Elbow

Question 1

Articulations of elbow

Answer 1

Humeroradial
Ulnohemeral
Superior radioulnar

Question 2

Humeroradial joint

Answer 2

Formed by radial head and capitellum of the humerus

Question 3

Ulnohermeral joint

Answer 3

Ulnar notch and trochlea of the humerus

Question 4

Ossesous anatomy provides stability in ___ and ___ of flexion

Answer 4

<20°

> 120°

Question 5

Stable joint due to

Answer 5

Strong fibrous synovial capsule
Collateral ligaments
Muscular attachments

Question 6

Lateral epicondylitis - in general

Answer 6

AKA - tennis elbow
An irritation, tendinosis and inflammation of the musculotendinous attachments of the long extensor muscles of the wrist and hand at the lateral epicondyle
The extensor carpi radialis brevis M. is most often involved
Most common cause of adult elbow pain

Question 7

Lateral epicondylitis - RF

Answer 7

Smoking
Obesity
40-50yo
Repetitive movements for at least 2h daily
Forceful activity - managing physical loads over 20kg

Question 8

Lateral epicondylitis - exam

Answer 8

Swelling over lateral elbow
Localized tenderness over the lateral epicondyle and proximal wrist extensor muscle mass
Pain with resisted wrist extension with the elbow in full extension
Pain with passive terminal wrist flexion with the elbow in full extension

Question 9

Lateral epicondylitis - tx

Answer 9

Observation - s/s may last 6 months to 2 yrs
Activity modification / biomechanics
Counter force bracing - wear 6-10 cm distal to elbow joint
Splints to reduce wrist flexion / extension
PT / OT
NSAIDs - oral / topical
Steroid injection
Platelet-rich plasma injection

Question 10

Lateral epicondylitis - management

Answer 10

Over 90% of cases can be managed non-operatively

X-ray to r/o bony abnormality or calcification

Question 11

Lateral epicondylitis - when to refer to ortho

Answer 11

Severe pain or marked dysfunction > 6 months
Failure of conservative management, including PT/OT
Requested

Question 12

Medial epicondylitis - in general

Answer 12

AKA - golfer’s elbow
Less common
An irritation, tendinosis and inflammation of the musculotendinous attachments of the long flexor muscles of the wrist and hand at the medial epicondyle

Question 13

Medial epicondylitis - exam

Answer 13

Localized tenderness over the medial epicondyle and proximal wrist flexor muscle mass - not the MCL
Pain with resisted wrist flexion with the elbow in full extension
Pain with passive terminal wrist extension with the elbow in full extension

Question 14

Olecranon bursitis - etiology

Answer 14

Direct injury or trauma
Prolonged pressure
Overuse or strenuous activity
Crystal-induced arthropathy - longstanding or tophaceous gout
Inflammatory arthritis such as RA or spondyloarthritis
Infection (septic bursitis) - this can occur due to transcutaneous transit of bacteria from penetrating injury or microtrauma (most commonly) or hematogenous seeding (less commonly)
Hemorrhage

Question 15

Olecranon bursitis - exam

Answer 15

Obvious swelling and inflammation
Possibly warmth and erythema
Pain (or not)
Look closely for overt abrasion or puncture wound

Question 16

Olecranon bursitis - imaging

Answer 16

Not necessary unless you suspect a foreign body

Question 17

Olecranon bursitis - aspiration and analysis

Answer 17

Palpable fluid
R/o infection
Dx microcrystalline d/o
examine the fluid and note color, thickness and sediment
Gram stain
Anaerobic / aerobic culture
Cell count
Crystal ID
Fungal and mycobacterium in immunosuppressed pts, gardeners and fishermen

Question 18

Olecranon bursitis - tx

Answer 18

If high suspicion of infection, begin abx

- >80% are S. aureus and other G+ organisms, but Gram stain is (+) only ub 50-66% of cases

Question 19

Olecranon bursitis - tx (mild)

Answer 19

Clindamycin
Doxycycline
Bactrim

Question 20

Olecranon bursitis - tx (severe)

Answer 20

Hospitalization

IV vancomycin + Zosyn or Ancef

Question 21

Olecranon bursitis - indications for sx

Answer 21

Inability to adequately aspirate
Recurrent bursitis
Presence of foreign body
Adjacent skin/soft tissue infection
Ill pt

Question 22

Distal Biceps Tendon

Answer 22

Attaches to the radial tubercle just distal to radial head

Major function is to supinate the forearm and also a secondary elbow flexor

Question 23

Distal Biceps Tendon Rupture - MOI

Answer 23

Usually forceful lifting

Question 24

Distal Biceps Tendon Rupture - presentation

Answer 24

Sudden pain in AC fossa
May have felt a pop
Swelling and ecchymosis in the AC fossa

Question 25

Distal Biceps Tendon Rupture - exam

Answer 25

Tenderness over the radial tubercle, deep in the AC fossa Pain / weakness with resisting flexion and supination of the forearm May have Popeye sig, but less reliable than a proximal tear Squeeze test Hook test

