KIN 191B – Advanced KIN 191B – Advanced Assessment of UpperAssessment of Upper

Extremity InjuriesExtremity Injuries

Elbow and Forearm Elbow and Forearm PathologiesPathologies

PatholgiesPatholgies

Elbow ligamentous sprainsElbow ligamentous sprains EpicondylitisEpicondylitis Rupture of distal biceps brachii tendonRupture of distal biceps brachii tendon Osteochondritis dissecans of capitellumOsteochondritis dissecans of capitellum Neurological injuryNeurological injury Elbow dislocationsElbow dislocations FracturesFractures Olecranon bursitisOlecranon bursitis

Elbow Ligamentous SprainsElbow Ligamentous Sprains

Medial (ulnar) collateral ligament Medial (ulnar) collateral ligament injuryinjury

Lateral (radial) collateral ligament Lateral (radial) collateral ligament injuryinjury

MCL/UCL InjuryMCL/UCL Injury

Can be acute (traumatic valgus force) Can be acute (traumatic valgus force) or chronic (e.g. - repetitive overhand or chronic (e.g. - repetitive overhand throwing)throwing)

Anterior bundle most affected – primary Anterior bundle most affected – primary stabilizerstabilizer

Posterior bundle may be involved if Posterior bundle may be involved if elbow flexed beyond 60 degrees at time elbow flexed beyond 60 degrees at time of injuryof injury

MCL/UCL InjuryMCL/UCL Injury Most common symptoms include:Most common symptoms include:

– Point tenderness, swelling (may be significant), Point tenderness, swelling (may be significant), neuro symptoms (ulnar and radial nerves), neuro symptoms (ulnar and radial nerves), limited elbow and forearm ROM due to tension on limited elbow and forearm ROM due to tension on ligaments and pain, laxity to valgus stress testligaments and pain, laxity to valgus stress test

Mild and moderate injuries often treated Mild and moderate injuries often treated conservatively with rest, NSAIDs, progressive conservatively with rest, NSAIDs, progressive flexibility and strengthening exercisesflexibility and strengthening exercises

Severe injuries, especially in competitive Severe injuries, especially in competitive athletes, typically treated surgicallyathletes, typically treated surgically– ““Tommy John” injury/surgeryTommy John” injury/surgery– Usually use palmaris longus tendon as graftUsually use palmaris longus tendon as graft

LCL/RCL InjuryLCL/RCL Injury

Much less common than MCL/UCL injuryMuch less common than MCL/UCL injury When occur, typically due to varus force When occur, typically due to varus force

application – may injure LCL/RCL and application – may injure LCL/RCL and annular ligamentannular ligament– May affect radial articulation with capitellum May affect radial articulation with capitellum

and/or proximal radioulnar articulationand/or proximal radioulnar articulation Most common symptoms include:Most common symptoms include:

– Point tenderness, swelling, limited elbow and Point tenderness, swelling, limited elbow and ROM and laxity to varus stress testROM and laxity to varus stress test

Almost always treated conservativelyAlmost always treated conservatively

EpicondylitisEpicondylitis

Medial epicondylitisMedial epicondylitis– Commonly referred to as “golfer’s Commonly referred to as “golfer’s

elbow”elbow”– May present as “little leaguer’s elbow”May present as “little leaguer’s elbow”

Lateral epicondylitisLateral epicondylitis– Commonly referred to as “tennis elbow”Commonly referred to as “tennis elbow”

Medial EpicondylitisMedial Epicondylitis

Irritation of medial Irritation of medial epicondyle from epicondyle from overuse of pronation overuse of pronation and flexion musclesand flexion muscles

May irritate ulnar May irritate ulnar nerve if significant – nerve if significant – most common most common presentation is point presentation is point tenderness, swelling tenderness, swelling at site and weakness at site and weakness to affected musclesto affected muscles

Medial EpicondylitisMedial Epicondylitis

““Little leaguer’s elbow” is avulsion of Little leaguer’s elbow” is avulsion of flexor/pronator common tendon from flexor/pronator common tendon from origin at medial epicondyleorigin at medial epicondyle

Typically treated conservatively with Typically treated conservatively with rest, NSAIDs, flexibility and rest, NSAIDs, flexibility and strengthening exercise programstrengthening exercise program

