Normal ROM for elbow

 0-150*

Muscles contributing to function are:

Two types of joints of elbow

3 Main bones of elbow

What are the Three synovial articulations & one joint capsule of elbow


 

A synovial joint, also known as a

 diarthrosis

Reason why arm is deviated radially when extended

 The axis of rotation is NOT a straight line between the 2 condyles of the distal humerus,
there is a 30 degree angle to the humeral shaft

• In elbow, Triceps attaches to

  olecranon tip

In elbow, what is the coronoid fossa and coronoid process

What bone is responsible for elbow stability


 

Where in the elbow does brachialis attaches

 coronoid, anteroir


The Superior Radio-Ulnar Joint is composed of the:

Interaction of the bones allows for a small amount of rotation. Functional example:

 eating--taking your hand to your mouth you will go from pronation to supination.

THE CARRYING ANGLE

 Clinical Gem: The carrying angle permits the arm to be swung without contacting the
hips. The carrying angle influences how objects are held by individuals – people with a
more extreme carrying angle may be more likely to pronate the forearm when holding
objects in the hand to keep the elbow closer to the body.

"Gunstock deformity"

 If the elbow carrying angle is decreased so that the arm points toward the body. Opposite
is called excessive carrying angle
 Because the carrying angle varies from person to person, it is important to compare one
elbow with the other when evaluating a problem with the carrying angle.
Distal humerus anatomy


 

LATERAL ELBOW


MEDIAL ELBOW Dynamic stability of the joint is accomplished through the ulnar
collateral ligament (UCL), also called the medial collateral ligament


Anterior Elbow, name the parts:


 

insertion site of biceps tendon

 Radial tuerosity

• Radial head articular portion articulates with

 

Brachialis: Nerve Supply, Origin, Insertion, and ranking in strength




 *stronger flexor of elbow joint because it is closes TO THE JOINT AXIS AND ONLY
STRETCH OVER ONE JOINT. Considered the “workhorse “ and is active during all
flexion
 70-80% OF PEOPLE, THE MUSCLE HAVE DOUBLE INNERVATION WITH THE
RADIAL NERVE
BICEPS: Nerve Supply, Origin of Long head, Origin of short head, Insertion,
Decreased/Increase activity with this position


 

BRACHIORADIALIS: Nerve Supply, Origin, Insertion, Action, Most active in this

position
 

TRICEPS: Nerve supply, Origin, Insertion, Action, Most active in this position


 Chief extensor of forearm

 Summary
ANCONEOUS: Nerve innervation, insertion, origin, action


 

This muscle is considered a dynamic stabilizer of the elbow with varus instability

 Anconeus


PRONATOR TERES: Nerve Innervation, Origin, Insertion, Action, Vascular supply

 Median Nerve (C6, C7, C8, T1)


 

FLEXOR CARPI RADIALIS: Vascular Supply, Origin, Insertion, Action

 

Normal AROM of elbow vs Morrey's ROM: Elbow flexion, extension, pronation,

supination
  “Please note lacking 30 degrees of extension does not apply to the professional thrower.
For throwers, 30º of extension is not functional.”

In Valgus instability, this bundle of ligament is compromised

How to execute valgus instability stress test

 

VALGUS ELBOW INSTABILITY: Cause, At risk, Symptoms

 

Grades of MCL tears

With grade III tear of MCL ligament, these two are recommended

 Grade III: surgical repair (Tommy John), brace wear

  GEM: Tommy John was a Los Angeles Dodger pitcher who underwent the first UCL
surgical repair

VARUS INSTABILITY: Ligaments affected

 Lateral Collateral Ligament Complex (LUCL). 4 ligaments

 

Lateral Ulnar Collateral Ligament is most often injured and this injury is called
  Posterolateralrotary instability of the elbow

What are the attachments of each of the following ligaments:


 

 Lateral elbow has 4 ligaments; however, often they are indistinguishable and can be
better described as the Lateral Collateral Ligament Complex.

Clinical Gem: A Simple elbow dislocation involving this specific ligament of the LCL is
worse than any type of MCL ligament injury. In a complex fracture dislocation, soft tissue
injury is less severe.

 1. RCL = Radial collateral ligament: Lateral epicondyle to annular ligament

Common cause of Varus


 

Classifications of LCL (Lateral Collateral Ligament) Tear; And PRECAUTIONS AND

AVOIDANCE


 

4. AL = Annular ligament: The annular ligament is a strong band of fibrous tissue that
encircles the head of the radius and supports it in the radial notch of the ulna. Where does
it attach?

 Posterior to the anterior margins of radial notch on the ulna, holds radial head against
radial notch

Nursemaid’s elbow or pulled elbow: Description, Symptoms, Imaging results, Treatment,

Avoidance
  Injury is most often to children and is called Nursemaid’s elbow or pulled elbow.

