PE General The patient is in no acute ____, mood and affect are _____, alert and oriented times ____. The patient is ambulating with a smooth and symmetric gait putting ____ weight on both lower extremities with good coordination and balance.

The patient is in no acute distress, mood and affect are appropriate, alert and oriented times three. The patient is ambulating with a smooth and symmetric gait putting full weight on both lower extremities with good coordination and balance.

Tenderness to Palpation Lateral ______? Medial ______? Radial H____? Ol______? Radial head is best palpated with the forearm in what position?

Lateral epicondyle? Medial epicondyle? Radial head? Olecranon? Radial head is best palpated with the forearm in supination

Strength Elbow as well as distally with ____ IP flexion, f______ abduction/adduction, and ______ extension. Sensation Intact to _____ touch distally without any focal (1) or (1). Stability V_____/V_____ Instability?

Elbow as well as distally with thumb IP flexion, finger abduction/adduction, and index extension. Intact to light touch distally without any focal numbness or tingling. Varus/Valgus Instability?

Lateral Epicondylitis Diagnosis Physical P_____ tenderness → _ _ _ _ at the lateral epicondyle _______ grip strength (sometimes) Normal se________ examination Provocative tests: Resisted _____ extension with elbow fully extended Resisted extension of the long ______ Maximal _______ of the wrist Passive wrist flexion in ___nation causes pain at the ______

Point tenderness → ECRB at the lateral epicondyle Decreased grip strength (sometimes) Normal sensory examination Provocative tests: Resisted wrist extension with elbow fully extended Resisted extension of the long fingers Maximal flexion of the wrist Passive wrist flexion in pronation causes pain at the elbow

Orthopedics Elbow Flashcards by Felita Salim

Normal Anatomy

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PE General

The patient is in no acute ____, mood and affect are _____, alert and oriented times ____.
The patient is ambulating with a smooth and symmetric gait putting ____ weight on both lower extremities with good coordination and balance.

The patient is in no acute distress, mood and affect are appropriate, alert and oriented times three.
The patient is ambulating with a smooth and symmetric gait putting full weight on both lower extremities with good coordination and balance.

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PE Inspection

Both elbows appear ______.
_____ is intact about both elbows without erythema.
Patients with elbow effusion generally hold the elbow flexed __-__degree (position of m______ capsular distention)
“____ness” of the elbow “_____ spot” (triangle formed by radial head, lateral epicondyle, and olecranon)
Olecranon _______?

Both elbows appear symmetric.
Skin is intact about both elbows without erythema.
Patients with elbow effusion generally hold the elbow flexed 70-80degree (position of maximum capsular distention)
“Fullness” of the elbow “soft spot” (triangle formed by radial head, lateral epicondyle, and olecranon)
Olecranon bursitis?

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Tenderness to Palpation

Lateral ______? Medial ______? Radial H____? Ol______?
- Radial head is best palpated with the forearm in what position?

Lateral epicondyle? Medial epicondyle? Radial head? Olecranon?
- Radial head is best palpated with the forearm in supination

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Range of Motion

Flexion/Extension: __ (extension)-___ (full flexion) (normal)
- “_______” → 30-130 (like feeding themselves)
Pronation/Supination:
- normal pronation: __
- normal supination __
- functional: __ pronation, __ supination

Flexion/Extension: 0 (extension)-140 (full flexion) (normal)
- “Functional” → 30-130 (like feeding themselves)
Pronation/Supination:
- normal pronation: 75
- normal supination 85
- functional: 50 pronation, 50 supination

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Strength

Elbow as well as distally with ____ IP flexion, f______ abduction/adduction, and ______ extension.

Sensation

Intact to _____ touch distally without any focal (1) or (1).

Stability

V_____/V_____ Instability?

Elbow as well as distally with thumb IP flexion, finger abduction/adduction, and index extension.
Intact to light touch distally without any focal numbness or tingling.
Varus/Valgus Instability?

