Elbow Injuries

Median nerve entrapment/Pronator syndrome

-Motor to APB, OP, FPL, FPB, FDS, palmaris longus, FDP 1 & 2, lumbricals 1 & 2 Sensory to palmar surface of thumb, index and middle fingers Best exam findings o If motor - decreased muscle strength (MMT) and possible positive MSTT o If sensory - diminished sensation in distribution, positive ULTT for median n. • Anterior interosseous nerve branch o Entrapped at the elbow by pronator teres and MOTOR only o Innervates: FPL, FDP, PQo Unable to do pinch grip test

What are the treatment interventions for displaced and non-displaced *olecranon fractures*?

-if displaced, requires surgical repair. -if non-displaced, requires casting and time to heal.

How would strength of the elbow change if a rupture biceps tendon weren't fixed?

-supination overall strength would decrease 50%. -elbow flexion strength would decrease 30%.

What are the major ligaments of the elbow?

1. *the ulnar collateral ligaments*. -the anterior, posterior, and transverse ligaments. 2. *the lateral collateral ligaments*. -the radial collateral ligament, and annular ligament.

5 Components of lateral epicondylitis treatment.

1. RICE. 2. NSAIDs. 3. Brace/splint. 4. stretching and strengthening therapy. 5. corticosteroid injection (severe cases).

Biceps tendonitis/tendinosis

1. Yergasen special test at the elbow - The patient should be seated or standing, with the humerus in neutral position and the elbow in 90 degrees of flexion. The patient is asked to externally rotate and supinate their arm against the manual resistance of the therapist 2. Biceps tendinitis or subluxation of the biceps tendon can normally be addressed by palpating the long head of the biceps tendon in the bicipital groove.

What are treatments of olecranon bursitis?

1. aspirate bursa, if infected. -aspirate=to draw out by suction. 2. antibiotics. 3. change in activity. 4. NSAIDs. 5. corticosteroid medication.

What are 3 Characteristics of *supracondylar fractures*?

1. common in children, but rare in adults. 2. caused by FOOSH. 3. distal bone fragment is most commonly displaced anteriorly. 1. a tear or entrapment of the *brachial artery*. 2. palsy of the *anterior interosseous nerve*. -palsy=paralysis with involuntary movement. 3. *ulnar nerve* damage during surgical repair.

4 Characteristics of lateral epicondylitis.

1. gradual onset. 2. pain over lateral elbow. 3. decreased grip strength. 4. pain with forced extension and supination.

List 3 inflammatory conditions of the elbow.

1. lateral epicondylitis. 2. medial epicondylitis. 3. olecranon bursitis.

What are the 3 major nerves around the elbow?

1. radial nerve. 2. ulnar nerve. 3. median nerve.

What are 3 causes of olecranon bursitis? Which one is most common?

1. repetitive motion injury. 2. prolonged compression -most common. 3. trauma. causes stiffness of joint

Radial nerve entrapment/Radial tunnel syndrome

Can be following trauma such as a fracture to the radial head Deep branch is motor only - EPL, EPB, APL; commonly entrapped at supinator muscle belly Superficial branch is sensory to the dorsal aspect of the hand; common entrapment at ECRB Best exam findings o If motor - decreased muscle strength (MMT)/positive MSTT for supination, decreased MLT and + P4T of supinator o If sensory - diminished sensation in distribution, positive ULTT (shldr, abd, pron, wrist flex, ulnar dev,) for radial n., MSTT/MMT reproduces symptoms, MLT - parasthesia with lengthening, + P4T at ECRB

Ulnar nerve entrapment (cubital tunnel syndrome)

Can be the result of a fracture, dislocation or subluxation at elbow Motor to hypothenar muscles and small, deep muscles in hand (Interossei), adductor policis Sensory to the ulnar side of the hand, pinky and ulnar half of ring finger Best exam findings o If motor - decreased muscle strength (MMT) and possible positive MSTT o If sensory - diminished sensation in distribution, positive ULTT (shld dep, 10 abd, elbow flex ,sup, ER, wrist ext, ulnar dev) ulnar n.

