Transcript Examination of the Elbow and Forearm

ATTR 322
Krzyzanowicz- Spring ‘13
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Understand bony and soft tissue anatomy of the
elbow and forearm
Understand movement relationships of the elbow
and forearm
Describe common injuries to the elbow and
forearm
Demonstrate the proper evaluation of the elbow
and forearm to include
◦ Special tests
◦ Palpation
◦ MMT’s
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Utilize EBP principles' in evaluation techniques
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The link between powerful movements of the
shoulder and fine motor control of the hand
◦ Often overlooked in injury evaluation
 Neurovascular structures
◦ Understanding anatomy is key
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Bony anatomy
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Medial epicondyle
Trochlea
Capitellum
Lateral epicondyle
Radial fossa
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Bony anatomy
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Ulna
Semilunar notch
Olecranon process
Olecranon fossa
Coronoid process
Coronoid fossa
Radial notch
Proximal radioulnar joint
Radial head
Bicipital tuberosity
Radial shaft
Radial styloid process
Lister’s tubercle
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Articulation and ligamentous anatomy
◦ Humeroulnar joint
 Flexion and extension
 Modified hinge joint
◦ Humeroradial joint
 Flexion and extension
 Pronation and supination
 Modified hinge joint
◦ Proximal and distal radioulnar joints
 Pronation and supination
 Syndesmotic joint
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Articulation and ligamentous anatomy
◦ Ligamentous support
 Ulnar collateral ligament (UCL)
 Anterior, transverse, and posterior bundle
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Lateral collateral ligament
Radial collateral ligament (RCL)
Annular ligament
Accessory lateral collateral ligament
◦ Interosseous membrane
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Radial Collateral Ligament
 Strong fan shaped ligament that runs from the lateral
epicondyle of the humerus to the outer edge of the
annular ligament
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Ulnar Collateral Ligament
 Three bands that pass between the medial epicondyle
and the medial edge of the trochlear notch
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Annular Ligament
 Wraps around the head and neck of the radius
 Both ends of the ligament are attached to the ulna
Medial View
Lateral View
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The elbow is encased by a synovial capsule,
which helps to lubricate the joint
There are two main bursa in the elbow:
 Olecranon bursa
 lies between the olecranon process and the skin
 helps to cushion blows to the posterior aspect of the
elbow
 Radial-humeral bursa
 lies anterior to the bicipital tuberosity
 helps to cushion the biceps tendon when the forearm is
pronated
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Table 17.1 (p.712)
◦ Extensors originate on lateral epicondyle
◦ Flexors originate on medial epicondyle
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Three primary nerves cross the elbow
◦ Median
 Anterior elbow, same path as brachial artery
 Follow flexor digitorum superficialis
 Important in elbow dislocations (TAN) and carpal tunnel
(wrist)
 Feeds the “W”
◦ Ulnar
 Medial, “funny bone”, impinged in throwers
 Feeds the 4th and 5th digits
◦ Radial
 Lateral
 Injury usually = motor loss
 Feeds the 1st and 2nd digits
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History
◦ Seasonal (golf, tennis)
◦ Cervical
◦ General medical health
 Neurovascular?
◦ Location
 Area and type of pain
(sharp, dull, achy, etc)
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History
◦ Onset
 Acute vs. chronic
◦ MOI
 Throwing/weight lifting?
 FOOSH?
 Repetition?
 Throwing technique,
ergonomics
◦ Table 17.2 (p.715)
 Possibly pathologies based
on location of pain***
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Inspection
◦ Functional observation
 70 deg
◦ Anterior structures
 Carrying angle
 Cubitus valgus
 Cubitus varus
 Cubital fossa
◦ Medial structures
 Medial epicondyle
 Flexor muscle mass
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Inspection
◦ Lateral structures
 Alignment of the wrist
and forearm
 Cubital recurvatum
 Extensor muscle mass
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Inspection
◦ Posterior structures
 Bony alignment
 Olecranon process and
bursa
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Palpation of the
anterior structures
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Biceps brachii
Cubital fossa
Brachioradialis
Flexor carpi radialis
Palmaris longus
Flexor carpi ulnaris
Pronator quadratus
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Palpation of the
medial structures
1.
