Elbow Flashcards
(165 cards)
1
Q
What type of joint is the elbow?
A
Trochoginglymoid (combo hinge and pivot)
2
Q
What percentage of elbow stability comes from the bone structure?
A
50%
3
Q
Anterior elbow symptoms suggest which conditions?
A
Ant capsule sprain, distal biceps tendon issues, dislocation, pronator syndrome (primarily throwers)
4
Q
Medial elbow symptoms suggest which conditions?
A
MET (medial elbow tendinopathy), UCL sprain, ulnar nerve injury, flexor-pronator muscle injury, fx, Little League elbow (in young), valgus extension overload
5
Q
Posteromedial elbow symptoms suggest which conditions?
A
Olecranon tip stress fx, posterior impingement (throwers), trochlea chondromalacia
6
Q
Posterior elbow symptoms suggest which conditions?
A
Olecranon bursitis, olecranon process stress fx, triceps tendinopathy
7
Q
Lateral elbow symptoms suggest which conditions?
A
Capitulum fx, LET, RCL sprain, osteochondral degenerative changes, osteochondritis dessecans (Panners disease), posterior interosseous nerve syndrome, radial head fx, radial tunnel syndrome, synovitis
8
Q
Forearm symptoms suggest which conditions?
A
W/ gradual onset can include radius or ulna stress fx, radial tunnel syndrome, cubital tunnel syndrome, and brachialis tendinopathy
9
Q
Pronator teres syndrome
A
Compression of median nerve by pronator teres
Symptoms: - Tenderness over PT muscle and pain with resisted pronation of the forearm
- Weakness could be present with abduction of the thumb as well as impairment to the pincer muscles
- Sensation changes may also be experienced in the first three fingers and the palm
10
Q
Difference between Panners disease and OCD?
A
Panner disease occurs in school-age children (7-12 y.o.) as opposed to adolescents (10-20 y.o.) and does not produce a loose foreign body
11
Q
Panner’s Disease
A
Young boys younger than 10 y/o
- Bone growth disorder (osteochondrosis) of the humeral capitellum
- Lateral elbow pain, stiffness, decreased ROM (especially EXTENSION)
12
Q
Osteochondritis Dissecans (OCD)
A
Young throwers (ages 12-14 y.o.)
- Inflammatory pathology of bone and cartilage. This can result in localized necrosis and fragmentation of bone and cartilage
- Lateral elbow pain, stiffness, popping, giving way, locking, instability, swelling
13
Q
Lower motor neuron lesion symptoms
A
- Muscle atrophy
- Fasciculations (muscle twitching)
- Diminished DTR
- Decreased tone
- Negative Babinski
- Flaccid paralysis
14
Q
Pancoast syndrome
A
Malignant neuoplasm of the superior sulcus of the lung
- Ipsilat shoulder/arm/hand pain
- Weakness and atrophy of the thenar eminence
- Horners syndrome (partial ptosis (drooping or falling of upper eyelid), miosis (constricted pupil), and facial anhidrosis (loss of sweating
15
Q
Normal carrying angle:
Men
Women
A
Men: 11-14°
Women: 13-16°
16
Q
Colles vs smiths fx
A
Colles is wrist extended, smiths is with wrist flexed
17
Q
POLICE meaning
A
Protection
Optimal Loading
Ice
Compression
Elevation
Used to initially manage acute conditions
18
Q
Only highly recommended special tests for the elbow (2)
A
Tinel, Elbow flexion tests for cubital tunnel syndrome
19
Q
Cubital tunnel is formed between the 2 heads of which muscle?
A
Flexor carpi ulnaris
20
Q
Elbow flexion test:
- Tests for?
- + result
A
Cubital tunnel syndrome (ulnar nerve)
+ = for new or worsening paresthesias
21
Q
Pressure provocation test:
- Tests for?
- + result
A
Cubital tunnel syndrome (ulnar nerve)
Compresses ulnar nerve in elbow flexion test position for 30”
+ = N/T in 4-5th digits
22
Q
Tinels sign:
- Tests for?