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Common Conditions of the Elbow

(6)

Lateral epicondylitis (“tennis elbow”)

Medial epicondylitis (“golfer’s elbow”)

Ulnar neuropathy / Cubital tunnel syndrome

Olecranon bursitis

Nursemaid’s elbow

Radial head fracture

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Lateral Epicondylitis “Tennis Elbow”

____ common cause of elbow pain
- Usually _______ arm
- 1-3% of adults annually
- __ - __ yrs-old
- Men __ Women
Caused by over___
Can be associated with r_____ sports, but more commonly it is not
Etiology:
- Inflammation of the _ _ _ _ tendon
- Sometimes associated with “micro_____”
Many “treatments” aka none of them work well
- Always (1)
BUT, it can take a _____ for the symptoms to resolve
Treatments help the symptoms and may accelerate pain resolution

Most common cause of elbow pain
- Usually dominant arm
- 1-3% of adults annually
- 35 - 50 yrs-old
- Men = Women
Caused by overuse
Can be associated with racquet sports, but more commonly it is not
Etiology:
- Inflammation of the ECRB tendon
- Sometimes associated with “microtears”
Many “treatments” aka none of them work well
- Always self-limiting
BUT, it can take a year for the symptoms to resolve
Treatments help the symptoms and may accelerate pain resolution

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Lateral Epicondylitis Diagnosis

History

Pain with ______ wrist _______
Pain with gr______ / decreased grip s______

Pain with resisted wrist extension
Pain with gripping / decreased grip strength

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Lateral Epicondylitis Diagnosis

Physical

P_____ tenderness → _ _ _ _ at the lateral epicondyle
_______ grip strength (sometimes)
Normal se________ examination
Provocative tests:
- Resisted _____ extension with elbow fully extended
- Resisted extension of the long ______
- Maximal _______ of the wrist
- Passive wrist flexion in ___nation causes pain at the ______

Point tenderness → ECRB at the lateral epicondyle
Decreased grip strength (sometimes)
Normal sensory examination
Provocative tests:
- Resisted wrist extension with elbow fully extended
- Resisted extension of the long fingers
- Maximal flexion of the wrist
- Passive wrist flexion in pronation causes pain at the elbow

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Lateral Epicondylitis Imaging

XR:
- Usually ______
- Sometimes ____cations in the extensor muscle mass
  - Up to 20% of patients
MR:
- Necessary for diagnosis?
- ECRB
  - Th_____, ed_____, tendon deg______
Ultrasound
- Necessary for diagnosis? but most useful diagnostic tool in experienced hands
  - ECRB tendon appears thickened and _____echoic

XR:
- Usually normal
- Sometimes calcifications in the extensor muscle mass
  - Up to 20% of patients
MR:
- Not necessary for diagnosis
- ECRB
  - Thickening, edema, tendon degeneration
Ultrasound
- Not necessary for diagnosis, but most useful diagnostic tool in experienced hands
  - ECRB tendon appears thickened and hypoechoic

Note: Hyechoic areas appear dark gray because they don’t send back a lot of sound waves. Solid masses of dense tissue are hypoechoic.

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Lateral Epicondylitis Treatment

GOAL
- Reduce pain / Restore function
Non-surgical
- Rest
- Activity modifications (1) Do things how?
- Counterforce ______
- NSAIDs (oral or topical) - _-_ weks, 2 weeks of non prn ______ __mg daily for 2 weeks then PRN , or more frequent ___mg _____TID then PRN
- PT / Ultrasound
- Injection
- up to __% success rate with nonoperative treatment, but _______ is required
Surgery
- ______ needed → De______ and R______ of ECRB
Refer → No improvement after full course of conservative options

GOAL
- Reduce pain / Restore function
Non-surgical
- Rest
- Activity modifications
  - “Palm up” do things palm up to rest lateral muscle
- Counterforce brace (strap) - 2nd pic
- NSAIDs (oral or topical) - 2-4 weks, 2 weeks of non prn meloxicon 50mg daily for 2 weeks then PRN , or more frequent 400mg motrin TID then PRN
- PT / Ultrasound
- Injection
- up to 95% success rate with nonoperative treatment, but patience is required
Surgery
- Rarely needed → Debridement (taking away some of the inflammatory tissue) and release of ECRB
Refer → No improvement after full course of conservative options

