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Elbow Injuries for the Primary Care Doc
Brian Badman M.D.Brian Badman M.D.
Disclosures:
ConsultantConsultant Smith and Nephew EndoscopySmith and Nephew Endoscopy UpEXUpEX DJO SurgicalDJO Surgical
I have no conflicts with current talk or I have no conflicts with current talk or industry supportindustry support
Basic Anatomy
Relevant Anatomy
HumerusHumerus UlnaUlna RadiusRadius
Distal Humerus
Medial Epicondyle Lateral Epicondyle
Trochlea Capitellum
Coronoid Fossa
Proximal Ulna
OlecranonProcess
Greater Sigmoid Notch
Lesser Sigmoid Notch
Coronoid Process
Proximal Radius
Head
Neck
Radial/Bicepital Tuberosity
Joints
Humeroulnar joint and HumeroradialHumeroulnar joint and Humeroradial Flexion/extensionFlexion/extension
Radioulnar jointRadioulnar joint Supination/pronationSupination/pronation
Muscles Around Elbow—Simple
BicepBicep TricepsTriceps Wrist flexorsWrist flexors Wrist extensorsWrist extensors
Wrist Flexors
Wrist Extensors
Forearm muscles Forearm flexorsForearm flexorsmedial epicondylemedial epicondyle Forearm extensorsForearm extensorslateral epicondylelateral epicondyle
Flexors of the elbow
BrachialisBrachialis BicepsBiceps BrachioradialisBrachioradialis
Extensors of the elbow
Triceps brachiiTriceps brachii Long headLong head Lateral headLateral head Medial headMedial head
Elbow Pronator
Pronator teresPronator teres
Elbow Supinators
Biceps brachiiBiceps brachii SupinatorSupinator
Ligaments Joint capsule surrounds jointJoint capsule surrounds joint Ulnar collateral (Tommy John)Ulnar collateral (Tommy John) Radial collateral Radial collateral Annular ligamentAnnular ligament
Other structures
NervesNerves Ulnar, radial, medianUlnar, radial, median
Palpable Landmarks Olecranon processOlecranon process Olecranon fossaOlecranon fossa Medial and lateral epicondylesMedial and lateral epicondyles Radial headRadial head Cubital Tunnel—Ulnar NCubital Tunnel—Ulnar N
Stability of Elbow
Primary StabilizersPrimary StabilizersMCL (55% @ 90MCL (55% @ 90°)°)Ulnohumeral JointUlnohumeral Joint
• CoronoidCoronoid50%50%
• OlecranonOlecranon
Secondary Secondary StabilizersStabilizers Radiohumeral Radiohumeral
JointJoint CapsuleCapsule Musculature Musculature
(dynamic)(dynamic)
Common Elbow Maladies
Soft Tissue
Olecranon Bursitis
Etiology AsepticAseptic
Direct blow or Direct blow or fallfallHemarthrosisHemarthrosis
GoutGout SepticSeptic
Insect BiteInsect Bite Cut/AbrasionCut/Abrasion HematogenousHematogenous
Signs & symptoms
PainPain SwellingSwelling Erythema/FebrileErythema/FebrileSepticSeptic
Treatment ColdCold CompressionCompression AspirateAspirate
If serous/bloodyIf serous/bloodyInject 40mg steroid Inject 40mg steroid +compressive dressing+elbow extension x 3 days+compressive dressing+elbow extension x 3 days
If pussIf pussRequires I+D (Ortho Consult)Requires I+D (Ortho Consult)
Recurrent aseptic bursitisRecurrent aseptic bursitisSurgerySurgery
Elbow Sprains
Mechanism
Hyperextension or a force that bends or Hyperextension or a force that bends or twists the lower arm outward twists the lower arm outward
Valgus stressValgus stress
Signs & Symptoms
PainPain Inability to throw or grasp an objectInability to throw or grasp an object POT (usually over UCL)POT (usually over UCL)
Treatment
IceIce CompressionCompression Sling for support @ 90 degreesSling for support @ 90 degrees Progress to full ROM and strengthProgress to full ROM and strength
Lateral EpicondylitisA.K.A “Tennis Elbow”
Epidemiology
44thth -5 -5thth Decade Decade M=FM=F Repetitive wrist extension +forearm Repetitive wrist extension +forearm
pronation/supinationpronation/supination 10-50% tennis players will develop10-50% tennis players will develop
ECRB Tendon primarily involvedECRB Tendon primarily involved #2=EDC#2=EDC
Histology
Angiofibroblastic hyperplasiaAngiofibroblastic hyperplasia No acute inflammationNo acute inflammation Likely begins as microtearLikely begins as microtear
Physical Examination
TTP anterior/distal LETTP anterior/distal LE Pain worse w/ resistive wrist/finger extensionPain worse w/ resistive wrist/finger extension
Imaging Typically clinical diagnosis and not initially Typically clinical diagnosis and not initially
necessarynecessary Consider plain XR for recalcitrantConsider plain XR for recalcitrant
