1. Musculosekeltal Diseases and Disorders: Elbow and Forearm
PTP 521

2. Anteroposterior view: A
Alignment:
Identify the structures from a proximal to distal view
Radial head should be aligned with the capitulum but not directly in contact with it
Olecranon should be centered in the olecranon fossa
Carrying angle should be noted and be ~ 15 dg.
Identify: Humerus, olecranon fossa, medial epicondyle, lateral epicondyle, olecranon, trochlea, capitulum, coronoid process and radial head

3. Abnormal Anteroposterior View
This view will demonstrate the following pathologies, if present:
Fractures of the distal humerus – supra, trans, and intercondylar
Fractures of the medial and lateral epicondyles
Fractures of the capitulum, trochlea and lateral aspect of radial head
Varus and Valgus deformities
Secondary ossification centers of the distal humerus

4. Anteroposterior view: B
Bone Density: pay particular attention to the radial head for any chips/fractures
Look for Trabecular lines
Pay attention to the medial and lateral epicondyles for any lucencies or breaks in the margins

5. Ossification Centers 6 ossification centers around the elbow joint.
Mnemonic C-R-I-T-O-E (Capitulum - Radius - Internal or medial epicondyle - Trochlea - Olecranon - External or lateral epicondyle).
The ages at which these ossification centers appear are highly variable and differ between individuals.
As a general guide you could remember years.
None should be open at age 13.
They appear and fuse to the adjacent bones at different ages. It is important to know the sequence of appearance since the ossification centers always appear in a strict order.

6. C and S Cartilage: Soft Tissue: not seen well on an AP view
Evaluated with an MRI, joint space is noted with the radial head and capitulum only
Soft Tissue: not seen well on an AP view
Fat Pad Sign (Sail Sign): evidence of swelling or bleeding anterior to the elbow
emedicine.medscape.com/article/
imaging

7. Lateral View of the Forearm
Anterior humeral line
Identify: trochlea, capitulum, radial head, coronoid process.
Alignment:
Line drawn through center of humeral shaft should intersect line through shaft of radius and be ~ 90 dg.
Radiocapitulum line

8. Radiocapitulum line:
Unless there is a dislocation of the radius, a line drawn through the center of the radius, should ALWAYS pass through the center of the capitulum.
Bottom right: dislocation

9. Anterior Humeral Line
Line drawn along the anterior surface of the humerus, in a lateral view, should pass through the middle third of the capitulum

10. Abnormal Lateral View
The lateral view will demonstrate the following pathologies, if present:
Supracondylar fractures of distal humerus
Fractures of anterior radial head and olecranon
Complex dislocations of the elbow joint
Dislocation of the radial head
pad sign (sail sign)

11. Lateral View
Bone Density: view the radial head, trabecular lines

12. Cartilage: Soft Tissue:
Able to see a joint space between the radius and the capitulum
Trochlea and the coronoid process
Soft Tissue:
May or may not be seen in this view
Evaluate for changes in density of the tissue which may indicate swelling
Fat pad sign (Sail sign) can be seen in this view as well

13. External Oblique View Radiohumeral joint (long white arrow)
Capitulum, radial head (yellow arrow)
Radial neck (orange arrow)
Radial tuberosity, coronoid process (dark blue arrowhead)
Trochlea notch/trochlea articulation (light blue arrowheads)
Proximal radioulnar articulation

14. Abnormal
The External Oblique view will demonstrate the following pathologies, if present:
Fractures of radial head and lateral epicondyle
s614.photobucket.com/albums/tt228/ex_cowboy/?...