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Medial Epicondylitis “Golfer’s Elbow”

Much ____ common than tennis elbow
- Usually ______ arm
- __ - __ yrs-old (30 - 40 most common)
- Men =__Women
Caused by ____use– can be associated with _____, but more commonly it is not
Etiology:
- Inflammation of the f____-p_____ mass (pronator teres __ flexor carpi radialis)
- Sometimes associated with “micro____”
Many “treatments” aka?
Usually resolves how?
- BUT, it can take a ____ for the symptoms to resolve
- Treatments help the symptoms and may accelerate pain resolution

Much less common than tennis elbow
- Usually dominant arm
- 35 - 60 yrs-old (30 - 40 most common)
- Men = Women
Caused by overuse – can be associated with golf, but more commonly it is not
Etiology:
- Inflammation of the flexor-pronator mass (pronator teres > flexor carpi radialis)
- Sometimes associated with “microtears”
Many “treatments”
Usually self-limiting
- BUT, it can take a year for the symptoms to resolve
- Treatments help the symptoms and may accelerate pain resolution

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Medial Epicondylitis Diagnosis

History

Pain with resisted wrist ______
Pain with ______ / _____ motion

Physical

______ tenderness → 5-10 mm _____ and ______ to the medial epicondyle
Provocative tests:
- Pain with resisted ______ and ______
Flexion _______ in chronic cases

History

Pain with resisted wrist flexion
Pain with gripping / elbow motion

Physical

Point tenderness → 5-10 mm distal and anterior to the medial epicondyle
Provocative tests:
- Pain with resisted flexion and pronation
Flexion contracture in chronic cases

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Medial Epicondylitis Imaging

XR:
- Usually normal
- Sometimes ca_______ in the __/__ muscle mass
  - Up to 25% of patients
MR:
- More to (1) ligament injury, rupture of flexor/pronator origin
Ultrasound
- Not necessary for diagnosis, but sensitive diagnostic tool in experienced hands
  - ____echoic/__echoic areas of focal degeneration

XR:
- Usually normal
- Sometimes calcifications in the flexor/pronator muscle mass
  - Up to 25% of patients
MR:
- More to rule-out ligament injury, rupture of flexor/pronator origin
Ultrasound
- Not necessary for diagnosis, but sensitive diagnostic tool in experienced hands
  - hypoechoic/anechoic areas of focal degeneration

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Medial Epicondylitis Treatment

GOAL
- Reduce pain / Restore function
Non-surgical
- Rest
- Activity modifications (1)
- Counterforce (1)
- NSAIDs (oral or topical)
- PT / Ultrasound
- Injection
Surgery
- Rarely needed → D_______ of pronator teres and flexor carpi radialis
Refer → No improvement after full course of conservative options

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GOAL
- Reduce pain / Restore function
Non-surgical
- Rest
- Activity modifications “Palm down”
- Counterforce brace (strap)
- NSAIDs (oral or topical)
- PT / Ultrasound
- Injection
Surgery
- Rarely needed → Debridement of pronator teres and flexor carpi radialis
Refer → No improvement after full course of conservative options

Ulnar Neuropathy/Cubital Tunnel Syndrome

________ neuropathy of the ulnar _____ caused by anatomic compression in the medial elbow
2nd most common compression neuropathy of upper extremity
Males __ Females
Incidence increases with ___ in both men and women

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Compressive neuropathy of the ulnar nerve caused by anatomic compression in the medial elbow
2nd most common compression neuropathy of upper extremity
Males > Females
Incidence increases with age in both men and women

Cubital Tunnel Syndrome Diagnosis

History

________ of (3) parts of the hand**
Exacerbating activities include
- Cell _____ use (excessive flexion)
- Occupational or athletic activities requiring repetitive _____ flexion and _____ stress
Night symptoms
- Caused by ______ with arm in _______

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Paresthesias of small finger, ulnar half of ring finger, and ulnar dorsal hand
Exacerbating activities include
- Cell phone use (excessive flexion)
- Occupational or athletic activities requiring repetitive elbow flexion and valgus stress
Night symptoms
- Caused by sleeping with arm in flexion

