1
Q
Carrying angle
A
- frontal plane
- affected by a person’s height, gender, and age
- avg for females: 13-16*
- avg for males: 11-14*
2
Q
Medial epicondyle
A
- more prominent than lateral
- point of attachment for common flexor tendon, pronator teres, and ulnar collateral ligament
3
Q
Lateral epicondyle
A
-attachment for supinator, radial collateral ligament, and extensor muscles
4
Q
Joint mechanics during elbow flexion
A
- ulna locks into coronoid fossa of distal humerus
- radial head articulates with capitellum - restrained by radial fossa on anterolateral side of humerus
5
Q
Capitellum and trochlea placement
A
Capitellum=lateral
Trochlea = medial
6
Q
Radius
A
- concave
- annula ligament surrounds radial head and attaches to radial notch of ulna
- 2408 of radial head’s margin articulates with ulna
7
Q
Ulna
A
- primary source of bony stabilization at elbow
- trochlear notch articulates with trochlea of humerus
8
Q
Oblique cord
A
- inserts into the radial tuberosity
- thickening of fascia of supinator and assists with limiting supination
9
Q
Humeroulnar articulation
A
- medial side
- medial lip of trochlea and trochlear notch of ulna
- olecrenon is posterior articulation
- contributes to flexion and extension
10
Q
Humeroradial articulation
A
- lateral aspect
- concave radial head, capitellum of humerus, prominent tubercle/groove on lateral lip of trochlea of humerus capitellum
- contributes to all planes of otion
- resists valgus stress
- radial head is essential to elbow stability in the absence of collateral ligament integrity or distal radioulnar stability
11
Q
Proximal radioulnar articulation
A
- radial head, annular ligament ring, radial fossa of ulna
- optimal motion is 70* pronation and 80* supination
- interosseous membrane - essential for distribution of loads and communication between the PRUJ to the distal radioulnar joint
- peak strain on interosseous membrane is during neutral forearm rotation
12
Q
Distal radioulnar articulation
A
- compound joint with PRUJ
- distal end of ulna, radius, joint capsule, triangular fibrocartilage complex (TFCC)
- pivot and glide allows for 70* pronation, 80* supination
13
Q
Full pronation ariticulation
A
-volar/anterior ligament of TFCC is taut
14
Q
Full supination articulation
A
-dorsal/posterior ligament of TFCC is taut
15
Q
Elbow capsule
A
- surrounds all 3 articulations (humeroulnar, humeroradial, PRUJ)
- anterior capsule taught in full extension
- posterior capsule taut in full flexion
- capsule demonstrates greatest extensibility bw 70-90* flexion
- blends with annular ligament and thickens on medial and lateral sides to form collateral ligaments
16
Q
Ulnar (medial) collateral ligament complex
A
3 parts - anterior, posterior, transverse
- origin is posterior to elbow joint
- becomes taut with flexion
- anterior: strongest of the 3. Attaches from anterior medial epicondyle to medial coronoid process
- anterior band: taught from extension to 60* flexion
- posterior band: taut from 60-120* flexion
- anterior part is greatest restraint to valgus stress
- Posterior: fan like thickening. Most taut at 90* flexion. restrains maximal gapping during pronation
- Transverse (oblique): less impactful on elbow stability.
17
Q
Radial (lateral) collateral ligament
A
- 4 parts: AL, radial portion, ulnar portion, variably present accessory portion
- primary role in elbow stabilization
- taut through flexion and extension
- tension increased during supination
- radial portion: taut throughout flexion and extension
- ulnar portion: most well known for posterolateral rotatory instability - taut in flexion and ext and provides stability to humeroulnar joint
- accessory portion - assists in stabilizing AL against varus stress
18
Q
Biceps brachii
A
- long and short head
- innervated by musculocutaneous
- distal attachment a common biceps tendon at radial tuberosity
- elbow flexion and supination
19
Q
Brachialis
A
- beneath biceps
- proximal attachment from anterior humerus and distal attachment on ulna tuberosity and coronoid process
- mechanical disadvantage for great force in flexion
20
Q
Brachioradialis
A
- greatest mechanical advantage for elbow flexion
- proximal attachment at lateral supracondylar ridge
- distal attachment at styloid process of the radius
21
Q
Triceps brachii
A
- 3 heads: long, lateral, medial
- extension of the elbow
- long head attaches at infraglenoid tubercle on scapula
- lateral attaches from proximal posterior humerus
- medial attaches at posteromedial humerus
- common distal attachment at olecrenon
22
Q
Anconeus
A
- from lateral epicondyle to posterolateral olecrenon
- joint stabilizer
23
Q
Common extensor tendon
A
-extensor carpi radialis brevis
-extensor digitorum
-extensor digiti minimi
-extensor carpi ulnarus
(lateral to medial order)
-radial nerve innervation
24
Q
Supinator
A
- -beneath extensor muscle group
- 4 proximal attachments: lateral epicondyle, RCL, AL, crista supinatoris o fulna on olecrenon
