8/22/2012

Examination of the Elbow

• The elbow is a complex modified hinge joint • The humero-ulnar joint is a hinge joint allowing flexion and extension • The radio-ulnar joint allows for pronation and supination of the forearm

Elbow Examination Structures to Examine

• Follows the same pattern as any • Muscles other joint – biceps and triceps • Visual assessment followed by active – Common flexor origin assessment – Common extensor origin • Rom, power, ligaments, nerve supply, • Ligaments circulation – Medial and Lateral collateral ligaments – Annular ligament

Active Range of Motion Active Range of Motion

• Quick screens • Quick bilateral of flexion and screens of extension can pronation and show supination problems should be which can be carried out further investigated

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Elbow Stability – Ligament Palpation of the Region Tests

• Each important • Varus and structure in the valgus stress tests (as in the elbow region knee) check should be the integrity of palpated and the lateral and the elicited medial ligamentous response noted restraints

Assessing the Forearm Assessing Radial and Ulnar Muscles Deviation

Structures Around the Elbow

• Radius, ulna and Humerus • Flexors - of elbow and wrist • Extensors - of elbow and wrist • Pronators and supinators • Nerves • Blood vessels

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Lateral Pain Anatomy of Injury

• Tennis elbow - blanket term for any soft tissue pain on the lateral aspect between the shoulder and the wrist. • Originally described as ‘lawn tennis arm’.

Suggested Causes Suggested Causes

• Radio-humeral bursitis • Tendinitis - ECRB, supinator • periostitis of the common extensor • Microtendinous tears of the common tendon extensor tendon with sub-tendinous granulation and fibrosis. • Myofascitis

Suggested Causes Suggested Causes

• Radial head fibrillation/chondromalacia • Hyperaemic synovial fringe • Calcification • Inflammation of the annular ligament • Radial nerve entrapment and subsequent • Cervical radiculopathy fibrosis • Stenosis of the orbicular ligament (Lee, 1986, cited in Norris, 1998)

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Zuluaga et al (1995)

• Tennis elbow results from overuse or constant repetitive stress of the upper attachments of extensor carpi radialis longus and brevis, and occasionally extensor carpi ulnaris and extensor digitorum.

Lateral Epicondylitis (Tennis Elbow)

• Affects approximately 40-50% of professional and amateur tennis players at some stage or other.

Lateral Epicondylitis (Tennis ‘Tennis’ Elbow? Elbow)

• Lateral epicondylitis can originate from other activities, such as digging. • Many patients with tennis elbow have never played tennis.

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Signs and Symptoms Signs and Symptoms

• Pain - elicited over the lateral epicondyle • Occasionally the superior radio-ulnar joint when muscles are contracted or stretched. may be problematic. • Static radial deviation and extension with • Release of any capsular tightening of this pronation will elicit pain. joint may decrease other symptoms due to the close proximity of the two structures. • Pain is usually localised just above the • May be caused by degenerative disease lateral epicondyle. causing some form of ischaemia.

Treatment Treatment

• Initial treatment will follow the RICE • A counterforce brace may be applied to regime and passive stretching. the upper forearm. • The causative stresses must be removed. • Biomechanical analysis of grip and stroke- play may decrease recurrence.

Steroid Injection Treatment

• With rest the condition may resolve in 6 months to 1 year. • A variety of electrotherapeutic modalities may be incorporated in treatment and deep transverse frictions are useful.

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Frictions to the Epicondyle Treatment

• Manipulation of the elbow joint with the wrist in flexion and pronation may release adhesions. • In more severe cases surgery to release the superior radio-ulnar capsule may be necessary.

Medial Pain Medial Epicondylitis

• Lesions of the medial aspect occur most • Commonly called Golfer’s Elbow often with throwing activities. • Repetitive strain injury to the common • The valgus stress on the joint initially flexor origin. stresses the ulnar collateral ligament. • Primary site is the pronator teres and • Rapid acceleration of the arm into flexor carpi radialis on the medial extension may damage the olecranon. epicondyle.