Cubital Tunnel Syndrome Diagnosis

Physical

Diagnosis is made clinically with presence of s_______ changes to the (2) finger, intrinsic muscle ____ness and a positive ______ sign (tap nerve near elbow and feel sensation) over the cubital tunnel.
Inspection and palpation
- Interosseous and first web space ______
- Ring and small finger ____ing
- Observe ulnar nerve ________ over the _______ epicondyle as the elbow moves through a flexion-extension arc

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Diagnosis is made clinically with presence of sensory changes to the ring and little finger, intrinsic muscle weakness and a positive tinel’s sign (tap nerve near elbow and feel sensation) over the cubital tunnel.
Inspection and palpation
- Interosseous and first web space atrophy
- Ring and small finger clawing
- Observe ulnar nerve subluxation over the medial epicondyle as the elbow moves through a flexion-extension arc

Cubital Tunnel Syndrome Diagnosis

Physical

Sensory
- _______ sensation in ulnar 1-1/2 digits
Motor
- loss of the ulnar nerve results in _______ of intrinsic muscles (adductor pollicis, deep head FPB, interossei, and lumbricals 4 and 5) which leads to weakened gr____ and weak p______
- Froment’s sign =

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Sensory
- Decreased sensation in ulnar 1-1/2 digits
Motor
- loss of the ulnar nerve results in paralysis of intrinsic muscles (adductor pollicis, deep head FPB, interossei, and lumbricals 4 and 5) which leads to weakened grasp and weak pinch
- Froment’s sign → compensatory thumb IP flexion (AIN, a branch of the median nerve)

Cubital Tunnel Syndrome Imaging/Studies

Imaging:
- Often _____/ ___-diagnostic
EMG/NCS:
- Helpful in diagnosis and to tease out (1) from cubital tunnel syndrome in certain cases

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Imaging:
- Often normal/ non-diagnostic
EMG/NCS:
- Helpful in diagnosis and to tease out C8 radiculopathy from cubital tunnel syndrome in certain cases

Cubital Tunnel Syndrome Treatment

GOAL
- Reduce pain / Restore function
Non-surgical (~50%)
- Rest
- NSAIDs (oral or topical)
- Elbow extension _____ at (____ time)
Surgery
- Ulnar nerve _________
  - Cubital tunnel _______ (release fascial structures superficial to nerve along medial aspect of elbow)
Refer?
- No improvement after full course of conservative options

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GOAL
- Reduce pain / Restore function
Non-surgical (~50%)
- Rest
- NSAIDs (oral or topical)
- Elbow extension splinting (night)
Surgery
- Ulnar nerve decompression
  - Cubital tunnel release (release fascial structures superficial to nerve along medial aspect of elbow)
Refer?
- No improvement after full course of conservative options

Olecranon Bursitis

Bursa = a th__, _____-filled sac that acts as a _____ and _____ structure between bones and soft tissues
Located at the boney ___ of the elbow (the ______)
Normally what shape?, but if it becomes irritated or inflamed, more ____ will _______ in the bursa and bursitis will develop.

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Bursa = a thin, fluid-filled sac that acts as a cushion and lubricating structure between bones and soft tissues
Located at the boney tip of the elbow (the olecranon)
Normally flat, but if it becomes irritated or inflamed, more fluid will accumulate in the bursa and bursitis will develop.

Olecranon Bursitis Diagnosis

History

Causes:
- Tr______
- Prolonged ______ (sitting at _____)
- In______
- Associated conditions (2)
Symptoms (3)

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Causes:
- Trauma
- Prolonged Pressure (sitting at desk)
- Infection
- Associated conditions (RA, gout)
Symptoms:
- Swelling, Pain, Redness/Warmth

Olecranon Bursitis Diagnosis ## Footnote Physical * Sw\_\_\_\_\_ / “\_\_\_\_\_ \_\_\_\_\_” * W\_\_\_\_\_\_ * __________ ROM * Constitutional symptoms are?

