copyright © 2013 wolters kluwer health | lippincott williams & wilkins upper arm, elbow, and...

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Upper Arm, Elbow, and Forearm Conditions

Upper Arm, Elbow, and Forearm Conditions

Chapter 15


AnatomyAnatomy


AnatomyAnatomy• 3 articulations (single capsule)

– Humeroulnar (elbow joint)

• Trochlea of humerus with trochlear fossa of ulna

• Hinge joint; flexion and extension

• Close-packed position – extension

– Humeroradial

• Capitellum of humerus with proximal radius

• Gliding joint

• Lateral to humeroulnar joint

• Close-packed position – elbow 90°; forearm supinated 5°


Anatomy (cont.)Anatomy (cont.)

– Proximal radioulnar

• Head of radius with radial notch of ulna; joined by annular ligament

• Pivot joint

Radius rolls medially and laterally over the ulna; pronation and supination

• Close-packed position – supination 5°



• Carrying angle

– Angle between humerus and ulna (arm in anatomic position)

– 10-15° angle

– Greater in females


Anatomy (cont.)Anatomy (cont.)• Ligaments

– Ulnar (medial) collateral

– Radial (lateral) collateral

– Annular

– Accessory lateral collateral



• Bursae

– Several small

– Olecranon bursa

• Superficial



• Nerves

– Musculocutaneous

– Median

– Ulnar

– Radial



• Blood vessels

– Brachial

• Ulnar and radial


KinematicsKinematics

• Movements

– Flexion and extension

• Humeroulnar joint and humeroradial joint

– Supination and pronation

• Proximal radioulnar


Kinematics (cont.)Kinematics (cont.)

• Muscles

– Flexors

• Brachialis; biceps; brachioradialis

• Effectiveness depends on supination/pronation position

– Extensors

• Triceps; anconeus

– Pronation and supination

• Pronator quadratus; pronator teres supinator; biceps


KineticsKinetics

• Non–weight bearing but still sustains significant loads

• Extremely large muscle forces generated with forceful throwing motions, weight lifting, and many resistance training exercises

• Extensor moment arm < flexor moment arm

– Extensors must generate more force than flexors to produce same amount of joint torque


Injury PreventionInjury Prevention

• Protective equipment

– Pads

– Braces

• Physical conditioning

– Flexibility and strength

– Focus on entire arm

• Proper skill technique

– Throwing

– Falling


ContusionsContusions• Susceptible due to:

– Lack of padding

– General vulnerability

• S&S

– Rapid swelling – can limit ROM

• Chronic blows

– Development of ectopic bone

• Myositis ossificans – brachialis belly; proximal deltoid insertion

• Tackler’s exostosis

– Painful periostitis and fibrositis may develop

• Management: standard acute; NSAIDs


Olecranon BursitisOlecranon Bursitis

• Acute and chronic– Mechanism

• Fall on a flexed elbow • Constantly leaning on elbow • Repetitive pressure and friction


Olecranon Bursitis (cont.)Olecranon Bursitis (cont.)

– S&S• 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



• Septic bursitis

– Related to seeding from infection at a distant site

– S&S

• Traditional signs of infection (within 1 week of symptoms)

• Skin lesion overlying bursa – 50% of cases

• Bursal tenderness – 92-100% of cases

• Peribursal cellulitis – 40-100% of cases



• Nonseptic

– Caused by crystalline deposition disease or rheumatoid involvement

– Associated with atopic dermatitis

– S&S

• Skin lesion – 5% of cases

• Bursal tenderness – 45% of cases

• Cellulitis – 25% of cases

• Management: physician referral


SprainSprain• Mechanism

– Fall on extended hand (hyperextension injury)

– Valgus or varus force

– More common; repetitive forces irritate and tear ligaments, especially UCL

• Ulnar nerve may also be affected

• S&S

– Localized pain

– Point tenderness

– Instability with stress test

• Management: standard acute


Anterior CapsulitisAnterior Capsulitis• Anterior joint pain caused by hyperextension

• S&S

– Diffuse, anterior elbow pain after a traumatic episode

– Deep tenderness on palpation (especially anteromedial)

• Need to rule out pronator teres strain and median nerve entrapment

• Management: immobilization for 3-5 days followed by AROM exercises as pain allows


DislocationDislocation

• 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 freewarrants immediate physician referral

– Immobilization for 3-6 weeks in flexion is usually necessary


Dislocation (cont.)Dislocation (cont.)