Terrible Triad Injuries at the Elbow: Cause, symptoms, Imaging, and Treatment



Elbow Dislocations: It stretches and pulls these tissues; sometimes over stretching,
sometimes tearing/_______them. Elbow joint is very stable and requires a significant force
to dislocate- most common mechanism is fall onto outstretched arm
  avulsing

Elbow Dislocations: Causes and symptoms

Elbow Dislocations: Describe classifications

Elbow Dislocations: Morrey’s classification: Morrey further describes by joint damage.

Posterior Elbow Dislocation: Treatment........ Surgery if acute dislocation is greater than

50º. Surgery if dislocation is associated with unstable fracture about the joint. If motion
does not steadily improve @ ______ consider ____ _____ ______ or a patient adjusted
progressive static orthosis.
  4-6 wks, dynamic elbow orthosis

Posterior Elbow Dislocation: Avoidance

Posterior Elbow Dislocation, Consider the following protocol:

 

Posterior Elbow Dislocation: ______ stress should be avoided during rehabilitation as it

can lead to instability or repeated dislocation.

 Valgus

Elbow Fractures: Elbow fractures can occur in one or more bones. Some can be plated,
allowing for early ROM protocols. Clinical gem: The radial head does not respond well to
______ fixation.

 plate

Distal Humerus: of all elbow ?/3 fxs; distal humerus fractures are most common in 12 – 19
year old males and women over 80 years old.

 1/3

Elbow Fractures: Causes, symptoms, and imaging

 

These nerves and artery should be evaluated post elbow fracture

 brachial artery and median, ulnar, and radial nerves

Elbow Fx: Intra vs Extraarticular

Elbow Fractures: Classification

 

Elbow Fractures: AO is one of the most common classification systems


 

Elbow Fractures: Difference between Type A, Type B, and Type C


 

Elbow Fractures: Treatment Type B or C

Elbow Fractures:

 Clinical gem: Dr. Andrews says, “Medial epicondylar _________ in throwers need
careful consideration for ORIF with screw if displaced – followed by early ROM in 5-7
days."
 Clinical gem: Most fractures will heal with some degree of ______ angulation but elbow
function is acceptable and will have good ROM for the non-athlete.
 Clinical gem: Early mobilization with gentle ROM will reduce risk of ___.
 avulsions , varus , HO
SUPRACONDYLAR FRACTURE


Medial epicondyle fracture: Describe and AKA

 Often referred to as Little League Elbow, it occurs when traction is applied to the
apophysitis of the medial epicondyle in 11- 13 year old throwers.

Medial epicondyle fracture: Cause, Symptoms Classification, Avoidance

 Avoidance: Medial stress

Medial epicondyle fracture: Test for Assessment (2)

Medial epicondyle fracture: Complications (3)

 

Capitellum/trochlea fracture


Capitellum/trochlea fracture.....Treatment: If there is any displacement =


 

Classifications of Elbow Fractures: Distal Humerus

 

Elbow Fracture Complications

Elbow Fracture: This nerve is involved in neuropathy

  Ulnar

If this occurs post elbow fracture, surgical excision and contracture release if needed.

 HO

Olecranon Fracture : Cause and Symptoms

Olecranon process fx: If a high energy injury, may also _______ have head _______
_______ or dislocation.

 radial, elbow joint

Olecranon Fx Treatment: Most are _______ and will need _______ and _______ nerve
transposition.
  displaced ORIF ulnar

Olecranon Fx: Non DIsplaced, -----> Consider: cast or custom orthosis at __ degrees for
______ weeks, then follow A/AAROM protocol.

 90 , 1-2 weeks

Olecranon Fx Complications: Stiffness, post-traumatic arthrosis, non-union, malunion

Coronoid Fracture : Cause and symptoms


Coronoid Fracture : Classifications

Coronoid Fracture: Orthosis Positioning ; Describe progressive extension

Coronoid Fracture: Avoid this position to prevent varus stress

The most common fracture in the adult elbow.

  Radial Head Fracture

In elbow, this is a secondary stabilizer to valgus stress

 radial head

Radial Head Fracture: o Morrey, et al have shown that selective radial head resection does
not influence the valgus instability as long as the ____ ligament is intact.