- + result
A
Cubital tunnel syndrome (ulnar nerve)
+ = Tingling or electrical sensations to 4-5th digits
23
Q
Scratch Collapse test:
- Tests for?
- + result
A
Cubital tunnel syndrome (ulnar nerve)
+ = Loss of ER tone on affected side after “scratching” the cubital tunnel
24
Q
Crossed finger test:
- Tests for?
- + result
A
Cubital tunnel syndrome (ulnar nerve)
+ = inability to cross middle finger over index
25
Shoulder internal rotation test:
- Tests for?
- + result
Cubital tunnel syndrome (ulnar nerve)
+ = any symptoms attributable to cubital tunnel syndrome occurs within 10"
26
Chair sign:
- Tests for?
- + result
Posterolateral rotary instability of elbow (PLRI)
+ = apprehension to push up
27
Special tests for cubital tunnel syndrome (6)
1) Elbow flexion
2) Pressure Provocation
3) Tinel sign
4) Scratch collapse
5) Crossed finger
6) Shoulder IR
28
PLRI stands for?
Posterior lateral rotary instability of the elbow
29
Special tests for PLRI (3)
1) Chair sign
2) Push-up sign
3) Table-top relocation
30
Special tests for UCL injury (3)
1) Valgus stress test
2) Milking maneuver (anterior band of UCL aka AUCL)
3) Moving valgus stress (chronic)
31
Special tests for Medial elbow tendinopathy (MET) (2)
1) Passive medial elbow tendinopathy (pain w/ PROM supination and wrist extension)
2) Active wrist flexion against resistance (MMT wrist flex)
32
LET stands for?
Lateral elbow tendinopathy
33
Special tests for lateral elbow tendinopathy LETS (3)
1) Cozen
2) Maudsley
3) Mill
34
Distal biceps tendon rupture is assessed with which special test
Biceps squeeze test (good - LR)
35
T/F: Inflammation is the cause of medial and lateral epicondylitis
False
They are often NOT inflammatory conditions and lack prostaglandin-mediated inflammation
Thought to be more degenerative conditions that likely involve both peripheral and CNS pathways
36
3 Etiologies of tendinopathy in the elbow
1) Vascular: focal areas of vascular compromise
2) Mechanical: Repetitive loading causes microscopic degeneration, fibroplasia, and eventually scar tissue
3) Neural modulation: Results from neurally-mediated mast cell degranulation and release of substance P
37
In terms of function, tendons can be classified as what 2 categories?
1) Positional (responsible for exact movements)
2) Energy-storing (locomotion and ballistic performance)
38
Progression of loading the tendons that are injured (resistance)
1) Isometrics (10" x 24 reps OR 40" x 6 reps)
2) Heavy, slow-motion resistance training
3) Endurance training to sustain compression loads (friction over the tendon and heavy stretching)
4) Introducing speed first and then energy-storying loads (plyometrics)
39
T/F: In LET conditions you don't need to look at c-spine and shoulder
False
To rule out use isometric wrist ext
40
Self-reported outcome measure for LET
Patient-rated tennis elbow evaluation (PRTEE)
Valid/reliable/sensitive
41
What nerve is commonly compressed at the arcade of Frohse
Posterior interosseous nerve
42
Standard of care for LETs includes:
1) NSAIDs
2) Cross friction massage
3) Electrical and thermal modalities
4) Therapeutic exercise
5) Bracing
6) Rest
NOTE: most studies are inconclusive as to the effectiveness of PT using the above interventions
43
Evidence for use of joint mobilization in LET treatment
Convincing substantiation show mobs can decrease pain and increased functional grip scores
44
Evidence for use of TFM in LET treatment
No sufficient evidence
Low-level benefits in later stages
45
Evidence for use of eccentric exercise in LET treatment
Limited but does suggest it is effective (more vs concentric with reducing pain and increasing strength)
46
Dosing of eccentric exercise in LET treatment
3 x 15 reps, 30" rest between sets
47
Evidence for use of electrophysical agents (US, ionto, pulsed electromagnetic field) in LET treatment
Little to NO evidence
48
Evidence for use of shockwave therapy in LET treatment
Not effective, less vs corticosteroids
49
Evidence for use of low-level laser in LET treatment
May help with pain in short-term vs placebo
50
LET treatment: stretching progression (jts)
Wrist (flex/ext), elbow (flex/ext), forearm (sup/pro)
51
LET treatment: strengthening progression (jts)
Wrist (ext/flex), Forearm (pro/sup), elbow (flex/ext)
52
Evidence for use of corticosteroid injections in LET treatment
High success rates for 6-8wks BUT then high recurrent rates and protracted recovery for long term
aka NOT good for long-term
53
Evidence for surgical intervention in LET management
Reserved for those who fail conservative tx
Evidence is insufficient effectiveness of surgery
54
How long post-op lateral epicondylar release can you start AROM and strengthening?