• Ulnar dislocation

– Younger than 20 years old

– Mechanism:

• Hyperextension

• Sudden, violent unidirectional valgus force drives ulna posterior or posterolateral

– Associated conditions


Dislocation (cont.)Dislocation (cont.)


Dislocation (cont.)Dislocation (cont.)– S&S

• 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


StrainsStrains

• Flexors and pronator teres

– Repetitive tensile stresses

• Extensor

– Decelerating type injury

• S&S

– Typical muscle strain S&S

– Self-limiting

• Management: standard acute


Biceps Brachii RuptureBiceps Brachii Rupture

• Mechanism: sudden eccentric load

• S&S

– Tenderness, swelling, and ecchymosis in antecubital fossa

– Weakness in supination and flexion

– Distal tendon not palpable

• Management: standard acute; immediate physician referral

• Nonoperative vs. surgical repair


Triceps Brachii RuptureTriceps Brachii Rupture

• Mechanism:

– Direct blow to posterior elbow

– Uncoordinated triceps contraction during a fall

• 80% involve olecranon avulsion fracture


Triceps Brachii Rupture (cont.)Triceps Brachii Rupture (cont.)• S&S

– Pain and swelling in distal attachment

– Palpable defect in the triceps tendon or a step-off deformity of the olecranon

– Active extension weak – partial tear; nonexistent – total rupture

• Management: standard acute; immobilize in sling; immediate physician referral


Compartment SyndromeCompartment Syndrome

• Anterior – wrist and finger flexors posterior – wrist and finger extensors

• Condition often secondary to other injuries• Potential for neurovascular compromise


Compartment Syndrome (cont.)Compartment Syndrome (cont.)

• S&S– Rapid onset– Swelling; discoloration– Absent or diminished distal pulse– Subsequent onset of sensory changes and paralysis– Severe pain at rest, aggravated by passive stretching of

muscles in involved compartment• Management: immobilization; ice and elevation; NO

compression; immediate physician referral


Overuse ConditionsOveruse Conditions

• Medial epicondylitis – Due to repeated valgus forces during

acceleration phase of throwing motion – Commonly involved tendons: pronator teres

and flexor carpi radialis


Overuse Conditions (cont.)Overuse Conditions (cont.)

– S&S• 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

• Ulnar nerve involved – tingling and numbness– Management: ice; NSAIDs; sling immobilization for 2-3

weeks with wrist in slight flexion; therapeutic exercise



• Lateral epicondylitis

– 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

• 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

• + “coffee cup” test

• + tennis elbow test

– Management: ice; NSAIDs; rest; support



• Neural entrapment

– Ulnar nerve

• Vulnerable to compression and tension

• S&S

Shocking sensation (medial elbow), radiating as if “hitting their crazy 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


Overuse Conditions (cont.)Overuse Conditions (cont.)– Median nerve

• Compression

• Involvement of pronator teres – pronator syndrome

• S&S

Pain in anterior proximal forearm, and aggravated with pronation

Numbness in anterior forearm, middle and index fingers, and thumb



– Radial nerve

• S&S

Aching lateral elbow pain, radiates down posterior forearm

Significant point tenderness over supinator muscle

Resisted supination more painful than wrist extension

Extreme cases: wrist drop

– Management of neural entrapment: immediate physician referral


FracturesFractures

• Epiphyseal and avulsion fractures

– Medial epicondyle growth plate sensitive to tension stress

• Repetitive or sudden contraction of the flexor-pronator muscle group → partial or complete avulsion fracture of the medial epicondyle (little league elbow)


Fractures (cont.)Fractures (cont.)

