Upper Arm, Elbow, and Forearm Conditions

Upper Arm, Elbow, and Forearm Conditions
Chapter 15

Anatomy

Anatomy 3 articulations (single capsule) Humeroulnar (elbow joint)
Trochlea of humerus with trochlear fossa of ulna Hinge joint; flexion and extension Close-packed position – extension Humeroradial Capitellum of humerus with proximal radius Gliding joint Lateral to humeroulnar joint Close-packed position – elbow 90°; forearm supinated 5° Humeroulnar joint -- motion capabilities are primarily flexion and extension, although in some individuals, particularly women, a small amount of overextension (5-15°) is allowed Humeroradial -- gliding joint, with motion restricted to the sagittal plane by the adjacent humeroulnar joint

Anatomy (cont.) Proximal radioulnar
Head of radius with radial notch of ulna; joined by annular ligament Pivot joint Radius rolls medially and laterally over the ulna; pronation and supination Close-packed position – supination 5°

Anatomy (cont.) Carrying angle
Angle between humerus and ulna (arm in anatomic position) 10-15° angle Greater in females Carrying angle -- angle is so-named because it causes the forearm to angle away from the body when a load is carried in the hand; given that loads are typically carried with the forearm in a neutral rather than a fully supinated position, functional significance of the carrying angle is questionable

Anatomy (cont.) Ligaments Ulnar (medial) collateral
Radial (lateral) collateral Annular Accessory lateral collateral Ligaments of the elbow Medial (ulnar) collateral ligament -- most important ligament for stability of the elbow joint -- divided into three oblique bands: anterior, transverse, and posterior -- anterior oblique band is taut throughout the ROM; primary restraint against valgus forces -- transverse oblique band provides little, if any, support to the medial elbow -- posterior oblique band: fan-shaped capsular thickening; generally taut when elbow flexed beyond 90° Lateral (radial) collateral ligament -- four components: lateral ulnar collateral, radial collateral, annular, and accessory ligaments -- radial collateral ligament: runs from the lateral epicondyle of the humerus and terminates at the annular ligament; resists varus forces -- lateral ulnar collateral ligament: posterior portion of radial collateral ligament; extends distally to lateral ulna -- annular ligament: fits tightly around the radial head and upper portion of the neck; permits pronation and supination of the forearm as the radius internally and externally rotates on the ulna; extreme supination – anterior fibers of the annular ligament are taut; extreme pronation – posterior fibers are taut -- accessory lateral collateral ligament: superficial layer of fibers that blends with the annular ligament to insert onto the supinator tubercle of the ulna

Anatomy (cont.) Bursae Several small Olecranon bursa Superficial

Anatomy (cont.)

Anatomy (cont.) Nerves Musculocutaneous Median Ulnar Radial
musculocutaneous nerve -- motor: flexor muscles of the anterior arm -- sensory: lateral forearm median nerve -- motor: flexor muscles of the anterior forearm -- sensory: palmar aspect of hand, including thumb, index finger, and middle finger, and lateral half of ring finger ulnar nerve -- motor: flexor carpi ulnaris and medial half of the flexor digitorum profundus -- sensory: medial border of hand including the little finger and medial half of ring finger radial nerve -- passes anteriorly to the lateral epicondyle at the elbow, then divides into the superficial and deep branches to continue along the posterolateral aspect of the forearm -- motor: arm and forearm extensor muscles -- sensory: posterior aspect of the arm and forearm

Anatomy (cont.) Blood vessels Brachial Ulnar and radial
brachial artery -- courses down medial side of arm; supplies the flexor muscles of the arm -- deep brachial artery branches off to supply the triceps brachii -- forms an anastomosis (network of communicating blood vessels) to supply the elbow joint -- main branch of the brachial artery crosses the anterior aspect of the elbow; brachial pulse can be readily palpated -- distal to elbow, splits into the ulnar and radial arteries ulnar artery -- supplies the medial forearm -- via one of its branches, the common interosseous artery, supplies the deep flexors and extensors of the forearm radial artery -- courses along the anterior aspect of the radius -- supplies the lateral forearm muscles