AROM: 2 wks, prior to that PROM of elbow
Strengthening: 3 wks, start w/ isometrics
55
Upcoming tx for LET and MET
PRP, Bone marrow aspirate concentrate (BMAC), collagen-producing cell injection
56
Bicipital tendinopathy is common in what population and age?
Athletic individuals >35 y/o
d/t repetitive hyperext of the elbow w/ pronation OR repetitive flex combined w/ stressful sup/pro
57
Bicipital tendinopathy symptoms
Pain over radial tuberosity, pain w/ elbow flex and supination (MMT)
58
Rehab of Bicipital tendinopathy includes 4 phases:
1) Rest
2) Stretching (scap mms, RTC, post GH jt capsule)
3) Eccentric strengthening of elbow flex and sup
4) Progressive return to sport or work
59
When does a distal bicep tear become chronic?
After 4 wks
60
Is early detection and intervention of distal bicep tear important?
Yes, delayed diagnosis may preclude primary repair and lead to chronic weakness
61
Common demographics for distal bicep tear
Male, 5th decade of life
62
Higher moment arm in what positions: Short head of biceps vs long head of biceps
SH: neutral and pronated
LH: supinated
63
Tests for diagnosing distal biceps tear
1) Hook test
2) Biceps squeeze test
3) Biceps crease interval test
64
Hook test for distal bicep tear
- Evidence
100% SN/SP, GREAT
Better vs MRI
65
Biceps squeeze test
- Evidence
SN 96%
66
Biceps crease interval
- Evidence
- positive test
- SN 92%/ SP 100%
- >6cm difference
67
Evidence for surgical repair of distal bicep tear:
- Partial
- Complete
Partial: trial conservative first, consider surgery if no improvement in 3-6months
Complete: surgery indicated
68
When can you start extension ROM of elbow post-op distal bicep repair
Start @90° flexion and increase by 10° weekly into extension
Start concentric triceps at wk 8
69
When to start isometrics of bicep post-op distal bicep repair
Week 12
70
Common findings for distal tricep tear
Inability to extend the arm overhead, loss of elbow extension strength
71
Non-surgical approach suggests immobilization for how long?
3 weeks
72
Known protocol for distal triceps repair (post-op)
None
73
When can someone return to full activities post-distal triceps repair
12 weeks approximately
74
3 types of olecranon bursitis
1) Aseptic (injury from direct trauma or sustained pressure)
2) Septic (infection)
3) Chronic (can be prolonged repetitive or secondary from comorbidities)
75
Common comorbidities that can cause chronic olecranon bursitis
DM, gout, pseudo-gout
76
Common diseases that can contribute to peripheral nerve trunk injury
DM, hypothyroidism, hereditary neuropathy, immune deficiency syndromes, RA, alcoholism
77
Nerve injury recovery (in mm) per day
- Proximal segments
- Distal segments
Prox: 2-3mm/day
Distal: 1-2mm/day
78
Double crush syndrome
Distinct compression at two or more locations along the course of a peripheral nerve that can coexist and synergistically increase symptom intensity
79
How to determine between single and double crush syndrome
Neuro exam in COMBO with nerve conduction tests
80
Fundamental sign of entrapment
Function loss with or without paresthesia and pain
81
Seddon: Neuropraxia
Mildest form of nerve injury
Focal segmental demyelination at the site of injury NO disruption of axon continuity
Sunderland: Grade I
82
Seddon: Axonotmesis
Moderate injury
Axon is disrupted in its myelin sheath. The neural tube, which consists of the endoperineurium and epineurium, remains intact
Sunderland: Grades II-IV
83
Seddon: Neurotmesis
Most severe PNI
Complete transection of a peripheral nerve.