Look for calcificationLook for calcification MRIMRIConcern for intraarticular pathologyConcern for intraarticular pathology
Treatment
Acute (<4wks)Acute (<4wks) RestRest NSAIDSNSAIDS PTPT
MassageMassageU/SU/S
Counterforce BracingCounterforce Bracing
Treatment (cont’d)
RehabRehab ROM exercisesROM exercises
stretchingstretching PRE’sPRE’s
strengtheningstrengthening Hand grasping while in supinationHand grasping while in supination Avoid pronation movementsAvoid pronation movements
Treatment
Chronic (>4wks)Chronic (>4wks) Steroid injection Steroid injection
40mg kenalogue +1/2 cc lidocaine40mg kenalogue +1/2 cc lidocaine
Surgery/Referral Must fail 6-12 months conservative mgtMust fail 6-12 months conservative mgt
85-90% Effective—Nirschl JBJS 197985-90% Effective—Nirschl JBJS 1979
Platelet Rich Plasma
Autologous BloodAutologous Blood Centrifuge to separate layers and Centrifuge to separate layers and
concentrate plateletsconcentrate platelets Growth FactorsGrowth FactorsMay potentiate/stimulate May potentiate/stimulate
healinghealing May stimulate Type 1 collagen formationMay stimulate Type 1 collagen formation
–Kajikawa J Cell Physiol 2008Kajikawa J Cell Physiol 2008
PRP Cont.
Expensive $200-600Expensive $200-600 Not covered by insuranceNot covered by insurance Early results poor study quality with Early results poor study quality with
research bias (financial incentive)research bias (financial incentive)
PRP Peer Reviewed Level 1 EvidenceGosens T, Peerbooms JC, van Laar W, den Oudsten BL. Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Am J Am J
Sports MedSports Med. 2011 Mar 21. . 2011 Mar 21. Ongoing Positive Effect of Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-Year Follow-Up.Controlled Trial With 2-Year Follow-Up.
100 patients100 patients49 cortisone/51 PRP49 cortisone/51 PRP
PRP group with significant improvement PRP group with significant improvement regarding pain c/w steroid group at 2 yearsregarding pain c/w steroid group at 2 years
Medial epicondylitis
A.K.A.
Pitcher’s elbowPitcher’s elbow Racquetball elbowRacquetball elbow Golfer’s elbowGolfer’s elbow Javelin-thrower’s elbowJavelin-thrower’s elbow
Epidemiology
Less commonLess common 44thth-5-5thth decade decade M=FM=F
Mechanism
Repeated forceful Repeated forceful forearm flexionforearm flexion
Excessive throwingExcessive throwing
Microtear of Microtear of FCR/Pronator TeresFCR/Pronator Teres
Physical Examination
TTP at medial epicondyleTTP at medial epicondyle Worse w/ wrist flexion or forearm pronationWorse w/ wrist flexion or forearm pronation Weak GripWeak Grip
May be associated with ulnar neuritisMay be associated with ulnar neuritis TTP ulnar nerveTTP ulnar nerve +Tinnels thru cubital tunnel+Tinnels thru cubital tunnel
Treatment Conservative management Conservative management
NSAIDSNSAIDS PT—Massage/US/strengthening/ROMPT—Massage/US/strengthening/ROM Counterforce BraceCounterforce Brace Steroid InjectionSteroid Injection Consider EMG if associated with ulnar nerve Consider EMG if associated with ulnar nerve
sxssxs Surgical Referral—Failure of 6-12 monthsSurgical Referral—Failure of 6-12 months
Distal Bicep Rupture
Epidemiology Male predominated injuryMale predominated injury 50-60yo 50-60yo Dominant armDominant arm Traumatic event of elbow Traumatic event of elbow
flexion against resistanceflexion against resistance Often times described as Often times described as
audible pop/”gunshot”audible pop/”gunshot”
Physical Examination
Tenderness/bruising Tenderness/bruising antecubital fossaantecubital fossa
Pain to resisted bicep flexion Pain to resisted bicep flexion and forearm supinationand forearm supination
Hook TestHook TestAble to hook Able to hook tendon from lateral side with tendon from lateral side with flexionflexion
Imaging: Clinical Exam typically confirmsClinical Exam typically confirms
If not obviousIf not obviousMRIMRI Helps evaluate partial tears and extent of Helps evaluate partial tears and extent of
partial tearingpartial tearing
Management
Typically recommend surgical repairTypically recommend surgical repairOrtho Ortho referralreferral 4-6 mo recovery4-6 mo recovery Retear <2%Retear <2%
Nonoperative managementNonoperative management 40% loss flexion strength40% loss flexion strength 50% loss supination power50% loss supination power
NERVES
Cubital Tunnel Syndrome