15. Internal Oblique
This view is taken to demonstrate the coronoid process, trochlea notch, and medial trochlea
Forearm is pronated ~ 45 dg
Abnormal: will demonstrate fractures of the medial epicondyle and the coronoid process

16. Radial Head/Capitulum or Trauma View
Trauma View is when the radius is completely on top of the ulna, not overlapped.
Humeroradial joint (white arrow)
Radial head (dark blue arrow)
Capitulum (orange arrow) radial notch of the ulnar and radioulnar joint (yellow arrow)
Neck of the radius (light blue arrow)
A properly positioned elbow with the correct tube angle will demonstrate the normal radial head aligned with the coronoid process, the medial trochlea (green arrowheads) will be seen distal to the capitulum without superimposition.
Look at this view and evaluate the difference between the lateral view and the trauma lateral view - Its in the radial head position

17. Radial Head /Capitulum Trauma View
The trauma view will demonstrate the following
Fractures of radial head, capitulum and coronoid process
Abnormalities of the humeroradial and humeroulnar joints

18. CT Imaging Utilized to determine the following abnormal pathology:
Complex fractures around the elbow, particularly comminuted fractures
Healing process
Non union of bones
Secondary infections

19. CT Imaging of the Elbow
MRI seems to replace a lot of CT imaging because of the soft tissue around the elbow
These images are of a trochlear fracture (sorry, I couldn’t get better resolution)

20. These two CT images demonstrate the radioulnar articulation.
On the left is a coronal image of the elbow showing the radioulnar joint (A) and on the right the head of the humerus (C) and ulna (B) that form the joint.

21. On the left is a sagittal cut through the elbow
On the right a coronal cut through the elbow.
Both pictures demonstrate the humeroradial joint formed by the capitulum of the humerus (A) and the head of the radius (B).
Reconstructions from axial data

22. 3D volume rendered image demonstrating the humeroradial joint (A).
The sagittal CT image demonstrates this articulation formed by the articulation (B) fovea of the head of the radius, and (C) capitulum of the humerus.

23. Can you name the anatomy? (Don’t click until you are ready to answer)
A = cornoid process, ulna
B = coronoid fossa, humerus
C = olecranon process
D = olecranon fossa

24. Midsagittal plane CT
Demonstrates the positions of the anterior (B) and posterior (A) fat pads.
If these fat pads are elevated following trauma, it may indicate intra-articular hemorrhage secondary to fracture of the radial head or neck.
Sail sign as seen on the radiographs.

25. MRI Imaging Demonstrates the following pathology: Bone Contusion
Abnormalities of the ligaments, tendons and muscles
Lateral epicondylitis
Bicipital tendonitis
Ulnar collateral ligament injury
Radial collateral ligament injury
Bone Contusion
Capsular ruptures
Joint effusions
Synovial Cysts
Hematomas
Osteochondritis Dissecans
Epiphyseal fractures in children

26. MRI Imaging Axial view, T1 weighted Humerus Ulna Tendons
Ligaments – image black
Nerves
Vascular
Muscles
lateral
medial

27. Axial View What is the anatomy of 1-5? 1= Biceps Brachii 2= Brachialis
3= Brachial artery
4= Humerus
5= Triceps

28. CFT: common flexor tendon
CET: common extensor tendon
RCL: radial collateral ligament
UCL: ulnar collateral ligament

29. CORMPGR
Coronal Plane
Sequence: MPGR (Multiplanar Gradient Recalled) This is an echo pulsed sequence
This image demonstrates the humerus, ulna, radius is not in the picture just yet
Radial collateral lig
Ulnar collateral lig
medial

30. CORPD Coronal View Proton Density
Here you can see the radius as well as the ulna, humerus, olecranon

31. US Imaging
Normal anterior elbow appearance at the humeroradial joint (wide short arrow) with the fat pad at the radial fossa demonstrated (thin arrow).

32. Normal distal biceps tendon (arrows) with insertion deep to vein (longitudinal)

33. Normal lateral common extensor tendon origin (arrows) with normal hyper- echogenicity of the longitudinal tendon

34. Normal medial epicondyle, common flexor tendon origin (large arrows on hyperechoic longitudinal tendon ) and ulnar collateral ligament (small arrows on hypoechoic ligament).

