UQ - Elbow (tendinopathies and ligamentous trauma)

What is the most common tendon involved in lateral epicondylalgia

ECRB, followed by ED

Where is the pain located in lateral epicondylagia

lateral epicondyle

When the ECRB tendon is stretched (wrist flexion/elbow extension, forearm pronation), the tendon is stretched over what structure

radial head

The onset for lateral epicondylalgia is __

gradual

In chronic situations of lateral epicondylalgia, what builds up between the tendon and bone

adhesions

Are there signs of acute inflammation in lateral epicondylalgia

no

List risk factors of lateral epicondylagia

obesity, genetics, sex hormones, meds, age, females

What are motor deficits that may be experienced with lateral epicondylagia

reduced grip strength, reaction time, coordination, altered nociceptive processing, shoulder girdle weakness

When would you feel pain with lateral epicondylalgia

stretching and contracting

Special tests for lateral epicondylalgia

cozens, maudsley, mills test, grip strength

What tendons are most commonly involved in medial epicondylalgia

pronator teres, FCR, PL

MOI of medial epicondylagia

forceful acceleration into wrist flexion with pronation, tendon overuse, failure UCL

Motor deficits found with medial epicondylalgia

decreased grip strength, weakness of thumb AB/AD

Where is pain located in medial epicondylalgia

medial elbow radiating into forearm and hand

Tests for medial epicondylitis

pronator teres/FCR MMT, golfer's, active wrist flexion

Most common mechanism for elbow dislocations

fall with hyperextension (FOOSH)

What occurs in an elbow dislocation in regards to the radius and ulna

rotational displacement of ulna on trochlea and radius sublux posteriorly from capitellum

What percentage of dislocations result in a fracture

50%

How long is the immobilization period for dislocations

7-10 days

When does the strengthening phase for elbow dislocations occur

between 6-8 weeks

What does the ROM progression look like in elbow dislocation recovery

10 degrees a week until full extension

What are the 3 main concerns/results of elbow fractures

nerve deficits, capsular tightness, flexor muscle contracture

Describe type 1 fracture

non displaced, immobilization required

Describe type 2 fracture

displaced, ORIF needed

Described type 3 fracture

comminuted, surgery for loose body removal, prosthesis

two types of distal humerus fractures

intra-articular and extra-articular

Difference between intra-articular vs extra-articular fractures in regards to treatment

intra-articular requires ORIF, extra-articular may be treated without surgery

What occurs at 6 weeks of distal humerus fracture treatment

active motion at elbow and wrist

What type of splint is used for distal humerus fractures

static progressive splint

What occurs with a radial head fracture

FOOSH with valgus load

Type 1 radial head fracture

less than 25% of radial head

Type II radial head fracture

two part displaced fracture

Type III radial head fracture

comminuted fx involving entire radial head

Type IV radial head fracture

comminuted and dislocation

Treatment for nondisplaced (type I) radial head fracture

conservative treatment with avoided valgus stress and full ROM by week 4

Treatment for displaced radial head fracture

ORIF or joint arhtroplasty

When should an ORIF for radial head fracture hae full ROM

6 weeks

What two kinds of splints are used in radial head fractures

supination splint or hinged elbow brace

What are important strengthening exercises to focus on for radial head fractures

wrist/elbow with emphasis on supination/pronation

What is a moteggia fracture

radial head dislocation and ulna fracture

What are MOIs of a moteggia fracture

direct blow to post. elbow, hyperpronated FOOSH, contracted biceps resisted forearm extension

MOI of olecranon fracture

direct fall, blow, dislocation

What is the standard treatment for displaced olecranon fractures

ORIF with posterior splinting

Main treatment guidelines for olecranon fracture

no active elbow extension, PROM all directions

When should motion be obtained in olecranon fractures

6 weeks

What muscle and when should strengthening occur in olecranon fractures

triceps, 6-8 weeks

Coronoid fractures occur in what percentage of elbow dislocations

2-15%

What is the terrible triad

high energy injury with elbow dislocation (UCL sprain), radial head fracture, coronoid fracture

