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Chapter 23: The Elbow

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... at the elbow help to protect it from overuse and traumatic injuries Elbow demonstrates a carrying angle due to distal projection ... of humeral condyle ... – PowerPoint PPT presentation

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Title: Chapter 23: The Elbow


1
Chapter 23 The Elbow
2
Anatomy of the Elbow
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7
Functional Anatomy
  • Complex that allows for flexion, extension,
    pronation and supination
  • 145 degrees of flexion and 90 degrees of
    supination and pronation
  • Bony limitations, ligamentous support and
    muscular stability at the elbow help to protect
    it from overuse and traumatic injuries
  • Elbow demonstrates a carrying angle due to distal
    projection of humerus
  • Normal in females is 10-15 degrees, males 5
    degrees
  • Critical link in kinetic chain of upper extremity

8
Assessment of the Elbow
  • History
  • Past history
  • Mechanism of injury
  • When and where does it hurt?
  • Motions that increase or decrease pain
  • Type of, quality of, duration of, pain?
  • Sounds or feelings?
  • How long were you disabled?
  • Swelling?
  • Previous treatments?

9
  • Observations
  • Deformities and swelling?
  • Carrying angle
  • Cubitus valgus versus cubitus varus
  • Flexion and extension
  • Cubitus recurvatum
  • Elbow at 45 degrees
  • Isosceles triangle (olecranon and epicondyles)

10
Palpation Bony and Soft Tissue
  • Humerus
  • Medial and lateral epicondyles
  • Olecranon process
  • Radial head
  • Radius
  • Ulna
  • Medial and lateral collateral ligaments
  • Annular ligament
  • Biceps brachii
  • Brachialis
  • Brachioradialis
  • Pronator teres
  • Triceps
  • Supinator
  • Wrist flexors and extensors

11
  • Special Tests
  • Circulatory and Neurological Function
  • Pulse should be taken at brachial artery and
    radial artery
  • Skin sensation should be checked - determine
    presence of nerve root compression or irritation
    in cervical or shoulder region
  • Tinels sign
  • Ulnar nerve test
  • Tap on ulnar nerve (in ulnar groove)
  • Positive test is found when athlete complains of
    sensation along the forearm and hand
  • Test for Capsular Injury
  • Tested after hyperextension of elbow
  • Elbow is flexed to 45 degrees, wrist is fully
    flexed and extended
  • If joint pain is severe, moderate/severe sprain
    or fracture should be suspected

12
  • Valgus/Varus Stress Test
  • Assess injury to the medial and lateral
    collateral ligaments, respectively
  • Looking for gapping or complaint of pain

13
  • Medial and Lateral Epicondylitis Tests
  • Elbow flexed to 45 degrees and wrist extension or
    flexion is resisted
  • Pain at lateral or medial epicondyle,
    respectively indicates a positive test
  • Pinch Grip Test
  • Pinch thumb and index finger together
  • Inability to touch fingers together indicates
    entrapment of anterior interosseous nerve between
    heads of pronator muscle
  • Pronator Teres Syndrome Test
  • Forearm pronation is resisted
  • Increased pain proximally over pronator teres
    indicates a positive test

14
Functional Evaluation
  • Pain and weakness are evaluated through AROM,
    PROM and RROM
  • Flexion, extension, pronation and supination
  • ROM of pronation and supination are particularly
    noted

15
Recognition and Management of Injuries to the
Elbow
  • Subject to injury due to broad range of motion,
    weak lateral bone structure, and relative
    exposure to soft tissue damage
  • Many sports place excessive stress on joint
  • Locking motion of some activities, use of
    implements, and involvement in throwing motion
    make elbow extremely susceptible

16
  • Contusion
  • Etiology
  • Vulnerable area due to lack of padding
  • Result of direct blow or repetitive blows
  • Signs and Symptoms
  • Swelling (rapidly after irritation of bursa or
    synovial membrane)
  • Management
  • Treat w/ RICE immediately for at least 24 hours
  • If severe, refer for X-ray to determine presence
    of fracture

17
  • Olecranon Bursitis
  • Etiology
  • Superficial location makes it extremely
    susceptible to injury (acute or chronic) --direct
    blow
  • Signs and Symptoms
  • Pain, swelling, and point tenderness
  • Swelling will appear almost spontaneously and
    w/out usual pain and heat
  • Management
  • In acute conditions, compression for at least 1
    hour
  • Chronic cases require superficial therapy
    primarily involving compression
  • If swelling fails to resolve, aspiration may be
    necessary
  • Can be padded in order to return to competition

