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Elbow Injuries for the Primary Care Doc

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Elbow Injuries for the Primary Care Doc Brian Badman M.D. Signs & Symptoms Ulna and/or radius displaced posteriorly, w/ olecranon process sitting posteriorly Severe ... – PowerPoint PPT presentation

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Title: Elbow Injuries for the Primary Care Doc


1
Elbow Injuries for the Primary Care Doc
  • Brian Badman M.D.

2
Disclosures
  • Consultant
  • Smith and Nephew Endoscopy
  • UpEX
  • DJO Surgical
  • I have no conflicts with current talk or industry
    support

3
Basic Anatomy
4
Relevant Anatomy
  • Humerus
  • Ulna
  • Radius

5
Distal Humerus
Coronoid Fossa
Medial Epicondyle
Lateral Epicondyle
Trochlea
Capitellum
6
Proximal Ulna
Greater Sigmoid Notch
Olecranon Process
Lesser Sigmoid Notch
Coronoid Process
7
Proximal Radius
Head
Neck
Radial/Bicepital Tuberosity
8
Joints
  • Humeroulnar joint and Humeroradial
  • Flexion/extension
  • Radioulnar joint
  • Supination/pronation

9
Muscles Around ElbowSimple
  • Bicep
  • Triceps
  • Wrist flexors
  • Wrist extensors

10
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11
Wrist Flexors
12
Wrist Extensors
13
Forearm muscles
  • Forearm flexors?medial epicondyle
  • Forearm extensors?lateral epicondyle

14
Flexors of the elbow
  • Brachialis
  • Biceps
  • Brachioradialis

15
Extensors of the elbow
  • Triceps brachii
  • Long head
  • Lateral head
  • Medial head

16
Elbow Pronator
  • Pronator teres

17
Elbow Supinators
  • Biceps brachii
  • Supinator

18
Ligaments
  • Joint capsule surrounds joint
  • Ulnar collateral (Tommy John)
  • Radial collateral
  • Annular ligament

19
Other structures
  • Nerves
  • Ulnar, radial, median

20
Palpable Landmarks
  • Olecranon process
  • Olecranon fossa
  • Medial and lateral epicondyles
  • Radial head
  • Cubital TunnelUlnar N

21
Stability of Elbow
  • Secondary Stabilizers
  • Radiohumeral Joint
  • Capsule
  • Musculature (dynamic)
  • Primary Stabilizers
  • MCL (55 _at_ 90)
  • Ulnohumeral Joint
  • Coronoid?50
  • Olecranon

22
Common Elbow Maladies
23
Soft Tissue
24
Olecranon Bursitis
25
Etiology
  • Aseptic
  • Direct blow or fall?Hemarthrosis
  • Gout
  • Septic
  • Insect Bite
  • Cut/Abrasion
  • Hematogenous

26
Signs symptoms
  • Pain
  • Swelling
  • Erythema/Febrile?Septic

27
Treatment
  • Cold
  • Compression
  • Aspirate
  • If serous/bloody?Inject 40mg steroid compressive
    dressingelbow extension x 3 days
  • If puss?Requires ID (Ortho Consult)
  • Recurrent aseptic bursitis?Surgery

28
Elbow Sprains
29
Mechanism
  • Hyperextension or a force that bends or twists
    the lower arm outward
  • Valgus stress

30
Signs Symptoms
  • Pain
  • Inability to throw or grasp an object
  • POT (usually over UCL)

31
Treatment
  • Ice
  • Compression
  • Sling for support _at_ 90 degrees
  • Progress to full ROM and strength

32
Lateral EpicondylitisA.K.A Tennis Elbow
33
Epidemiology
  • 4th -5th Decade
  • MF
  • Repetitive wrist extension forearm
    pronation/supination
  • 10-50 tennis players will develop
  • ECRB Tendon primarily involved
  • 2EDC

34
Histology
  • Angiofibroblastic hyperplasia
  • No acute inflammation
  • Likely begins as microtear

35
Physical Examination
  • TTP anterior/distal LE
  • Pain worse w/ resistive wrist/finger extension

36
Imaging
  • Typically clinical diagnosis and not initially
    necessary
  • Consider plain XR for recalcitrant
  • Look for calcification
  • MRI?Concern for intraarticular pathology

37
Treatment
  • Acute (lt4wks)
  • Rest
  • NSAIDS
  • PT
  • Massage
  • U/S
  • Counterforce Bracing

38
Treatment (contd)
  • Rehab
  • ROM exercises
  • stretching
  • PREs
  • strengthening
  • Hand grasping while in supination
  • Avoid pronation movements

39
Treatment
  • Chronic (gt4wks)
  • Steroid injection
  • 40mg kenalogue 1/2 cc lidocaine

40
Surgery /Referral
  • Must fail 6-12 months conservative mgt
  • 85-90 EffectiveNirschl JBJS 1979

41
Platelet Rich Plasma
  • Autologous Blood
  • Centrifuge to separate layers and concentrate
    platelets
  • Growth Factors?May potentiate/stimulate healing
  • May stimulate Type 1 collagen formation
  • Kajikawa J Cell Physiol 2008

42
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43
PRP Cont.
  • Expensive 200-600
  • Not covered by insurance
  • Early results poor study quality with research
    bias (financial incentive)

44
PRP Peer Reviewed Level 1 Evidence
  • Gosens T, Peerbooms JC, van Laar W, den Oudsten
    BL. Am J Sports Med. 2011 Mar 21. Ongoing
    Positive Effect of Platelet-Rich Plasma Versus
    Corticosteroid Injection in Lateral
    Epicondylitis A Double-Blind Randomized
    Controlled Trial With 2-Year Follow-Up.
  • 100 patients?49 cortisone/51 PRP
  • PRP group with significant improvement regarding
    pain c/w steroid group at 2 years

