Transcript Ch 14 - Upper Arm Elbow and Forearm Conditions

Upper Arm, Elbow, and
Forearm Conditions
Anatomy
Anatomy Cont’d…
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3 articulations (single capsule)
– Humeroulnar (elbow joint)
– Humeroradial
– Proximal radioulnar
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Carrying angle
– Angle between humerus and ulna (arm
in anatomic position)
– 10-15° angle
– Greater in females
Anatomy Cont’d…
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Ligaments
– Ulnar (medial) collateral
– Radial (lateral) collateral
– Annular
Anatomy Cont’d…
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Bursae
– Several small
– Olecranon bursa
 Superficial
Anatomy Cont’d…
Anatomy Cont’d…
Anatomy Cont’d…
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Nerves
– Musculocutaneous
– Median
– Ulnar
– Radial
Anatomy Cont’d…
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Muscles
– Flexors (at the humeroradial and humeroulnar
joints)
Brachialis; biceps; brachioradialis
 Effectiveness depends on supination/pronation
position
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– Extensors (at the humeroradial and
humeroulnar joints)
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Triceps; anconeus
– Pronation and supination (at the proximal
radioulnar joint)
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Pronator quadratus; pronator teres; supinator;
biceps
Kinematics
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Non–weight bearing but still sustains
significant loads
Extremely large muscle forces
generated with forceful throwing
motions, weight lifting, and many
resistance training exercises
Injury Prevention
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Protective equipment
– Pads
– Braces
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Physical conditioning
– Flexibility and strength
– Focus on entire arm
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Proper skill technique
– Throwing
– Falling
Contusions
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Susceptible due to:
– Lack of padding
– General vulnerability
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S&S
– Rapid swelling – can limit ROM
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Chronic blows
– Development of ectopic bone
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Tackler’s exostosis
– Painful periostitis and fibrositis may develop
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Management: standard acute; NSAIDs
Olecranon Bursitis
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Acute and chronic
– Mechanism
Fall on a flexed elbow
 Constantly leaning on elbow
 Repetitive pressure and friction
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– S&S
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Tender, swollen, relatively painless
Rupture – goose egg visible
50% history of abrupt onset; 50% insidious onset over
a few weeks
Motion limited at extreme of flexion – tension
increases over bursa
– Management: standard acute; NSAIDs; possible
aspiration
Sprain
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Mechanism
– FOOSH - Fall on outstretched hand (hyperextension
injury)
– Valgus or varus force
– More common; repetitive forces irritate and tear
ligaments, especially UCL
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Ulnar nerve may also be affected
S&S
– Localized pain
– Point tenderness
– Instability with stress test
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Management: standard acute
Dislocation
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Proximal radial head
– Adolescents: often associated with
immature annular ligament
– Due to: longitudinal traction of an
extended and pronated upper extremity
– Inability to pronate and supinate pain
free warrants immediate physician
referral
– Immobilization for 3-6 weeks in flexion is
usually necessary
Dislocation
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Ulnar dislocation
– Younger than 20 years old
– Mechanism:
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Hyperextension
Sudden, violent unidirectional valgus force drives ulna
posterior or posterolateral
– Associated conditions
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fractures of the medial epicondyle, radial head, coronoid
process, and olecranon process
disruption of the anterior capsule
tearing of the brachialis muscle
injury to the ulnar collateral ligament
Dislocation Cont’d…
– S&S
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Snapping or cracking sensation
Severe pain, rapid swelling
Total loss of function
Obvious deformity
Arm held in flexion, with forearm appearing shortened
Olecranon and radial head palpable posteriorly
Slight indentation in triceps visible just proximal to
olecranon
Nerve palsy
– Management: immediate immobilization in
vacuum splint; activation of EMS
Strains
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Flexors and pronator teres
– Repetitive tensile stresses
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Extensor
– Decelerating type injury
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S&S
– Typical muscle strain S&S
– Self-limiting
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Management: standard acute
Triceps Brachii Rupture
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Mechanism:
– Direct blow to posterior elbow
– Uncoordinated triceps contraction during a fall
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80% involve olecranon avulsion fracture
S&S
– Pain and swelling in distal attachment
– Palpable defect in the triceps tendon or a stepoff deformity of the olecranon
– Active extension weak – partial tear; nonexistent
– total rupture
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Management: standard acute; immobilize in
sling; immediate physician referral
Overuse Conditions
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Medial epicondylitis (aka – Little League Elbow)
– Due to repeated valgus forces during acceleration
phase of throwing motion
– Commonly involved tendons: pronator teres and flexor
carpi radialis
– S&S
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Swelling, ecchymosis, and point tenderness at humeroulnar joint or
over the flexor/pronator origin
Severe pain; aggravated by:
 Resisted wrist flexion and pronation
 Valgus stress applied at 15-20° of elbow flexion
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Ulnar nerve involved – tingling and numbness
– Management: ice; NSAIDs; sling immobilization for 2-3
weeks with wrist in slight flexion; therapeutic exercise
Overuse Conditions
Cont’d…
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Lateral epicondylitis (aka – Tennis Elbow)
– Due to eccentric loading of extensor muscles
(especially extensor carpi radialis brevis)
during deceleration phase of throwing motion
or tennis stroke
– Contributing factors
– S&S
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Pain anterior or just distal to lateral epicondyle; may radiate
into forearm extensors during and after activity
Repetition produces pain that becomes more severe and
↑ with resisted wrist extension
– Management: ice; NSAIDs; rest; support
Overuse Conditions
Cont’d…
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Ulnar nerve Entrapment
– Vulnerable to compression and tension
– S&S
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Shocking sensation (medial elbow), radiating as if
“hitting their funny bone.”
+ Tinel sign – ulnar groove (tingling and
numbness of medial forearm into ring and little
finger)
Pain not present, ROM is not limited
Grip strength may be weak
Fractures
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Olecranon
– Direct blow
– Triceps tension pulls bone fragment superiorly
– Intra-articular fracture – does not respond to
conservative treatment, requires surgical
intervention
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Ulna (forearm fracture)
– Direct blow
– Also known as “nightstick” fracture
Assessment
History
 Observation/inspection
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– Carrying angle
– Position of function
Palpation
 Physical examination tests
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Assessment Cont’d…
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AROM
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–
–
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Elbow flexion
Elbow extension
Supination
Pronation
Wrist flexion
Wrist extension
AROM
AAROM
PROM
RROM
ROM (cont.)
Special Tests
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Ligamentous instability
– Valgus stress
– Varus stress
**Test at multiple angles
Special Tests
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Common extensor tendinitis (lateral
epicondylitis)
– Resisted extension and radial deviation of wrist
– Passive stretching of wrist extensors
– Resisted extension of extensor digitorum
communis in middle finger with wrist extended
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Common flexor tendinitis (medial
epicondylitis)
Special Tests (cont.)
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Tinel’s sign for ulnar neuritis
Rehabilitation (cont.)
 Restoration
motion
of
– Use of opposite hand
to supply load
– UBE
Rehabilitation (cont.)
 Restoration
of proprioception and balance
– Closed-chain exercises
 Muscular
strength, endurance, and power
– Open-chain exercises
– PNF-resisted exercises
 Cardiovascular
fitness