Anatomy and Injuries of Elbow

What motions occur at the elbow?

Elbow Elbow The elbow

Bony Anatomy of the Elbow Humerus Lateral Epicondyle Medial Epicondyle Olecronon Process Trochlea Capitulum Ulna Radius Left pic is back of elbow, right pic is front

Elbow Articulations Joints Humeroradial Humeroulnar Radial head w/ capitulum of humerus Humeroulnar Olecranon process of ulna w/ trochlea of humerus Proximal Radioulnar Radial head w/ radial notch of ulna Articulation literally means the state of being joined together

Muscles – Flexors and Supinators Biceps Brachii Brachialis Brachioradialis Brachialis- reflex tendon

Muscles of the Elbow Triceps Brachii Anconeus

Muscles of the Elbow and Forearm Supinator Pronator Quadratus Pronator Teres

Nerves and Blood Supply Nerves – 3 primary nerves at the elbow Median nerve- middle of elbow- C7 Ulnar nerve- “funny bone”- C8 Radial nerve- thumb and pinky- C6 Arteries Brachial- middle Splits into radial and ulnar Medial- medial Veins Superficial Close to the skin in front of the elbow

Elbow Ligaments A capsule surrounds each joint in the body Medial (ulnar) collateral ligament Medial epicondyle to olecranon Prevents valgus force Lateral (radial) collateral ligament Radius up to lateral epicondyle head Prevents varus force Annular ligament Radial head to ulna Keeps radial head in place (rotation)

Ligaments of Elbow

Elbow Injuries Elbow Injuries Elbow injuries

Elbow Trauma

http://www.youtube.com/watch?v=d4os7Wa8gtM

Sprains Ligament/Capsule under ↑ stress Excessive motion Partial tear Hyperextension Valgus Varus Partial tear Types Falling on an extended arm Injury to anterior capsule UCL Injury to primary stabilizing unit of elbow Tommy John Surgery Complete tear Torn UCL makes more probable for dislocation or fracture.

Strains S/S: Partial tear of muscle fibers Result from: Point tenderness ↑ pain w/ passive elbow extension and resisted elbow flexion weakness Partial tear of muscle fibers Result from: Inadequate warm-up Excessive training past point of fatigue Inadequate rehabilitation of previous muscular injuries

Epicondylitis Common injury, chronic condition MOI: overuse injury Prolonged stress may result in stress or avulsion fracture Pattern of injury: Poor technique Fatigue Overuse Two types: Medial Lateral

Medial Epicondylitis Management A.k.a Golfer’s Elbow Ice/NSAIDs Immobilization for 2-3 weeks w/ wrist in slight flexion EMS, US Work early ROM Gentle ROM isometric→isotonic Wrist flexors Bracing A.k.a Golfer’s Elbow Repeated, medial, tension/lateral compression (valgus) forces placed on the arm During acceleration phase S/S: Swelling/pain Possible ecchymosis Pt. tenderness over humeroulnar joint Pain over medial epicondyle ↑ pain w/ resisted wrist flexion and forearm pronation ↑ pain w/ valgus stress at 30° flexion S/S: point tenderness over the medial epicondyle and muscle/tendons that attach there Management – wear counter force or Neoprene elbow sleeve

Lateral Epicondylitis A.k.a. Common Extensor Tendinitis/Tennis Elbow Most common overuse injury Eccentric loading of extensor muscles Predominately Extensor carpi radialis brevis During deceleration phase Faulty mechanics Leading w/ elbow Off-center hits in racquet sports Poorly fitted equipment Handle size String tension S/S: Pain anterior or just distal to lateral epicondyle Radiating pain into extensors Pain comes and goes Comes back more severe w/ repitition Pain increases w/ resisted wrist extension Management Same as Medial epicondylitis Increase strength, endurance, and flexibility of extensor muscle Wear counterforce/neoprene elbow sleeve CC: pain over the lateral epicondyle, dec grip strength, and pain with gripping S/S: swelling/pain and pain with passive stretching. Management: avoid activities that cause symptoms. Stretch and strengthen the elbow flexors and focus on wrist extension. **Find the cause of the cause

Olecranon Bursitis Tx: NO COMPRESSION! Cryotherapy NSAIDS Inflammation of the subcutaneous olecranon bursa Acute/Chronic Largest bursa in elbow Facilitates smooth gliding of the skin over the olecranon process during elbow flexion and extension Superficial Predisposed to direct macrotrauma or cumulative microtrauma Tx: NO COMPRESSION! Cryotherapy NSAIDS Olecranon bursa lies between the olecranon and the skin. Cushions olecranon process during normal flexion/extension of the elbow. MOI: usually direct trauma/injury to bursa Can become septic (infection gets into blood and spreads throughout body) – in which case, refer to physician.

