Clinical Orthopedics 222 Exam 3 Elbow and forearm common conditions

Olecranon Bursitis
-where is this located

Superficial location
-easily irritated through trauma or repetitive motions

Olecranon Bursitis
-swelling where?

Swelling over olecranon process
-varies in size
-can be gradual or sudden

Olecranon Bursitis
-can be what?

Occasionally becomes infected
-red, hot
-requires immediate medial attention if it does become infected

Olecranon Bursitis
-sensitivity and what

sensitivity and decreased range of motion

Olecranon Bursitis
-treatment?

modalities
sling
PROM

Olecranon Bursitis
-this is also called

Student’s elbow

Distal Biceps Rupture
-where is this rupture located

musculotendinous junction or the radial tuberosity

Distal Biceps Rupture
-most common in what demographic

in males of dominant arm

Distal Biceps Rupture
-what is felt with this injury

Sharp or tearing pain with acute injury

Distal Biceps Rupture
-swelling where and what else

Swelling and actively related pain at the antecubital fossa

Distal Biceps Rupture
-signs?

Ecchymosis (Bruise)
Palpable defect of distal biceps
- “Popeye deformity”

Distal Biceps Rupture
-objective findings?

Loss of strength of elbow flexion, grip and supination

Distal Biceps Repair
-primary treatment is what

Surgical repair of the tendon attachment

Distal Biceps Repair
-if the surgery doesn’t happen then what happens to the bicep

30% loss of flexion and 40% loss of supination

Distal Biceps Repair
-how can partial injury be treated and for how long
-what is a factor that you should keep in mind

it may be treated with immobilization for 3 weeks
a consideration to think about is age

Triceps Tendon Rupture
-how can this happen

Deceleration force during extension or uncoordinated contraction of triceps against a flexing elbow

Triceps Tendon Rupture
-what kind of findings are what

Physical findings are similar to distal biceps tendon rupture
-Loss of extension strength
-Inability to extend OH against gravity

Overuse Injuries- Triceps Tendinosis
-what causes this

repetitive extension

Overuse Injuries- Triceps Tendinosis
-TTP where

tenderness to palpation along triceps insertion to olecranon

Overuse Injuries- Triceps Tendinosis
-pain during what action?

resisted elbow extension

Overuse Injuries- Triceps Tendinosis
-what kind of exercises can we do to treat this

Closed Chain, Eccentric exercises

Overuse injuries- Brachialis strain
-how often does this happen
-how can this happen

-rare to occur
-overuse with lifting

Overuse injuries- Brachialis strain
-prone to what
-TTP where?

Prone to myositis ossifcans
tenderness to palpation to anterior distal arm

Overuse injuries- Brachialis strain
-pain where

When doing elbow flexion and pronation

Overuse injuries- Brachialis strain
-what is the difference between biceps?

during pronation, the biceps are disadvantaged so brachialis takes over thats why pain is felt but during supination the biceps take up the slack

Myositis Ossificans
-what is it physically, and what does it refer to

Pathologic bone formation
it is a painless enlarging mass

Myositis Ossificans
-traumatic?

calcifications that develop within the site of an injured muscle following trauma

Myositis Ossificans
-Progressive?

Inherited condition where the ossification occurs without injury that typically follows a specific pattern
-typically starts at the neck and back and progresses into the trunk and extremities

Lateral Epicondylitis
-what is it known as

Tennis Elbow

Lateral Epicondylitis (tennis elbow)
-what causes this

Repetitive overuse of the wrist extensors that leads to tendonitis of the origin of the extensor carpi radialis brevis tendon

Lateral Epicondylitis (tennis elbow)
-what are the common complaints
(pain touching where )

pain with palpation of the lateral epicondyle

Lateral Epicondylitis (tennis elbow)
-what are the common complaints
(pain with what type of forces )

Pain with active or resisted wrist extension and radial deviation

Lateral Epicondylitis (tennis elbow)
-what are the common complaints
(pain and problem doing what )

pain and difficulty with grasping objects with the affected hand

Lateral Epicondylitis (tennis elbow)
-how common is this compared to which other condition

4-6x more common than medial epicondylitis (golfer’s elbow)

Lateral Epicondylitis (tennis elbow)
-common extensor tendon has which muscles

extensor carpi radialis brevis
extensor carpi radialis longus
extensor digitorum
extensor digiti minimi
extensor carpi ulnaris

Treatment for Lateral Epicondylitis (tennis elbow)
-what motions can we do to increase flexibility

