The Elbow and Forearm Complex

Joints of the Elbow and Forearm

Ligaments of the Elbow

Muscle at the Elbow and Forearm Elbow Flexion Brachialis. Biceps brachii Brachioradialis.

Elbow Extension Triceps brachii Anconeus. Forearm Supination Supinator. Biceps brachii. Brachioradialis.

Forearm Pronation Pronator teres. Pronator quadratus. Wrist flexor muscles. flexor carpi radialis, flexor carpiulnaris, palmaris longus, and flexor digitorum superficialis flexor digitorum profundus

Wrist extensor muscles extensor carpi radialis longus extensor carpi radialis brevis, extensor carpi ulnaris extensor digitorum

Examination of Elbow History Observation and inspection Examination of movements. Active range of motion with passive over pressure of the following movements: a. Flexion and extension of the elbow b. Pronation and supination of the forearm c. Wrist flexion, and extension d. Radial deviation and ulnar deviation of the wrist

Examination of Elbow . Finger flexion and finger extension (MCP, PIP, and DIP joints) f. Finger abduction and adduction g. Thumb flexion, extension, abduction, adduction h. Opposition of the thumb and little finger v. Resisted isometric movements; a. Elbow flexion and extension b. Pronation and supination of the forearm c. Wrist flexion and extension d. Radial deviation and ulnar deviation of the wrist

Examination of Elbow d. Radial deviation and ulnar deviation of the wrist e. Finger flexion and finger extension (MCP, PIP, and DIP joint~) f. Finger abduction and adduction g. Thumb flexion, extension, abduction, adduction h. Opposition of the thumb and little finger VI. Palpation VII. Neurologic tests as appropriate (reflexes, sensory scan, peripheral nerve assessment) VIII. Joint mobility tests:

Examination of Elbow a. Distraction/compression of the ulnohumeral joint b. Medial and lateral glide of the ulnohumeral joint c. Distraction of the radiohumeral joint d. Anterior and posterior glide of the radial head e. Anterior and posterior glide of the proximal radioulnar joint f, Anterior and posterior glide of the distal radioulnar joint

Referred Pain and Nerve Injury in the Elbow Region Common Sources of Referred Pain into the Elbow Region Symptoms referred from the C5, C6, T1, and T2 nerve roots cross the elbow region but are not usually isolated in the elbow.

Nerve Disorders in the Elbow Region Ulnar nerve Most common site for compression of this nerve is in the cubital tunnel. Radial nerve ( Deep and Superficial Branches) Entrapment of the deep branch may occur under the edge of the extensor carpi radialis brevis, or injury may occur with a radial head fracture. The superficial branch may receive direct trauma as it courses along the lateral aspect of the radius.

Median nerve Entrapment may occur between the heads of the pronator muscle, mimicking carpal tunnel syndrome.

Management of Elbow and Forearm Disorders and Surgeries

Joint Hypomobility: Nonoperative Management Differential Diagnosis Rheumatoid arthritis (RA), Juvenile rheumatoid arthritis (JRA) degenerative joint disease (DJD) Acute joint reactions after trauma, dislocations, or fractures affect this joint complex. Postimmobilization contractures and adhesions

Common Structural and Functional Impairments Acute stage Joint effusion, Muscle guarding, and pain restrict elbow flexion and extension, Pain at rest Subacute and chronic stages Capsular pattern usually exists Elbow flexion is more restricted than extension Firm end-feel and decreased joint play

Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities) Difficulty turning a doorknob or key in the ignition Difficulty or pain with pushing and pulling activities, such as opening and closing doors Restricted hand-to-mouth activities for eating and drinking and hand-to-head activities for personal grooming and using a telephone Difficulty or pain when pushing up from a chair Inability to carry objects with a straight arm Limited reach

Joint Hypomobility: Management— Protection Phase Educate the Patient Reduce Effects of Inflammation or Synovial Effusion and Protect the Area Maintain Soft Tissue and Joint Mobility Maintain Integrity and Function of Related Areas

CLINICAL TIP When immobilizing the elbow, position in relative extension (20° to 30° flexion) and use a posterior splint bubbled out around the cubital tunnel to prevent or treat ulnar neuropathy. Splinting in this position is used to minimize pressure on the ulnar nerve, which may be at risk from joint swelling in the cubital tunnel.

Joint Hypomobility: Management— Controlled Motion Phase Increase Soft Tissue and Joint Mobility Passive joint mobilization techniques Manipulation to reduce a “pushed elbow.” Manipulation to reduce a “pulled elbow.” Manual stretching and self-stretching Home instructions

2. Improve Joint Tracking of the Elbow

3. Improve Muscle Performance and Functional Abilities

Precautions Following Traumatic Injury to the Elbow

CLINICAL TIP A quick, compressive manipulation (high-velocity thrust) with supination is applied to the radius to reposition the radial head when there is a “pulled elbow.” If it is an initial injury, there may be soft tissue trauma from the injury, which is treated with cold and compression.

CLINICAL TIP For an acute “pushed elbow” (and no fracture), apply a distal traction to the radius to reposition the radial head. If chronic, repetitive stretching with sustained grade III distal traction to the radius is necessary in addition to the soft tissue stretching and strengthening techniques needed for increasing motion.

Joint Hypomobility: Management— Return to Function Phase Improve Muscle Performance Restore Functional Mobility of Joints and Soft Tissues Promote Joint Protection

Joint Surgery and Postoperative Management

Radial Head Excision or Arthroplasty Indications for Surgery Severely comminuted fracture or fracture-dislocations of the head or neck of the radius that cannot be reconstructed and stabilized with internal fixation Chronic synovitis and mild deterioration of the articular surfaces associated with arthritis of the HR and proximal RU joints resulting in joint pain at rest or with motion Possible subluxation of the head of the radius, and significant loss of upper extremity function

CONTRAINDICATIONS Growing child. Damaged lateral ulnar collateral ligament complex. Active infection

Severity of Elbow Joint Disease and Selection of Surgical Procedure

Complications of Surgery Intraoperative complications. Damage to the posterior interosseous nerve Malpositioning HR instability Postoperative complications. Delayed wound closure, Infection, Limited ROM of the elbow and/or forearm, Cubital laxity, Persistent pain Sense of instability Slight proximal migration of the radius Osteoarthritis of the HR joint Aseptic loosing or long-term implant wear and breakage Complex regional pain syndrome

Postoperative Management Immobilization The elbow is immobilized continuously in a well-padded posterior resting splint in a position of 90° of flexion and midposition of the forearm after surgery

Exercise: Maximum Protection Phase Maintain mobility of unoperated joints Maintain mobility of the elbow and forearm Minimize muscle atrophy

CLINICAL TIP Some specific motions initially may need to be restricted to prevent excessive stress on reconstructed ligaments. Restrictions vary depending on the extent of ligament disruption and which ligaments were repaired. For example, if the lateral collateral complex was repaired, supination is limited to 20° during the early weeks of rehabilitation

Exercise: Moderate and Minimum Protection Phases Increase ROM Improve functional strength and muscular endurance Resumption of recreational and work-related activities