The Elbow Flashcards
(33 cards)
1
Q
What is the purpose of the condyles in the elbow?
A
- Tendon attachment points
- Supinators attach to the lateral condyle
- pronators attach to the medial condyle
2
Q
What are the two articulations in the elbow? What are their functions?
A
- ulnohumeral: flexion/extension
- radioulnar: pronation/supination
3
Q
What is the primary functional component of the elbow?
A
Flexion
4
Q
What is the purpose of the olecranon fossa?
A
Provide stability for the elbow from varus and valgus along with the collateral ligaments.
5
Q
What are the three main ligaments involved in stability of the elbow?
A
- Lateral epicondyle: radial collateral ligament - stability in extension, prevent varus and valgus
- Medial epicondyle: ulnar collateral ligament - stability in extension, prevent varus and valgus
- Annular Ligament - stability of the radial head
6
Q
Which muscles and nerve(s) are responsible for supination of the forearm?
A
- Muscles: biceps, supinator
- Nerves: C5-6
7
Q
Which muscles and nerve(s) are responsible for pronation of the forearm?
A
- Muscles: pronator quadratus, pronator teres
- Nerves: C6-8, T1
8
Q
What is the typical ROM for pronation/supination?
A
- Pronation: 70 degrees
- Supination: 85 degrees
9
Q
Which views are commonly used in elbow radiography?
A
AP, Lateral, Oblique
10
Q
What is the sail sign?
A
Fat pad sign, showing effusion (blood) in the joint capsule. Suggests occult supracondyllar fracture in kids or occult radial head fracture in adults.
11
Q
Lateral Epicondylitis
A
- “Tennis Elbow”
- Likely a degenerative process instead of inflammatory
- “Inflammation” of the extensor origin at their insertion onto the lateral epicondyle
- May present as a dull ache on the outer aspect of the elbow that increases with grasping, twisting and resisted extension of the wrist or fingers.
12
Q
Lateral Epicondylitis Physical Exam
A
- Point tenderness over insertion of extensor tendon on lateral elbow
- Increasing pain with resisted extension/supination of wrist
13
Q
Lateral Epicondylitis Treatment
A
- Rest, avoidance of aggravating activities like gripping
- Ice if due to acute trauma or repetitive injury (2-3 days)
- PT, iontophoresis/friction massage
- Compression, possible ace wrap?
- Anti-inflammatories
- NSAIDs
- +/- steroid injection and marcaine or lidocaine (2-3 max)
- Surgery: lateral epicondylectomy
14
Q
Medial Epicondylitis
A
- AKA golfer’s, pitcher’s, or bowler’s elbow
- microtrauma to the flexor carpi radialis tendon insertion on the medial epicondyle
- Physical Findings:
- tender to palpation on the medial epicondyle
- increased pain with resisted flexion and pronation of the wrist
15
Q
Medial Epicondylitis Treatment
A
- Rest, avoid aggravating activity
- +/- ice
- NSAIDs
- PT for iontophoresis, etc.
- Referral for resistant cases
- Use caution when considering injection - ulnar nerve
16
Q
Olecranon Bursitis
A
- Inflammation, swelling and +/- pain over the olecranon process
- Causes:
- trauma
- infection - puncture wounds, microscopic (not clinically evident) wounds
- inflammation - gout, pseudo-gout, rheumatoid arthritis, uremia in renal failure
17
Q
Olecranon Bursitis Risk Factors
A
Diabetes
Chronic alcohol abuse
Occupation/hobbies
Gout
Immunocompromised
18
Q
Olecranon Bursitis Diagnosis
A
x-ray if trauma or suspicion of foreign body and +/- gout
CBC if suspicion of significant infection
ESR, CRP and serum uric acid if suspicion of gout
Aspiration is controversial, consider specialist consult
19
Q
Olecranon Bursitis Treatment
A
- First line for non-infectious is nothing
- Rest - avoid direct trauma, elbow padding may help
- NSAIDs if pain is present (or APAP)
- Aspiration (specialist)
- Gram stain & culture
- > 5000 WBC/mL indicates infection
- If infection present, staph aureus is most common pathogen
- Do NOT inject steroids unless positive there is no infection
- Typically resolves in 2-4 weeks
- Consider close follow-up after steroid injections
20
Q
Ulnar Nerve Entrapment Syndromes Basics
A
- May be from acute trauma such as a fracture or dislocation