Extrinsic Injury

1. Club hits ground. 2. Shaft continues forward in swing. 3. Wrist forced into hyperextension. 4. Elbow forced into abduction. (It is not designed to do that)

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Golfer’s Elbow Treatment

• Can be complicated by involvement of the • For the most part, treatment is similar to ulnar nerve. that of tennis elbow. • Tinel’s sign may be positive - tapping the • Transverse frictions are performed with ulnar nerve at the elbow sends tingles the wrist in extension and the forearm down the hand. supinated. • Static test for elbow flexors confirms diagnosis.

Thrower’s Elbow Treatment

• Caused by repetitive stress to the medial collateral ligament. • Initial treatment is to remove the causative • Pain is generally localised over the medial forces. joint line. • Surgical repair of the ruptured ligament is • Pain is increased on abduction stress test. recommended. • With severe injuries gapping of the joint may be visible.

Things to look up Fractures to the Elbow

• Usually immobilised for 3 weeks with a • Posterior Pain - Olecranon bursitis POP back-slab with a collar and cuff. • Posterior impingement • Swelling is monitored and released by • Muscle Injuries - biceps and triceps pumping actions of the hand and fingers. • Myositis Ossificans traumatica • Olecranon process fractures are commonly reduced by tension band • Elbow dislocations wiring.

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Fractures to the Humerus Fixation Post-Fracture

• Elbow fracture fixed with K-wiring • Fractures at the elbow often involve the joint line

Injury Action for Wrist, Elbow Fractures of the Wrist (Colles) and Shoulder Fractures

• Most common in women aged 40+ (peak • FOOSH injury @ 50). • Fall On the Out • Fracture of the distal end of radius usually - Stretched about 1-2 inches from the distal end. Hand • Result from a fall on the outstretched hand.

Displacement With Colles Displacement of Colles #’s Fractures

• Radial displacement of distal fragment. –Anterior angulation of distal fragment. –Severe violence may cause tearing of the periosteum. –Dorsal displacement of distal fragment. –Associated with impaction –Dinner-fork displacement due to shape on X-ray

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Classic Dinner-Fork X-ray of Colles Fracture Deformity

Colles Fracture Post-Op Management of Colles #’s

• Fracture is reduced if necessary. • Plaster back slab is prepared. • Manual traction is applied to reduce the #. • PoP is applied with the arm in full pronation, full ulnar deviation and slight palmar flexion and put in a collar & cuff. • PoP checked at 2 weeks for slippage.

Physiotherapy Management

• The patient can perform finger movements and elbow movements with the cast is in Hand Assessment situ (4-6 weeks). • Rehab begins once the PoP is removed and strengthening of the forearm muscles should begin. • Care should be taken to regain full RoM at the wrist and radio-ulnar joints.

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Examination of the Hand & Range of Motion Activities Fingers

• Observation of palmar and dorsal aspects

Types of Grip Ulnar Nerve Assessment

• Lateral pinch • Fine pinch grip • Tip pinch • Flat pinch • Tripod grip • Wide grip • Power grip

Traumatic Injury

• Amputation of Hand Injuries the thumb or fingers is the WARNING! worst case. The next slide is a bit gross

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Scaphoid Fractures Scaphoid Fractures Scaphoid fractures account for about 60 percent of all Signs and symptoms wrist (carpal) fractures. Pain and tenderness on the They usually occur in men thumb side of the wrist. between ages 20 and 40 Motion (gripping) may be years, and are less common painful. in children or in older adults. May be some swelling on The break usually occurs back and thumb side of wrist. during a fall on the outstretched wrist. Pain may subside, then return as a deep, dull aching. It’s a common injury in sports and motor vehicle accidents. Marked tenderness to pressure on the "anatomical • The angle at which the wrist hits the ground determines the injury. snuffbox," a triangular-shaped • If the wrist is extended at a 90-degree angle or greater, the scaphoid area on the side of the hand bone will break; if the angle is less than 90 degrees, the lower arm between two tendons that bone (radius) will break. lead to the thumb.

