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Ortho 1-first half > Elbow Pathology > Flashcards

Elbow Pathology Flashcards

1
Q

examination and evaluation

A
  • should include comprehensive exam of the upper quarter
  • presence of co-morbidities requires different techniques than in those patients without these issues
  • medical history along with objective information forms basis for chosen interventions
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2
Q

relevant scales

A 
VAS
DASH
PSFS
UEFS
American shoulder and elbow surgeons elbow form
Boston questionnaire
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3
Q

DASH

A

disabilities of the arm, shoulder and hand

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4
Q

PSFS

A

patient specific functional scale

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5
Q

UEFS

A

upper extremity functional scale

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6
Q

Boston questionnaire

A

carpal tunnel

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7
Q

general observations

A
  • *posture- head and neck
  • *limb position
  • muscle tone
  • quality, color, temp of skin
  • carrying angle- elbow 10-13 deg
  • swelling
  • resting position of elbow
  • ability to use limb
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8
Q

clearing tests

A
  • joint above and below
  • always consider c-spine
  • shoulder girdle: AROM, PROM, break tests
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9
Q

mobility examination

A

AROM/PROM

overpressure- flexion/extension, pronation/supination

accessory motion exam:

1: humeroulnar joint
- distraction
- radial and ulnar gapping
2: humeroradial joint
- distraction
- dorsal and volar glides
3: prox & distal radioulnar joint
- dorsal and volar glides

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10
Q

muscle performance examination

A

MMT

Performance based functional measures (asterisk signs)

  • pushing (push off test)
  • pulling
  • curling
  • grip strength
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11
Q

other tests

A
  • ligament stability
  • soft tissue mobility
  • neurologic status
  • functional status
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12
Q

common pathologies of the elbow

A
  • lateral epicondylitis (-algia)
  • medial epicondylitis (-algia)
  • olecranon bursitis
  • dislocation/instability
  • radial head subluxation
  • Volkman’s contracture
  • nerve entrapment syndromes
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13
Q

lateral epicondylitis

A

“tennis elbow”

-degeneration, micro/macro tearing, trauma of common extension insertion on the lateral epicondyle (focus ECRB, EDC 3 digit)
-initially a viscous cycle of I
inflammation>tissue weakness->tearing

more common >35 y/o

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14
Q

differential diagnosis of lateral epicondylitis

A
  • radiohumeral DJD
  • radial nerve entrapment
  • ligamentous injury
  • proximal pathology
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15
Q

mechanism of lateral epicondylitis

A

repetitive active forceful wrist extension, forceful gripping

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16
Q

clinical presentation of lateral epicondylitis

A
  • tender over lateral humeral epicondyle, extensor tendon and proximal muscle belly
  • possibly some edema noted in acute phase, possibly tight fascial bands noted in chronic phase
  • pain on active wrist extension (esp w/ radial deviation)
  • pain on passive wrist flexion (esp w/ ulnar deviation, elbow extended, pronated)
  • plain films: 7% show abnormal calcification
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17
Q

medial epicondylitis

A

“Golfer’s elbow”

-micro/macro tearing, trauma of common flexor insertion on medial epicondyle
-initially a viscous cycle of:
inflammation->tissue weakness-> tearing

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18
Q

mechanism of medial epicondylitis

A

repetitive active forceful wrist flexion

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19
Q

clinical presentation of medial epicondylitis

A
  • tender over medial humeral epicondyle, flexor tendon and proximal muscle belly
  • possibly some edema noted in acute phase, possibly tight fascial bands noted in chronic phase
  • pain on active wrist flexion and pronation
  • pain on passive wrist extension (possible supination)
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20
Q

treatment of ACUTE lat & med epicondylitis

A

cochrane review supports:

  • topical NSAIDS
  • local injections of steriods > oral NSAIDS
  • patient education: refrain from offending activities
  • stretching
  • splints/straps
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21
Q

treatment of SUBACUTE lat & med epicondylitis

A
  • deep friction massage
  • Mill’s manipulation & radial head mobs
  • exercise (iso-> conc-> ecc) through pain
  • acupuncture, laser, US
  • assess cervical spine and wrist
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22
Q

Mill’s Manipulation

A
  • designed to elongate and tear the scar formed in chronic lateral epicondylitis
  • before performing, ensure full elbow extension PROM exists, and there is a restriction in extension ROM with wrist fully flexed (stretch pain over common extensor tendon)
  • while maintaining full wrist extension, thrust into elbow extension
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23
Q

olecranon bursitis

A
  • trauma- fall on elbow
  • excessive friction
  • infection
  • systemic disease (RA, gout)
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24
Q

clinical presentation of olecranon bursitis

A
  • confined swelling
  • palpation painful, increased temp
  • decreased elbow extension strength
  • decreased extension ROM
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25
Q

treatment of olecranon bursitis

A

conservative “wait and see”

