Elbow and Forearm Flashcards
(38 cards)
1
Q
Extensors vs. Flexors insertion
A
- Extensors insert on lateral epicondyle
- Flexsors insert on medial epicondlye
2
Q
Location of an elbow effusion?
A
-Always at the antecubital fossa
3
Q
What does normal ROM exclude?
A
-Intra-articular pathology
4
Q
What is the primary complaint of an intra-articular process?
A
“I can’t straighten my elbow”
***Loss of smooth elbow motion in athletes is suspicious for osteonecrosis (osteochondritis dissecans) of the humerus
5
Q
Inspection
A
- swelling over the olecranon–> olecranon bursitis
- “popeye” deformity in upper arm–> ruptured biceps tendon
- Signs of inflammation or effusion
- Carrying angle: 5-10 degrees men, 10-25 degrees women
- “Gunstock deformity”–> cubitus varus deformity
6
Q
Referred pain to the elbow
A
- Cervical radiculopathy (esp C5)–> elbow pain
- Rotator cuff can cause referred pain to the elbow
- **85% of cervical radics involve c6 and c7–> refer to the hand
- **Key element in the history is that elbow movement would have no effect on pain complaints.
7
Q
How to assess the Ulnar Collateral Ligament?
A
- Valgus Stress test
- Moving valgus stress test
- Milking maneuver
8
Q
Moving Valgus Stress Test
A
- Also assesses UCL, may be more sensitive
- Shoulder abducted, arm externally rotated, elbow flexes maximally
- Examiner provides constant valgus force while elbow is quickly extended from this position
- Positive test is reproduction of medial elbow pain which is worse from 120-70 degrees of elbow flexion
9
Q
Valgus Stress test
A
- apply valgus stress with elbow at full extension and 20-30 degrees of flexion
- positive test is medial elbow pain or increased laxity
***positive test in full extension implies more extensive injury (i.e. ligament and capsular involvement).
10
Q
Milking maneuver
A
- Also assesses UCL
- elbow flexed, valgus force applied to elbow by supporting the elbow and pulling back on the thumb
- positive test is medial elbow pain
11
Q
How to assess the Radial Collateral Ligament?
A
- Varus stress test
- Lateral pivot shift test
12
Q
Varus stress test
A
- Assesses radial (or lateral) collateral ligament
- Apply varus stress with elbow at full extension and 20-30 degrees of flexion
- Positive test is reproduction of lateral elbow pain or increased laxity compared to the other side
***Injury to the RCL is rare.
13
Q
Lateral pivot shift test
A
- Assesses for posterolateral rotorary instability or injury to the ulnar part of radial (lateral) collateral ligament
- Pt supine, arm is extended overhead and supinated (palm down when over head)—> examiner then provides valgus and axial force while flexing the elbow.
- Positive test is feeling of apprehension or impending dislocation
- Under general anesthesia may produce “clunk” from subluxation at around 40 degrees of elbow flexion
14
Q
Tinnel Sign
A
- “tapping” over the medial epicondylar groove
- positive test is radiation of pain into the 4th and 5th digits imply ulnar neuropathy
- high false positives
15
Q
Pinch Grip Test
A
- “make an okay sign”
- inability to do so signifies AIN syndrome–> weakness of the FPL and FDP
16
Q
Lateral Epicondylosis
A
- “Tennis elbow”
- Overuse of the extensor/supinator muscles in forearm
- Thought to be tendinosis of the ECRB
- Exam findings: tender over or just distal to lateral epicondyle and positive Cozen test
- May cause neurologic symptoms radiating to forearm/hand due to irritation of sensory brach of radial nerve (controversial)
17
Q
What test do you use for lateral epicondylosis?
A
Cozen Test
- elbow extended, hand pronated–> have patient resist wrist
- positive test is lateral elbow pain
- **can also do resisted supination
-pt may also have pain with passive wrist flexion and report pain when trying to hold a heavy book when hand is pronated, pain with hand shake, etc.
18
Q
Medial Epicondylosis
A
- Golfer’s elbow
- Overuse injury of flexor/pronator muscles in forearm, occasionally related to acute injury
- exam findings: pain over or just distal to medial epicondyle, pain with resisted wrist flexion/pronation, may have pain with passive wrist extension
- **Less common than lateral epicondylitis
- **Ulnar nerve symptoms reported in up to 50%
BUT with ulnar neuropathy you get CONSTANT numbness!
19
Q
Radial Tunnel Syndrome
A
- controversial
- compression of radial nerve near elbow– generally weakness is not present
- some overlap with lateral epicondylosis- coexist in ~5% of patients
- tenderness is 4-5cm DISTAL to lateral epicondyle, pain reproduced with resisted middle finger extension and/or resisted supination
20
Q
PIN Syndrome
A
PIN- pure motor branch of the RADIAL nerve that arises near the elbow joint
- patient presents with WEAKNESS of radial nerve muscles
- always spares the brachioradialis and the ECRL, usually spares the ECRB and supinator
21
Q
What is arcade of frohse?