18
  • Strains
  • Etiology
  • MOI is excessive resistive motion (falling on
    outstretched arm), repeated microtears that cause
    chronic injury
  • Rupture of distal biceps is most common muscle
    rupture of the upper extremity
  • Signs and Symptoms
  • Active or resistive motion produces pain point
    tenderness in muscle, tendon, or lower part of
    muscle belly
  • Management
  • RICE and sling in severe cases
  • Follow-up w/ cryotherapy, ultrasound and exercise
  • If severe loss of function encountered - should
    be referred for X-ray (rule out avulsion or
    epiphyseal fx

19
  • Ulnar Collateral Ligament Injuries
  • Etiology
  • Injured as the result of a valgus force from
    repetitive trauma
  • Can also result in ulnar nerve inflammation, or
    wrist flexor tendinitis overuse flexor/pronator
    strain, ligamentous sprains elbow flexion
    contractures or increased instability
  • Signs and Symptoms
  • Pain along medial aspect of elbow tenderness
    over MCL
  • Associated paresthesia, positive Tinels sign
  • Pain w/ valgus stress test at 20 degrees
    possible end-point laxity
  • X-ray may show hypertrophy of humeral condyle,
    posteromedial aspect of olecranon, marginal
    osteophytes calcification w/in MCL loose bodies
    in posterior compartment

20
  • Ulnar Collateral Ligament Injuries (cont.)
  • Management
  • Conservative treatment begins w/ RICE and NSAIDs
  • W/ resolution, strengthening should be performed
    analysis of the throwing motion (if applicable)
  • Surgical intervention may be necessary (Tommy
    John procedure)
  • Throwing athlete can return to activity 22-26
    weeks post surgery

21
  • Lateral Epicondylitis (Tennis Elbow)
  • Etiology
  • Repetitive microtrauma to insertion of extensor
    muscles of lateral epicondyle
  • Signs and Symptoms
  • Aching pain in region of lateral epicondyle after
    activity
  • Pain worsens and weakness in wrist and hand
    develop
  • Elbow has decreased ROM pain w/ resistive wrist
    extension

22
  • Lateral Epicondylitis (continued)
  • Management
  • RICE, NSAIDs and analgesics
  • ROM exercises and PRE, deep friction massage,
    hand grasping while in supination, avoidance of
    pronation motions
  • Mobilization and stretching in pain free ranges
  • Use of a counter force or neoprene sleeve
  • Mechanics training

23
  • Medial Epicondylitis
  • Etiology
  • Repeated forceful flexion of wrist and extreme
    valgus torque of elbow
  • Signs and Symptoms
  • Pain produced w/ forceful flexion or extension
  • Point tenderness and mild swelling
  • Passive movement of wrist seldom elicits pain,
    but active movement does
  • Management
  • Sling, rest, cryotherapy or heat through
    ultrasound
  • Analgesic and NSAID's
  • Curvilinear brace below elbow to reduce elbow
    stressing
  • Severe cases may require splinting and complete
    rest for 7-10 days

24
  • Elbow Osteochondritis Dissecans
  • Etiology
  • Impairment of blood supply to anterior surface
    resulting in degeneration of articular cartilage,
    creating loose bodies
  • Repetitive microtrauma in movements of elbow
    rotation, extension, valgus stress causing
    compression of the radial head ad shearing of the
    radiocapitular joint
  • Seen in young athletes involved in throwing
    motion
  • Panners disease in incidents of children age lt10
  • Signs and Symptoms
  • Sudden pain, locking range usually returns in a
    few days

25
  • Signs and Symptoms (continued)
  • Swelling, pain at radiohumeral joint, creptitus,
    decreased ROM (full extension) grating w/
    pronation and supination
  • X-ray may show flattening and crater of capitulum
    w/ loose bodies
  • Management
  • Activity restriction for 6-12 weeks NSAIDs
  • Splint and cast applied for cases of extensive
    deterioration
  • If repeated locking occurs, loose bodies are
    removed surgically

26
  • Little League Elbow
  • Etiology
  • Caused by repetitive microtraumas that occur from
    throwing (not type of pitch)
  • May result in numerous disorders of growth in the
    pitching elbow
  • Signs and Symptoms
  • Onset is slow slight flexion contracture,
    including tight anterior joint capsule and
    weakness in triceps
  • Athlete may complain of locking or catching
    sensation
  • Decreased ROM or forearm pronation and supination

27
  • Little League Elbow (continued)
  • Management
  • RICE, NSAIDs and analgesics
  • Throwing stops until pain resolved and full ROM
    is regained
  • Gentle stretching and triceps strengthening
  • Throwing under supervision w/ good technique to
    prevent recurrence

28
  • Cubital Tunnel Syndrome
  • Etiology
  • Pronounced cubital valgus may cause deep friction
    problem
  • Ulnar nerve dislocation
  • Traction injury from valgus force, irregularities
    w/ tunnel, subluxation of ulnar nerve due to lax
    impingement, or progressive compression of
    ligament on the nerve
  • Signs and Symptoms
  • Pain medially which may be referred proximally or
    distally
  • Tenderness in cubital tunnel on palpation and
    hyperflexion
  • Intermittent paresthesia in 4th and 5th fingers

