Elbow-Mod II.docx

Elbow Modalities II The elbow The primary function of the elbow is to help position the hand in the appropriate location to perform its function. Anatomy review Joints Ulnohumeral joint (trochlear)-located between the trochlea of the humerus and the trochlear notch of the ulna Classified as a uniaxi...

Elbow Modalities II The elbow The primary function of the elbow is to help position the hand in the appropriate location to perform its function. Anatomy review Joints Ulnohumeral joint (trochlear)-located between the trochlea of the humerus and the trochlear notch of the ulna Classified as a uniaxial hinge joint Allows for flexion and extension Closed packed position is extension with the forearm supinated Radiohumeral joint-located between the capitulum of the humerus and the head of the radius Classified as a uniaxial hinge joint Closed packed position is elbow flexed to 90 degrees and forearm supinated 5 degrees Superior radioulnar joint Head of the radius is held in proper relation to the ulna and humerus by the annular ligament which makes up 4/5ths of the joint Closed packed position is supination 5 degrees Middle radioulnar articulation (not a true joint)-made up of the radius, ulna and interosseous membrane Other support structures Supported medially by the ulnar collateral ligament (fan-shaped structure) Supported laterally by the radial collateral ligament (cord-like structure) Pathologies Lateral epicondylitis- “tennis elbow” Affects the common wrist extensor origin Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum Extensor digiti minimi Can affect anyone involved in repetitive activities of the wrist extensors Symptoms Pain with palpation of the lateral epicondyle Pain with active or resisted wrist extension Positive middle digit test Pain occasionally with grasping activities of the affected hand Medial epicondylitis-“golfer’s elbow” Affects the muscles attached at the medial epicondyle Pronator teres Flexor carpi radialis Flexor digitorum Flexor carpi ulnaris Much less common than lateral epicondylitis (7:1) Symptoms Pain with palpation of the medial epicondyle Pain with active or resisted wrist flexion Pain with full passive wrist extension Medial valgus stress overload Occurs commonly among patients who participate in repetitive throwing and racquet sports Affects the capsiloligamentous structures (medial (ulnar) collateral ligament) due to repetitive valgus stress Symptoms Pain over the medial aspect of the elbow Pain over the posterior aspect of the olecranon Can perform a medial valgus stress test to assess the stability of the ligament Fractures of the distal humerus Supracondylar fracture: a transverse fracture of the distal third of the humerus Often occurs in children Classification of types of fractures Type I-Most common, occurs because of a fall on an extended, outstretched arm. The distal humerus fragment is displaced posteriorly and is maintained in that position because of the strong pull of the triceps. Type II-Considered a flexion injury, occurs after direct trauma to the posterior aspect of the elbow. The distal humeral fragment lies anterior to the humerus. Commonly treated with closed reduction and immobilization for 4-6 weeks. The elbow is held in flexion to allow the triceps to help maintain the fracture in a stable position. Complications Non-union Malunion Joint contracture Volkmann’s ischemic contracture hemorrhage beneath the deep fascia produces an ischemic injury that creates an arterial and venous obstruction (usually affecting the brachial artery) Symptoms of vascular obstruction Severe pain in forearm muscles Limited and extremely painful finger movement Purple discoloration of the hand with prominent veins Initial paresthesia followed by loss of sensation Loss of radial pulse and later loss of capillary return Pallor, anesthesia, and paralysis Intercondylar “T” or “Y” fractures-extend between the condyles of the humerus and involve the articular surfaces of the elbow joint Classifications of intercondylar fractures that display a “T” or “Y” configuration Type I-nondisplaced fracture that extends between the two condyles Type II-displaced fracture without rotation of the fracture fragments Type III-displaced fracture with a rotational deformity Type IV-severely comminuted fracture with significant separation between the two condyles Treatment-dependent upon the type of fracture Type I-immobilization for approximately 3 weeks followed by progressive, gentle ROM Type II and III-ORIF Type IV-adults treated with ORIF, while older adults with poor bone quality will be treated with a “bag of bones” technique (use of collar and cuff in as much flexion as pain and swelling will allow in attempts for gravity to assist with reduction of the fracture fragments) Radial head fractures Often occur with a fall on an outstretched arm Represent 1/3rd of all elbow fractures Carrying angle-formed between the intersection of the long axis of the humerus and ulna with the elbow joint in full extension (males 10 degrees of valgus, females 13 degrees of valgus) Radial head fractures can lead to changes in the carrying angle Classifications Type I-nondisplaced fracture Type II-marginal fracture with displacement Type III-comminuted fracture of the entire radial head Type IV-any radial head fracture with dislocation Treatment-dependent upon the type of fracture Type I-immobilization 5-7 days to 3-4 weeks (may be months before full extension is recovered) Type II-fracture site is either treated with ORIF or excised Type III-fracture site is excised Olecranon fractures Commonly occur after a fall on the point of the elbow or indirectly from forceful contraction of the triceps Classified as displaced or nondisplaced Treatment Nondisplaced-immobilization (position is controversial) with gentle ROM allowed as early as 3 weeks. Flexion not to exceed 90 degrees for the first 6-8 weeks Displaced-treated with ORIF, can excise 80% of the olecranon without loss of joint stability Fracture-Dislocations Occur with a fall on an outstretched arm Posterior dislocations most common Second only to the shoulder in most frequently dislocated joint in the body Radial head fractures occur in 10% of elbow dislocations Can have associated nerve injuries including median, radial and ulnar nerves as well as injury to the brachial artery