Kinematics Flexion and extension
Movements Flexion and extension Humeroulnar joint and humeroradial joint Supination and pronation Proximal radioulnar

Kinematics (cont.) Muscles Flexors Brachialis; biceps; brachioradialis
Effectiveness depends on supination/pronation position Extensors Triceps; anconeus Pronation and supination Pronator quadratus; pronator teres supinator; biceps Elbow flexors -- cross anterior side of the joint -- primary elbow flexor – brachialis; because the distal attachment is the coronoid process of ulna, it’s equally effective when the forearm is in supination and pronation -- biceps brachii – both long and short heads attached to the radial tuberosity via a single common tendon; contributes effectively to flexion when forearm is supinated, because it is slightly stretched; when forearm is pronated, muscle is less taut and consequently less effective -- brachioradialis – most effective when the forearm is in a neutral position (midway between full pronation and full supination) -- flexor carpi ulnaris and flexor digitorum superficialis – provide significant stability to the medial elbow during activities such as throwing Elbow extensors -- major elbow extensor – triceps - the three heads have separate origins, but attach to the olecranon process of the ulna through a common distal tendon -- anconeus assists with extension Three radioulnar articulations: the proximal, middle, and distal radioulnar joints -- proximal and distal joints are pivot joints -- middle radioulnar joint is a syndesmosis, with an elastic interconnecting membrane permitting supination and pronation, but prevents longitudinal displacement of one bone with respect to other

Kinetics Non–weight bearing but still sustains significant loads
Extremely large muscle forces generated with forceful throwing motions, weight lifting, and many resistance training exercises Extensor moment arm < flexor moment arm Extensors must generate more force than flexors to produce same amount of joint torque KINETICS Examples 1) estimated that the compressive load at the elbow reaches 300 Newtons (N) (67 lb) during activities such as dressing and eating, 1,700 N (382 lb) when the body is supported by the arms when rising from a chair, and 1,900 N (427 lb) when pulling a table across the floor 2) during performance of one-handed push-up, compression at the elbow ranges around 65% of body weight Forces are generated by muscles crossing the elbow -- during an activity such as pitching, valgus stress at the elbow during the late cocking and acceleration phases of the throw can exceed the strength of the ulnar collateral ligament, resulting in microscopic tears within it; triceps, wrist flexor-pronator muscles, and anconeus must develop tension to assist the ulnar collateral ligament in resisting the valgus load -- attachment of the elbow extensors to the ulna is closer to the joint center than the attachments of the elbow flexors on the radius and ulna, so the extensor moment arm is shorter than the flexor moment arm; translates to greater joint compression forces during extension than during flexion, when movements with comparable speed and force requirements are executed

Injury Prevention Protective equipment Pads Braces
Physical conditioning Flexibility and strength Focus on entire arm Proper skill technique Throwing Falling Protective equipment -- standard shoulder pads may not extend far enough to protect the upper arm; need additional biceps pad attached to the shoulder pads to protect this vulnerable area -- pads to protect the olecranon from direct trauma and abrasions, particularly when playing on artificial turf -- counterforce braces – reduce muscle tensile forces that can lead to medial or lateral epicondylitis -- hinged braces – add compression and support to reduce excessive varus and valgus forces Physical conditioning -- movement of the muscles that move the elbow also move the shoulder or wrist; flexibility and strengthening exercises must focus on the entire arm Proper skill technique -- nearly all overuse injuries are directly related to repetitive throwing-type motions that produce microtraumatic tensile forces on the surrounding soft tissue structures -- children who pitch sidearm motions are 3x more likely to develop problems than those who use a more traditional overhead technique -- movement analysis can detect improper technique in the acceleration and follow-through phases that contribute to these excessive tensile forces -- teach sport participants the shoulder-roll method of falling; falling on an extended hand or flexed elbow is the most common mechanism for acute injuries in the upper extremity; excessive compressive forces can be transmitted along the long axis of the bones, leading to a fracture or dislocation