* Swelling / “golf ball” * Warmth * Decreased ROM * Constitutional symptoms (rare)

Olecranon Bursitis Imaging * Imaging * Often \_\_\_\_\_/ \_\_\_-diagnostic * Associated with bone \_\_\_\_\_ * Sometimes associated with a f\_\_\_\_\_ b\_\_\_\_ * Aspiration / Fluid Analysis: * If **(2)** suspected

* Imaging * Often normal / non-diagnostic * Associated with bone spur * Sometimes associated with a foreign body * Aspiration / Fluid Analysis: * If **infection or gout** is suspected

Olecranon Bursitis Treatment ## Footnote * GOAL * Reduce pain / Restore function * Non-surgical (~50%) * Rest * Activity changes / elbow \_\_\_\_ * NSAIDs (oral or topical) * \_\_\_\_\_\_\_(usually only recommended after 3 - 6 weeks of symptoms) + \_\_\_\_\_\_ * Surgery * _______ (rarely needed) * Refer? * No improvement after full course of conservative options and/or suspicion of _______ (red/warm/pain out of proportion/severe ROM limitation)

* GOAL * Reduce pain / Restore function * Non-surgical (~50%) * Rest * Activity changes / elbow pad * NSAIDs (oral or topical) * Aspiration (usually only recommended after 3 - 6 weeks of symptoms) + steroid * Surgery * Bursectomy (rarely needed) * Refer? * No improvement after full course of conservative options and/or suspicion of infection (red/warm/pain out of proportion/severe ROM limitation)

Nursemaid's Elbow ## Footnote * “\_\_\_\_\_ elbow” → Radial _____ sub\_\_\_\_\_\_ * Subluxation = * Very common (very little force) * __ - __ yrs most common * But can be 0 - 7 * Mechanism of injury * Sudden, longitudinal ______ applied to the hand with the elbow _______ and forearm \_\_\_\_\_nated * May also be caused by a \_\_\_\_\_

* “Pulled elbow” → Radial head subluxation * Subluxation = partial dislocation * Very common (very little force) * 1 - 4 yrs most common * But can be 0 - 7 * Mechanism of injury * Sudden, longitudinal traction applied to the hand with the elbow extended and forearm pronated * May also be caused by a fall

Nursemaid's Elbow History ## Footnote * History * A _____ may be heard or felt by the person pulling the child's arm * Symptoms * Child ______ to use the affected limb * Holds the elbow in slight ______ and the forearm \_\_\_\_\_\_

* History * A click may be heard or felt by the person pulling the child's arm * Symptoms * Child refuses to use the affected limb * Holds the elbow in slight flexion and the forearm pronated

Nursemaid's Elbow PE * P\_\_\_\_ and \_\_\_\_\_\_\_ness localized to the _____ aspect of the elbow * Range of motion * _____ flexion and extension * Pain with \_\_\_\_\_nation

* Pain and tenderness localized to the lateral aspect of the elbow * Range of motion * Full flexion and extension * Pain with supination

Nursemaid's Elbow Imaging ## Footnote * XR: * Not required in the setting of the ______ presentation: * History of _____ injury * Child _____ years or younger * Consistent clinical exam * When obtained, elbow radiographs are usually \_\_\_\_\_ * Obtain (1) if there is any in\_\_\_\_\_\_ * \_\_\_\_\_\_ * Helpful to confirm diagnosis “when necessary” * When the mechanism of injury is not evident * When physical examination is inconclusive

* XR: * Not required in the setting of the classic presentation: * History of traction injury * Child 5 years or younger * Consistent clinical exam * When obtained, elbow radiographs are usually normal * Obtain xray if there is any inconsistency * Ultrasound * Helpful to confirm diagnosis “when necessary” * When the mechanism of injury is not evident * When physical examination is inconclusive

Nursemaid's Elbow Treatment ## Footnote * Reduction * \_\_\_\_\_nation → \_\_\_\_\_nation and then m\_\_\_\_\_\_ ____ the elbow * _____ applies ______ over the radial head and a palpable _____ is often heard with reduction of the radial head * Aftercare * Child should begin to use the arm within _______ after reduction * I\_\_\_\_\_\_\_\_\_ is unnecessary after first episode * Refer * Recurrence? * Not reducible (surgery _____ required)