45
Medial epicondylitis
46
A.K.A.
  • Pitchers elbow
  • Racquetball elbow
  • Golfers elbow
  • Javelin-throwers elbow

47
Epidemiology
  • Less common
  • 4th-5th decade
  • MF

48
Mechanism
  • Repeated forceful forearm flexion
  • Excessive throwing
  • Microtear of FCR/Pronator Teres

49
Physical Examination
  • TTP at medial epicondyle
  • Worse w/ wrist flexion or forearm pronation
  • Weak Grip
  • May be associated with ulnar neuritis
  • TTP ulnar nerve
  • Tinnels thru cubital tunnel

50
Treatment
  • Conservative management
  • NSAIDS
  • PTMassage/US/strengthening/ROM
  • Counterforce Brace
  • Steroid Injection
  • Consider EMG if associated with ulnar nerve sxs
  • Surgical ReferralFailure of 6-12 months

51
Distal Bicep Rupture
52
Epidemiology
  • Male predominated injury
  • 50-60yo
  • Dominant arm
  • Traumatic event of elbow flexion against
    resistance
  • Often times described as audible pop/gunshot

53
Physical Examination
  • Tenderness/bruising antecubital fossa
  • Pain to resisted bicep flexion and forearm
    supination
  • Hook Test?Able to hook tendon from lateral side
    with flexion

54
Imaging
  • Clinical Exam typically confirms
  • If not obvious?MRI
  • Helps evaluate partial tears and extent of
    partial tearing

55
Management
  • Typically recommend surgical repair?Ortho
    referral
  • 4-6 mo recovery
  • Retear lt2
  • Nonoperative management
  • 40 loss flexion strength
  • 50 loss supination power

56
NERVES
57
Cubital Tunnel Syndrome
  • Ulnar N compression thru medial elbow
  • 2nd most common compressive neuropathy UE
  • 30-60yo
  • DDx
  • C8/T1 cervical compression
  • Pancoast Tumor

58
Physical Examination
  • Check neck and axilla
  • Spurlings sign
  • Axillary mass/tinnels
  • Tinnels thru cubital tunnel
  • Direct compression Test
  • Numbness to RF/SF
  • Semmes-Weinstein Monofilament
  • Intrinsic Weakness
  • Adductor Pollicis
  • 1st Dorsal Interosseus

59
Special Tests
  • Fromments sign
  • Weakness of Adductor Pollicus compensated by FPL
  • IP flexion with lateral pinch
  • FOX vs. RABBIT
  • Jeannes sign?MP hyperextension w/ IP flexion

60
Management
  • CONSIDER EMG TO DOCUMENT SEVERITY
  • Severe
  • Persistant Pain
  • Atrophy
  • ? Surgical Referral
  • Mild to Moderate
  • Night splinting
  • Avoids elbow hyperflexion
  • Heelbo
  • NSAIDS
  • Steroid Injection
  • Work Ergonomic Modification

61
Bones
62
Dislocation of Elbow
63
Mechanism of injury
  • Second most frequent joint dislocation
  • Fall on extended elbow with outstretched hand
  • Majority posterior/posterolateral (90-95)

64
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65
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66
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67
Signs Symptoms
  • Ulna and/or radius displaced posteriorly, w/
    olecranon process sitting posteriorly
  • Severe swelling/bleeding
  • Extreme pain

68
Classification
  • Simple
  • No fracture?purely ligamentous
  • Complex
  • Associated with fracture
  • Radial Head?most common fx

69
Treatment
  • Immobilize in position you find it
  • Send to ER
  • Radiographs

70
SIMPLE POSTEROLATERAL DISLOCATION
71
TreatmentSimple
  • Closed Reduction
  • Long arm splint/cast x 2 weeks
  • Progressive ROM
  • Protect terminal extension x 6wks
  • Major Complication?Extension Loss

72
Reduction Maneuver
  • Gentle traction
  • Anterior directed force on olecranon
  • Gradual flexion

73
COMPLEX ELBOW DISLOCATION W/ RADIAL NECK FRACTURE
Radial Head
74
Treatment--Complex
  • Splint in situ?No reduction
  • Exception NV compromise
  • Ortho Referral?Surgery

75
Radial Head Fractures
  • Most Common Adult elbow fracture
  • Mechanism?FOOSH
  • PE
  • Pain/Effusion Elbow
  • Commonly associated with wrist pain
  • Pain with forearm rotation
  • Check for mechanical click

76
Radial Head Fractures
  • Radiographs
  • Can be subtle
  • Look for fat pad sign

FAT PAD SIGN
77
Mason Classification
  • I?Nondisplaced
  • II?lt30 head and gt2mm displacement
  • III?Comminuted

78
Treatment
  • II?Debatable
  • Ortho Referral
  • No Mechanical Sx
  • Conservative
  • Early ROM
  • Close XR F/U
  • Mechanical Sx
  • Possible SURGERY
  • ORIF
  • I?Nonoperative
  • Sling for comfort
  • ROM 3-4 days
  • Possible Aspiration Hematoma
  • Repeat XR 2wks
  • Complication
  • Extension/Supination Loss
  • Inject Joint 3months

79
Treatment--Continued
  • III?Ortho Referral
  • Surgery
  • ORIF
  • RADIAL HEAD REPLACEMENT

80
Thank You Terre Haute Medical Community!!!
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