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.