* Reduction * Pronation → supination and then maximally flex the elbow * Thumb applies pressure over the radial head and a palpable click is often heard with reduction of the radial head * Aftercare * Child should begin to use the arm within minutes after reduction * Immobilization is unnecessary after first episode * Refer * Recurrence *(does often recur)* * Not reducible (surgery rarely required)

Nursemaid's Elbow Prevention * Once a nursemaid's elbow has occurred, there is a high likelihood of? * Guidelines parents and caregivers can follow that may prevent the injury. * To safely lift a child, grasp gently _____ the arms. Do not lift children by holding their h\_\_\_\_\_ or a\_\_\_\_. * Do not _____ a child by holding the hands or arms. * Avoid t\_\_\_\_\_ or pulling on a child's hands or arms.

* Once a nursemaid's elbow has occurred, there is a high likelihood of recurrence. * Guidelines parents and caregivers can follow that may prevent the injury. * To safely lift a child, grasp gently under the arms. Do not lift children by holding their hands or arms. * Do not swing a child by holding the hands or arms. * Avoid tugging or pulling on a child's hands or arms.

Radial Head Fracture * Common injuries, occurring in about \_\_% of all acute elbow injuries. * Many elbow d\_\_\_\_\_\_\_\_ also involve fractures of the radial head. * Women __ Men, __ and __ years of age.

* Common injuries, occurring in about 20% of all acute elbow injuries. * Many elbow dislocations also involve fractures of the radial head. * Women \> Men, 30 and 40 years of age.

Radial Head Fracture History ## Footnote * ____ on out\_\_\_\_\_\_ hand * Elbow in ________ + forearm in \_\_\_\_\_\_\_ * Most force transmitted from (1) to (1)

* Fall on outstretched hand * Elbow in extension + forearm in pronation * Most force transmitted from wrist to radial head

Radial Head Fracture Symptoms ## Footnote * Pain on the \_\_\_\_side of the elbow * Sw\_\_\_\_\_\_ in the elbow joint * Difficulty in b\_\_\_ing or st\_\_\_\_\_ning the elbow accompanied by pain * Inability or difficulty in t\_\_\_\_\_\_ the forearm (palm up to palm down or vice versa)

* Pain on the outside of the elbow * Swelling in the elbow joint * Difficulty in bending or straightening the elbow accompanied by pain * Inability or difficulty in turning the forearm (palm up to palm down or vice versa)

Radial Head PE ## Footnote * Pain and tenderness ______ to radial head * Range of motion (mechanical _____ - can they fully pronate or supinate or is there a bone _______ blocking the full motion) * Be sure to palpate w\_\_\_\_/d\_\_\_\_\_\_ radius

* Pain and tenderness localized to radial head * Range of motion (mechanical blocks - can they fully pronate or supinate or is there a bone fractureblocking the full motion) * Be sure to palpate wrist/distal radius

Radial Head Imaging ## Footnote * XR: * Non-dis\_\_\_\_\_\_ fractures are often hard to diagnose… * Check for ___ \_\_\_ sign indicating occult minimally displaced fracture * (1): always abnormal * (1): can be normal * CT: * ______ fracture delineation, usually for surgical planning

* XR: * Non-displaced fractures are often hard to diagnose… * Check for fat pad sign indicating occult minimally displaced fracture * Posterior: always abnormal * Anterior: can be normal * CT: * Better fracture delineation, usually for surgical planning

Radial Head Fracture Treatment ## Footnote * (1) * Sling * Usually just a few weeks (prevent stiffness) * (1) * Depends… * Displacement + mechanical block → \_\_\_\_\_\_ * ORIF v. excision v. arthroplasty * Refer * Appropriate to refer all elbow \_\_\_\_\_\_\_

* Non-displaced * Sling * Usually just a few weeks (prevent stiffness) * Displaced * Depends… * Displacement + mechanical block → surgery * ORIF v. excision v. arthroplasty * Refer * Appropriate to refer all elbow fractures

Orthopedics Elbow Flashcards

(39 cards)