Hypomobility due to prolonged immobilization

Following surgery, injury/fracture Best exam findings o Decreased A/PROM with capsule tightness end-feels o Decreased accessory mobility

Myositis Ossificans

Heterotopic bone formation between muscle fibers that results from trauma/bleeding in area; commonly seen in brachialis muscle with supracondylar fractures, posterior dislocations of elbow, and aggressive stretching of elbow flexors Best exam findings o P4C - increased warmth over muscleo Decreased A/PROM - going further into range is painfulo Normal accessory PROM - the muscle is limiting, not the capsule o MSTT/MMT - resistance causes increased paino Positive P4T over muscle, may feel a mass • NO stretching, massage or possibly use US with caution, use pulsed settings

Elbow anatomy

It consists of two separate articulations: -Trochlear notch of the ulna and the trochlea of the humerus -Head of the radius and the capitulum of the humerus The radial collateral ligament is found on the lateral side of the joint, extending from the lateral epicondyle, and blending with the annular ligament of the radius (a ligament from the proximal radioulnar joint). The ulnar collateral ligament originates from the medial epicondyle, and attaches to the coronoid process and olecranon of the ulna.

Elbow Fat Pad Sign;

Normally, you can't see the posterior fat pad, and just a little of the anterior. If you see them sticking out in the breeze like a sail, it means there is fluid in the joint.

What is a *gunstock deformity*?

a cubitus varus caused by poor repair of an elbow injury. -the elbow joint is angled laterally rather than medially (proximal radius and ulna are pointed laterally). not a serious problem

What is nursemaid's elbow?

a dislocation of the elbow caused by pulling on an extended, pronated arm, which causes the radial head to sublux. -torn annular ligament involved. -reduction and casting.

What is the "mobile wad of 3"?

a group of muscles: -ECRB, ECRL, and brachioradialis.

What percentage of elbow dislocations are posterolateral?

about 90%!

anterior interosseous nerve (AIN)

branch of median nerve

What is the best prevention for UCL injury?

careful strength and conditioning, *with sufficient rest* between games. If torn = Tommy John surgery a tendon graft from palmaris longus, if a person has it.

What most commonly causes an *olecranon fracture*?

direct trauma to the elbow. 1. intense pain over elbow. 2. swelling. 3. inability to extend the forearm/elbow.

In what position is the elbow immobilized after a biceps tendon repair?

in a position of pronation with flexion, to unload the tendon after repair.

Radial head fractures?

not much said other than they are almost always accompanied with other elbow fractures, like an ulna fracture.

What is the highest predictor UCL injury in pitchers?

number of pitches thrown in a single season. -also, not getting enough rest.

Posterior interosseous nerve (PIN)

superficial and deep extensors supinator arcade of froce weakness in wrist and digital extensors, pain may be present, no sensory deficit MMT Wrist Extension for testing

What is most frequently the intervention for a biceps tendon rupture?

surgical repair with immobilization.

What is a divergent elbow dislocation? What major ligament is torn in the process?

the elbow is pushed straight down, and ulna and radius are separated away from the midline of the humerus. Ow... -annular ligament gets torn, which allows ulna and radius to separate from each other.

How many types/directions of dislocation are there in the elbow?

there are five. -anterior, posterior, lateral, medial, and divergent.

What is most commonly the cause of ulnar collateral ligament tears?

these are typically throwing injuries; common in pitchers.

What is the function of the annular ligament, and where does it attach?

this ligament attaches around the head radial head, and attaches it to the ulna. -allows supination/pronation.

Medial epicondylitis

~ Golfer's elbow ~ a chronic over use of elbow flexion/extension that causes inflammation over the medial epicondyle; much less common than lateral epicondylitis; signs, symptoms, and treatment are similar to lateral epicondylitis. -involves FCR and pronator teres.

What is Lateral Epicondylitis?

~ Tennis elbow ~ a chronic overuse of forearm rotation with wrist extension that causes inflammation over the lateral epicondyle; ~ commonly in men 30-50 years of age. ~ mainly involves the tendon of the Extensor Carpi Radialis Brevis (ECRB), but also the "mobile wad of 3."

What is a *Volkmann's contracture*, and what causes it?

~ a contracture in wrist flexion with finger extension as a result of delayed or inadequate repair of a brachial artery, ~ May result from a compartment syndrome of the anterior forearm.

Where do the majority of triceps tendons rupture? (proximal or distal)

~ almost always tear distally. ~ may be partial or complete.

Biceps tendon rupture

~ more commonly a distal rupture. ~ more commonly in men, & the dominant arm. ~ pain in *antecubital fossa* ~ decreased strength during supination.