Sunderland: Grade V
84
Non-operative tx is indicated in nerve entrapment cases with the following criteria:
- Frequency of symptoms
- 2 point discrim
- Atrophy
- Intermittent
- No change in 2 point
- No atrophy
85
Focus of non-operative tx of nerve entrapment
Avoiding provoking movements or prolonged positions, padding/splinting when needed for protection
86
Claw hand is typical of which PNI?
Ulnar
87
Prescribed exercises for median nerve
Thumb opposition, precision grip, digit strength
88
Prescribed exercises for Ulnar nerve
Key pinch, power grip, coordination
89
Prescribed exercises for Radial nerve
MCP jt extension, thumb abd, wrist ext
90
How to differentiate between CTS and Pronator Syndrome
Tinels test at wrist
Provocation through prolonged wrist flexion
Both negative in pronator syndrome
91
What nerve is compressed with abnormal okay sign?
Anterior interosseous nerve (AIN)
92
Posterior interosseous nerve (PIN) branches from which main nerve?
Radial
93
Anterior interosseous nerve (AIN) branches from which main nerve?
Median
94
AIN syndrome
aka Kiloh-Nevin's syndrome
Pain in the forearm accompanied commonly by the weakness of the index and thumb finger pincer movement
Isolated palsy of FPL, the index and long fingers of the FDP, and the pronator quadratus muscles of the forearm
95
PIN syndrome
Compression of posterior interosseous nerve (branch of radial) which innervates the extensor compartment of the forearm
- Motor loss but NO sensory loss
Weakness in finger and thumb extension
96
Radial Tunnel Syndrome (RTS)
Compressive neuropathy of the posterior interosseus nerve (PIN) in the radial tunnel
Pain WITHOUT motor or sensory pathology
JUST tenderness over radial tunnel
97
Tx for cubital tunnel syndrome
Activity mod (no excessive elbow flexion), protection (night splits 40-60° flex)
Key for exercises: DON'T reproduce distal nerve symtoms
98
Tx for pronator syndrome
Gentle massage along fibers to break adhesions
99
Tx for AIN syndrome
Rest, splinting (90° flexion)
100
Tx for PIN syndrome
Cock-up splint in COMBO w/ STM and neural glides
Wrist extensor stretching (elbow in full ext) is initiated after a spontaneous recover
101
Tx for radial tunnel syndrom
Splinting, avoid provoking positions (elbow ext and sup)
102
Can nerve glides be used as a stand alone tx for PNI?
No, must always be used in conjunction with sub/obj findings
103
When is decompression of a PNI warranted?
Chronic (3-4 months) AND have muscle atrophy, persistent sensory changes, persistent symptoms
104
Symptoms of elbow instability
Hx of recurrent painful clicking, snapping, clunking, or locking of the elbow (in ext/sup)
105
Evidence for non-operative management of UCL tears?
Shown not to increase the risk of recurrent instability
106
Tx for non-operative UCL tears
After rest and pain control:
- Immediate mobilization of elbow
- Dynamic brace (progressively increasing ext)
- Strengthening: start isometrics and progress
107
Valgus instability (UCL) presentation
- Pain worst in pronation
- Vague elbow discomfort
- Clicking and clunking
Typically from outstretched arm fall or throwers
108
Varus instability (RCL) presentation
- Most unstable feeling in supination
- May be associated tendinopathy
Typically from elbow dislocation, varus elbow stress (deformities), Iatrogenic causes (post-op lat epicondyle tendinopathy surgery)
109
ULC instability will be more painful/unstable in pronation or supination
Pronation
110
RLC instability will be more painful/unstable in pronation or supination
Supination
111
What is the elbow's most common instability?