Lateral EpicondylitisLateral Epicondylitis Irritation of lateral Irritation of lateral

epicondyle from overuse epicondyle from overuse of supination/extension of supination/extension musclesmuscles

Most commonly involves Most commonly involves extensor carpi radialis extensor carpi radialis longus and brevislongus and brevis

Most common Most common presentation is point presentation is point tenderness, swelling at tenderness, swelling at site and weakness to site and weakness to affected musclesaffected muscles

““Tennis Elbow” TestTennis Elbow” Test Clinician palpates lateral Clinician palpates lateral

epicondyle with elbow at epicondyle with elbow at 90 – resists extension of 90 – resists extension of wristwrist

Positive if painful and/or Positive if painful and/or weak at lateral weak at lateral epicondyle – ECRB epicondyle – ECRB involvementinvolvement

If test replicated with If test replicated with elbow extended, elbow extended, indicates ECRL indicates ECRL involvementinvolvement

Rupture of Distal Biceps Rupture of Distal Biceps TendonTendon

Etiology is eccentric loading of tendon Etiology is eccentric loading of tendon with elbow extended (hyperextension)with elbow extended (hyperextension)

Often accompanied by “pop” at elbowOften accompanied by “pop” at elbow– X-ray used to rule out avulsion fractureX-ray used to rule out avulsion fracture

Visible/palpable defect present, Visible/palpable defect present, typically has considerable typically has considerable swelling/ecchymosis to cubital fossaswelling/ecchymosis to cubital fossa

Rupture of Distal Biceps Rupture of Distal Biceps TendonTendon

AROM/PROM may be WNL but RROM AROM/PROM may be WNL but RROM limited to elbow flexion and forearm limited to elbow flexion and forearm supinationsupination

Almost always treated surgically Almost always treated surgically followed by progressive ROM and followed by progressive ROM and strengthening programstrengthening program

OCD of CapitellumOCD of Capitellum

Etiology is repetitive valgus loads at the Etiology is repetitive valgus loads at the elbow compressing radial head on elbow compressing radial head on capitellum – overhead throwingcapitellum – overhead throwing

Gradual vs. acute onset of symptomsGradual vs. acute onset of symptoms

Typical complaints of lateral elbow pain Typical complaints of lateral elbow pain which worsens with activity – often which worsens with activity – often accompanied by elbow flexion accompanied by elbow flexion contracturecontracture

OCD of CapitellumOCD of Capitellum

X-ray can reveal non-displaced defect or X-ray can reveal non-displaced defect or loose body in jointloose body in joint

If non-displaced, usually treated If non-displaced, usually treated conservativelyconservatively

If loose body, surgical removal is indicatedIf loose body, surgical removal is indicated

Atypical to return to prior activity and/or Atypical to return to prior activity and/or performance levelperformance level

Neurological InjuryNeurological Injury

Ulnar nerveUlnar nerve

Median nerveMedian nerve

Radial nerveRadial nerve

Forearm compartment syndromeForearm compartment syndrome– Volkmann’s ischemic contractureVolkmann’s ischemic contracture

Ulnar NerveUlnar Nerve Superficial orientation in cubital tunnel predisposes Superficial orientation in cubital tunnel predisposes

ulnar nerve to injuryulnar nerve to injury

May be contused via direct trauma, compressed by May be contused via direct trauma, compressed by flexor/pronator mass, and/or sublux from cubital flexor/pronator mass, and/or sublux from cubital tunneltunnel

Numbness/tingling to medial forearm, hand and Numbness/tingling to medial forearm, hand and ring/little fingersring/little fingers

Weakness to finger flexion, abduction and Weakness to finger flexion, abduction and adductionadduction

Evaluated with Tinel’s signEvaluated with Tinel’s sign

Cubital Tunnel SyndromeCubital Tunnel Syndrome

General term given General term given to ulnar nerve to ulnar nerve injury or irritationinjury or irritation

Median NerveMedian Nerve

Median nerve most commonly affected at Median nerve most commonly affected at wrist – may be compressed with pressure wrist – may be compressed with pressure in cubital fossain cubital fossa

