearm. Loss of grip strength (loss of painless grip strength). Loss of elbow ROM in extension (think joint derangement of the elbow).

What are the S&S of Tennis Elbow?

History of Trauma Elbow is held in full extension The upper arm appears shortened, while the forearm is elongated and held in supination. Focal pain Extremely limited ROM Edema

What are the Signs & Symptoms of an Anterior dislocation?

History of trauma Elbow is flexed, with an exaggerated prominence of the olecranon Focal pain Extremely limited ROM Edema

What are the Signs and Symptoms of a posterior dislocation?

A. Graston B. ART C. Counterforce brace (during high stress activity) D. Eccentric strengthening of the wrist extensors (start low and slow to avoid flares)

What are the Sub-acute Tx? (Select all that apply) A. Graston B. ART C. Counterforce brace D. Eccentric strengthening of the wrist extensors

A. PRICES B. Counterforce brace C. Acupuncture D. Ultrasound E. E-stim *Etc*.

What are the acute Rx? (select all that apply) A. PRICES B. Counterforce brace C. Acupuncture D. Ultrasound E. E-stim

NSAID medications Application of ice after activity Strengthen the FCU Graston, ART, etc. Stretching and flexibility programs *Change Pitching Style!* *Change Pitching Frequency!*

What are the conservative treatments for apophyseal stress reactions, ligamentous sprains, muscle strains, and minimally displaced apophyseal avulsions?

A. Medial (flexor) tendonitis B. Medial epicondylitis C. Pitcher's Elbow

What are the other names for Golfer's Elbow? (select all that apply) A. Medial (flexor) tendonitis B. Medial epicondylitis C. Pitcher's Elbow

Hot Very painful Limited ROM Get Patient out of the Office!

What are the symptoms of Bursitis?

Donut KT Graston/ART US, etc. Drainage

What are the treatment options for Bursitis?

B. Separation and fragmentation of the medial epicondylar apophysis Pain and tenderness over the medial epicondyle in their pitching arm. Since that early description, in 1960, the designation of little league elbow has expanded to include a host of abnormalities that affect the throwing elbow in adolescent pitchers.

What is Little Leaguer's Elbow? A. Lateral Epicondylalgia B. Separation and fragmentation of the medial epicondylar apophysis C. Epiphyseal ischemic necrosis of the capitulum D. Localized fragmentation of the bone and overlying cartilage of the capitulum

D. Localized fragmentation of the bone and overlying cartilage of the capitulum It may progress to loos body formation, and sometimes progresses to post-traumatic arthritis.

What is Osteochondritis Dissecans? A. Lateral Epicondylalgia B. Medial Epicondylitis C. Epiphyseal ischemic necrosis of the capitulum D. Localized fragmentation of the bone and overlying cartilage of the capitulum

C. Epiphyseal ischemic necrosis of the capitulum Similar to Osteochondritis Dissecans (OCD).

What is Panner's Disease? A. Lateral Epicondylalgia B. Medial Epicondylitis C. Epiphyseal ischemic necrosis of the capitulum D. Localized fragmentation of the bone and overlying cartilage of the capitulum

A. Tennis Elbow B. Lateral Epicondylalgia C. Lateral Epicondylitis D. Lateral Epicondylosis E. Shooter's Elbow F. Archer's Elbow G. Lateral elbow pain

What is another name for Lateral Epicondylitis? (select all that apply) A. Tennis Elbow B. Lateral Epicondylalgia C. Lateral Epicondylitis D. Lateral Epicondylosis E. Shooter's Elbow F. Archer's Elbow G. Lateral elbow pain

An impact to the posterior aspect of a flexed elbow.

What is the MOI for an anterior dislocation?

A. Limitation of activity B. Rest C. Application of ice D. Adequate pain control E. Consider placing patient in a sling for pain relief only G. Use of modalities H. Surgical intervention (indicated in cases of progressive joint contracture, failed conservative treatment, partially attached or completely detached fragments, or locking and catching of the joint with extension and/or flexion) *Prolonged splinting or casting* is not usually necessary and may increase the risk of flexion contracture.

What is the Rx for Panners Dz and OCD? (select all that apply) A. Limitation of activity B. Rest C. Application of ice D. Adequate pain control E. Consider placing patient in a sling for pain relief only F. Prolonged splinting or casting G. Use of modalities H. Surgical intervention

B. 30-50 Carpenters, mechanics, etc. Typically micro-trauma from repetitive use.

What is the common age for Tennis elbow? A. 10-30 B. 30-50 C. 50-70 D. All of the above

A. Flexor Carpi Ulnaris

What is the major muscle group that is affected in Golfer's Elbow? A. Flexor Carpi Ulnaris B. Flexor Carpi Radialis C. Supinator D. Flexor Carpi Radialis Brevis

Staph aureus Typically due to local abrasion.

What is the typical bacteria that infects a bursa?

B. Posterior (90%) Dislocations of the elbow are not rare, with shoulder and finger being more common. A fall onto an extended abducted arm is the mechanism of injury seen in posterior dislocations of the elbow. -An example of this is someone who, falling backward, extends an arm behind to break the fall.

What is the usual direction of dislocation of the elbow? A. Anterior B. Posterior C. Inferior D. Superior

C. Extensor Carpi Radialis Brevis *Extensor indicis* in computer geeks.

What is the usual tendon involved in the tennis elbow? A. Extensor Indicis B. Extensor Carpi Ulnaris Brevis C. Extensor Carpi Radialis Brevis D. Pronator Teres

A. Children C. Adolescents

What patients do Supracondylar fractures occur in? Select all that apply? A. Children B. Adults C. Adolescents D. Elderly

C. 30%

What percent of adult elbow fractures occur in the radial head? A. 10% B. 20% C. 30% D. 40%

B. 10-15%

What percentage of Coronoid process fractures occur in dislocations of the elbow? A. 40-45% B. 10-15% C. 20-25% D. 30-35%

A. 10-20%

What percentage of olecranon process fractures account for all of elbow injuries in adults? A. 10-20% B. 20-30% C. 30-40% D. 40-50%

Medial elbow and proximal forearm pain a few days after pitching. Symptoms abate the rest initially, but with progression, pain becomes more continuous and the player may report difficulty "loosening up" or maintaining throwing accuracy.

Where is the common site of pain with a patient with little leaguer's elbow?

A. Anterior band Providing the major restraint to *valgus* stress at the elbow. The anterior band arises from the anteroinferior aspect of the medial epicondyle and inserts upon the sublime tubercle of the ulna.

Which band of the ulnar collateral ligament is the most important? A. Anterior band B. Transverse band C. Posterior band D. All are important