A
- formed from proximal tendinous origin of supinator muscle
- MC site of PIN compression
22
Q
What is a Monteggia fracture?
A
- fracture of proximal 1/3 of ulna with associated dislocation of radial head
- may be associated with PIN syndrome
23
Q
What are the exam findings of PIN syndrome?
A
- Radial deviation with wrist extension (KNOW THIS!)
- May have pain over lateral epicondyle or more distally near arcade of Frohse
- Weakness of thumb/finger extension at MCP joint, also weakness of wrist extension due to involvement of ECU (radial n.)
Injection options:
-PIN block- If patient has pain may inject 3 cm proximal to wrist joint and 1 cm ulnar to Lister’s tubercle
24
Q
Why do you get radial deviation with wrist extension in PIN syndrome?
A
- Because ECRL and ECRB come off in the same area–> spared!!
- Therefore, you get radial deviation due to unopposed action.
25
What is Monteggia fracture associated with??
ALWAYS think PIN syndrome--> high incidence!
26
Ulnar (or medial) Collateral Ligament Injury
- Usually in throwing athletes, esp pitchers.
- Assessed by valgus stress, moving valgus stress, or milking maneuver
- >2mm separation in valgus stress radiographs c/w injury, however, MRI is test of choice
-Tommy John surgery: UCL reconstruction
27
Little Leaguer's Elbow
- repetitive microtrauma to the medial epicondyle leading to medial epicondyle apophysitis or medial epicondyle fragmentation
- Usually seen with repetitive VALGUS stress in adolescents (pitchers)
- Exam usually reveals pain with valgus stress test and no instability, tenderness over medial epicondyle
- Treatment: conservation vs. surgical (if avulsion >3-4 mm)
28
Panner's Disease
- Osteochondrosis or AVN of elbow (capitellum) seen in young boys (age 5-12), usually <10 years
- Exam- tenderness and swelling of lateral aspect of elbow, limited elbow extension (typically lack 20-30 degrees from full extension)
- Treatment: immobilation followed by gradual ROM
29
What disease should you think of in a boy <10 years old who can't fully straighten the elbow?
Panner's disease--> AVN of the elbow
30
What disease should you think of in a boy 10-16 years old who have elbow pain?
Osteochrondritis dissecans (OCD)
31
Nursemaid's Elbow
- Subluxation of the radial head usually seen in pre-school age children
- MC ortho injury in children <2 years, girls>boys
- Usually caused by swinging the child
- Typically hold arm in flexion/pronation across the body and the child will not use the arm
- Reduced by supination/elbow flexion and /or hyperpronation
32
Olecranon Bursitis
- located at the tip of the elbow/olecranon process- may be affected by gout, RA, sepsis, or trauma (usually repetitive from leaning on elbows/laying carpet, etc.)
- Dx by identifying cystic swelling over the olecranon process
- KEY: Elbow ROM is preserved!!!
- Aspiration may be performed
- Rx: give elbow pad
33
Ulnar Neuropathy
MC site of entrapment is at the elbow/cubital tunnel
Exam findings:
- Elbow flexion test: pt holds arm in >90 degrees elbow flexion, supination, and wrist extended--> reproduction of pain/paresthesias in <60 sec is positive
- positive tinel's at the elbow (false positives)
- Atrophy of FDI/weakness of ulnar innervated muscles
- Wartenberg sign (inability to adduct 5th digit)--> wallet sign!
- Froment's sign (inability to do lateral pinch grip)
34
What borders the Cubital tunnel?
- bordered by the medial epicondyle, olecranon
| - aponeurosis of FCU and Osborne's ligament form the roof of the tunnel
35
AIN Syndrome
- pure motor branch of median nerve
- Innervated the FPL, 2ng and 3rd digits of FDP, and pronator quadratus
- Patient unable to make "okay" sign--> positive pinch grip test
36
What are the sites of AIN compression?
- Pronator teres (deep head)- MC
- Thrombosed radial or ulnar artery
- Fascial band at origin of FDS
- Gantzer's muscle (accessory head to FPL)
- Other (enlarged bicipital tendon bursa, other aberrant accessory muscles)
37
Triceps Tendonitis
- overuse injury 2/2 repetitive arm extension
- posterior elbow pain with tenderness at insertion of triceps tendon
- pain with resisted elbow extension (activates the triceps)
38
Distal biceps tendonitis
- Overuse injury due to repetitive elbow flexion or supination vs. eccentric overload injury
- may lead to ruptured biceps tendon- "popeye deformity"
- Pain in antecubital fossa, pain with resisted elbow flexion or supination