- supination is primarily accomplished by biceps and less by supinator
25
Pronator teres
- strong pronator of forearm, but weak elbow flexor
- 2 proximal attachments; medial epicondyle and coronoid process
- resist valgus stress
26
flexor carpi radialis
- medial to pronator
- attachment with common flexor tendon
- flexion and radial deviation
27
Flexor carpi ulnaris
- common flexor tendon
| - 2 heads that are split by the ulnar nerve
28
Radial nerve
C5-8
29
Ulnar nerve
C8-T1
30
Median Nerve
C5-6, C8-T1
31
Musculocutaneous
C5-7
32
Elbow axes of motion
2: flexion (150*)/extension (0*) and uniaxial rotation (pronation - 80*, supination - 90*)
33
Elbow tendinopathy
- common concern with epicondylar inury
| - 50% of athletes participating in over head sports
34
Lateral tendinopathy
- lesion at common extensor origin of lateral epicondyle
| - higher ratio of incident in general population and at risk professions
35
Lateral tendinopathy presentation
- point tenderness at distal lateral humerus one cm distal to epicondyle
- concerns of gripping, pain upon passive stretching into wrist flexion, painful contraction of wrist and finger extensors
36
Lateral tendinopathy demographics
- age 35-50
- gender (female)
- high levels of physical work
- low social support at work
- workers belonging to a profession classified as "strenuous"
37
Provocative tests
-lack diagnostic accuracy
38
DD for lateral tendinopathy
- cervical nerve root compression (c6-c7)
- radial tunnel syndrome
- posterolateral rotatory instability
- compression of the PIN
- intraarticular disease
- injury to lateral antebrachial nerve
39
Medial tendinopathy
-incidence is less than that of lateral involvement
40
Medial tendinopathy patient presentation
- equal distrubtion of males and females
- 75% report symptoms on dominant elbow
- associated with forceful work and overuse
41
3 common reasons for medial tendinopathy
1) flexor-pronator tissue fatigue in response to repeated stress
2) suddent change in level of stress that predisposes the elbow to ligamentous injury
3) failure of UCL to consistently and sufficiently stabilize valgus forces
42
Medial tendionpathy DD
- cervical spine nerve root compression (C7, C8, T1)
- thoracic outlet syndrome
- msk conditions of shoulder region
- ulnar nerve injury
- medial elbow ligamentous instability
43
non operative treatment for medial and lateral tendinopathy
-more research necessary to develop strong base of evidence
-if acute, patients see immediate improvement with intervention to surrounding soft tissue (rest, avoiding aggravating activities, splinting)
-
44
Operative management for tendinopathy
-patients whose symptoms and functional limitations do not resolve with an intervention of multiple cortisone injections; failure of rehab with symptoms greater than 1 yr; constant pain; intraarticular pathology = greatest success with surgical intervention
45
Distal biceps tendon rupture
- less common
- greatest in males in 4th-6th decade of life
- MOI: rapid eccentric contraction of biceps in response to load into extension and supination and flexion
- partial ruptures are rare
- use of anabolic steroids and smoking = risk factors
46
Patient presentation for distal biceps rupture
- "pop" at time of injury
- acute onset of weakness
- rare to have preceeding symptoms
- tenderness over biceps tendon
- echymosis
- deformity
47
Operative management of distal biceps rupture
- surgical delay of less than 10 days
| - satisfaction is high
48
RCL ligament insufficiency: 3 scenarios
1) simple or complex elbow dislocation
2) varus elbow stress
3) iatrogenic causes
49
Varus posteromedial rotatory instability
- result of elbow subluxation that avulses part of RCL or RCL entirely
- may be misinterpreted due to subtlety of coronoid fracture
50
Posterolateral rotatory instability
-MOI: combination of axial compression, valgus stress, supination forces that produce rotation at humeroulnar joint
51
Posterolateral rotatory instability patient presentation
- vague elbow discomfort
- lateral elbow pain
- clicking, snapping, clunking that is worse with supination
- "something not right"
- DD should include PlRI vs. RCL insufficiency, lateral epincondylaglia, radial tunnel syndrome, cervical spine refferal
52
Posterolateral rotatory instability non-op management
- little literature to support strength training
| - avoidance of shoulder abduction and IR when performing flexion and extension elbow exercises
53
Valgus instability (ulnar collateral ligament insufficiency)
- response to excess valgus force
- may occur acutely or insidiously
- acute disruption of UCL = FOOSH
- insidious onset is typically overuse or chronic attenuation (throwing athlete)
54
Gravity assisted varus stress test
- seated or standing w/ shoulder abducted to 90* - ask patient to flex/extend elbow
- (+) - reproduction of symptoms
- tests for varus posteromedial rotatory instability
55