Ulnar N compression thru medial elbowUlnar N compression thru medial elbow 22ndnd most common compressive neuropathy most common compressive neuropathy
UEUE 30-60yo30-60yo DDx: DDx:
C8/T1 cervical compressionC8/T1 cervical compression Pancoast TumorPancoast Tumor
Physical Examination Check neck and axillaCheck neck and axilla
Spurling’s signSpurling’s sign Axillary mass/tinnelsAxillary mass/tinnels
Tinnel’s thru cubital tunnelTinnel’s thru cubital tunnel Direct compression TestDirect compression Test Numbness to RF/SFNumbness to RF/SF
Semmes-Weinstein MonofilamentSemmes-Weinstein Monofilament
Intrinsic WeaknessIntrinsic Weakness Adductor PollicisAdductor Pollicis 11stst Dorsal Interosseus Dorsal Interosseus
Special Tests Fromment’s signFromment’s sign
Weakness of Adductor Weakness of Adductor Pollicus compensated by Pollicus compensated by FPLFPL
IP flexion with lateral IP flexion with lateral pinchpinch
FOX vs. RABBITFOX vs. RABBIT
Jeanne’s signJeanne’s signMP MP hyperextension w/ IP hyperextension w/ IP flexionflexion
Management
CONSIDER EMG TO DOCUMENT SEVERITYCONSIDER EMG TO DOCUMENT SEVERITY
SevereSevere Persistant PainPersistant Pain AtrophyAtrophy
Surgical ReferralSurgical Referral
Mild to ModerateMild to Moderate Night splinting Night splinting
Avoids elbow Avoids elbow hyperflexionhyperflexion
HeelboHeelbo NSAIDSNSAIDS Steroid InjectionSteroid Injection Work Ergonomic Work Ergonomic
ModificationModification
Bones
Dislocation of Elbow
Mechanism of injury
Second most frequent joint dislocationSecond most frequent joint dislocation
Fall on extended elbow with outstretched Fall on extended elbow with outstretched handhand
Majority posterior/posterolateral (90-95%)Majority posterior/posterolateral (90-95%)
Signs & Symptoms
Ulna and/or radius displaced posteriorly, w/ Ulna and/or radius displaced posteriorly, w/ olecranon process sitting posteriorlyolecranon process sitting posteriorly
Severe swelling/bleedingSevere swelling/bleeding Extreme painExtreme pain
Classification
SimpleSimple No fractureNo fracturepurely ligamentouspurely ligamentous
ComplexComplex Associated with fractureAssociated with fracture
Radial HeadRadial Headmost common fxmost common fx
Treatment Immobilize in position you find itImmobilize in position you find it Send to ERSend to ER RadiographsRadiographs
SIMPLE POSTEROLATERALDISLOCATION
Treatment—Simple
Closed ReductionClosed Reduction Long arm splint/cast x 2 weeksLong arm splint/cast x 2 weeks Progressive ROMProgressive ROM
Protect terminal extension x 6wksProtect terminal extension x 6wks
Major ComplicationMajor ComplicationExtension LossExtension Loss
Reduction Maneuver
Gentle tractionGentle traction Anterior directed force Anterior directed force
on olecranonon olecranon Gradual flexionGradual flexion
COMPLEX ELBOWDISLOCATION W/ RADIAL NECK FRACTURE
Radial Head
Treatment--Complex
Splint in situSplint in situNo reduction No reduction Exception: NV compromiseException: NV compromise
Ortho ReferralOrtho ReferralSurgerySurgery
Radial Head Fractures Most Common Adult elbow fractureMost Common Adult elbow fracture MechanismMechanismFOOSHFOOSH
PE:PE: Pain/Effusion ElbowPain/Effusion Elbow Commonly associated with wrist painCommonly associated with wrist pain Pain with forearm rotationPain with forearm rotation Check for mechanical clickCheck for mechanical click
Radial Head Fractures
RadiographsRadiographs Can be subtleCan be subtle Look for fat pad signLook for fat pad sign
FAT PADSIGN
Mason Classification
IINondisplacedNondisplaced
IIII<30% head and <30% head and >2mm displacement>2mm displacement
IIIIIIComminutedComminuted
Treatment
IINonoperativeNonoperative Sling for comfortSling for comfort ROM 3-4 daysROM 3-4 days Possible Aspiration Possible Aspiration
HematomaHematoma Repeat XR 2wksRepeat XR 2wks ComplicationComplication
Extension/Supination Extension/Supination LossLoss
Inject Joint 3monthsInject Joint 3months
IIIIDebatableDebatable Ortho ReferralOrtho Referral
No Mechanical SxNo Mechanical Sx ConservativeConservative
• Early ROMEarly ROM
• Close XR F/UClose XR F/U
Mechanical SxMechanical Sx Possible SURGERYPossible SURGERY ORIFORIF
Treatment--Continued
IIIIIIOrtho ReferralOrtho Referral SurgerySurgery
ORIFORIF RADIAL HEAD RADIAL HEAD
REPLACEMENTREPLACEMENT
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