Epicondilite do cotovelo + Rigidez + Ossificação Heterotópica

Question 1

Quais movimentos desencadeiam a dor na epicondilite lateral do cotovelo?

Answer 1

Lateral epicondylitis can occur during activities that require repetitive supination and pronation of the forearm with the elbow in near full extension.

Question 2

Qual o músculo envolvido na epicondilite lateral do cotovelo?

Answer 2

Lateral epicondylitis is initiated as a microtear, most often within the origin of the extensor carpi radialis brevis. The pathological process mainly involves the origin of the extensor carpi radialis brevis but can involve the tendons of the extensor carpi radialis longus and the extensor digitorum communis.

Question 3

Quais são os achados de exame físico na epicondilite lateral do cotovelo?

Answer 3

Tenderness is present over the lateral epicondyle approximately 5 mm distal and anterior to the midpoint of the condyle. Pain usually is exacerbated by resisted wrist dorsiflexion and forearm supination, and there is pain when grasping objects.

Question 4

Quais são os achados radiológicos da epicondilite lateral?

Answer 4

Plain radiographs usually are negative; occasionally calcific tendinitis may be present. MRI shows tendon thickening with increased T1 and T2 signal intensity.

Question 5

Quais são os diagnósticos diferenciais da epiondilite lateral do cotovelo?

Answer 5

Other entities that can produce pain in this general vicinity are osteochondritis dissecans of the capitellum, lateral compartment arthrosis, varus instability, and, perhaps most commonly, radial tunnel syndrome.

Question 6

A síndrome do túnel radial comprime qual estrutura anatômica?

Answer 6

Radial tunnel syndrome is a compressive neuropathy of the posterior interosseous nerve.

Question 7

Quais estruturas podem comprimir o nervo interósseo posterior na síndrome do túnel radial?

Answer 7

Four diferent anatomical structures can do it in the radial tunnel, including a fibrous band near the anterior aspect of the radial head, a vascular leash of the recurrent radial artery, the distal extensor carpi radialis brevis tendon margin, or the supinator margin at the arcade of Frohse.

Question 8

Onde localiza-se a dor nos pacientes com síndrome do túnel radial?

Answer 8

The pain of radial tunnel syndrome is located 3 to 4 cm distal to the lateral epicondyle and may be reproduced with long finger extension against resistance.

Question 9

Qual a porcentagem de pacientes que possuem epicondilite lateral e síndrome do túnel radial?

Answer 9

True lateral epicondylitis and radial tunnel syndrome may coexist in 5% of patients.

Question 10

Qual a porcentagem de pacientes que melhoram com o tratamento conservador da epicondilite lateral?

Answer 10

Nonoperative treatment is successful in 95% of patients with tennis elbow.

Question 11

Como é realizado o tratamento conservador da epicondilite lateral?

Answer 11

Nonoperative treatment includes rest, ice, injections, and physical therapy with ultrasound, iontophoresis, electrical stimulation, manipulation, soft tissue mobilization, friction massage, stretching and strengthening exercises, and counterforce bracing.

Question 12

Quais modalidades terapêuticas mais recentes se mostram promissoras no tratamento da epicondilite lateral?

Answer 12

More recently, platelet-rich plasma (PRP) injections have been reported to be more effective than corticosteroid injections in relieving pain and improving function, although some studies found that autologous blood injections were more successful than PRP.

Question 13

Quanto tempo deve-se esperar para considerar o tratamento conservador falho?

Answer 13

If prolonged (6 to 12 months) nonoperative treatment is inefective, operative treatment may be considered; it is efective in 90% of properly selected patients.

Question 14

Qual o tratamento cirurgico advocado pra a epicondilite lateral?

Answer 14

Manipulation under anesthesia, especially in patients with concomitant flexion contractures, has been advocated. The technique involves sudden, forcible, full extension of the elbow with the wrist and fingers flexed and the forearm pronated to place the extensor carpi radialis brevis and extensors under tension. An audible, palpable snap frequently can be elicited, and the results can be excellent.

Question 15

Qual o tratamento cirúrgico proposto pelo autor no tratamento da epicondilite lateral?

