Elbow Injuries - 1.ppt

Elbow Injuries
Dr. Mohammed Haidar
‫الطالبية‬ ‫للخدمات‬ ‫االصدقاء‬ ‫مكتبة‬ ‫تحيات‬ ‫مع‬
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Basic Anatomy
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Relevant Anatomy
 Humerus
 Ulna
 Radius
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Distal Humerus
Medial Epicondyle
Lateral Epicondyle
Trochlea Capitellum
Coronoid Fossa
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Proximal Ulna
Olecranon
Process
Greater Sigmoid Notch
Lesser Sigmoid
Notch
Coronoid Process
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Proximal Radius
Head
Neck
Radial/Bicepital Tuberosity
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Joints
 Humeroulnar joint and Humeroradial
 Flexion/extension
 Radioulnar joint
 Supination/pronation
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Muscles Around Elbow
 Bicep
 Triceps
 Wrist flexors
 Wrist extensors
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Wrist Flexors
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Wrist Extensors
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Forearm muscles
 Forearm flexors  medial epicondyle
 Forearm extensors  lateral epicondyle
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Flexors of the elbow
 Brachialis
 Biceps
 Brachioradialis
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Extensors of the elbow
 Triceps brachii
 Long head
 Lateral head
 Medial head
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Elbow Pronator
 Pronator teres
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Elbow Supinators
 Biceps brachii
 Supinator
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Ligaments
 Joint capsule surrounds joint
 Ulnar collateral (Tommy John)
 Radial collateral
 Annular ligament
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Other structures
 Nerves
 Ulnar, radial, median
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Palpable Landmarks
 Olecranon process
 Olecranon fossa
 Medial and lateral epicondyles
 Radial head
 Cubital Tunnel—Ulnar N
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Stability of Elbow
 Primary Stabilizers
 MCL (55% @ 90°)
 Ulnohumeral Joint
• Coronoid50%
• Olecranon
 Secondary
Stabilizers
 Radiohumeral
Joint
 Capsule
 Musculature
(dynamic)
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Common Elbow Injuries
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Soft Tissue
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Olecranon Bursitis
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Etiology
 Aseptic
 Direct blow or fall
Hemarthrosis
 Gout
 Septic
 Insect Bite
 Cut/Abrasion
 Hematogenous
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Signs & symptoms
 Pain
 Swelling
 Erythema / Febrile  Septic
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Treatment
 Cold
 Compression
 Aspirate
 If serous/ bloody  Inject 40mg steroid
+compressive dressing + elbow extension x 3
days
 If puss  Requires I+D (Ortho Consult)
 Recurrent aseptic bursitis  Surgery
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Elbow Sprains
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Mechanism
 Hyperextension or a force that bends or
twists the lower arm outward
 Valgus stress
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Signs & Symptoms
 Pain
 Inability to throw or grasp an object
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Treatment
 Ice
 Compression
 Sling for support @ 90 degrees
 Progress to full ROM and strength
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Lateral Epicondylitis
“Tennis Elbow”
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Epidemiology
 4th -5th Decade
 M = F
 Repetitive wrist extension + forearm
pronation / supination
 10 -50% tennis players will develop
 Tendon primarily involved
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Histology
 Angiofibroblastic hyperplasia
 No acute inflammation
 Likely begins as microtear
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Physical Examination
 Pain worse w / resistive wrist /finger
extension
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Imaging
 Typically clinical diagnosis and not initially
necessary
 Consider plain XR for recalcitrant
 Look for calcification
 MRI  Concern for intraarticular
pathology
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Treatment
 Acute (<4wks)
 Rest
 NSAIDS
 PT
 Massage
 U/S
 Counterforce Bracing
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Treatment (cont’d)
 Rehabilitation
 ROM exercises
 stretching
 strengthening
 Hand grasping while in supination
 Avoid pronation movements
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Treatment
 Chronic (>4wks)
 Steroid injection
 40mg kenalogue +1/2 cc lidocaine
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Surgery
 Must fail 6 -12 months conservative mgt
 85 - 90% Effective
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Medial epicondylitis
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Another names
 Pitcher’s elbow
 Racquetball elbow
 Golfer’s elbow
 Javelin-thrower’s elbow
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Epidemiology
 Less common
 4th-5th decade
 M = F