29
  • Cubital Tunnel Syndrome (continued)
  • Management
  • Rest, immobilization for 2 weeks w/ NSAIDs
  • Splinting or surgical decompression or
    transposition of subluxating nerve may be
    necessary
  • Athlete must avoid hyperflexion and valgus
    stresses

30
  • Dislocation of the Elbow
  • Etiology
  • High incidence in sports caused by fall on
    outstretched hand w/ elbow extended or severe
    twist while flexed
  • Bones can be displaced backward, forward, or
    laterally
  • Distinguishable from fracture because lateral and
    medial epicondyles are normally aligned w/ shaft
    of humerus
  • Signs and Symptoms
  • Swelling, severe pain, disability
  • Complications w/ median and radial nerves and
    blood vessels
  • Often a radial head fracture is involved

31
  • Management
  • Cold and pressure immediately w/ sling
  • Refer for reduction
  • Neurological and vascular fxn must be assessed
    prior to and following reduction
  • Physician should reduce - immediately
  • Immobilization following reduction in flexion for
    3 weeks
  • Hand grip and shoulder exercises should be used
    while immobilized
  • Following initial healing, heat and passive
    exercise can be used to regain full ROM
  • Massage and joint movement that are too strenuous
    should be avoided before complete healing due to
    high probability of myositis ossificans
  • ROM and strengthening should be performed and
    initiated by athlete (forced stretching should be
    avoided

32
Elbow Dislocation
33
  • Fractures of the Elbow
  • Etiology
  • Fall on flexed elbow or from a direct blow
  • Fracture can occur in any one or more of the
    bones
  • Fall on outstretched hand often fractures humerus
    above condyles or between condyles
  • Condylar fracture may result in gunstock
    deformity
  • Direct blow to ulna or radius may cause radial
    head fracture as well
  • Signs and Symptoms
  • May not result in visual deformity
  • Hemorrhaging, swelling, muscle spasm

34
  • Elbow Fractures (continued)
  • Management
  • Decrease ROM, neurovascular status must be
    monitored
  • Surgery is used to stabilize adult unstable
    fracture, followed by early ROM exercises
  • Stable fractures do not require surgery
  • Removable splints are used for 6-8 weeks

35
  • Volkmanns Contracture
  • Etiology
  • Associate w/ humeral supracondylar fractures,
    causing muscle spasm, swelling, or bone pressure
    on brachial artery, inhibiting circulation to
    forearm
  • Can become permanent
  • Signs and Symptoms
  • Pain in forearm - increased w/ passive extension
    of fingers
  • Pain is followed by cessation of brachial and
    radial pulses, coldness in arm
  • Decreased motion
  • Management
  • Remove elastic wraps or casts
  • Close monitoring must occur

36
Rehabilitation of the Elbow
  • General Body Conditioning
  • Must maintain pre-injury fitness levels -
    cardiovascular and strength (lower body)
  • Flexibility
  • Restoring ROM is critical in elbow rehab
  • Variety of approaches can be used as long as they
    dont force the joint
  • Joint Mobilizations
  • Loss of proper arthrokinematics following
    immobilization is expected
  • Joint mobilization and traction can be very
    useful to increase mobility and decrease pain
    through restoration of accessory motions

37
  • Strengthening
  • Achieved through low-resistance, high-repetition
    exercises - must be pain free
  • Shoulder and grip exercises should also be
    performed
  • Continuous passive motion units followed by
    dynamic splinting is ideal following surgery
  • Isometrics can be used while elbow is immobilized
  • PNF and isokinetics are useful in early and
    intermediate active stages of rehab
  • A graded PRE program w/ tubing, weights or manual
    resistance should be included
  • Closed kinetic chain activities should also be
    incorporated - assist in both static and dynamic
    stability to the elbow
  • Proprioceptive training should also incorporated

38
  • Functional Progressions
  • Will enhance healing and performance
  • PNF, swimming, pulley machines and rubber tubing
  • to simulate sports activities
  • Should include steps
  • Warm-up
  • Gradual build up to activity, becoming
    increasingly more difficult
  • Return to Activity
  • Can re-engage in activity when criteria has
    successfully been completed
  • ROM w/in normal limits, strength should be equal
    w/ no complaint of pain
  • Return should progress with use of restrictions
    in an effort to objectively measure activity
    progression

39
  • Protective Taping and Bracing
  • Should be continued until full strength and
    flexibility have been restored
  • Chronic conditions usually cause gradual
    debilitation of surrounding soft tissue
  • Must restore maximum state of conditioning w/out
    encouraging post-injury aggravation
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