35. Normal ulnar nerve at the joint in longitudinal (left) and transverse (right) planes (arrows).

36. Musculoskeletal Injury
Bone
Fractures
Arthritic Disorders
Bruise
Other
Muscle
Strain and Inflammation
Rupture
Trigger Points
Tendon
tendonosis
strain
Nerve
Entrapment
Ligament
Sprain and Inflammation
Capsule and Joint
Arthritis: OA and RA
Osteochondrosis
Dislocations
Other - Bursitis
Systems that refer pain to area
Other joints that refer pain to area

37. Fractures: Musculoskeletal Practice Pattern 4G
Fractures of the Distal Humerus
1. Suprachondylar fractures: extra- articular
Most common fracture in children- 65%
Uncommon fracture in adults
Left arm more than right – protective response
98% occur with arm extended and wrist dorsiflexed
Possible neurovascular complications: ~22% neuro and 10% vascular
Possible permanent impairment and deformity
McKinnis LN, 2005

38. Gunstock Deformity
Common complication of a suprachondylar fracture

39. SX: Signs: purple discoloration of hand,
severe pain in forearm muscles initially
paresthesias as the dysfunction progresses
Signs:
cool pale extremity with altered pulse
pain on passive stretch
swelling initially
numbness distal to the ischemic region

40. 2. Transcondylar: intracapsular but extraarticular fracture
Common in elderly
3. Epicondylar Fractures: extra-articular
4. Condylar Fractures
McKinnis LN, 2005

41. 5. Intercondylar Fractures
T intercondylar, Y Intercodylar Medial or Lateral Condyle
6. Intra-Articular Fractures
Compressive forces across the elbow
McKinnis LN, 2005

42. Volkmann's Ischemia Compartment Syndrome
Prolonged ischemia of the forearm muscles
muscle necrosis
replacement of tissue with fibrous tissue
severe deformities of the hand and wrist
paralysis of muscles.
Three stages: mild, moderate and severe
Causes:
Arterial injury caused by an open laceration,
Arterial disruption secondary to a severely displaced fracture or dislocation

43. Fractures of the Radial Head: Mason Classification System
Type I
Non-displaced fracture
Often missed on x-ray
Positive posterior fat pad sign
RX: minimal immobilization, early ROM

44. Radial Head Fracture Type II Displaced fracture
Separation or angulations of the fracture fragment
RX: ORIF, early motion

45. Radial Head Fractures Type III Comminuted fracture of the entire head
Children ages 4-14
RX: ORIF and early motion

46. Radial Head Fractures Type IV Comminuted fracture
Dislocation of the elbow
Usually cause some functional limitation
RX: radial head resection

47. Fractures of the Coronoid Process
RX:
Open reduction generally necessary
Concern for elbow instability
Classified: Regan-Morrey
Type I: tip of coronoid
Type II: less than 50% coronoid tip
Type III: more than 50% of the coronoid
boneandspine.com/wp-content/uploads/2009/02/c...

48. Fractures of the Olecranon
MOI: fall onto the flexed elbow
MOI: Boxer’s elbow: avulsion fracture of the olecranon

49. Monteggia Fracture
Dislocation of radial head – most common lateral or anterolateral, posterior rare
Fracture of ulnar metaphysis or diaphysis

50. Badu Classification of Monteggia Fractures
Type
Description
Frequency, % 3 I
Fracture of the middle or proximal third of the ulna and anterior dislocation of the radial head 65 II
Fracture of the middle or proximal third of the ulna and posterior dislocation of the radial head 18
III
Ulnar fracture distal to the coronoid process with lateral radial head dislocation 16 IV
Fracture of the proximal or middle third of the ulna with an anterior dislocation of the radial head and fracture of the proximal third of the radius 1
Resnick D. Physical injury: extraspinal sites. In: Diagnosis of Bone and Joint Disorders. 3rd ed. 1992.