Dislocation Most common traumatic injury Associated fractures: Longitudinal traction of an extended and pronated upper extremity i.e. Small child swung by arms Immature/weakened annular ligament Outstretched hand w/ elbow in a position of hyperextension or severe twist while in a flexed position Associated fractures: Medial epicondyle Radial head Coronoid process Olecranon process Ulna/radius displacement Posteriorly (most common for both) Anteriorly Laterally

Dislocations Management EMERGENCY!!!! Ice, compression, sling, and refer to physician IMMEDIATELY!!! NEVER reduce S/S: Obvious deformity, loss of ROM Rupturing and tearing stabilizing ligamentous tissue Profuse hemorrhage and swelling Severe pain and disability Injury to median and radial nerves, major blood vessels and arteries http://www.youtube.com/watch?v=k_mw704tezU http://vids.myspace.com/index.cfm?fuseaction=vids.individual&videoID=968875930

http://www.youtube.com/watch?v=XZiLPZXjZd4

Olecranon fossa, olecranon process, medial epicondyle, lateral epicondyle, cubital tunnel,, radius, ulna, humerus, bicep, tricep, flexor muscles, extensor muscles, brachioradialis Palpations

Olecranon Fossa Olecranon Process, Bicep, Tricep, Lat Epicondyle

Medial Epicondyle Cubital Tunnel

Radius Ulna

Flexor Muscles Extensor Muscles

Humerus Brachioradialis

AROM Flexion, AROM Extension, AROM Pronation, AROM Supination, MMT Flexion, MMT extension, MMT pronation, MMT Supination ROM

Lateral Epicondylitis Test/Resistive Tennis Elbow Test/Cozen's Test Steps Athlete is sitting Examiner stabilizes the involved elbow while palpating along the lateral epicondyle With closed fist, the athlete pronates and radially deviates the forearm and extends the wrist against the examiner's resistance Positive Test Pain along the lateral epicondyle region of the humerus or objective muscle weakness as a result of complaints of discomfort Positive Test Implications Lateral epicondylitis https://www.youtube.com/watch?v=ehYTeDN4usc Lateral Epicondylitis Test/Resistive Tennis Elbow Test/Cozen's Test

Lateral Epicondylitis Test/Passive Tennis Elbow Test Steps Athlete is sitting with elbow fully extended Examiner passively pronates the forearm and flexes the athlete's wrist Positive Test Pain along the lateral epicondyle region of the humerus Positive Test Implications Lateral epicondylitis Lateral Epicondylitis Test/Passive Tennis Elbow Test

Medial Epicondylitis Test/Golfer's Elbow Test Steps Athlete is sitting or standing and makes a fist with the involved side Examiner faces the athlete and palpates along the medial epicondyle with one hand and grasps the athlete's wrist with the other hand Examiner passively supinates the forearm and extends the elbow, wrist and fingers Positive Test Complaints of discomfort along the medial aspect of the elbow Positive Test Implications Medial epicondylitis https://www.youtube.com/watch?v=7rBCpk3jFaQ Medial Epicondylitis Test/Golfer's Elbow Test

Elbow Flexion Test Steps Athlete is sitting or standing Athlete maximally flexes the elbow and holds the position for 3 to 5 minutes Positive Test Radiating pain into the median nerve distribution in the athlete's arm and/or hand Positive Test Implications Cubital fossa syndrome https://www.youtube.com/watch?v=wMIlm9SULvo Elbow Flexion Test

Steps Athlete is sitting with elbow flexed to 20 to 30 degrees Examiner stands with the distal hand around the athlete's wrist (laterally) and the proximal hand over the athlete's elbow joint (medially) Examiner stabilizes the wrist and applies a varus stress to the elbow with the proximal hand Positive Test Lateral elbow pain and/or increased varus movement with diminished or absent endpoint Positive Test Implications Radial (lateral) collateral ligament sprain https://www.youtube.com/watch?v=jUKxFwh5QjU Varus Stress Test

Steps Athlete is sitting with the elbow flexed to 20 to 30 degrees Examiner stands with distal hand around the athlete's wrist (medially) and the proximal hand over the athlete's elbow joint (laterally) Examiner stabilizes the wrist and applies a valgus stress to the elbow with the proximal hand Positive Test Medial elbow pain and/or increased valgus movement with a diminished or absent endpoint Positive Test Implications: Ulnar (medial) collateral ligament sprain https://www.youtube.com/watch?v=KXQxH0UTn-8 Valgus Stress Test

Steps Athlete is sitting with the elbow in slight flexion Examiner grasps athlete's wrist (laterally) with distal hand Examiner stabilizes the wrist and taps on the ulnar nerve in the ulnar notch with the index finger Positive Test Tingling along the ulnar distribution of the forearm, hand and fingers Positive Test Implications Ulnar nerve compromise https://www.youtube.com/watch?v=CPJpT_C0I4k Tinel's Sign Test

Pinch Grip Test Steps Athlete is sitting or standing Examiner instructs athlete to pinch the tips of the thumb and index finger together Positive Test Inability to touch the tips of the thumb and index finger together or touching the pads of the thumb and index finger together Positive Test Implications Pathology of the anterior interosseous nerve between the two heads of the pronator muscle Pinch Grip Test