Answer 15

Currently, we favor a more limited approach, which consists of exposure of the diseased extensor carpi radialis brevis origin, resection of degenerative tissue, and direct repair to bone.

Question 16

Como Morrey dividiu os pacientes que apresentaram falha do tratamento conservador ou cirúrgico paraa epicondilite lateral?

Answer 16

Morrey divided these failures into two groups based on postoperative symptoms. Patients in the first group had symptoms similar to those experienced before surgery, whereas patients in the second group reported a different symptom complex after surgery. Treatment failed in patients in the first group because of inadequate release or incorrect initial diagnosis, most often related to radial tunnel syndrome; in the second group, treatment failed because of capsular or ligamentous insuficiency that resulted in either a capsular fistula or posterolateral instability.

Question 17

A melhora da dor ocorre em quanto tempo após o tratamento cirúrgico na epicondilite lateral?

Answer 17

According to most authors, patients who will improve after surgery do so within 3 to 4 months. We believe that 1 year is a reasonable period to consider repeat intervention if symptoms have not improved.

Question 18

Como é classificada artroscopicamente a epicondilite lateral do cotovelo?

Answer 18

Three distinct patterns of pathological changes have been identified in the lateral capsule and at the undersurface of the extensor carpi radialis brevis. Type I lesions appear arthroscopically with intact capsules, type II are linear tears at the undersurface of the capsule, and type III are complete tears of the capsule with partial or complete avulsion of the extensor carpi radialis brevis tendon.

Question 19

Quais são os músculos envolvidos na epicondilite medial?

Answer 19

The origin of the flexor carpi radialis and pronator teres (flexor pronator mass) are commonly involved and, less typically, the flexor digitorum supericialis and flexor carpi ulnaris.

Question 20

Quais são os diagnósticos diferenciais da epicondilite medial do cotovelo?

Answer 20

This entity must be diferentiated from ulnar nerve neuropathy and medial collateral ligament instability.

Question 21

Quais são as atividades envolvidas na gênese da epicondilite medial?

Answer 21

Medial epicondylitis frequently occurs with repetitive overhead motion and afects athletes involved in racket sports and others who participate in activities that create a valgus force at the elbow.

Question 22

Quais são os achados de exame físico na epicondilite medial?

Answer 22

Physical examination usually reveals pain along the medial elbow that becomes worse on resisted forearm pronation or wrist lexion. The area of maximal tenderness is approximately 5 mm distal and anterior to the midpoint of the medial epicondyle.

Question 23

Quais são os achados radiográficos da epicondilite medial?

Answer 23

Radiographs usually are normal, but medial ulnar traction spurs and medial collateral ligament calcifications may be seen and may be associated with a chronic ulnar collateral ligament injury.

Question 24

Quais são as modalidades de tratamento para a epicondilite medial do cotovelo?

Answer 24

Conservative treatment is the mainstay of management. Antiinflammatory medication, splinting, and an occasional steroid injection provide sustained relief in most patients. If nonoperative treatment fails, excision of the diseased tendon origin and reattachment usually are successful.

Question 25

Qual cuidado deve ser tomado caso seja realizado a epicondilectomia medial do cotovelo para o tratamento da epicondilite?

Answer 25

Epicondylectomy also can be done, but no more than 20% to 25% of the epicondyle should be removed.

Question 26

Qual a diferença da cirurgia de Vangsness e Nirschl para a epicondilite medial do cotovelo?

Answer 26

Vangsness and Jobe described release of the flexor pronator origin, excision of the pathological tissue, and reattachment of the flexor pronator origin to bleeding bone. Nirschl preferred excising the pathological tissue of the flexor-pronator origin in a manner that leaves normal tissue intact and repairing the subsequent defect.

Question 27

Qual a ADM normal do cotovelo?

Answer 27

A normal range of elbow motion is 0 to 150 degrees.

Question 28

Qual o arco de movimento funcional do cotovelo?

Answer 28

A functional range of motion generally is considered to be 30 to 130 degrees, an arc of 100 degrees. A flexion contracture that exceeds 45 degrees markedly impairs the ability to position the hand in space.

Question 29

Quais são as causas de rigidez do cotovelo?