51. Galeazzi Fracture Fracture of distal shaft of radius
Dislocation of distal radial ulnar joint

52. Muscle and Tendon Dysfunctions
Overuse Injuries
1. Risk Factors: Intrinsic and Extrinsic
2. Types: Lateral epicondylitis, Medial
epicondylitis, Triceps tendonitis, Bicipital
Tendonitis, bursitis, ligamentous injuries
Trauma

53. Soft Tissue Injuries of the Elbow
Lateral Epicondylitis
Medial Epicondylitis
Triceps Tendonitis
Biceps Strain
Myositis Ossificans

54. Lateral Epicondylitis
Adults 35 years or older: occupation or hobby involves repetitive extension of the wrist i.e. carpenter, electrician, tennis, baseball, or golf
Etiology: unknown: cumulative trauma causes inflammatory process at ECRB origin
Differential Diagnosis: Posterior Interosseous Syndrome and C6-7, T 4 syndromes

55. SX of Lateral Epicondylitis:
Gradual onset
Pain over lateral epicondyle
Pain associated with gripping
May have some shoulder, neck pain associated with it

56. Signs of Lateral Epicondylitis:
ROM: full, passive movement into extension, may be painful at end range
Limited wrist flexion combined with finger flexion at end range
Strength: painful resisted wrist extension and radial deviation
Joint Play: full and pain free
Palpation: tender over the lateral epicondyle
Special tests: + Cozens test, + Mill’s test, - Middle Digit Extenstion Test

57. Medial Epicondylitis Golfer’s elbow Symptoms
Pain on medial side of elbow
Involved in repetitive flexion activities of wrist finger flexion and active pronation

58. Signs of Medial Epicondylitis:
Palpation:  direct over the medial epicondyle
Resisted movement:  resisted flexion of the fingers increases pain but is strong, may have a loss of strength with gripping activities
Observation:  swelling/erythema on medial aspect

59.   Triceps Tendonitis:
1)  Onset:  sudden, severe strain as the arm is fully extended or with a sudden snapping of the elbow into extension
2)  Signs: 
pain with resisted elbow extension – may be strong or weak
pain with PROM of elbow flexion and shoulder flexion – passive stretch of the muscle

60. Biceps Muscle Strain: 1) Onset: athletic activity,
very strong elbow flexion force
hyperextension force leading to elongation and stretch.
need to be aware of possible anterior posterior joint capsule impingement.
Biceps rupture:  may have a history of repeated corticosteroid injections

61. 2) SX: depends on the degree of the strain 3) Signs: depends on the degree of the strain

62. Myositis Ossificans Common complication of trauma to the elbow,
muscle ossifies and can bridge the elbow joint.
Cause: contusion to the brachialis muscle from a posterior dislocation or a suprachondylar fracture.
May also be caused by too vigorous stretching after an injury and elbow immobilization
SX: pain with elbow flexion and extension
Signs: palpable area on muscle, warm to touch, bony end feel, limitation of range, + radiograph

63. Medial and Lateral Ligamentous structures of the elbow

64. Posterolateral Rotary Instability
MOI:
Rotational displacement of the ulna
Radius subluxes or dislocates posterior
Sx: catching, clicking and locking
Pain
Apprehension with elbow supinated and fully extended
Signs: lateral pivot-shift is most sensitive
Forces: : axial compression, external rotation and valgus (lateral to medial) force

65. Three stages
Stage I: Lateral Ulnar Collateral Ligament disruption
Stage II:
Anterior and posterior disruption
Perched dislocation

66. Stage III:
III A: all soft tissue except Ulnar collateral lig (medial side) is disrupted
III B: UCL disrupted
III C: Entire distal humerus stripped of soft tissue

67. Ligament Sprain
Medial (Ulnar) Collateral Ligament sprain (little league elbow): 
Articular damage to the radiohumeral and ulnohumeral joint with repeated stresses
MOI: adolescent involved with overhead throwing activities.
FOOSH injury
The compressive forces at the radiohumeral joint and distraction forces on the medial aspect of the elbow  will overstretch and injure the ligament.                 