Contusions Susceptible due to: Lack of padding General vulnerability
Rapid swelling – can limit ROM Chronic blows Development of ectopic bone Myositis ossificans – brachialis belly; proximal deltoid insertion Tackler’s exostosis Painful periostitis and fibrositis may develop Management: standard acute; NSAIDs Ectopic bone – proliferation of bone ossification in an abnormal place in either the belly of the muscle (myositis ossificans) or as bony outgrowth (exostosis) of underlying bone Myositis ossificans -- common sites: brachialis muscle belly; proximal to deltoid’s insertion on lateral humerus -- developing mass can become painful and disabling if the radial nerve is contused, leading to transitory paralysis of the extensor forearm muscles “Tackler’s exostosis” (blocker’s spur) -- commonly seen in football linemen -- not a true myositis ossificans -- ectopic formation is not infiltrated into the muscle, but rather is an irritative exostosis arising from the bone - painful bony mass, usually in the form of a spur with a sharp edge, can be palpated on the anterolateral aspect of the humerus - a painful periostitis (inflammation of the periosteum) and fibrositis (inflammation of fibrous tissue) may develop

Olecranon Bursitis Acute and chronic Mechanism Fall on a flexed elbow
Constantly leaning on elbow Repetitive pressure and friction Olecranon bursitis -- lubricating function of bursa facilitates gliding of the skin over olecranon process during elbow flexion and extension -- superficial location predisposes the bursa to either direct macrotrauma or cumulative microtrauma -- significant distention may necessitate aspiration, for comfort, followed by a compressive dressing for several days

Olecranon Bursitis (cont.)
S&S Tender, swollen, relatively painless Rupture – goose egg visible 50% history of abrupt onset; 50% insidious onset over a few weeks Motion limited at extreme of flexion – tension increases over bursa Management: standard acute; NSAIDs; possible aspiration

Septic bursitis Related to seeding from infection at a distant site S&S Traditional signs of infection (within 1 week of symptoms) Skin lesion overlying bursa – 50% of cases Bursal tenderness – % of cases Peribursal cellulitis – % of cases Septic -- seeding from an infection at a distant site, such as paronychia (infection of the folds of skin surrounding a fingernail), cellulitis of the hand, or forearm infection

Nonseptic Caused by crystalline deposition disease or rheumatoid involvement Associated with atopic dermatitis S&S Skin lesion – 5% of cases Bursal tenderness – 45% of cases Cellulitis – 25% of cases Management: physician referral

Sprain Mechanism Fall on extended hand (hyperextension injury)
Valgus or varus force More common; repetitive forces irritate and tear ligaments, especially UCL Ulnar nerve may also be affected S&S Localized pain Point tenderness Instability with stress test Management: standard acute Acute tears to ligamentous and joint structures at the elbow are rare.

Anterior Capsulitis Anterior joint pain caused by hyperextension S&S
Diffuse, anterior elbow pain after a traumatic episode Deep tenderness on palpation (especially anteromedial) Need to rule out pronator teres strain and median nerve entrapment Management: immobilization for 3-5 days followed by AROM exercises as pain allows Anterior joint pain caused by hyperextension is usually attributed to acute anterior capsulitis, rather than chronic, repetitive throwing. Microtears in the capsule are usually not sufficient to cause dislocation.

Dislocation Proximal radial head
Adolescents: often associated with immature annular ligament Due to: longitudinal traction of an extended and pronated upper extremity Inability to pronate and supinate pain free warrants immediate physician referral Immobilization for 3-6 weeks in flexion is usually necessary Dislocation of the proximal radial head -- aka “nursemaid’s elbow” or “pulled-elbow syndrome” -- results from longitudinal traction of an extended and pronated upper extremity, such as when a young child is swung by the arms; causes a small tear in the annular ligament that allows the radial head to migrate out from under the annular ligament

Dislocation (cont.) Ulnar dislocation Younger than 20 years old
Mechanism: Hyperextension Sudden, violent unidirectional valgus force drives ulna posterior or posterolateral Associated conditions Most ulnar dislocations occur in individuals younger than 20 years, with a peak incidence in the teenage years. Associated conditions -- fractures of the medial epicondyle, radial head, coronoid process, and olecranon process -- disruption of the anterior capsule -- tearing of the brachialis muscle -- injury to the ulnar collateral ligament

Dislocation (cont.)