2.
3.
4.
5.
Medial epicondyle
Ulna
Anterior band UCL
Posterior band UCL
Transverse band
UCL
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Palpation of the
lateral structures
1. Lateral epicondyle
2. Radial head
3. Radial collateral
ligament
4. Capitellum
5. Annular ligament
6. Lateral ulnar
collateral ligament
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Palpation of the posterior
structures
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Olecranon process
Olecranon fossa
Triceps brachii
Anconeus
Ulnar nerve
Extensor carpi ulnaris
Extensor carpi radialis brevis
Extensor carpi radialis
longus
Extensor digitorum
Extensor digiti minimi
Extensor pollicis brevis
Abductor pollicis longus
Radial tunnel
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Joint and muscle function
assessment
◦ Active range of motion
(AROM)
 Flexion and extension
 Pronation and supination
◦ Manual muscle tests (MMT)
◦ Passive range of motion
(PROM)
 Flexion and extension
 Pronation and supination
Flexion
Extension
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Neurologic testing
◦ Innervated by the
brachial plexus
 Injury may disturb sensory
or motor function in elbow,
forearm, and hand
◦ Upper quarter screen
Pathologies of the
Elbow and Forearm
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MOI: axial force
through forearm with
elbow flexed
◦ Usually displaced
posteriorly
◦ Extremely painful and
obvious deformity
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Terrible triad
◦ Posterior dislocation, fx
of radial head, fx of
coronoid
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Medical Emergency
◦ Initiate EAP
 Do not relocate it yourself!
◦ Always check distal neurovascular function
 Pulse
 Sensation
◦ Splint and sling (if possible)
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Fractures of the Elbow
◦ Supracondylar fracture
 MOI: hyperextension or fall
on flexed elbow
◦ Olecranon process
fracture
 MOI: falling on flexed
elbow
◦ Radial head fracture
 MOI: longitudinal
compression (FOOSH)
◦ Forearm fracture
 Open or closed, simple or
complex, degree of
angulation, rotation or
displacement
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Supracondylar fracture
◦ Almost always in adolescent athletes, direct fall on
flex elbow or hyperextension
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Olecranon process fracture
◦ Falling on flexed elbow, P! with extension
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Radial head fractures
◦ FOOSH, P! with flex/ext and sup/pro
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Forearm fractures
◦ Common in athletics; can compromise
neurovascular structures in wrist and hand
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Very common in athletics
◦ Radial collateral ligament (varus)
 Not as common due to varus forces being protected by
the body
 Varus special test
◦ Ulnar collateral ligament (valgus)**
 “Tommy John Injury”
 Common in throwers, racquet sports
 Valgus special test
Valgus
Varus
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UCL is stressed secondary to valgus loading
◦ Occurs during overhand pitching motion
 Force generated is too great, UCL cannot handle
tension on it’s own
 Must rely on triceps brachii, wrist flexor-pronator muscles
and anconeus for dynamic stabilization
 When forces generated during the cocking and acceleration
phases of throwing are greater than the tensile strength,
tearing occurs
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Presentation
◦ P! on medial aspect of elbow that increases with
motion
 Compression of radial nerve may produce radicular p!