Question 26

Squeeze test

Answer 26

Firm squeeze of biceps muscle belly causes forearm supination

Question 27

Hook test

Answer 27

The pt flexes the affected elbow to 90° with the forearm fully supinated The examiner then attempts to "hook" the distal biceps tendon with their index finger and pull it forward

Question 28

Distal Biceps Tendon Rupture - imaging

Answer 28

MRI of elbow

Question 29

Distal Biceps Tendon Rupture - tx

Answer 29

Referral to ortho ASAP Most require sx unless low demand pt

Question 30

Elbow dislocation - in general

Answer 30

Classified according to the direction of the distal bone Posterior dislocations are the most common type (80-90%) Predominantly 10-20yo Both collateral ligaments are disrupted

Question 31

Elbow dislocation - MOI

Answer 31

Axial force applied to the extended elbow

Question 32

Elbow dislocation - presentation

Answer 32

Shortened extremity | Elbow in slight flexion

Question 33

Elbow dislocation - imaging

Answer 33

Obtain pre- and post-reduction radiographs

Question 34

Elbow dislocation - exam

Answer 34

Always check NV status before and after reduction | Watch for compartment syndrome

Question 35

Elbow dislocation - tx

Answer 35

Elbow should be splinted in flexion and pronation after reduction Early immobilization is important to prevent muscle contractures Refer to ortho to r/o more complex injuries

Question 36

Cubital tunnel syndrome - definition

Answer 36

An ulnar neuropathy caused by compression at the cubital tunnel along the medial elbow

Question 37

Cubital tunnel syndrome - MOI

Answer 37

Swelling from trauma or PG Osteophytes about the elbow Arthritis Repeated microtrauma or pressure

Question 38

Cubital tunnel syndrome - Presentation

Answer 38

Numbness and tingling in the fourth and fifth digits Medial elbow pain Medial forearm pain Nocturnal numbness and paresthesia Worsening with elbow and/or repeated wrist flexion

Question 39

Cubital tunnel syndrome - exam

Answer 39

May have weakness of the innervated muscles (interossei, adductor pollicis, the hypothenar eminence, and flexor carpi ulnaris. Look for muscle wasting / atrophy. May have a positive Tinel's sign at the elbow Elbow flexion test Fell the medial elbow during flexion and extension for subluxing nerve Sensation testing

Question 40

Tinel's sign at the elbow

Answer 40

Tapping over the tunnel causes / increases s/s

Question 41

Elbow flexion test

Answer 41

Hyperflexion at elbow and put pressure on cubital tunnel

Question 42

NCS

Answer 42

Externally applied stimuli and analysis for the consequent neurophysiologic responses of individual peripheral nerves

Question 43

NSC are used to

Answer 43

Dx focal and generalized d/o of peripheral nerves Aid in the differentiation of primary nerve and muscle d/o Classify peripheral nerve conduction abnormalities due to - axonal degeneration - demyelination - conduction block Tracks progression regarding clinical course and efficacy of tx

Question 44

NCS - goals in Cubital tunnel syndrome

Answer 44

Localized the lesion to the ulnar N at the elbow Determine the character and severity of the injury Aid in prognosis Examine for the presence or absence of alternative dx

Question 45

Cubital tunnel syndrome - tx (non-operative)

Answer 45

PT/OT Protective pad Night splint Nerve glide exercises

Question 46

Cubital tunnel syndrome - tx (sx)

Answer 46

Convincing clinical weakness, sensory loss NCS evidence of moderate to severe degree Moderate to severe progressive s/s for 6m despite conservative measures

Question 47

Olecranon fx - MOI

Answer 47

Bimodal - high energy injuries in young Low energy fall in the elderly A direct blow or as an avulsion injury with a forceful triceps contraction

Question 48

Olecranon fx - presentation

Answer 48

Pain Swelling Ecchymosis Pain with elbow extension

Question 49

Olecranon fx - exam

Answer 49

May feel palpable defect | Inability to extend elbow - loss of extensor mechanism

Question 50

Olecranon fx - imaging

Answer 50

X-ray (best viewed on lateral) | CT by ortho if sx is planned

Question 51

Olecranon fx - tx

Answer 51

Immobilization if the fx is non-displaced and the extensor mechanism is still intact ORIF

Question 52

Radial head fx - MOI

Answer 52

Most commonly from longitudinal loading from a fall on an outstretched arm

Question 53

Radial head fx - imaging

Answer 53

If fx not apparent, look for fat pad or sail sign on radiograph

Question 54

Radial head fx - the Mason classification

Answer 54

Type I - non-displaced Type II - single, large displaced fragment Type III - comminuted Type IV - fx associated with an elbow dislocation

Question 55

Radial head fx - tx

Answer 55

Type I - non-sx with early motion Type II, with near normal motion: <2mm displacement, no other injuries, non-sx Type II, with any associated injuries or mechanical block - ORIF Type III - fragement excision or radial head prosthesis Type IV - follows above guidelines

Question 56

Nightstick fx - in general

Answer 56

An isolated ulna shaft fx | Usually from contact, not a fall

Question 57

Nightstick fx - tx

Answer 57

``` Non-operative casting if - <50% displacement - <10% angulation - no radial head dislocation - located within the distal 2/3 of ulna Refer ```