Scaphoid Fractures Scaphoid Fractures

The scaphoid is more susceptible to injury than any of the other carpal bones because of its unique position bridging the proximal and distal rows of the carpal bones. This frequency is due to a tenuous blood supply, with only one dorsoradial artery to the proximal pole, which results in a nearly 100% incidence of avascular necrosis in proximal fractures and a 30% incidence in distal fractures. Any tenderness in the anatomic snuffbox over the dorsal scaphoid (figure 1b) should prompt treatment as for a fracture.

Computer Usage and Carpal Tunnel Carpal Tunnel Syndrome • The flexor retinaculum becomes restricted and inflamed. • As the flexor tendons pass below the retinaculum they cause compression and pain. • Increased compression due to swelling can compress the median nerve giving a nerve palsy from the wrist down.

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Carpal Tunnel Syndrome

2. Transverse 1. Carpal Bones • The retinaculum must be stretched to Carpal allow clear passage of the tendons, Ligament failing this then it must be cut surgically. • The pain from this condition is usually localised but may spread into the hand 4. Nine Flexor Tendons 3. Median Nerve - 4 flexor digitorum and fingers. superficialis - 4 flexor digitorum profundus - 1 flexor pollicis

Carpal Tunnel Syndrome Carpal Tunnel Syndrome

Carpal Tunnel Syndrome Carpal Tunnel Syndrome

Pressure Overuse on median of flexor nerve muscles

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Carpal Tunnel Syndrome Carpal Tunnel Syndrome

Symptoms Modification in activities Pain and Table height, wrist angle, elbow angle numbness in 1-3 10-15 minute breaks fingers and half of th Exercises and warm-up wrist flexor the 4 or ring muscles finger Flex fingers tightly then extend and abduct Symptoms do not fingers for 5 seconds include palm or With arms extended, flex and extend wrist little finger several times followed by circumduction of the wrist

Carpal Tunnel Syndrome Finger Tendinitis

• This is inflammation of the tendons of the muscles moving the fingers due to Removable wrist brace some form of overuse or repetitive Anti-inflammatory medicines strain injury. NSAID • Usually the flexors are involved and Cortisone contraction is painful. Surgery – carpal tunnel release • Continued stress may eventually lead to rupture and subsequent surgical repair.

Dupytren’s Contracture Dupytren’s Contracture

• This is a thickening and tightening of • More tightening holds the metacarpo- the palmar fascia, especially the phalangeal joints in flexion and even medial aspect. more causes distal inter-phalangeal • As the fascia tightens it draws down joint flexion. the little and ring fingers into flexion. • Extension in the index and middle fingers is limited and these rigid bands of tightened fascia are easily palpated.

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Dupytren’s Contracture De Quervain’s Disease

• They are treated by massage, • Also known as washer woman’s stretching, ultrasound and in the final strain. stages surgery. • It is a strain to extensor pollicis brevis and abductor pollicis longus tendons.

De Quervain’s Disease De Quervain’s Disease

• Movement causes pain and static • The synovial sheaths of these muscle test elicit pain. tendons pass through the flexor • Palpation of the tendons in their retinaculum. sheaths is tender. • Overuse causes an inflammatory response to be set up causing swelling and pain.

De Quervain’s Disease De Quervain’s Disease

• Adhesions may form after the acute • If stenosing paratenonitis occurs the stage, between the tendon sheaths tendon begins to stick in the sheath which restricts movement and sets up and movement again is halted. a restrictive synovitis. • Movement must be maintained in the sheath at all times and if adhesion are great then surgery may be necessary.

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Things To Look Up Yourself

• Galeazzi fracture. • Smith’s fractures. Any Questions? • Scaphoid fractures. • Fracture/dislocation of the lunate. ? • Fracture of the metacarpals and phalanges • Bennett’s fracture (thumb)

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