Posterolateral rotary instability (PLRI)
112
PLRI is typically caused by what injury
Fall on outstretched arm
Tear of LUCL
113
Special tests for diagnosis of PLRI
1) Lateral pivot-shift (optimal @40° flexion)
2) chair sign
3) push-up test
4) Table-top relocation
114
Which is better for PLRI: non-operative vs operative
Nonoperative is often ineffective, mild cases may benefit but most go with surgery
115
Varus posteromedial rotary instability is caused by what MOI?
Valgus and axial load is applied with forearm in pronation
Can cause fx to ateromedial fact of coronoid and ruture of RCL
116
What is the most specific/sensitive test for varus posteromedial rotary instability (PMRI)?
Gravity-assisted varus stress test
117
Which is better for varus PMRI: non-operative vs operative
Non-op for mild cases (small fx of coronoid and NO humeroulnar sublux)
Large fx and sublux = surgery
Expect full ROM by wk 12
118
Posterior elbow impingement is also known as?
Pitchers elbow or valgus extension overload
119
Cause of posterior elbow impingement?
Typically build up of forces in post-med olecranon causing reactive bone formation (aka osteophytes)
120
Typical hx for posterior elbow impingement
- Hx repetitive throwing or overhead activity
- Limited elbow extension and locking/catching
- Crepitus and TTP over posteromedial olecranon
- Bony end-feel extension
121
Most sensitive test for posterior elbow impingement
Moving valgus stress test
122
Location of pain in little league elbow?
Medial epicondyle
123
Symptoms of little league elbow
- TTP medial epicondyle
- Acute motion loss and pain at end-ranges
With apophysitis:
- Recent increase in activity level
- Steady increase in discomfort during throwing and lingering aching
124
Recommendations for tx of little league elbow (non-op)
Rest for 2-3wks
No throwing or provoking activity
Total body conditioning
125
Osteochondritis dissecans (OCD) affects what part of the elbow
Capitulum (lateral humerus)
In 10-20 y/o adolescents
126
Stages of Osteochondritis dissecans (OCD)
1) Hyperemic bone, swelling of surrounding soft tissues
2) Epiphysis (end of the bone) deforms, sometimes w/ deformation
3) Necrotic bone replaced by granulation tissue
127
Heterotopic Ossification
Bone growth in atypical sites
aka Ectopic ossification or myositis ossificans
128
Typical cause of HO?
Direct elbow trauma or surgery
129
Clinical presentation of HO
- Limited A/ROM elbow flex/ext
- Painful/weak elbow flex/ext
- End-feels = rigid or abrupt
130
Prophylactic strategies for prevention of HO
Low-dose radiation and NSAIDS
131
Aggressiveness of passive elbow exercises in HO cases
Slow and progressive
132
Most common direction of elbow dislocations
Posterior
133
3 classifications of elbow dislocation
Anterior, posterior, divergent (U/R apart and disconnected from humerus)
134
Monteggia lesion or fx
Fx of prox ulna in combo with radial head dislocation or fx, can have coronoid process fx
135
Bado classification
To distinguish 4 types of Monteggia lesions
Type I: Ant disl. of radial head, fx to ulna (common in child/young adults)
Type II: Post disl. radial head, fx to ulna (adults)
Type III: Lat disl. radial head, fx to ulna metaphysis
Type IV: Disl. any direction, fx to ulna & radius
136
Nursemaids elbow
Partial displacement of annular ligament in children, from pulling on arm
137
Tx for radial head dislocation
Young: closed reduction
Adults: surgery
No need to splint non-operative unless unstable
Early ROM is important
138
Olecranon fracture MOI
Fall backward onto elbow
139
Intervention for non-op olecranon fx
Must be minimally or undisplaced fx
Goal: Allow triceps function while initiating early ROM
- Avoid extremes of elbow FLEXION for 2 months
- Avoid resistance for 3 months
140
Terrible triad injury of the elbow
1) Coronoid fx
2) Olecrenon fx
3) Radial head dislocation (post/lat)
141
Medial epicondyle fx common demographics
Adolescents and older children (typically associated with dislocation)
NOT common in adults
142
Which is better for medial epicondyle fx: non-operative vs operative
Undiplaced/minimally displaced = treated w/ immobilization
If valgus instability or ulnar nerve entrapment = surgery
143
What is NOT allowed in post-op medial epicondyle fracture repair for 4-6wks?