Answer 29

Elbow contractures result from a variety of causes, including trauma, heterotopic ossification, burns, spasticity, postoperative scarring, and prolonged immobilization. Of these, only the last can be efectively prevented.

Question 30

Quais são os pacientes candidatos ao tratamento cirúrgico para rigidez do cotovelo?

Answer 30

Surgery should be considered for patients with arcs of motion of less than 100 degrees after nonoperative treatment, especially patients with flexion contractures of more than 45 degrees.

Question 31

Como são classificadas as rigidez do cotovelo?

Answer 31

Causes of motion loss are classified as intrinsic or extrinsic. Extrinsic causes include contractures of the capsule or collateral ligaments, extraarticular malunions, and heterotopic ossification. Intrinsic causes include the sequelae of intraarticular fractures, such as cartilage damage, articular incongruity, and adhesions. Contracture resulting from primarily extrinsic causes can be treated with resection of the contracted structures. In contrast, contractures resulting from intrinsic causes may require alteration of the articular anatomy. Extrinsic causes (capsular contracture) are almost always present when intrinsic causes are primary.

Question 32

Quais são as opções cirúrgicas para rigidez do cotovelo de acordo com a classificação?

Answer 32

If joint surfaces are normal, and contractures are secondary to capsular problems, a simple arthroscopic or open release is performed. If intraarticular surfaces have been altered or destroyed, or extensive intraarticular adhesions are present, a distraction arthroplasty with or without fascial interposition is done.

Question 33

Quais complicações a manipulação sob anestesia podem trazer para a rigidez do cotovelo?

Answer 33

Although elbow manipulation with the use of anesthesia has been reported to improve range of motion, we do not recommend isolated manipulation in patients with long-standing contractures because it may predispose to fracture, hematoma formation, scarring, and heterotopic ossification. Rather, manipulation after operative contracture release has been found to be a useful adjunct.

Question 34

Qual a opinião dos autores em relação a ossificação heterotópica ao redor do cotovelo?

Answer 34

If ectopic bone around the elbow is causing or contributing to a loss of functional elbow motion, then an operative procedure is warranted to remove the ofending bone and release the joint capsule.

Question 35

Quando deve ser feito a cirurgia para ressecção da ossificação heterotópica?

Answer 35

Criteria suggested for early excision (3 to 6 months ater injury) include union of all fractures, healing of all initial wounds, and resolution of inlammation. Excision of heterotopic ossification around the elbow is typically done through a limited or extended Kocher approach; a multiple incision technique also has been described for heterotopic ossification excision ater burn injuries, in which soft tissue preservation is paramount to avoid skin breakdown and infection.

Question 36

Qual o local mais comum de ossificação heterotópica no cotovelo pós trauma?

Answer 36

Posterolateral elbow; anterolateral compartment second most common location;

Question 37

Qual o local mais comum de ossificação heterotópica no cotovelo após queimadura?

Answer 37

Most often posteromedial

Question 38

Qual o local mais comum de ossificação heterotópica no cotovelo de causa neurogênica?

Answer 38

Most common anteriorly in flexor muscles or posteriorly in extensors.

Question 39

Quais são os fatores de risco para desenvolvimento de ossificação heterotópica ao redor do cotovelo?

Answer 39

Trauma
■ Open elbow dislocation requiring extensive or multiple débridements ■ Elbow dislocation associated with fractures that require ORIF
■ Radial head fractures treated with surgery > 24 hours after injury

Surgery
■ Distal biceps tendon repair
■ Repeated procedures with an improper exposure in the first 2 weeks ■ Central nervous system injury
■ Traumatic brain injury
■ Elbow trauma in patients with traumatic brain injury

Burns
■ Third-degree burns over 20% of total body area
■ Third-degree burns over the elbow
■ Long periods of bed coninement

Genetic Conditions
■ Fibrodysplasia ossificans progressiva
■ History of heterotopic bone formation

Question 40

Qual é a epidemiologia da epicondilite lateral do cotovelo (tennis elbow)?

Answer 40

Occurs more frequently in nonathletes than athletes, with a peak incidence in the early fith decade and a nearly equal gender incidence.