Dislocation (cont.) S&S Snapping or cracking sensation
Severe pain, rapid swelling Total loss of function Obvious deformity Arm held in flexion, with forearm appearing shortened Olecranon and radial head palpable posteriorly Slight indentation in triceps visible just proximal to olecranon Nerve palsy Management: immediate immobilization in vacuum splint; activation of EMS nerve palsies -- common; makes pre- and postreduction neurovascular examination critical ulnar nerve dysfunction -- usually transient -- numbness will extend into the little finger median nerve -- may become trapped within the joint, within a healing medial epicondyle fracture, or looped anteriorly into the joint -- persistent unexplained pain and median nerve dysfunction (e.g., finger flexor weakness or numbness in the palm of the hand) necessitate immediate re-evaluation by a physician -- closed reduction under general or regional anesthesia is necessary

Strains Flexors and pronator teres Repetitive tensile stresses
Extensor Decelerating type injury S&S Typical muscle strain S&S Self-limiting Management: standard acute Muscular strains commonly result from inadequate warm-up, excessive training past the point of fatigue, and inadequate rehabilitation of previous muscular injuries.

Biceps Brachii Rupture
Mechanism: sudden eccentric load S&S Tenderness, swelling, and ecchymosis in antecubital fossa Weakness in supination and flexion Distal tendon not palpable Management: standard acute; immediate physician referral Nonoperative vs. surgical repair rupture of the biceps brachii -- 97% of all biceps brachii ruptures are proximal -- in many cases, pre-existing degenerative changes in the distal tendon make it vulnerable to rupture following a sudden eccentric load (e.g., during weight lifting or trying to catch oneself during a fall) -- individuals at increased risk for this injury tend to be men under 30 years of age with a history of using steroid medication Treatment -- nonoperative approach: recent studies have found a significant loss of elbow flexion (30%) and supination (40%) strength; although this decreased level of function may suffice for daily activities, the distal biceps tends to scar to the brachialis muscle, illuminating the normal contour of the muscle -- surgical repair to reattach the avulsed distal biceps tendon to the radial tuberosity provides the greatest likelihood of maximal functional results and return to sports

Triceps Brachii Rupture
Mechanism: Direct blow to posterior elbow Uncoordinated triceps contraction during a fall 80% involve olecranon avulsion fracture rupture of the triceps brachii -- partial tears are treated conservatively -- total rupture – surgical reattachment is necessary

Triceps Brachii Rupture (cont.)
S&S Pain and swelling in distal attachment Palpable defect in the triceps tendon or a step- off deformity of the olecranon Active extension weak – partial tear; nonexistent – total rupture Management: standard acute; immobilize in sling; immediate physician referral

Compartment Syndrome Anterior – wrist and finger flexors posterior – wrist and finger extensors Condition often secondary to other injuries Potential for neurovascular compromise compartment syndrome -- deep fascia of the forearm encloses the wrist and finger flexor and extensor muscle groups in a common sheath; two groups are separated into compartments by an interosseous membrane between the radius and ulna -- anterior compartment: wrist and finger flexors -- posterior compartment: wrist and finger extensors -- often secondary to other conditions: elbow fracture or dislocation, crushing injury, forearm fracture, postischemic edema, or excessive muscular exertion, as in weight lifting -- hemorrhage or edema causes increased pressure within the compartment, leading to excessive pressure on neurovascular structures and tissues within the space -- external compression should not be applied to the area, as the neurovascular structures are already compressed by the swelling -- immediate referral to a physician is necessary because a fasciotomy may be needed to decompress the area

Compartment Syndrome (cont.)
S&S Rapid onset Swelling; discoloration Absent or diminished distal pulse Subsequent onset of sensory changes and paralysis Severe pain at rest, aggravated by passive stretching of muscles in involved compartment Management: immobilization; ice and elevation; NO compression; immediate physician referral