posterolateral rotatory instability test of elbow (lateral pivot shift of elbow)
- supine - shoulder passively flexed past 90*
- elbow begins in extension, the examiner applies axial compression through the ulna and radius towards the humerus with a supination and valgus force causing elbow to sublux at -40-70* of elbow flexion
- (+) - reproduction of pain or observable clunk
56
Push up sign
- posterolateral rotatory instability
- active apprehension sign: patient completes active floor push up
- test is positive if apprehension occured as affected elbow was extended from flexed position
57
Chair Sign
-posterolateral rotatory instability
-patient seated with elbow flexed to 90*, supinated, arms abducted greater than shoulder width
(+)=reluctance to extend elbow fully as patient raised body up from chair
58
Patient presentation for valgus instability
- medial elbow pain
- question level of participation, # of pitches, biomechanics of thrower, phase in which pain occurs
- patient may report pop on day of inury
59
Imaging for valgus instsability
- will shoe gapping at medial joint line
- AP angle - full shoulder ER and forearm pronation
- radiographs traditionally used
60
Valgus extension overload syndrome
- compression of olecrenon of ulna against humerus with a valgus stress generating a postermedial impingement
- found in people who experience tremendous forces acting at the elbow - especially into hyperextension
61
Radio-capitellar overload syndrome (lateral compression injury)
- incompetence of UCL leads to decreased stability of elbows
- radial head at risk for chronic abutment against capitellum
- s/s include palpation sensitivity at radial head, tip of lateral distal humerus, thickening in the area, aggrevation of symptoms during tasks in teh valgus direction
62
little leaguer's elbow
- medial elbow
| - apophysitis an dfragmentation due to insufficient stability of ossification centers
63
Moving valgus stress test
-UCL ligament sufficiency
-patient upright and shoulder ABD to 90*
-elbow maximally flexed, apply valgus torque until shoulder reaches max ER
-elbow is quickly extended to 10* of flexion
(+) = medial elbow pain. Sn 1.0 Sp. 0.75
64
Milking test
-UCL ligament sufficiency
-patient seated, clinician stabilizes involved extremity into shoulder ER and humeral adduction
-elbow flexion of 70* and then imposes valgus force
(+)=reproduction of medial elbow pain
65
UCL ligament operative management
- chronic instability
- failure of non-op rehab
- continued pain
- sense of movement in elbow with valgus loads
- inability to return to PLOF
- reconsstruction of UCL = higher rate of success for return to sport
66
Elbow sublux/dislocation
- second most commonly dislocated joint in adults
- 5 considerations:
1) timing
2) articulations involved
3) direction of displacement
4) degree of displacement
5) presence or absence of fractures
-posterior lateral or posterior are most common
67
Olecrenon fractures
- most common in elderly
| - excision of bony fragments, screw fixation, tension band wiring, plate fixation, bone grafting
68
Radial head fractures
-1/3 of all elbow fractures
-females age 20-60
-axial load to pronated forearm, direct blow to elbow, hyperflexion injury
-
69
Cubital tunnel syndrome
- ulnar nerve
- DD = cervical radic and TOS
- symptoms may be prominent when awoken from sleep
70
Pronator syndrome
- high median nerve compression of insidious onset
- associated with reptitive pronation and supination
- vague hx of symptoms with weakness of thumb, index, middle fingers
71
Anterior interosseous nerve syndrome
-entrapment by a fibrous band
-initial onset = deep forearm pain taht resolves
-s/s occur intermitttently
-
72
Lateral epicondylalgia - why cahnge from itis to algia?
o itis implies inflammation
o theory was chronic inflammation, but histopatholgoical cases as early as the 1970's have shown absence of inflammation
o tendon shows a degenerative process in reality
o "algia" = pain
73
Generally accepted lateral epicondylalgia criteria
1) pain over lateral epicondyle
2) TTP of extensor tendon mass
3) pain with gripping, resisted wrist extension, or extension of 2nd or 3rd finger
74
Lateral epicondylalgia prognosis
-duration of symptoms have NOT been shown to influence outcome
75
Lateral epicondylalgia and modalitites
- laser - no benefit
- diathermy - no benefit
- ionto - no effect in short term
- US and phonophoresesis - insufficient evidence
76
Lateral epicondylalgia and joint manipulation
- elbow extension manip - no effect when paired with cross fiction massage - both were inferior to eccentric exercise
- MWM - WORKS
- scaphoid manip - HELPS
- spine - thoracic and cervical help
77
lateral epicondylalgia and soft tissue mobilization
- cross friction not studied in isolation
- marginal evidence in long term to support massage ocmpared to injection
- acupuncture - no evidence
- MWM and dry needling - case study, but effective
OCS
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