Elbow and Forearm Pathologies Chapter 16 Elbow and Forearm Pathologies

Clinical Anatomy Bony anatomy Medial epicondyle Trochlea Capitellum Lateral epicondyle Radial fossa

Clinical Anatomy Bony anatomy Ulna Semilunar notch Olecranon process Olecranon fossa Coronoid process Coronoid fossa Radial notch Proximal radioulnar joint Radial head Bicipital tuberosity Radial shaft Radial styloid process Lister tubercle

Clinical Anatomy Articulation and ligamentous anatomy Humeroulnar joint Flexion and extension Modified hinge joint Humeroradial joint Pronation and supination Proximal and distal radioulnar joints Syndesmotic joint

Clinical Anatomy Articulation and ligamentous anatomy Ligamentous support Ulnar collateral ligament (UCL) Anterior, transverse, and posterior bundle Lateral collateral ligament Radial collateral ligament (RCL) Annular ligament Accessory lateral collateral ligament Interosseous membrane

Clinical Anatomy Elbow extensor and pronator group Elbow flexor and supinator group Elbow extensor and pronator group

Clinical Anatomy Nerves Bursa Median nerve Anterior interosseous nerve Ulnar nerve Arcade of Struthers Tunnel of Guyon Radial nerve Superficial branch Deep branch Subcutaneous olecranon bursa Subtendinous olecranon bursa

Clinical Evaluation of the Elbow and Forearm Past medical history History of the present condition Previous history Seasonal pain Cervical injury General medical health Vascular, neurological, or systemic conditions Location of the symptoms Onset of the symptoms MOI Technique Associated sounds and sensations

Clinical Examination of the Elbow and Forearm Inspection Functional observation Anterior structures Carrying angle Cubitus valgus Cubitus varus Cubital fossa Medial structures Medial epicondyle Flexor muscle mass

Cubital Fossa The cubital fossa is a triangular area demarcated by the brachioradialis muscle laterally and the pronator teres medially. The brachial artery and its two subdivisions (the radial and ulnar arteries), the median nerve, and the musculocutaneous nerve pass through this fossa.

Clinical Examination of the Elbow and Forearm Inspection Lateral structures Alignment of the wrist and forearm Cubital recurvatum Extensor muscle mass

Clinical Examination of the Elbow and Forearm Inspection Posterior structures Bony alignment Olecranon process and bursa

Clinical Examination of the Elbow and Forearm Palpation of the anterior structures Biceps brachii Cubital fossa Brachioradialis Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Pronator quadratus

Clinical Examination of the Elbow and Forearm Method of approximating the superficial muscles of the flexor forearm.

Clinical Examination of the Elbow and Forearm Palpation of the medial structures Medial epicondyle Ulna Anterior band UCL Posterior band UCL Transverse band UCL

Clinical Examination of the Elbow and Forearm Palpation of the lateral structures Lateral epicondyle Radial head Radial collateral ligament Capitellum Annular ligament Lateral ulnar collateral ligament

Clinical Examination of the Elbow and Forearm Palpation of the posterior structures Olecranon process Olecranon fossa Triceps brachii Anconeus Ulnar nerve Extensor carpi ulnaris Extensor carpi radialis brevis Extensor carpi radialis longus Extensor digitorum Extensor digiti minimi Extensor pollicis brevis Abductor pollicis longus Radial tunnel

Clinical Examination of the Elbow and Forearm Joint and muscle function assessment Active range of motion (AROM) Flexion and extension Pronation and supination Manual muscle tests (MMT) Passive range of motion (PROM)

Clinical Examination of the Elbow and Forearm Passive range of motion

Passive Range of Motion Elbow: Ulnohumeral and radiohumeral joint capsular patterns and end-feels Capsular pattern: Flexion, extension Extension: Hard Flexion: Soft Elbow: Superior radioulnar joints Capsular pattern: Supination and pronation equally Radioulnar supination: Firm Radioulnar pronation: Hard or firm

Passive Range of Motion Forearm: Distal radioulnar joint Capsular pattern: Supination and pronation equally Radioulnar supination: Firm Radioulnar pronation: Firm

Clinical Examination of the Elbow and Forearm Joint stability tests Stress testing Medial ligament laxity Lateral ligament laxity Joint play

Valgus Stress Test

Varus Stress Test

Clinical Examination of the Elbow and Forearm Neurological testing Innervated by the brachial plexus Injury may disturb sensory or motor function in elbow, forearm, and hand Upper quarter screen

Pathologies and Related Special Tests Elbow dislocations MOI: Axial force through the forearm with the elbow flexed Extremely painful Obvious deformity “Terrible triad of the elbow” Swelling can be rapid, masking deformity

Pathologies and Related Special Tests Fracture about the elbow Supracondylar fracture MOI: Hyperextension or fall on flexed elbow Olecranon process fracture MOI: Falling on flexed elbow Radial head fracture MOI: Longitudinal compression (FOOSH) Forearm fracture Open or closed, simple or complex, degree of angulation, rotation or displacement

Pathologies and Related Special Tests Elbow sprains Ulnar collateral ligament Valgus extension overload Elbow posterolateral rotatory instability Radial collateral ligament MOI: Varus force

Selective Tissue Test: Moving Valgus Stress Test

Selective Tissue Test: Posterolateral Rotatory Instability Test (Pivot Shift)

Pathologies and Related Special Tests Epicondylalgia Lateral epicondylalgia Inflammation or repetitive stress at the lateral epicondyle Swelling TTP Pain with active wrist extension “Tennis elbow” Medial epicondylalgia TTP on medial epicondyle “Little Leaguer’s elbow” Neuropathy of the ulnar nerve

Selective Tissue Test: Lateral Epicondylalgia (“Tennis Elbow” Test)

Pathologies and Related Special Tests Distal biceps tendon rupture Most common in males over 40 years of age MOI: Eccentric loading of the biceps brachii when the elbow is flexed to 90 Complete or partial Signs and symptoms Pain “Pop” within elbow Palpable defect Usually treated with a surgical repair

Selective Tissue Test: Hook Test for Distal Biceps Tendon Rupture

Pathologies and Related Special Tests Nerve pathology Ulnar nerve pathology Radial nerve pathology Median nerve pathology Forearm compartment syndrome

On-Field Evaluation of Elbow and Forearm Injuries On-field history On-field inspection Position of the arm Type of force involved Alignment of forearm and wrist Posterior triangle of the elbow

On-Field Evaluation of Elbow and Forearm Injuries On-field palpation On-field joint and muscle function tests Alignment of the elbow Collateral ligaments Radius and ulna On-field neurological tests Assessment of forearm and hand AROM MMT PROM

On-Field Management of Elbow and Forearm Injuries Elbow dislocations Management Activate EMS Immobilize in the position found in Monitor distal pulse Rule out injury to GH joint, proximal humerus, and wrist Immediately transport athlete to medical facility for further evaluation and treatment

On-Field Management of Elbow and Forearm Injuries Fractures about the elbow Management Monitor distal pulse Immobilize elbow, forearm, and wrist Treat for shock Immediately transport athlete to medical facility for further evaluation and treatment