1) Elbow jt mobs
2) Strengthening - wrist flexors or pronators
3) Stretching - wrist flexors or pronators
4) Valgus stress to elbow
5) Lifting > 5#
144
Jakob classification of lateral epicondyle fractures
Stage I is non-displaced with an intact articular surface, goes through capitellar ossification center, min displacement (<2mm)
Stage II fracture extends through the articular surface (medial to capitellar ossification center) 2-4mm displacement
Stage III involves complete displacement
145
What stages of lateral epicondyle fractures can be managed non-operatively
Stage I and occasionally stage II if pinning is not needed
146
What is compartment syndrome
Increased tissue fluid pressure within an osseofascial compartment causing capillary blood perfusion to fall below level necessary for tissue viability
147
Which forearm compartments are at highest risk for developing ACS following trauma
Both deep flexor (affected more often) and superficial flexor anterior compartments
148
2 common injuries in UE leading to ACS
1) Supracondylar humerus fractures (children)
2) Distal radius fx (adults)
149
Tissue compartment's normal pressure
0-8mmHg
150
Capillary blood flow becomes compromised when tissue pressure reaches what level?
25-30mmHg
NOTE: can feel pain starting at 20mmHg
151
Signs of ACS
- Pain w/ palpation
- Swollen/tense compartment w/ pink or red skin
- Pain w/ passive stretch of muscles in involved compartment
- Sensory deficits (30min-2hrs after onset)
- Muscle weakness (2-4hrs after onset)
- Possible absence of radial/ulnar pulses
152
Signs of Chronic or exertional CS
- Pain and firmness w/ palpation of muscles
- Pain with passive stretch
Comes on w/ activity and eases w/ rest
153
CRPS symptoms
- Allodynia or hyperaglesia
- Alterations in sweating, skin color, skin temp, trophic changes in skin/hair/nails
- Stiffness/swelling
154
Intervention for CRPS should include:
- Cognitive therapy
PT:
- Gentle AAROM
FOLLLOWED by:
- Sensory threshold techniques (vibration, fluidotherapy, light and heavy pressures, TENS, contrast bath)
AROM and strengthening exercises should be as tolerated and progressed slowly. Same for weight bearing and active loading
155
Symptoms of elbow OA:
Decreased ROM, stiffness, weakness, instability, decrease in quality of life
156
Capsular pattern of elbow
Elbow flexion, elbow extension
157
Non-op tx of elbow OA should consist of:
NSAIDs, PT, and cortisone injections
158
Types of joint arthroplasty in elbow (TEA)
1) Linked semi-constrained aka sloppy hinge (hinge connecting humeral and ulnar components)
2) Unlinked (independent parts)
159
Post-traumatic stiff elbow is defined as what ROM?
<120° elbow flexion
Loss of >30° elbow extension
160
Müller et al compared effectiveness of static, dynamic, and static-progressive splints on elbow stiffness; which which was the best
Static-progressive stretching 3x for 30 mins/day in each direction should be first line of tx
(in post-traumatic or post-op situations)
161
Mnemonic for C8-T1 nerve root muscle innervation in hand
AbOF the Law
aka above the law that the hand intrensics are all supplied by ulnar nerve
162
AbOF the Law
Ab- Abductor pollicis brevis
O- Opponens pollicis
F- Flexor pollicis brevis
Law - Lateral 2 lumbricals
163
Saturday night palsy
Compression of radial nerve
"Wrist drop"
164
Martin-gruber anastomosis
Connection of median and ulnar nerve in forearm
165
