Elbow Flashcards
(42 cards)
Special Exam Maneuvers for Med UCL? Not a RC Q
“Milking maneuver, moving valgus stress test, opens to valgus, tender over posterolateral UH joint, examine ULNAR nerve<div><img></img><br></br></div><div><img></img><br></br></div>”
Exam maneuvers for PLRI?
-lateral pivot shift (supination, Forward shoulder flexion, valgus load while moving from ext to flex)<div>-posterolateral rotatory drawer test (flex elbow to 40 deg -> apply AP force on forearm relative to humerus)</div><div>-Chair push up and prone push up <b><i>(combined sens 100% vs 37% for pivot shift)</i></b></div><div><i>-</i>Table top relocation test</div>
Additional procedure while addressing elbow OA - not RC Q
-ulnar nerve release/transposition if loss of 30 deg extention<div><br></br></div><div>surgical options</div><div>-debridement: open or arthroscopic</div><div>-arthrodesis</div><div>-TEA</div>
<div>What is true about a comminuted distal humerus fracture in an elderly patient? </div>
<div>A. TEA has improved outcome over ORIF at 1 year </div>
<div>B. Patient functional outcomes for TEA are better at 1 year </div>
<div>C. Re-operation rates for ORIF are significantly higher at 1 yr </div>
<div>D. It is “almost impossible” to do a quality ORIF with poor bone</div>
“B<div>-TEA better 6weeks-1 year; at 2 years, TEA = ORIF</div><div>-no diff in ROM, re-op, compo</div><div>-wrt ‘D’ - McKee states that 25% of distal humerus #s are not amenable to fixation</div><div><br></br></div><div><img></img><br></br></div>”
Tx approach for stiff elbow - not a RC Q
-non-op: splint, ROM<div>-column procedure (arthrotomy, capsular release, osteophyte excision)- lateral or medial (sometimes need to get to post bundle MCL)</div><div>-TEA</div><div><br></br></div><div>-address ulnar nerve!</div>
<div>List 4 long term complications of radial head fractures. (2011, 2013)</div>
Elbow stiffness<div>Radiocapitellar arthrosis<div>Loss of pronation/supination</div><div>Longitudinal forearm instability</div><div>Weaker: Infection PIN injury HO/Synostosis Elbow Instability<br></br></div></div>
<div>list 3 stabilizers to posterolateral instability, and which is most impotant?</div>
-LUCL*<div>-RC joint</div><div>-coronoid</div>
<div>Regarding elbow dislocation, what is true:</div>
1.An LCL injury should be rehabilitated in supination<div>2.Should be immobilized for at least 3 weeks</div><div>3.Often associated with posterior capitellar impaction</div><div>4. Instability is a common complication<br></br></div>
3.<div><br></br></div><div>LCL injury need pronation (think about sup–> RH goes out the back!)</div><div>instability is uncommon 2%</div>
<div>Elbow dislocation with no fracture. Unstable in valgus stress? What is the best management? </div>
hinged external fixation to protect the ligament and allow early ROM.<div>splint at 90 in supination for 1-2 weeks</div><div>splint at 90 in supination for 3-4 weeks</div><div>fix mcl<br></br></div>
B- splint at 90 in supination for 1-2 weeks
<div>All are true except:</div>
-Radio capitellar joint bears 20% of the load through elbow<div>-Radial head fractures account for 2-4% of all fractures</div><div>-Radio capitellar joint is only a secondary stabilizer to valgus stress (exact wording!)<br></br></div>
A is false: RC articular accounts for as much as 60% of load transfer across the elbow
<div>Which of the following is the most common complication after a distal biceps reconstruction?</div>
<ol> <li>PIN injury</li> <li>Lateral antebrachial cutaneous nerve injury</li> <li>HO</li> <li>Symptomatic elbow flexion contracture</li></ol>
- LACB 9% - from aggressive retraction<div><br></br></div><div>HO 7%</div>
<div>What are 6 risk factors that will lead to radioulnar synostosis following a both bones forearm fracture. (2010, 2011, 2013, 2014)</div>
<ul> <li>Injury:</li> <ul> <li>Proximal Third</li> <li>Fractures at the same level</li> <li>Comminution of both bones</li> <li>Severe local soft-tissue injury</li> <li>Interosseous membrane injury</li> <li>Head Injury</li> </ul> <li>Surgical Technique:</li> <ul> <li>Delayed Surgical Management</li> </ul> <ul> <li>Single Incision/Boyd Approach</li> <li>Violation of IO membrane</li> <li>Retained bone fragment in IO space</li> <li>Hardware into IO membrane</li> <li>Primary onlay bone grafting</li> </ul></ul>
MOI for elbow dislocation?