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Mechanism
 Repeated forceful
forearm flexion
 Excessive throwing
 Microtear of
Pronator Teres
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 Worse w/ wrist flexion or forearm pronation
 Weak Grip
 May be associated with ulnar neuritis
 + Cubital tunnel
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Treatment
 Conservative management
 NSAIDS
 PT—Massage/US/strengthening/ROM
 Counterforce Brace
 Steroid Injection
 Consider EMG if associated with ulnar
nerve
 Surgical Referral—Failure of 6-12 months
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Distal Bicep Rupture
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Epidemiology
 Male predominated
injury
 50 – 60 yo
 Dominant arm
 Traumatic event of
elbow flexion against
resistance
 Often times described as
audible pop/”gunshot”
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 Tenderness / bruising
antecubital fossa
 Pain to resisted bicep
flexion and forearm
supination
 Hook Test Able to hook
tendon from lateral side
with flexion ‫الطالبية‬ ‫للخدمات‬ ‫االصدقاء‬ ‫مكتبة‬ ‫تحيات‬ ‫مع‬
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Imaging:
 Clinical Exam typically confirms
 If not obvious  MRI
 Helps evaluate partial tears and extent of
partial tearing
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Management
 Typically recommend surgical repair 
Ortho referral
 4-6 mo recovery
 Retear <2%
 Nonoperative management
 40% loss flexion strength
 50% loss supination power
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NERVES
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Cubital Tunnel Syndrome
 Ulnar N compression through medial elbow
 2nd most common compressive neuropathy
of UE
 30 – 60 yo
 DDx:
 C8 / T1 cervical compression
 Pancoast Tumor
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 Check neck and axilla
 Spurling’s sign
 Axillary mass
 Tinnel’s sign
 Direct compression Test
 Numbness
 Intrinsic Weakness
 Adductor Pollicis
 1st Dorsal Interosseus
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Special Tests
 Fromment’s sign
 Weakness of Adductor
Pollicus
 IP flexion with lateral
pinch
 Jeanne’s sign  MP
hyperextension w / IP
flexion
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Management
 CONSIDER EMG TO DOCUMENT SEVERITY
 Severe
 Persistant Pain
 Atrophy
 Surgical Referral
 Mild to Moderate
 Night splinting
 Avoids elbow
hyperflexion
 NSAIDS
 Steroid Injection
 Work Ergonomic
Modification
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Bones
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Dislocation of Elbow
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Mechanism of injury
 Second most frequent joint dislocation
 Fall on extended elbow with outstretched
hand
 Majority posterior/ posterolateral (90-95%)
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Signs & Symptoms
 Ulna and/or radius displaced posteriorly, w/
olecranon process sitting posteriorly
 Severe swelling / bleeding
 Extreme pain
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Classification
 Simple
 No fracture  purely ligamentous
 Complex
 Associated with fracture
 Radial Head  most common fx
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Treatment
 Immobilize in position you find it
 Send to ER
 Radiographs
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SIMPLE POSTEROLATERAL
DISLOCATION
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Treatment—Simple
 Closed Reduction
 Long arm splint / cast x 2 weeks
 Progressive ROM
 Protect terminal extension x 6wks
 Major Complication  Extension Loss
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Reduction Maneuver
 Gentle traction
 Anterior directed force
on olecranon
 Gradual flexion
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COMPLEX ELBOW
DISLOCATION W/ RADIAL NECK
FRACTURE
Radial Head
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Treatment - Complex
 Splint in situ  No reduction
 Ortho Referral  Surgery
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Radial Head Fractures
 Most Common Adult elbow fracture
 Mechanism  FOOSH
 Signs and symptoms:
 Pain/Effusion Elbow
 Commonly associated with wrist pain
 Pain with forearm rotation
 Check for mechanical click
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Radial Head Fractures
 Radiographs
 Can be subtle
 Look for fat pad sign
FAT PAD
SIGN
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Mason Classification
 I  Nondisplaced
 II <30% head and
>2mm displacement
 III  Comminuted
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Treatment
 I  Nonoperative
 Sling for comfort
 ROM 3-4 days
 Possible Aspiration
Hematoma
 Repeat XR 2wks
 Complication
 Extension / Supination
Loss
 Inject Joint 3months
 II  Debatable
 Ortho Referral
 No Mechanical Sx
 Conservative
• Early ROM
• Close XR
 Mechanical Sx
 Possible SURGERY
 ORIF
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Treatment - Continued
 III  Ortho Referral
 Surgery
 ORIF
 RADIAL HEAD
REPLACEMENT
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Thank You !!!
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Elbow Injuries - 1.ppt

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Elbow Injuries - 1.ppt