Overuse Conditions Medial epicondylitis
Due to repeated valgus forces during acceleration phase of throwing motion Commonly involved tendons: pronator teres and flexor carpi radialis Throwing mechanism can lead to overuse injuries at the elbow. -- during the initial acceleration phase, the body is brought rapidly forward, but the elbow and hand lag behind the upper arm; results in a tremendous tensile valgus stress being placed on the medial aspect of the elbow, particularly the ulnar collateral ligament and adjacent tissues -- as acceleration continues, the elbow extensors and wrist flexors contract to add velocity to the throw; whipping action produces significant valgus stress on the medial elbow and concomitant lateral compressive stress in the radiocapitellar joint -- prior to ball release, the elbow is almost fully extended and is positioned slightly anterior to the trunk -- during release, the elbow is flexed approximately 20 to 30°; as these forces decrease, the extreme pronation of the forearm places the lateral ligaments under tension -- during deceleration, eccentric contractions of the long head of the biceps brachii, supinator, and extensor muscles decelerate the forearm in pronation Epicondylitis is a common chronic condition seen in activities involving pronation and supination, such as in tennis, javelin throwing, pitching, volleyball, and golf. The condition is sometimes referred to as a tendinosis because degeneration, rather than inflammatory conditions, exist; individual often reveals a pattern of poor technique, fatigue, and overuse. Medial epicondylitis -- valgus forces often produce a combined flexor muscle strain, ulnar collateral ligament sprain, and ulnar neuritis -- if the medial humeral growth plate is affected, it is called “little league elbow” -- intra-articular injuries, ulnar nerve problems, or moderate to severe cases of pain or instability: referral to a physician is indicated

Overuse Conditions (cont.)
S&S Swelling, ecchymosis, and point tenderness at humeroulnar joint or over the flexor/pronator origin Severe pain; aggravated by: Resisted wrist flexion and pronation Valgus stress applied at 15-20° of elbow flexion Ulnar nerve involved – tingling and numbness Management: ice; NSAIDs; sling immobilization for 2-3 weeks with wrist in slight flexion; therapeutic exercise

Lateral epicondylitis Due to eccentric loading of extensor muscles (especially extensor carpi radialis brevis) during deceleration phase of throwing motion or tennis stroke Contributing factors lateral epicondylitis (common extensor tendinitis) -- pain over the lateral epicondyle denotes extensor tendon overload and is the most common overuse injury in the adult elbow -- contributing factors: faulty mechanics (e.g., “leading” with the elbow, off-center hits in racquet sports), poorly fitted equipment (e.g., handle too small, string too tight), and age (i.e., 30 to 50 years of age) -- “coffee cup” test (i.e., pain increases while picking up a full cup of coffee) Management -- grasping an object with the forearm pronated is highly discouraged until acute symptoms resolve -- rehabilitation should focus on increasing the strength, endurance, and flexibility of the extensor muscle group -- counterforce strap placed 2 to 3 inches distal to the elbow joint can limit excessive muscular tension placed on the epicondyle

S&S Pain anterior or just distal to lateral epicondyle; may radiate into forearm extensors during and after activity Repetition produces pain that becomes more severe and ↑ with resisted wrist extension + “coffee cup” test + tennis elbow test Management: ice; NSAIDs; rest; support

Neural entrapment Ulnar nerve Vulnerable to compression and tension S&S Shocking sensation (medial elbow), radiating as if “hitting their crazy bone.” + Tinel sign – ulnar groove (tingling and numbness of medial forearm into ring and little finger) Pain not present, ROM is not limited Grip strength may be weak ulnar nerve -- passes behind the medial epicondyle of the humerus through the cubital tunnel to rest against the posterior portion of the ulnar collateral ligament -- vulnerable to compression and tensile stress, which may be caused by trauma (acute or chronic), cubital valgus deformity, irregularities within the ulnar groove, or subluxation as a result of a lax ulnar collateral ligament -- often referred to as cubital tunnel syndrome