– S&S

• Initial phase – aching during performance, but no limitations of performance or residual pain

• Progression – aching pain during activity limits performance, and a mild postexercise ache

• Localized tenderness

– Management

• Initial phase: standard acute; activity modification

• Performance limitations – physician referral



• Stress fractures– Ulna diaphysis – intensive weight lifting– Bilateral distal radius and ulna – young individuals who

lift heavy weights• Osteochondritis dissecans

– Complication of repetitive stress to skeletally immature elbow

– Lateral compressive forces during throwing motion damage radial head, capitellum, or both



– S&S• Pain with activity, improves with rest• Occasional clicking or locking of elbow• Swelling and tenderness over radiocapitellar joint• Grating during passive pronation and supination• Limited full extension

• Management: physician referral



• Supracondylar fractures– Fall on outstretched hand

• Volkmann’s contracture:

Complication from supracondylar fractures

Ischemic necrosis of forearm muscles

Damage to brachial artery or median nerve from fractured bone ends



• Olecranon

– Direct blow

– Triceps tension pulls bone fragment superiorly

– Intra-articular fracture – does not respond to conservative treatment, requires surgical intervention


Fractures (cont.)Fractures (cont.)• Radial head

– Valgus stress tears UCL → compression and shearing on radial head

– S&S

• Swelling lateral to the olecranon

• Point tenderness radial head

• Flexion and extension may or may not be limited; passive pronation and supination is painful and restricted

• Possible associated valgus instability of the elbow or axial instability of the forearm



• Ulna (forearm fracture)

– Direct blow

– Also known as “nightstick” fracture



• Fracture management

– Neurologic and circulatory assessment

• Radial nerve damage

Weak forearm supination; elbow, wrist, or fingers extension

Sensory changes – dorsum of hand



• Median nerve

Weak wrist and finger flexion

Sensory changes – palm of hand

• Ulnar nerve

Weak ulnar deviation and finger abduction/adduction; sensory changes – ulnar border of the hand

– Assess pulse at wrist or assess capillary refill

– Apply vacuum splint; transport immediately to nearest medical facility


AssessmentAssessment• History

• Observation/inspection

– Carrying angle

– Position of function

• Palpation

• Physical examination tests


Range of Motion (ROM)Range of Motion (ROM)• Active range of motion (AROM)

– Elbow

• Flexion/extension

• Pronation/supination

– Wrist

• Flexion/extension

• Passive range of motion (PROM)

– Elbow flexion – tissue approximation

– Elbow extension – bone to bone

– Supination and pronation – tissue stretch


ROM (cont.)ROM (cont.)

• Normal ranges

– Elbow flexion: 140-150°

– Elbow extension: 0-10°

– Supination: 90°

– Pronation: 90°

– Wrist flexion: 80-90°

– Wrist extension: 70-90°



• Resisted range of motion (RROM)

– Elbow flexion

– Elbow extension

– Supination

– Pronation

– Wrist flexion

– Wrist extension


Stress TestsStress Tests• Ligamentous instability

– Valgus stress

– Varus stress

– Perform at multiple angles (full extension → 20-30° flexion)


Special TestsSpecial Tests• 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


Special Tests (cont.)Special Tests (cont.)• Medial epicondylitis

• Tinel’s sign for ulnar neuritis

• Elbow flexion for ulnar neuritis

• Pronator teres syndrome


Special Tests (cont.)Special Tests (cont.)

• Pinch grip test


Neurologic TestsNeurologic Tests

• Myotomes– Scapular elevation – C4

– Shoulder abduction – C5

– Elbow flexion and/or wrist extension – C6

– Elbow extension and/or wrist flexion – C7

– Thumb extension and/or ulnar deviation – C8

– Abduction and/or adduction of fingers – T1


Neurologic Tests (cont.)Neurologic Tests (cont.)

• Reflexes

– Biceps – C5-C6

– Brachioradialis – C6

– Triceps – C7



• Dermatomes



• Cutaneous patterns


RehabilitationRehabilitation

• Restoration of motion

– Use of opposite hand to supply load

– UBE


Rehabilitation (cont.)Rehabilitation (cont.)

• Restoration of proprioception and balance

– Closed-chain exercises

• Muscular strength, endurance, and power

– Open-chain exercises

– PNF-resisted exercises

• Cardiovascular fitness

copyright © 2013 wolters kluwer health | lippincott williams & wilkins upper arm, elbow, and...

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