“think of PLRI: supination, valgus, axial load<div><br></br></div><div><img></img><br></br></div>”
Mason classification RH Fracture?
“<img></img>”
What remains intact in VPMRI?
MCL, RH<div><br></br></div><div><ul> <li>MOI: Fall backwards onto pronated outstretched hand, varus, axial load</li> <ul> <li>Mechanism (in the name): varus/posteromedial rotation with axial load</li> <li>Results in LCL rupture and compression of AMCF</li> </ul></ul></div>
DDX Medial Elbow Pain
<ol> <li>ucl injury (acute rupture, chronic)</li> <ol> <li>Valgus instability</li> </ol> <li>ulnar neuritis (as per reasons listed above)</li> <li>flexor-pronator tendonitis (medial epicondylitis)</li> <li>medial epicondyle apophysitis (peds)</li> <li>valgus extension overload with posterior olecranon impingement due to osteophyte formation</li> <li>olecranon stress fracture</li> <li>ocd of capitellum</li></ol>
important ddx for stiff elbow?
INFECTION - RULE OUT!
Treatment options for stiff elbow or arthritic elbow?
“<ul> <li>Arthritis</li> <ul> <li>Debridement and capsule release/resection</li> <ul> <li>Open: column procedure</li> <li>Arthroscopic</li> </ul> <li>RA: synovectomy +/- RH excision</li> <li>Fusion</li> <li>TEA</li> </ul> <li>Stiffness</li> <ul> <li>R/O Infection</li> <li>MUA if <3/12 with no progression with physio</li> <li>Column procedure: lateral +/- medial</li> <ul> <li>Consider releasing posterior bundle MCL for deep flexion</li> <li>Ulnar nerve release:</li> <ul> <li>Symptoms pre-op</li> <li>Increasing ROM>50 deg</li> <li>Contracture >90 deg</li> </ul> </ul> <li>Post-op Rads for HO: 700cGy (7Gy)</li> </ul> </ul> <ul> <li><img></img></li></ul>”
pathoanatomy of epicondyilitis? tendons involved in lateral vs medial?
<ul> <li>Non-inflammatory, degenerative angiofibroblastic hyperplasia</li> <ul> <li>Inadequate healing response to microtears</li> </ul><li>lateral: ECRB</li><li>medial: FCR, PT, FCU</li><li>80-90% will improve at 1 year</li></ul>
options for synostosis of BBFA interposition?
<ul> <li>Excision of synostosis +/- interposition grafting</li> <ul> <li>Fat, muscle, fascia, bone wax, silicone, polyethylene</li> <ul> <li>Non-vascularized fat graft not recommended due to risk of displacement</li> </ul> </ul> <li>No good high quality evidence</li></ul>
Complications after distal biceps tendon repair
- LABCn palsy (most common)<div>- Incisional pain</div><div>- Radioulnar synostosis</div><div>- PIN palsy</div>
What are the static and dynamic stabilizers of the elbow? Primary and secondary?
Primary static constraints:<div>1. Ulnohumeral articulation</div><div>2. Anterior bundle of the MCL</div><div>3. LCL complex</div><div><br></br></div><div>Secondary static constraints:</div><div>1. Radiocapitellar articular</div><div>2. CFO</div><div>3. CEO</div><div>4. Capsule</div><div><br></br></div><div>Dynamic constraints</div><div>1. Triceps</div><div>2. Anconeus</div><div>3. Brachialis</div>
What is the anatomy and function of the MCL?<div>- Function</div><div>- Origin</div><div>- Insertion</div>
Function<div>- Primary static stabilizer. Resists valgus.</div><div>- Anterior band is tight in extension</div><div>- Posterior band is tight in flexion</div><div><br></br></div><div>Origin</div><div>- Anterior, inferior and lateral aspect of the medial epicondyle</div><div>- <b>Posterior to the elbow axis of rotation</b></div><div><br></br></div><div>Insertion</div><div>- Sublime tubercle and UCL ridge (ridge extends distally as the ligament tapers out)</div><div>- Recently shown to have a longer and distally tapered insertion (extending beyond the sublime tubercle)</div>
What is the anatomy of the LUCL?<div>- Function</div><div>- Origin</div><div>- Course</div><div>- Insertion</div>
“Function<div>- Primary static stabilizer - resists varus</div><div>- Resists PLRI</div><div><br></br></div><div>Origin</div><div>- CENTER of capitellum, ANTERIOR to lateral epicondyle</div><div><br></br></div><div>Course</div><div>- Attached to the annular ligament, located at the 8-9 o’clock position of the radial head</div><div>- Acts as a hammock to the radial head</div><div><br></br></div><div>Insertion</div><div>- From lesser sigmoid notch to the supinator crest</div><div>- Proximal edge is 7mm distal to the proximal radial head</div>”