 UCL

Radial Head Fracture: Cause and Symptoms

Classification of Radial Head Fractures:


 

Radial Head Fracture: SURGERY: Radial head resection

 

Radial Head Fracture: Therapy post radial head resection


 

Valgus vs Varus Stress

 

Classification of Radial Head Fracture


SURGERY: Radial head resection

• Complications of excision:

Galeazzi Fracture


 

Monteggia’s Fracture/Hume Fracture


 

Essex-Lopresti injury:


SURGERY: Radial head resection

Galeazzi Fracture


 

Essex-Lopresti injury:

Essex-Lopresti injury: CAUSE

Essex-Lopresti injury: SYMPTOMS

Essex-Lopresti injury, TREATMENT

 

Lateral Epicondyle Tendinopathies aka

 Often called tendonitis, but this term implies an inflammatory process and histological
studies confirm it probably is not inflammatory but chronic in nature. You may hear the
term tendonosis, which suggests a degenerative, rather than inflammatory, condition.
 Sometimes called tennis elbow,but seen more often in non-athletes. Can arise from single
event such as direct trauma or by repetitive activity.

Called this angio-fibroblastic hyperplasia.

  Lateral Epicondyle Tendinopathies : It is characterized by vascular hyperplasia,
disorganized collagen, and fibroblasts.

Lateral Epicondyle Tendinopathies : AVOID

 Avoidance Lifting, gripping

Lateral Epicondyle Tendinopathies : SYMPTOMS

 Lateral elbow and forearm pain during gripping, lifting, grasping, hitting or a motion
such as hitting a backhand in tennis.
Lateral Epicondyle Tendinopathies : 3 SOURCES OF PAIN

Lateral Epicondyle Tendinopathies : Defect may be measured by ...


Lateral Epicondyle Tendinopathies : TREATMENT

Lateral Epicondyle Tendinopathies : TEST

Medial Epicondyle Tendinopathies aka

 Also known as Golfers elbow
 Note: Less common than lateral epicondyle tendinopathies.
Medial Epicondyle Tendinopathies: Cause

 Repetitive overuse, micro tearing

Medial Epicondyle Tendinopathies: SYMPTOMS


Medial Epicondyle Tendinopathies: Classification: Classification is determined by what
tendon/s is/are involved.

Medial Epicondyle Tendinopathies: IMAGING

 Imaging: Ultrasound to visualize tear, X ray or MRI to rule out other pathology.
Medial Epicondyle Tendinopathies: TREATMENT AND AVOIDANCE

Provocative Tests for Lateral Epicondylitis:


 

Provocative Tests for Lateral Epicondylitis: Resisted Middle Finger Extension Test
Technique


 

Distal Tricep Tendinopathies: CAUSE AND SYMPTOMS

 Cause: quick elbow extension with force

 Symptoms: pain with active or resistive elbow extension
 Imaging: ultrasound, MRI

Distal Biceps Rupture:

 

Distal Biceps Rupture: CAUSE, COMPLICATIONS, SYMPTOMS

Distal Biceps Rupture: CLASSIFICATION


Distal Biceps Rupture: TREATMENT


Distal triceps ruptures : CAUSE

 Cause: Direct trauma -- fall on outstretched hand causing forced contraction of triceps.
Predisposition: endocrine disease, chronic renal failure, anabolic steroid use.

Distal triceps ruptures : SYMPTOMS

 Symptoms: Swelling, ecchymosis, tender to palpation, pain with resisted elbow

extension. Test: triceps strength with elbow fully flexed.

Distal triceps ruptures : TREATMENT

 

Distal triceps ruptures : AVOIDANCE

Nerve Injuries Associated with Elbow Pathology: 4 NERVES

Anatomy of the Cubital Tunnel

 

STRUCTURES OF POSTERIOR ELBOW

Structures of cubital tunnel

 

Symptoms of cubital tunnel syndrome

Test for ulnar nerve

• Wartenberg's sign

 Wartenberg's sign is a neurological sign consisting of involuntary abduction of the fifth

(little) finger, caused by unopposed action of the extensor digiti minimi

• Elbow flexion test

 

 The examiner examines the patient during the three-minute hold. He may apply pressure
gently to increase flexion of the elbow.

Frontment's Sign

 Deep palmar nerves. Froment's sign is a special test of the wrist. It tests for palsy of the
ulnar nerve, specifically, the action of adductor pollicis.
 

For unlar nerve, what to do if patient presents early with mild sensory and no motor
changes, and no impinging pathology is noted

 Non-Operative Treatment trial conservative treatment

The cubital tunnel is at its narrowest in --------- which contributes to nerve compression.

 flexion

Cubital tunnel , Surgical Treatment: There are several surgical options for cubital tunnel
syndrome. However, there is no conclusive agreement about which operative procedure is
indicated for select cases and that is why there are 6-7 different treatment options.
 

Fracture Fixation Most physicians, at the time of fracture fixation, will perform a
neurolysis of the ulnar nerve and transpose it anterior to the axis of rotation. This is called
anterior transposition. The goal is to....

 ... place the nerve in a nice “bed or home” so it is not compressed, stretched, or irritated.
Nerves are like “live wires” and are temperamental to their environment.