Median nerve Compression Involvement of pronator teres – pronator syndrome S&S Pain in anterior proximal forearm, and aggravated with pronation Numbness in anterior forearm, middle and index fingers, and thumb median nerve -- travels across the cubital fossa, passing between the two heads of the pronator teres and the two heads of the flexor digitorum superficialis, to give off its largest branch, the anterior interosseous nerve -- compression may be caused by hypertrophied muscles, particularly the pronator teres, or by compression from fibrous arches near the flexor digitorum superficialis muscle, bicipital aponeurosis, or supracondylar process -- can lead to a condition called “pronator syndrome”

Radial nerve S&S Aching lateral elbow pain, radiates down posterior forearm Significant point tenderness over supinator muscle Resisted supination more painful than wrist extension Extreme cases: wrist drop Management of neural entrapment: immediate physician referral radial nerve -- may be damaged during a midshaft humeral fracture -- less frequently, direct trauma or entrapment occurs at the elbow as the nerve passes anterior to the cubital fossa, pierces the supinator muscle, and runs posterior again into the forearm (radial tunnel syndrome) -- terminal branch, the posterior interosseous nerve, supplies the deeper lying extensor muscles of the forearm; when injured, symptoms often mimic lateral epicondylitis

Fractures Epiphyseal and avulsion fractures
Medial epicondyle growth plate sensitive to tension stress Repetitive or sudden contraction of the flexor-pronator muscle group → partial or complete avulsion fracture of the medial epicondyle (little league elbow) epiphyseal and avulsion fractures -- closing growth plate of the medial epicondyle in adolescents is sensitive to tension stress -- tension stress is related to throwing curve balls and other breaking pitches that require forceful pronation; use of this term, however, negates the fact that other individuals, such as golfers, gymnasts, javelin throwers, tennis players, bowlers, squash and racquetball players, wrestlers, and weight lifters are also susceptible to the condition

Fractures (cont.) S&S Initial phase – aching during performance, but no limitations of performance or residual pain Progression – aching pain during activity limits performance, and a mild postexercise ache Localized tenderness Management Initial phase: standard acute; activity modification Performance limitations – physician referral

Fractures (cont.) Stress fractures
Ulna diaphysis – intensive weight lifting Bilateral distal radius and ulna – young individuals who lift heavy weights Osteochondritis dissecans Complication of repetitive stress to skeletally immature elbow Lateral compressive forces during throwing motion damage radial head, capitellum, or both stress fractures -- adolescents in a weight-lifting program should be properly instructed and supervised to prevent injury osteochondritis dissecans -- in adolescents with open growth plates (ages 12 to 15 years), a focal lesion can lead to destruction of the overlying articular cartilage with fragmentation and softening of the underlying subchondral bone; a microfracture (loose bodies) and eventual avascular necrosis lead to further joint degeneration Panner’s disease -- associated osteochondrosis condition; occurs at a younger age (ages 7 to 10 years) -- encompasses the entire capitellum -- pain is present over the lateral and anterior elbow and increases with deep palpation or pronation-supination -- elbow extension may be limited by 20° or more secondary to synovitis and a deformed capitellar congruity -- treatment is usually conservative, with rest for 6 to 18 months; if no loose body is present, no further treatment may be needed; if a fragment is displaced, surgery may be necessary to reattach a large articular fragment or to excise a small fragment

Fractures (cont.) S&S Pain with activity, improves with rest
Occasional clicking or locking of elbow Swelling and tenderness over radiocapitellar joint Grating during passive pronation and supination Limited full extension Management: physician referral

Fractures (cont.) Supracondylar fractures Fall on outstretched hand
Volkmann’s contracture: Complication from supracondylar fractures Ischemic necrosis of forearm muscles Damage to brachial artery or median nerve from fractured bone ends supracondylar fractures -- occur largely in children -- catastrophic complication from this fracture is ischemic necrosis of the forearm muscles known as Volkmann’s contracture fracture of the olecranon process of the ulna -- results from direct trauma, such as being struck with a field hockey or lacrosse stick, or falling on a flexed elbow