  • symptom reduction tx (warm soaks, splinting, protection)
  • no evidence that this is better or worse

aspiration: temp/permanent relief of swelling
- analyze fluid for infection

aspiration with steroid injection
-faster reduction of symptoms
-increase in complications 
skin atrophy-20%
septic bursitis- 10%
chronic pain or pressure 30%
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26
Q

elbow dislocation

A

dislocation is a medical emergency

  • high chance of nerve and vascular
  • often complicated by fx and log disruptions
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27
Q

elbow instability

A

medial: throwing athletes
- stretching/rupture of ulnar collateral ligament

lateral: trauma
- stretching/rupture of radial collateral ligament

28
Q

clinical presentation of instability

A
  • feeling of “giving way”

- pain on activities that stress the damaged ligaments

29
Q

treatment of dislocation/instability

A

-ability to dynamically stabilize-FCU?
stabilize proximal/proper form

-surgical reconstruction
post op rehab stresses early protected motion

30
Q

medial elbow pain- differential diagnoses

A

Medial elbow instability: conservative rx in nonthrowing athletes; reconstruction for athletes. don’t over-stress healing tissue, establish flexibility, muscle balance, neuromuscular control

medial epicondyle apophysitis- traction apophysitis at ME as result of valgus stresses in immature elbow- inflammation along medial apophsysis

valgus extension overload-olecranon on fossa with combined valgus; swelling, medial and posterior pain, +valgus extension overload

31
Q

olecranon fractures

A

mechanism of injury: FOOSH w/ elbow flexed, triceps contracts
-ulnar nerve vulnerable

32
Q

radial head fractures

A

MOI: FOOSH w/ supination (dislocation?)

33
Q

FOOSH

A

fall on out stretched hand

34
Q

fracture treatment

A
  • short immobilization and early motion
  • biceps shortening: C/R stretch, arm swing
  • extension loss: jt mobs w/ distraction
35
Q

Nursemaid’s elbow

A

radial head subluxation

36
Q

radial head subluxation

A

“nursemaid’s elbow”

  • longitudinal force at forearm (pronated)
  • pulls radial head from annular ligament
37
Q

clinical presentation of nursemaid’s elbow

A
  • localized pain
  • reluctant/inability to move (held in pronation)
  • often palpate sulcus
38
Q

treatment of nursemaid’s elbow

A
  • reduction (emergency room)
  • guarded motion
  • PT for inflammation/symptom/impairments
39
Q

Volkmann’s ischemic contracture

A

=deformity of the hand, fingers and wrist caused by trauma induced ischemia

  • crush injury to the forearm
  • elbow fracture in children
40
Q

swelling of Volkmann’s ischemic contracture causes…

A

“compartment syndrome”

pressure causes ischemia and tissue death

  • pressure reduced blood inflow
  • pressure prevents blood outflow

tissue dies/becomes fibrotic and shortened

41
Q

treatment of volkmann’s contracture

A
  • medical emergency
  • fasciotomy
  • later rehab to regain strength & ROM
42
Q

nerve entrapment syndromes

A

1: cubital tunnel syndrome
2: radial tunnel syndrome

43
Q

cubital tunnel syndrome

A

ulnar nerve in tunnel (medial epicondyle, olecranon, MCL, ligament of Struthers

flexion tightens nerve in the tunnel

  • decreased blood supply
  • parasthesias & pain
  • decreased sensation
  • decreased strength
44
Q

signs & symptoms of cubital tunnel syndrome

A

parasthesias medial forearm/ulnar hand

prolonged/repeated end range flexion

  • sleep, combing hair, driving, phone
  • Chronic: weak turning keys, grip/pinch, dropping objects
45
Q

exam for cubital tunnel syndrome

A 
special tests
ULTT
muscle bulk
digits 4 & 5
sensory testing
46
Q

differential diagnosis for cubital tunnel syndrome

A

C8-T1 nerve root
TOS
Guyon’s canal

47
Q

treatment for cubital tunnel syndrome

A

Conservative:

  • refrain from activities w/ elbow flexion
  • night splints in 40-60 deg flexion to prevent full flexion
  • physical agents to reduce inflammation (TENS)
  • nerve gliding (ulnar bias)
  • stretching (extrinsic flexors, intrinsics (ulnar innervated)

Surgery: transposition of nerve anteriorly

48
Q

radial tunnel syndrome

A

posterior interosseous nerve in tunnel

  • radial tunnel entrance
  • leash of Henry (radial recurrent vessels)
  • ECRB tendon
  • Arcade of Froshe
  • supinator origins

Caused by repetitive:

  • pronation/supination
  • wrist flexion/extension
49
Q

symptoms of radial tunnel syndrome

A
  • pain in common extensors mid belly
  • can appear similar to tennis elbow
  • decreased strength
50
Q

treatment for radial tunnel syndrome

A

Conservative:

  • refrain from symptom producing activities; keep forearm in neutral
  • cock-up splints at wrist (3-6 months)
  • physical agents to reduce inflammation (TENS)
  • nerve gliding (radial bias)
  • stretching: extrinsic extensors & flexors, supinator

Surgery: transposition of nerve anteriorly

51
Q

lateral epicondylitis special tests

A

1: Cozen’s test
2: Lateral epicondylitis test

52
Q

Cozen’s test

A

indicates lateral epicondylitis
positive test= reproduced pain along the lateral epicondyle/ common extensor tendons

pt seated. makes a fist with forearm in pronation and radial deviation of wrist.
PT palpates origin of common extensor tendon at the lateral epicondyle with own thumb. resists wrist extension

53
Q

Lateral epicondylitis test

A

indicates lateral epicondylitis

positive test=reproduction of pain along lateral epicondylitis, pain over radial head or common extensor tendon

pt elbow in full extension and full pronation
strongly resist wrist extension and ulnar deviation supporting the wrist

54
Q

elbow stability special tests

A

1: moving valgus stress test
2: posterior lateral rotary instability
3: varus stress test:
4: valgus stress test

55
Q

moving valgus stress test

A

indicates chronic MCL tear of the elbow

Positive test=reproduced medial elbow pain between 120-70 deg of flexion

with pt in upright position, passively abduct shoulder to 90 deg. place elbow in full flexion. PT applies modest valgus force to elbow until shoulder reaches full ER. maintaining constant valgus force, quickly extend elbow to 30 deg extension.

  • *speed is patient dependent
  • *sit in chair to stabilize shoulder
56
Q

posterior lateral rotary instability

A

indicates posterior lateral instability of the radius

positive test=post lat displacement, apprehension of the radius, reduction of the radius as elbow approaches 90 deg

pt lies supine
PT flexes shoulder above head. elbow in full extension and supinated. 1 hand prevents ER. other hand grasps forearm maintaining supination.
PT brings elbow into flexion (maintaining supination) and a valgus force at the elbow

**stabilize the humerus, don’t allow ER!

57
Q

Varus stress test (LCL)

A

indicates the integrity of the lateral collateral complex

positive test=reproduction of distraction pain laterally at joint line

  • reproduction of compression pain medially at joint line
  • joint line laxity with stress

pt seated or standing.
PT has 1 hand at the elbow and other hand over proximal wrist.
**elbow fully extended
PT applies varus force while palpating LCL

**compare bilaterally

58
Q

valgus stress test (MCL)

A

indicates integrity of the medial collateral complex

positive test=reproduction of distraction pain medially at the joint line, reproduction of compression pain laterally at the joint line, joint pain with stress

  • *compare bilaterally
  • don’t allow elbow flexion
59
Q

nerve entrapment tests

A

1: elbow flexion test
2: pressure provocation
3: tinel’s sign

60
Q

elbow flexion test

A

indicates cubital tunnel syndrome

positive test=reproduction of pain, tingling, numbness along ulnar nerve distribution

pt is sitting. shoulders neutral, elbows fully flexed (not forcibly) with full wrist extension.
pt describes any symptoms after holding for 3 minutes

61
Q

pressure provocation

A

indicates cubital tunnel syndrome

positive test=reproduction of symptoms along ulnar nerve

PT’s 1st and 2nd fingers pressed over pt’s ulnar nerve proximal to cubital tunnel with elbow in 20 deg flexion and supinated
test is held for 60 sec

62
Q

Tinel’s sign

A

indicates cubital tunnel syndrome

positive test=reproduction of symptoms along ulnar nerve

PT applies 4-6 taps to the pt’s ulnar nerve just proximal to cubital tunnel

63
Q

medial epicondylitis test

A

indicates medial epicondylitis

positive test= reproduction of pain over the medial epicondyle or common flexor tendon

PT resists wrist flexion

64
Q

humero-ulnar joint mobilizations

A

1: distraction
2: medial gap (valgus force)
3: lateral gap (varus force)

65
Q

humero-radial joint mobilizations

A

1: distraction
2: dorsal glide- also affects prox RU jt
3: ventral glide- also affects prox RU jt
4: Mill’s manipulation

66
Q

distal radio-ulnar joint

A

1: dorsal glide
2: ventral glide

  • *do your best to stabilize one while gliding the other, use grades 3&4 mostly.
  • *half grip
67
Q

elbow short axis distraction

A

supine, elbow in 90 deg

Ortho 1-first half (10 decks)

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