 Tensile forces on the ulnar nerve can cause paresthesia
in distal ulnar nerve distribution patterns
 Swelling my be present and in most cases the anterior
oblique section of the UCL is traumatized
 Tenderness is noted along it’s length from med. Epi to
coronoid process
 Elbow flexed past 60 degrees the pos. oblique band may be
involved
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Special tests
◦ Moving valgus stress test
 ID’s UCL instability between 120 and 70 deg
 Similar to late cocking and early acceleration phases of
throwing
◦ Valgus stress test
 ID’s UCL instability
 Always perform at 0 and 20-30 degrees
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Valgus extension overload
◦ Weakness of ant. bundle leads to valgus ext. overload
 Collection of tensile, shear and compressive forces that
result from UCL laxity
 Tensile stresses on UCL and ulnar nerve; compressive and
shear forces on radial head and post. Medial olecranon
process
 These all create bone spurs, loose bodies, “joint mice”
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Posterolateral rotatory instability
◦ Tears of the lateral UCL cause a rotational
subluxation of the radius and ulna on the humerus
 Causing external rotation of the radius and ulna, and
valgus opening of the elbow.
 Won’t want to push out of a chair or fully extend elbows
with the forearms supinated
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Chronic overload
◦ Pitchers, overhead athletes
 Chronic p! medially, overuse
 Lose IR of shoulder and gain excessive ER to compensate
for elbow p!
 Can lead to kinetic chain issues, shoulder pain, don’t just
treat the pain, find the cause of the pain!
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Valgus force
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Pitch Count
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Curve balls?
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Why not softball?
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Origin
◦ Both lateral and medial epicondyles serve as origin
for muscles acting on wrist and fingers
 Epicondylitis- does not accurately capture most
conditions at these origins
 Chronic pathology is more likely a degenerative tendinosis
than an actual true inflammatory condition
 The term epicondylalgia is a better encompassing term
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Inflammation or repetitive stress
◦ Irritates common attachment of wrist extensor
group
 Any or all muscles may be involved, extensor carpi
radialis brevis is most commonly affected though
 Very broad origin
 Repeated, forceful eccentric contractions of wrist extensor
muscles result in accumulation of degenerative forces at
the attachment site
 Small area of attachment = greater force load applied to
bone
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More prevalent in racquet sports
◦ “Tennis elbow”
 Most common in patients over 40 y/o, p! over lateral
condyle, decreased grip strength, p! with gripping
 Racquet sports- increased p! during backhand strokes
 Swelling, active wrist extension increases p!
 Tennis elbow test
 TX
 Avoiding activity, NSAIDS, biomechanical analysis
 Increase grip size
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MOI:
◦ “Golfer’s elbow”
 Activities involving swift, powerful snapping of the
wrist and pronation of the forearm load the medial
epicondyle
 Pt tenderness at origin of pronators and flexors
 Pronator teres
◦ TX
 “Little league elbow”- avulsion of tendon from med. Epi.
 Same as lateral epicondylalgia
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Biceps tendon ruptures most common in
males older than 40
◦ Usually proximal (short head of biceps)
 Distal tears are not as common
 Tendon and its aponeurosis degrade with time, resulting
in spontaneous rupture
 MOI:
 Eccentric loading of biceps brachii when elbow is flexed to
90 degrees
 Complete or partial tears
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Signs and symptoms
◦ Loss of strength during elbow flexion and supination
 Immediate p!, hearing a “pop”
 Swelling and ecchymosis in cubital fossa
 Palpable defect may be noted
 ROM may remain normal, MMT’s will be decreased
 “Hook Test”
 TX
 Conservative vs. surgical
 MRI?