Fractures (cont.) Olecranon Direct blow
Triceps tension pulls bone fragment superiorly Intra-articular fracture – does not respond to conservative treatment, requires surgical intervention

Fractures (cont.) Radial head
Valgus stress tears UCL → compression and shearing on radial head S&S Swelling lateral to the olecranon Point tenderness radial head Flexion and extension may or may not be limited; passive pronation and supination is painful and restricted Possible associated valgus instability of the elbow or axial instability of the forearm radial head fracture -- nondisplaced (type I) -- displaced (type II) -- comminuted (type III)

Fractures (cont.) Ulna (forearm fracture) Direct blow
Also known as “nightstick” fracture

Fractures (cont.) Fracture management
Neurologic and circulatory assessment Radial nerve damage Weak forearm supination; elbow, wrist, or fingers extension Sensory changes – dorsum of hand

Fractures (cont.) Median nerve Weak wrist and finger flexion
Sensory changes – palm of hand Ulnar nerve Weak ulnar deviation and finger abduction/adduction; sensory changes – ulnar border of the hand Assess pulse at wrist or assess capillary refill Apply vacuum splint; transport immediately to nearest medical facility

Assessment History Observation/inspection Carrying angle
Position of function Palpation Physical examination tests Equipment is often associated with overuse problems; it is important to determine whether the individual uses a bat, racquet, field hockey or lacrosse stick, or other implement; check for proper grip size, excessive string tension, and excessive racquet weight or stiffness, and assess skill technique to rule out possible contributing factors. It is mportant to understand that pain may be referred from the cervical region, shoulder, or wrist. resting position -- slightly flexed position -- allows the joint to have maximal volume to accommodate intra-articular swelling carrying angle -- normal: slight valgus angle with the forearm fully supinated and elbow extended cubital valgus – angles 20°; cubital varus – angles 10° cubital recurvatum – extension beyond 0° is common, especially in females position of function: 90° of flexion with the hand held halfway between supination and pronation cubital fossa -- triangular area; lateral: brachioradialis muscle; medial: pronator teres muscle -- biceps brachii tendon, median nerve, and brachial artery pass through the fossa Medial aspect of the elbow -- prominent medial epicondyle -- wrist flexor muscle mass Lateral aspect of the elbow -- wrist extensor muscle mass Position of the olecranon relative to the epicondyles of the humerus -- flexed position: olecranon process and epicondyles should form an isosceles triangle -- extended position: olecranon process and two epicondyles form a straight line

Range of Motion (ROM) Active range of motion (AROM) Elbow
Flexion/extension Pronation/supination Wrist Passive range of motion (PROM) Elbow flexion – tissue approximation Elbow extension – bone to bone Supination and pronation – tissue stretch

ROM (cont.) Normal ranges Elbow flexion: 140-150°
Elbow extension: 0-10° Supination: 90° Pronation: 90° Wrist flexion: 80-90° Wrist extension: 70-90°

ROM (cont.) Goniometry measurement. A, Elbow flexion and extension. The fulcrum is centered over the lateral epicondyle of the humerus. The proximal arm is aligned along the humerus, using the acromion process for reference. The distal arm is aligned along the radius, using the styloid process for reference. B, Forearm supination. The fulcrum is centered medial to the ulnar styloid process. The proximal arm is parallel to the midline of the humerus, and the distal arm is placed across the palmar aspect of the forearm just proximal to the styloid processes of the radius and ulna. C, Forearm pronation. The fulcrum is centered lateral to the ulnar styloid process. The arms are placed in the same position but on the dorsal aspect of the forearm.

ROM (cont.) Resisted range of motion (RROM) Elbow flexion
Elbow extension Supination Pronation Wrist flexion Wrist extension

ROM (cont.) Resisted manual muscle testing for the elbow. The myotomes for each motion are listed in parentheses. A, Elbow flexion (C6). B, Elbow extension (C7). C, Forearm supination. D, Forearm pronation. E, Wrist flexion (C7). F, Wrist extension (C6).