Wrist Flexion/Extension
Elbow Flexion/Extension
Forearm Supination/Pronation

Treatment for Lateral Epicondylitis (tennis elbow)
-how can we decrease inflammation/pain

Cryotherapy
phonophoresis (ultrasound sound waves to push pain-relieving or anti-inflammatory medication deep through your skin)
Iontophoresis (pouring medication or water on skin then using electricity to push that liquid into the skin and deeper tissue )

Treatment for Lateral Epicondylitis (tennis elbow)
-how can we promote tissue healing

avoiding painful movements
cross friction massage

Treatment for Lateral Epicondylitis (tennis elbow)
-how can we increase strength

concentric-eccentric exercise
shoulder strength

Treatment for Lateral Epicondylitis (tennis elbow)
-relative rest is meant for

minimize stress on the inflamed wrist extensor tendons

Treatment for Lateral Epicondylitis (tennis elbow)
-what don’t we want to do when treating this

we DO NOT want to immobilize the wrist as we want to encourage proper collagen alignment and scar tissue maturation while maintaining functional mobility

Treatment for Lateral Epicondylitis (tennis elbow)
-bracing?

wrist cock-up splint to minimize stress on the extensors

Treatment for Lateral Epicondylitis (tennis elbow)
-Counter bracing

Bind the muscle with a clasp, band, brace

Treatment for Lateral Epicondylitis (tennis elbow)
-what does bracing do

Limits expansion to descrease contribution to force production by muscle fibers proximal to band

Treatment for Lateral Epicondylitis (tennis elbow)
-what kind of effect does this have and to what

Beneficial effect on force couple imbalances
-Flexor/extensors
Decreased elbow angular acceleration
Decrease Electromyography activity

Treatment for Lateral Epicondylitis (tennis elbow)
-Physical therapy intervention

Gentle, static stretching to maintain mobility
Modalities as indicated
Strengthening

Treatment for Lateral Epicondylitis (tennis elbow)
-how can we do strength base activities

Eccentric loading
Progressive resistance exercise to wrist extensors

Treatment for Lateral Epicondylitis (tennis elbow)
-when starting strengthening exercise what might the patient feel

the patient might be painful initially

Medial Epicondylitis
-what is this also known as

golfer’s elbow

Medial Epicondylitis
-what causes this

overuse of common flexor tendon

Medial Epicondylitis
overuse of common flexor tendon
-most often which muscle

Most often flexor carpi radialis and Pronator Teres
-flexor digitorum and flexor carpi ulnaris, palmaris longus

Medial Epicondylitis
-occurs how many times less

Occurs less frequently than lateral epicondylitis with a 7:1 ratio

Medial Epicondylitis
-pain when

Pain with resisted wrist flexion and full passive wrist extension as well as palpation

Medial Epicondylitis
-symptoms and treatment?

the same as lateral epicondylitis

What did you notice about treatments of tennis and golfer’s elbow?

they are essentially the same
but You must treat the WRIST based on tendon attachments and muscle actions

Little league elbow
-what causes this

Growth plate injury
Due to repetitive motions

Little league elbow
-growth plate injury?

typically of the medial elbow

Little league elbow
-due to repetitive motions where and when?

Typically OH
throwing One sport, all year round athletes

Medial valgus stress overload
Ulnar Collateral Ligament sprain
-what causes this

Chronic attenuation of valgus and external rotation forces
-tennis
-pitching
-FOOSH

Medial valgus stress overload
Ulnar Collateral Ligament sprain
-irritation to what

irritation to the ulnar nerve may also be present

Medial valgus stress overload
Ulnar Collateral Ligament sprain
-pain where

pain at the medial elbow medial collateral ligament insertion

Medial Valgus Stress Overload
-where does this happen

Occurs at the capsulo-ligamentous structures as a result of repetitive valgus stress to the elbow

Medial Valgus Stress Overload
-where will pain be located

Patient will complain of pain of the medial aspect of the elbow and the posterior aspect of the olecranon

Medial Valgus Stress Overload
-on assessment what will the patient show

On assessment, the patient will demonstrate ulnar collateral ligament laxity

Medial Valgus Stress Overload
-what is the most vulnerable

anterior oblique band of the ulnar collateral ligament is the most vulnerable

which ligament in the elbow is the most injured

the ulnar collateral ligament

Conservative Treatment
-how many weeks resting

2-4 weeks: Rest, activity modification
-ROM exercises, modalities

Conservative Treatment
-strengthening and stretching what

Flexor carpi ulnaris, pronator teres, flexor digitorum superficialis
-pain free at mid range