Cubital Tunnel Post-Op: The various treatment options and protocols are too lengthy and
numerous to specifically address every one. However, postoperative rehabilitation is
divided into three stages, and time frames are based on procedure.

• Elbow Injury: When reading about elbow trauma and fractures, the primary nerve
injured is the _______ nerve due to its proximity and pathway through the osseous
structures of the medial aspect of the elbow.

 ulnar

Elbow Injury: • Injury to the radial nerve occurs with shaft ________ fractures, with
approximately __% resulting with the complication of radial nerve palsy.

 humeral ,20%

Elbow Injury: Injury to these nerves in relationship to trauma/fracture of the elbow must
be minimal due to lack of information available in the text books. All nerves are subject to
compression and predictable compression neuropathies.

 Median and Musculocutaneous Nerves

 

• A bursa

 is a flattened pouch of the synovial membrane that is situated between two tissue layers
to reduce friction by creating a discontinuity between those tissues.

The bursa allow two structures to ______ over each other smoothly.

 glide
The most common sites of bursitis are beneath the _________ at the shoulder, at the
greater trochanter of the hip, at the patella in the knee, and over the _________ at the
elbow (although it can occur at any bursa).

 Beneath the acromion , Over the olecranon at the elbow

Elbow Bursitis, Symptoms

 Pain and pressure with A/PROM which compress the bursa, typically with elbow flexion.
 Swollen and tender to palpation and if large enough a “goose egg” type of appearance on
the back of the elbow over the olecranon.

Elbow Bursitis, Evaluation

 Resisted testing: Typically negative, but pain with a strong contraction can be
experienced in the acute phase.

Elbow Bursitis,Causes

 • Infection • Rarely from acute trauma (irritation)

Elbow Bursitis, Treatment: Note: treatment of any form of bursitis depends on whether or
not ______ is involved.

 infection

Elbow Bursitis, Treatment:

Differential Diagnosis of Elbow Pain According to Symptom Locations: Anterior

 

Differential Diagnosis of Elbow Pain According to Symptom Locations: Medial

Differential Diagnosis of Elbow Pain According to Symptom Locations: Posteromedial

Differential Diagnosis of Elbow Pain According to Symptom Locations: Posterior

Differential Diagnosis of Elbow Pain According to Symptom Locations: Lateral

Carrying Angle : Degrees in Men vs Women

 

Flexor Contracture Management: There is ________ “true way” to manage a contracture

complication. Dynamic orthotics approach is _________. Drop out casting has been shown
to be __________.

 There is not one specific “true way” to manage a contracture complication. Chapter
authors' personal preference is static-progressive orthotics.
 Dynamic orthotics approach is generally less effective.
 Drop out casting has been shown to be effective; however, supporting literature is not
published.

Flexor Contracture Management: Heat and stretch technique

Flexor Contracture Management: Flexion DEFICITS

 Cuff and collar approach sling/device (shown below) has yielded good results.

Elbow capsulotomy: Indications

 

Elbow capsulotomy, Rehabilitation following surgery : Provide therapy within ___ hours
post-op. Remove bulky dressing and reapply a light compression to allow __________

Elbow capsulotomy, Rehabilitation following surgery : • Patient must begin AROM

___________

Elbow capsulotomy, Rehabilitation following surgery : CPM

Elbow capsulotomy, Rehabilitation following surgery : Pain management following surgery

 

Elbow capsulotomy, (elbow capsulotomy/capsulectomy for limited flexion)

 3 to 5 days post-op

Elbow capsulotomy, (elbow extension contracture)

 10 to 14 days post-op

Elbow capsulotomy, (extension contraction)

 6 weeks post-op
 

• Valgus stress test:

Milking Maneuver


Moving Stress Test

Lateral Epicondylopathy: Chair lift test

• Medial Epicondylopathy:
 

• Valgus Extension Overload test:


 

• Thinkers' Sign: for medial epicondylopathy

Patient Rated Tests:

MRI Application for Elbow

Clinical Note: Elbows: It has been the author’s experience that elbows respond best to
_______motion. Forced motion often will result in pain, greater stiffness and difficulty
gaining motion.

 Clinical Note: Elbows: It has been the author’s experience that elbows respond best to
gentle motion. Forced motion often will result in pain, greater stiffness and difficulty
gaining motion.
Clinical Note: It is always helpful to obtain a _________ report if possible or to discuss with
the surgeon how the repair was performed, the quality of the repair and soft tissue and the
anticipated ROM.

 Clinical Note: It is always helpful to obtain a surgical report if possible or to discuss with
the surgeon how the repair was performed, the quality of the repair and soft tissue and the
anticipated ROM.

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