68. Little League Elbow

69. Articular damage to the capitulum,
Ligamentous instability of the medial elbow
Tardy nerve palsy
may see medial muscle hypertrophy. 
In adolescents whose growth plate has not yet ossified, it may cause on avulsion injury of the medial epicondyle. 
Complete ligamentous rupture is usually associated with acute trauma

70. Radiology: Osteochondritis Dissecans of the Capitulum
Note fracture of the condlye on the ulnar aspect of the elbow

71. SX:  pain/swelling on the medial aspect of the elbow
Patient c/o pain with throwing or pushing motions

72. Signs: Tender with varus stress if the radiohumeral joint is involved
Valgus instability with ligamentous stress test
Tender with varus stress if the radiohumeral joint is involved
Painful axial compression with the radius on the humeral
Joint tender over the MCL ligament
Severe cases will get locking of the elbow due to capitulum fragments

73. Joint Dysfunctions of the Elbow
Dislocations
Osteoarthritis RA
Osteochondritis Dessicans

74. Elbow Dislocations MOI:
FOOSH
Direct Trauma
MVA
Described by the direction the ulna and radius have been displaced relative to the humerus
Most common types
Posterior or Posterolateral direction

75. Perched Dislocation Not a true dislocation Subluxation of the joint
Less ligamentous damage
Humerus is PERCHED on top of the coronoid process of the ulna

76. Posterior:
a.  straight posterior

77. b.  posterolateral -
c.  posteromedial
d. Divergent
What soft tissue structures may be involved with each one of these type of dislocations?

78. Additional injuries to soft tissue
Anterior capsule rupture
Radial collateral ligament damage
Brachial muscle injuries
Extensor tendon injuries
Radial head and neck fractures
Tear of brachial artery
Nerve injuries
Avulsion/entrapment of medial epicondyle

79. Anterior Dislocation Rare 1-2% of the population
Ulnar collateral ligament involved, what other structures?
Fractures of radial head may occur

80. Dislocations Physical Exam: gross deformity of the elbow
Anatomical triangle is disrupted
Elbow held in 45 dg flexion
Forearm appears shorter (posterior) and olecranon is more prominent posterior
boneandspine.com/.../10/dislocation-elbow.jpg

81. Subluxations of the Radius
Nursemaids Elbow
MOI: axial force on the arm
SX: pain, child will refuse to move the arm
Relocation, no immobilization needed

83. Osteoarthritis of the Elbow
Fill in signs and symptoms

84. Rheumatoid Arthritis

85. Elbow Replacement

86. Osteochondritis Dissecans and osteochondrosis (Panner’s Disease)
Described by some as different stages, same entity related to age of individual and direction and level of activity
Controversy: Panners disease encompasses entire capitellum and occurs at a younger age (5-16)
MOI: Vascular insufficiency from repetitious lateral compression at the humeroradial joint

87. Panners Disease
Younger child, no ossification of growth plates

88. 12- 15 year old: Osteochondritis Dissecans
Leading cause of permanent disability to the young pitching athlete
Repetitive lateral compression at the radiocapitellar joint during late cocking
Loose body formation in joint

90. Signs, Symptoms & Interventions
SX: pain present over lateral and anterior elbow
Pain increase with deep palpation, pronation and supination
ROM: extension limited by 20 dg or more
Intervention: Rest, gentle stretching
NO loose bodies: may drill bone to restore vascular supply
LOOSE bodies: may need arthroscopic surgery to remove the loose bodies

91. Bursitis: 12 bursae about the elbow with 3 of clinical significance
1)  Olecranon bursae allows smooth gliding of
the skin on the triceps Onset:  traumatic, inflammatory (gout),
prolonged pressure

92. Signs:  painless swelling of the bursae on the posterior aspect of the elbow (goose egg)
Nearly full AROM and PROM into elbow flexion secondary to compression of the bursae by the triceps
Classic inflammatory responses with redness, temp. increases, edema, and pain

93. 2) Bicipital Radial Bursitis:
Bursae is between the radial tuberosity and the insertion of the biceps tendon. 
Allows smooth gliding of the tendon on the bone. SX:  pain in the antecubital fossa, radiating up the biceps tendon Signs: 
palpation:  deep at the radial tuberosity and insertion of the biceps tendon
Resisted movements of elbow flexion and supination are painful

94. 3) Radiohumeral Bursitis:
Deep to the common extensor tendons, attaches to the lateral epicondyle. 
Aids in the gliding of the extensor tendons over the radiocapitellar bones/ capsule of the elbow complex.
Frequently is diagnosed as lateral epicondylitis with signs and symptoms similar to the lateral epicondylitis