- Initial treatment requires prompt reduction
- Document neurovascular status before and after reduction
21
Q
Cubital Tunnel Syndrome
A
- AKA “truck driver’s elbow”
- Chronic pressure on the ulnar nerve where it passes between bone, tendons and ligaments at the elbow
- Can also be entrapment of the nerve from hypertrophy of the triceps or the flexor/pronator musculature
- May be remote result of trauma
22
Q
Tardy Ulnar Palsy
A
ulnar neuropathy remotely after an injury at the condylar groove
23
Q
Ulnar Nerve Entrapment Syndromes Symptoms
A
- paresthesias in the ring and small fingers
- weakness of the intrinsic muscles of the hand
- weakness of abduction of 5th digit
- chronic entrapment –> Pope’s Blessing Sign
- Positive Froment’s sign
24
Q
Ulnar Nerve Entrapment Syndromes Diagnosis & Treatment
A
- Diagnosis:
- Clinical
- EMG
- Treatment:
- Splinting, NSAIDs, Surgery
25
Radial Nerve Palsy
* AKA Saturday Night Palsy
* wrist drop and loss of sensation in dorsal web space between thumb and index finger
* cock-up splint for wrist
* orthopedic follow-up
* occupational therapy
* claw hand in non-resolving cases
* painless loss of ability to extend the wrist and fingers
26
Radial Tunnel Syndrome
* Actually posterior interosseous nerve in forearm
* Use caution with tennis elbow straps
* Loss of motor function
27
Nursemaid's Elbow
* Subluxation of radial head
* non-calcified radial head is pulled out from under the annular ligament
* usually pt is around 2 years old, peak age 1-4
* About 20% of all upper extremity injuries in children
* Sudden longitudinal pull on arm with forearm pronated
* Arm usually held in slight flexion and pronation
* Child will not want to use arm to grap anything
* Xray first if question of fracture
* Reduction technique - supinate the forearm and flex the elbow. feel over radial head for click
* Re-examine in about 10 min
28
Nursemaid's Elbow Follow-up
* sling for pain for 1-2 days
* APAP or ibuprofen for pain
* generally the child will begin using the arm immediately but will be sore for 3-5 days
* educate parent on mechanism and what to avoid
29
Elbow Dislocation
* Most commonly posterior dislocation
* Associated with fall on nearly extended elbow or other similar energy applied to joint
* If ulnohumeral joint is dislocated there is often an injury to the radial head too
* Flexion and extension are extremely painful. Pronation and supination will be painful if radial head is also injured.
30
Elbow Dislocation Management
* Initial Management:
* immobilize in sling, posterior splint or pillow splint, narcotic analgesics
* Evaluation:
* X-rays
* Physical exam: document neurovascular exam
* Reduction:
* IV conscious sedation, stabilize upper arm, in line traction of lower arm, flexion of elbow, push toward hand on olecranon, long arm posterior splint, post-reduction xrays, record CMS in hand, specialist referral
31
Fracture of Radial Head
* Mechanism:
* FOOSH
* Radial head driven into capitellum
* Symptoms:
* Elbow pain, +/- swelling
* Physical Exam:
* Tenderness over radial head
* Limitation of motion, especially in extension and pro-supination
* Diagnosis:
* AP, lateral and oblique xray series
* Radial head views if needed
* Positive fat pad sign - fluid in the anterior joint capsule
* Treatment:
* Sling for comfort
* Ice for swelling, pain
* Analgesics, avoid NSAIDs in fractures
* Encourage early AROM
* Follow xrays week 1,3,6
32
Elbow Fractures
* Fall backward on partly extended elbow
* Be suspicious for vascular compromise, especially brachial artery
* Be suspicious for nerve injury of median, ulnar or radial nerve
* Not a primary care fracture
* Treatment:
* initial - closed reduction or ORIF
* Complications:
* loss of ROM/joint contracture
* post-traumatic arthritis if articular surface is disrupted
* non-union of fx site
* infection
* tardy ulnar palsy
* nerve or vascular injury
33
Elbow Arthritis
* Post Traumatic:
* most common
* arthroplasty is becoming better but not a great option
* injection technique is difficult
* Rheumatoid:
* best managed with DMARDs