Conservative Treatment
-isometric exercises

Forearm flexors, ulnar deviators and pronators
*** dynamic stabilizers of the medial elbow ***

Conservative Treatment
-strengthening what 2 major joints

the shoulder and elbow

Conservative Treatment
-what kind of program

3 months: supervised throwing/conditioning program
(but this doesn’t mean they are back to 100%)
-Must have full strength and ROM to return to sport

Tommy John Surgery
-what is it

Reconstruction of the ulnar collateral ligament
-mostly anterior oblique band
-using autologous (from the same person) free tendon

Tommy John Surgery
using autologous (from the same person) free tendon
-what tendon is mainly used

Palmaris longus most frequently used (when we take it, it doesn’t affect us because it doesn’t do much)
-they can also use the plantaris and toe extensor tendons but its not as common

Tommy John Surgery
-with or without what

ulnar nerve transposition
(The surgeon moves the ulnar nerve from its natural groove behind the inner elbow bone (cubital tunnel) to a new position under the skin, fat, or muscle in front of the elbow joint)

Tommy John Surgery
-what are the factors before doing the surgery

Age, Activity level, health, integrity of uninvolved elbow

Post Surgical Rehab
-what kind of force you don’t want to put on this

a valgus force

Post Surgical Rehab
-Acute phase

AROM of shoulder, hand, wrist
-NO shoulder external rotation
Week 3 Post Op
-ROM elbow 20-110 degrees
-Concentric/Eccentric wrist exercises
-Submax isometrics elbow flexion/extension

Post Surgical Rehab
-subacute

Week 4-6 Post Op
-Elbow ROM 0-130 degrees
-Introduction of concentric/eccentric exercises of elbow
-Includes pronation/supination

Post Surgical Rehab
-chronic

Week 8-16 Post Op
-Functional training
1 year Post Op
-Return to heavy manual labor / sport

Fractures of the elbow

Distal humeral (supracondylar) fractures
Intercondylar fractures
Radial head fractures
olecranon fractures

Fractures of the elbow
-which fracture needs a ORIF surgery

Intercondylar fractures

Fractures of the elbow
-which fracture is the hardest to heal

radial head fractures
-since the radius needs to rotate over the ulna

Fractures of the elbow
-treatment?

long arm splint with elbow at 60-90 degrees of flexion

Fractures of the elbow
-these fractures may need surgery to do what

-prevent further injury
-restore anatomy
-provide optimal healing

Fractures of the elbow
-treatment timeline?

takes about 6-12 weeks to heal

Fractures of the elbow
-treatment goals?

ROM
strength
fixing impairments

Complications following fractures
-what are they

Mal-union
Non-union
joint contracture
Vascular compromise

Complications following fractures
-mal-union is what

bad union/ healed incorrectly

Complications following fractures
-Non-union is what

didn’t come together to heal

Complications following fractures
-joint contracture is what

when it’s in a cast or brace for a long time now the arm is stuck in the position

Complications following fractures
-Vascular compromise

blood flow issues

Complications following fractures
Volkmann’s Ischemic contracture
-what is it

occurs when the fracture particles are displaced causing a hemorrhage beneath the fascia producing an ischemic(reduced blood flow) injury that obstructs both arterial and venous flow

Complications following fractures
Volkmann’s Ischemic contracture
-what could this lead to

Could result in permanent fibrosis, muscle degeneration, and a claw-like hand

Symptoms of Volkmann’s ischemic contracture

Swollen and tender compartment (hypersensitivity)
Severe pain in the forearm
-Worse with passive stretch of forearm muscles
Limited/painful finger movement
Prominent veins of the hand with discoloration (purple)
-No loss of radial/ulnar pulses
Initial paresthesia(no feeling) followed by loss of sensation
Loss of radial pulse and eventually loss of capillary return
Pallor, anesthesia,
Motor weakness, paralysis

Volkmann’s Ischemic contracture
-how long does this take to reverse it

a couple months to reverse it

Intercondylar Fractures
-what can cause this

results of fall or direct trauma to the elbow

Intercondylar Fractures
-how far does this fracture spread

Extends between the condyles of the humerus and involve the articular surfaces of the elbow joint

Intercondylar Fractures
-manageability?

Most difficulty fracture to manage

Radial head Fractures
-what is the important thing about this

that this fracture heals properly so it can rotate properly around ulna

Radial head Fractures
-what causes this

Results from a fall on an outstretched arm (FOOSH)
Force through the hand and wrist absorbed by radial head forced into the capitulum