1. The Elbow and Forearm Complex

2. Joints of the Elbow and Forearm

3. Ligaments of the Elbow

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

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

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

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

8. 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

9. 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

10. 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:

11. 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

12. 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.

13. 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.

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

15. Management of Elbow and Forearm Disorders and Surgeries

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 2. Improve Joint Tracking of the Elbow

23. 3. Improve Muscle Performance and Functional Abilities

24. Precautions Following Traumatic Injury to the Elbow

25. 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.

26. 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.

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

28. Joint Surgery and Postoperative Management

29. 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

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

31. Severity of Elbow Joint Disease and Selection of Surgical Procedure

32. 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

33. 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

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

35. 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

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