What is the MOI of pushed elbow

FOOSH

What is the result of pushed elbow injuries

damage to articular cartilage of radiohumeral joint

What presenation is similar to pushed elbow

posterolateral instability

What injury can occur with a pushed elbow

colles fracture

What would you find on an exam for pushed elbow

pain with compression of the joint

What is the intervention for pushed elbow

distraction

What is the MOI for biceps tendon tear

rapid eccentric contraction on chronically damaged muscle

What population do bicep ruptures typically occur in

weight lifters/body builders, 30-60 yo

Signs and symptoms of biceps tendon tear

pop, tenderness, ecchymosis, deformity, steroid use

What is the surgical intervention for biceps tears

repair within 10 days

What splint are bicep tendon tears placed in

posterior hinge with 60 degree extension block

When should full ROM be acheved in biceps tears

week 4

When does the strengthening phase occur in biceps tears

6-8 weeks

Myositis ossificans(MO)/heterotropic ossification (HO)

bone forms in and replaces muscle tissue as a result of trauma

What should you avoid once HO is present and why

passive stretching because it stimulates bone growth

What 2 conditions are more susceptible to predispose a patient to development of MO

supracondylar fracture and elbow dislocation

3 surgical techniques for tommy john

ulnar transposition, figure 8 graft, docking technique

What arethe two grafts for tommy john

palmaris longus and hamstring

In pitchers specifically, which leg and why do they pull hamstring graft from for tommy john

ipsilateral because planting leg takes brunt of force with eccentric loading of hamstrings

What occurs in the first 4 weeks of UCL reconstruction

immobilization, ROM, modalities, maintain shoulder strength

What occurs in 4-6 weeks after UCL reconstruction

protection from valgus, increase AROM 15-115, avoid contracture, isometrics

What occurs in 6-12 weeks after UCL reconstruction

increase strength, power, endurance, full AROM

Why is trunk strengthening important with UCL recovery

overhead throwing requires trunk stability and power

In a typical throwing program, what does progression of distance look like

45 ft to 120/150 ft throws, crow hop used when needed

In a typical throwin program, what does progression of volume look like

25 throws from 1 to 3 sets, warm up throws not included

In a typical throwing program, what does recovery/rest period look like

5-10 minute rest per set

In a typical throwing program, what does throwing progression and mound work look like

fastball and changeups only, throwing at front of mound (10-25 pitches, 1-3 sets, 5 minute rest), long toss up 120ft before pitching and cool down 60ft after

When does return to compettiive level occur in UCL repair

9-12 months

What is posterior medial impingement in the elbow

compression of olecranon with medial portion of olecranon fossa created with valgus stress

What does locking and catching indicate for posterior medial impingement

loose bodies

Signs and symptoms of valgus overload syndrome (posterior medial impingement)

flexion cx, painful active extension, PROM is painful in pronation, valgus, extension, point tenderness

What does treatment of valgus extension overload syndrome look like

conservative treatment for 6-12 weeks, UCL reconstruction typically follows

Posterior lateral overload syndrome

valgus extension overload instability progresses to lateral side of elbow stressing capitulum and radial head

Signs and symptoms of posterior lateral overload syndrome

pain on lateral humerus/radial head, increase in lateral pain with valgus tests, thickening of area, tender, neural deficits

MOI of posterolateral rotary instability

valgus stress with supination and compression (CKC shoulder IR)

cheif complaints of posterolateral rotary instability

clicking, snapping, locking when elbow is extended and supinated

Treatment for posterolateral rotary instability

4-6 weeks of unloading with hinged brace

complex regional pain syndrome

generalize edema in forearm/hand, hypersensitivity to touch, trophic changes in skin/nails

What are preventative measures for CRPS

frequent active movement of free joints, regular periods of elevation of involved limb

Management of little leaguers elbow

shut them down, pitch count recommednations, one sport athlete

Cause of little leaguers elbow

overhead valgus stress leading to apophysitis, fragmentations, avulsion fx

What occurs in nursemaids elbow

head of radius pulled inferiorly through annular ligament

MOI of nursemaids elbow

pulling child out of tub by hands, swinging child by wrist

Pain presentation of nursemaids elbow/pulled elbow

accompanied with click, poorly localized, refusal to use arm, passive supination/pronation

Differential dx for nursemaids elbow

brachial plexus injury

Pulled elbow treatment

high velocity thrust manipulation/reduction, education on MOI

Osteochondritis dissecans

fatigue failure of subchondral bone followed by bone resoption and separation

MOI of osteochondritis dissecans

repetitive wt bearing/overhea activities in young atheltes (12-17)

Pain description of osteochondritis dissecans

lateal elbow pain, swelling, limited ROM in extension, tenderness at radiocapitellar joint

Treatment of OCD

activity mods, rest for 4 weeks, full return in 2-6 months

Differential dx of osteochondritis dissecans

panners disease

Panners disease

epicondyle apophysisits: necrosis of entire capitellum wihtout trauma