Stress Tests Ligamentous instability Valgus stress Varus stress
Perform at multiple angles (full extension → 20-30° flexion) Medial elbow instability (UCL sprain) Valgus stress (tests integrity of ulnar collateral ligament) Patient (pt) is seated or standing; elbow flexed at 25° Examiner standing to side; one hand supports lateral elbow (fingers around back of elbow to palpate medial joint line); opposite hand grasps distal forearm Examiner applies valgus force to joint; repeat in various degrees of elbow flexion Test is + if: increased laxity and/or pain is present = UCL sprain Lateral elbow instability Varus stress (tests integrity of radial collateral ligament) Pt is seated or standing; elbow flexed ~25° Examiner applies varus force to joint; repeat in various degrees of elbow flexion Test is + if: increased laxity and/or pain = RCL/LCL sprain

Special Tests Common extensor tendinitis (lateral epicondylitis)
Resisted extension and radial deviation of wrist Passive stretching of wrist extensors Resisted extension of extensor digitorum communis in middle finger with wrist extended Epicondylitis Lateral (tennis elbow or lateral epicondylitis) Pt is seated or standing; elbow flexed ~90°, forearm pronated Examiner uses one hand to grasp forearm at elbow, palpating lateral epicondyle with thumb (fingers grasp around posterior elbow); other hand grasps pt’s hand/fist Pt is instructed make a fist and pronate the forearm Pt is instructed to radially deviate and extend wrist against examiner resistance Test is + if: pain over lateral epicondyle is present = lateral epicondylitis

Special Tests (cont.) Medial epicondylitis
Tinel’s sign for ulnar neuritis Elbow flexion for ulnar neuritis Pronator teres syndrome Medial (golfer’s elbow or medial epicondylitis) Pt is seated or standing; elbow flexed; forearm pronated/neutral Examiner uses one hand to palpate medial epicondyle and support elbow; other hand grasps hand/wrist Examiner extends wrist and elbow; pt is instructed to resist this movement Test is + if: pain over medial epicondyle is present = medial epicondylitis Tinel’s sign for ulnar neuritis Pt is seated or standing; elbow flexed 90°; forearm neutral/supinate Examiner stands to side/behind pt; uses one hand to support forearm and the other hand to palpate ulnar nerve in groove at elbow (between olecranon process and medial epicondyle) Examiner taps nerve in/over groove Test is + if: tingling sensation into ulnar distribution of forearm/hand = nerve compression Elbow flexion test for ulnar neuritis Pt is seated or standing; instructed to completely flex the elbow and hold that position for 5 minutes Test is + if: tingling or numbness in ulnar distribution of forearm/hand = ulnar neuropathy Pronator teres syndrome test (test for median nerve compression) Pt is seated or standing; elbow flexed 90° Examiner resists forearm pronation while elbow is extended Test is + if: tingling or paresthesia in median distribution of forearm/hand = median nerve compression

Special Tests (cont.) Pinch grip test
Pinch grip test (test for median nerve entrapment) Pt is seated or standing; instructed to pinch tips of index finger and thumb together Test is + if: pt pinches with pulp-to-pulp pinch with fingers instead of tip-to-tip = pathology of anterior interosseous nerve, branch of median nerve; entrapment between heads of pronator teres

Neurologic Tests Myotomes Scapular elevation – C4
Shoulder abduction – C5 Elbow flexion and/or wrist extension – C6 Elbow extension and/or wrist flexion – C7 Thumb extension and/or ulnar deviation – C8 Abduction and/or adduction of fingers – T1

Neurologic Tests (cont.)
Reflexes Biceps – C5-C6 Brachioradialis – C6 Triceps – C7

Dermatomes

Cutaneous patterns

Rehabilitation Restoration of motion
Use of opposite hand to supply load UBE

Rehabilitation (cont.)
Restoration of proprioception and balance Closed-chain exercises Muscular strength, endurance, and power Open-chain exercises PNF-resisted exercises Cardiovascular fitness

Upper Arm, Elbow, and Forearm Conditions

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