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Osteochondritis Dissecans of the capitellum
◦ Develops gradually due to increased valgus loading
compressing the radial head and capitellum with
overhead throwing
 Compressive and shear forces on the capitellum
 OCD develops secondary due to disrupted blood flow
 Usually results in bony fragments too
 Pt c/o
 Lateral elbow p! increases with activity, flexion contracture
is usually present
 X-ray
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Emanate from brachial plexus
◦ Easily compromised by chronic or repetitive trauma
 Can be found in intramuscular fascia, tunnels beneath
ligaments, bony tracts through which nerve passes
 Post injury scarring is common as well
 Ulnar nerve
 Median nerve
 Radial nerve
 All can cause dysfunction in wrist, hand and fingers,
symptoms radiate distally, paresthesia, decreased grip
strength
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Superficial
◦ Crossing the medial aspect of elbow’s jt line
 Predisposing it to concussive forces “funny bone”
◦ Sublux
 If nerve’s tunnel is unstable, nerve will sublux in and
out
 Common in pitchers
◦ Traction forces
 During throwing increased traction force
◦ All can cause progressive inflammation
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Inflammation
◦ Increases in pressure, therefore increasing p! with
elbow flexion and with wrist extension
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Signs and Symptoms
◦ Decreased sensory and motor function in the hand
and fingers
 c/o increase in symptoms when elbow is flexed for
prolonged periods (sleeping)
 Burning sensation in medial forearm, little and ring fingers
 Numbness on dorsal aspect of hand = elbow
 Numbness on palmar side of hand = tunnel of guyon
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Chronic neurological
deficit
◦ Hand to deviate radially
during flexion
 Clawhand
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Tinel’s sign
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Radial nerve most often injured by deep
lacerations of the elbow
◦ Secondary to fractures of humerus or radius
 Posterior interosseous nerve (deep branch of radial
nerve) dedicated to motor function of thumbs
extensor’s, wrist extensors, finger extensor’s and
supinators
 Injury to this nerve can be damaging to ADL’s
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Radial tunnel
syndrome (RTS)
◦ Clinically resembles
lateral epicondylalgia
 RTS symptoms more
distally on forearm and
can persist for more than
6 months
 Symptoms reproduced with
resisted supination or
during resisted extension
of the middle finger
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Typically injured or compressed on the distal
portion of the forearm
◦ Pressure in cubital fossa may compress nerve
 Carpal tunnel syndrome (chapter 18)
 Pronator teres syndrome
 Anterior interosseous nerve is compressed by the pronator
teres
 Patient’s inability to pinch tips of the thumb and index
fingers together
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Forearm contains three compartments
◦ Volar wad
◦ Dorsal wad
◦ Mobile wad
 Increased pressures within these compartments
increases risk of compromising circulation and
neurological function of the hand
 Usually due to hypertrophic muscles or fractures
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Signs and Symptoms
◦ Pressure in forearm, sensory disruption in hand and
fingers, decreased strength
 Flexor digitorum profundus and flexor pollicis longus
most commonly affected due to deepness in arm
◦ Volkmann’s ischemic contracture
 Chapter 18
◦ Surgery is often needed to decrease pressures
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Always rule out fracture of forearm or
dislocation of elbow first
◦ Position of arm
 Obvious deformity?
◦ Type of force
 Valgus, varus or FOOSH?
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Gross deformity?
◦ Alignment of forearm and wrist
 Are they same length bilaterally?
◦ Posterior triangle of the elbow
 Alignment of medial and lateral epicondyle and
olecranon process
 Should form an isosceles triangle when elbow is flexed to
90 degrees
 If it does not, possible dislocation
 Posterior dislocation
 Olecranon process becomes prominent
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Quickly
◦ Alignment of elbow
◦ Collateral ligaments (UCL/RCL)
◦ Radius and Ulna
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Elbow dislocation
◦ Immobilize in position found
 Check distal pulse, capillary bed refill, neuro status
 Transport immediately to E.D. for reduction (911 if
needed)
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Fractures
◦ Forearm fractures (radius and ulna) are very common
 Immobilize in position found
 Check distal pulse, capillary bed refill, neuro status
 Transport immediately to E.D. (911 if needed)
 Monitor for shock
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Knowing all anatomy (bony, ligament, muscle
and nerve) is needed for proper evaluation
and management of elbow/forearm injuries
The UCL is a complex ligament bundle that
causes major injury in patients
Fractures are common when FOOSHing
Neurological functioning can easily be altered
with elbow/forearm injuries