Branch of median nerve, anterior Branch of median nerve, anterior interosseous nerve, passes between heads interosseous nerve, passes between heads of pronator teres – may be compressed of pronator teres – may be compressed there causing pronator teres syndromethere causing pronator teres syndrome– Inability to pinch together tips of thumb and Inability to pinch together tips of thumb and

index fingerindex finger

Radial NerveRadial Nerve

Rarely injured unless associated with Rarely injured unless associated with laceration, fracture or dislocationlaceration, fracture or dislocation

Sensory deficit to dorsal aspect of Sensory deficit to dorsal aspect of hand (1hand (1stst dorsal webspace) dorsal webspace)

Motor deficit to wrist/finger extension Motor deficit to wrist/finger extension and supinationand supination

Forearm Compartment Forearm Compartment SyndromeSyndrome

Forearm compartments similar to legForearm compartments similar to leg

Increased pressure can occur from:Increased pressure can occur from:– Muscle hypertrophy, fractures, dislocationsMuscle hypertrophy, fractures, dislocations

Neurovascular compromise can present Neurovascular compromise can present with sensory and/or motor deficits – if with sensory and/or motor deficits – if severe, can present with decreased or severe, can present with decreased or absent radial and ulnar pulsesabsent radial and ulnar pulses– Volkmann’s ischemic contracture – flexion Volkmann’s ischemic contracture – flexion

contracture of wrist/hand/fingerscontracture of wrist/hand/fingers

Elbow DislocationsElbow Dislocations

PosteriorPosterior

AnteriorAnterior

Posterior Elbow DislocationPosterior Elbow Dislocation Typically results from hyperextension, Typically results from hyperextension,

trochlea levered over coronoid processtrochlea levered over coronoid process

Most common direction is posterolateralMost common direction is posterolateral

Involve injury to most ligamentous structures, Involve injury to most ligamentous structures, and potential for injury to neurovascular and potential for injury to neurovascular structures – if stable post-reduction, treat structures – if stable post-reduction, treat conservatively and if unstable, treat surgicallyconservatively and if unstable, treat surgically

Most present with subsequent myositis Most present with subsequent myositis ossificansossificans

Posterior Elbow DislocationPosterior Elbow Dislocation

Anterior Elbow DisocationAnterior Elbow Disocation

Rare occurrencesRare occurrences

FracturesFractures

HumerusHumerus

UlnaUlna

RadiusRadius

Humerus FracturesHumerus Fractures

Supracondylar Supracondylar fracturefracture

Supracondylar Supracondylar fracture with fracture with posterior elbow posterior elbow dislocationdislocation

Humerus FracturesHumerus Fractures

Most common in Most common in children/adolescents children/adolescents from fall on flexed from fall on flexed elbow or elbow or hyperextension hyperextension mechanismmechanism

Deformity present if Deformity present if displaced, often displaced, often missed on initial missed on initial evaluation if evaluation if nondisplacednondisplaced

Ulnar FracturesUlnar Fractures

Olecranon process Olecranon process fracturesfractures– If If

stable/nondisplaced, stable/nondisplaced, short immobiliazation short immobiliazation period (45-90 period (45-90 degrees of flexion)degrees of flexion)

– If displaced, ORIF If displaced, ORIF with longer with longer immobilization period immobilization period and early ROM if and early ROM if toleratedtolerated

Ulnar FracturesUlnar Fractures

Coronoid process Coronoid process fracturefracture

May be associated May be associated with posterior with posterior elbow dislocationelbow dislocation

Radial FracturesRadial Fractures

Radial head fracture Radial head fracture classifications classifications (Mason)(Mason)– Type I: nondisplacedType I: nondisplaced– Type II: fracture with Type II: fracture with

displacement, displacement, depression or angulationdepression or angulation

– Type III: comminuted Type III: comminuted fracture of headfracture of head

– Type IV: comminuted Type IV: comminuted fracture associated with fracture associated with elbow dislocationelbow dislocation

Olecranon BursitisOlecranon Bursitis

Typically due to Typically due to direct traumadirect trauma

Usually easily Usually easily treated with rest, treated with rest, modalities modalities compression, and compression, and NSAIDsNSAIDs

If persists, may be If persists, may be aspirated – risk of aspirated – risk of infectioninfection