clinical patterns of elbow

  1. what are common lateral elbow conditions?
    • common extensor tendinopathy
    • lateral epicondylitis
    • posterior interosseous nerve entrapment
  2. what are extra screening questions for the elbow?
    • handedness
    • clicking/clunking
    • activities involving:
    • - wrist ext
    • -weight bearing ie. lying, leaning, pushing through hand/elbow
    • -grip
    • -lifting
    • -carrying
  3. what tendons are involved in extensor tendinopathy? and where do they attach
    • extensor carpi radialis longus (lat. supracondylar ridge)
    • extensor carpi radialis brevis (lat epicondyle)
    • extensor digitorum (lat epicondyle)
    • extensor carpi ulnaris (lat. epicondyle)
  4. what are the contributing factors to extensor tendinopathy?
    • repetitive activity
    • age (30 years +) and associated degenerative tendon tissue changes - repetitive micro trauma leads to micro tears
    • poor blood supply to tendon at CEO
    • faulty technique or equipment in sport or workplace
  5. what are the symptoms of extensor tendinopathy?
    • area: 1-2cm below origins of ECRB +/- radiating down forearm (mid substance) or insertional (on CEO)
    • agg: gripping activities especially with load, activities with arm pronated and extended (hammer, computer)
    • Ease: rest, splint, NSAIDs
    • Hx: insidious, usually with new activity. Rarely trauma but blunt blow can do it
    • SQ's - steroid injection can contribute to early problems with tendons
  6. what are the signs of extensor tendinopathy?
    • AROM: NAD unless acute 
    • PROM: pain with elbow E/pron + wrist F/UD
    • special tests: mills test +ve (same as above)
    • pass acc glides: NAD
    • RSC: pain wrist E with EE (especially third MC)(2nd mc = ECRL, 3rd mc= ECRB)
    • palp: tender 1-2cm distal to epicondyle or at insertion
  7. what is the management for extensor tendinopathy
    • EPAs (US, IFR)
    • DTF and myofascial release
    • stretches - P, F, UD, full E of elbow to stretch, against wall
    • strengthening - eccentric (hold hammer in hand then lower slowly into E. Use supinator eccentrically by lowering slowly into pronation with E)
    • activity modification
    • bracing/taping - alter line of pull (wear brace around elbow)
  8. what is lateral epicondylitis?
    • similar presentation although p/tenderness is directly on insertion of CEO onto lateral epicondyle
    • presentation is more inflam. and therefore treatment is anti-inflam i.e.. EPAs, RICE, modified use, NSAIDs, then treat similar to common extensor tendinopathy
  9. what is the posterior interosseous nerve, and what does it supply?
    • PIN passes through supinator and supplies ECRB and supinator
    • may be irritated by ECRB
    • OR by supinator in arcade of frohse
    • Function: deep motor branch of radial nerve
    • supplies all extrinsic wrist, finger and thumb extensors except ECRL.
  10. what are symptoms of PIN entrapment?
    • history: gradual onset/overuse
    • area: local tenderness +/- post forearm
    • nature: ache
    • agg: twisting action (pronation/supination)
    • Social history: work/sport contributing factors
  11. what are signs of PIN entrapment?
    • AROM: supination is painful
    • PROM: EOR pronation - painful + (if supinator muscle is tight, as put on stretch)
    • RSC: ECRB, sup, wrist E - painful + (particularly supinator)
    • MMT: +/- weakness of wrist, thumb, and finger Es if severe
    • ULTT 2b: positive 
    • neurological: sensation - normal, power - may be weakness

    Note - if you get pain from PIN, with arm extended then move the shoulder and neck. It will stretch the nerve and bring on pain by tractioning the arm.
  12. what is the management for PIN entrapment?
    • neural mobilising techniques - take pressure off the nerve by stretching. Get into elbow extension then AROM shoulder through depression and elevation, then glide arm - gliding nerve through area of compression.
    • local treatment to CE tendon or supinator such as EPAs, DTF and myofascial massage, eccentric exercises, bracing and strapping to take the load off
  13. what are other sources of lateral elbow pain?
    • strain of lateral ligament
    • synovitis of radiohumeral joint
    • radiohumeral bursitis
    • osteochondritis dissecans
    • C6 nerve root
    • referral from Cx spine
  14. what are sources of problem at the medial elbow?
    • golfers elbow (medial epicondylitis) eg. tendonitis of pronator teres, FRC, palmaris longus, FCU
    • medial collateral ligament
    • ulnar nerve entrapment (2 heads FCU)
    • C8 nerve root
    • Cx spine
    • humeroulnar joint (intra-articular, capsular)
  15. what is the mechanism for a bicondylar fracture?
    a fall onto the point of the elbow drives the olecranon (ulna) upwards, splitting the humeral condyles.
  16. what is management for bicondylar fracture?
    • undisplaced: elbow flex in 90 degrees in backslab for 2/52 weeks - AROM
    • displaced: ORIF with screws +/- plates to fixate
    • severely comminuted: (usually poor results)
    • early active motion
    • collar and cuff (c+c) or hinged brace
    • may not regain full elbow ROM
  17. Image Upload 1what type of fracture is this?
  18. Image Upload 2what type of fracture is this?
    angulated intact posterior fracture
  19. Image Upload 3what type of fracture is this
    displaced distal fragment posteriorly
  20. what are complications of a bicondylar fracture?
    • brachial artery disruption
    • medial or ulnar nerve disruption
    • joint stiffness 
    • myositis ossificans - elbow can develop bone around areas if kept immobile for too long
    • mal-union
  21. what are complications of an elbow fracture
    • median nerve disruption
    • brachial artery disruption
  22. what is the mechanism for a posterior dislocation?
    • FOOSH with elbow extended
    • soft tissue disruption is usually severe 
    • anterior capsule
    • brachial torn
    • collateral ligaments stretched or ruptured
    • obvious deformity
  23. what are the complications to a posterior dislocation?
    • early: brachial artery, median, or ulnar nerve damage
    • late: myositis ossificans, calcification of capsule or ligaments, recurrent dislocation
    • associated fractures - medial epicondyle, head of radius, olecranon process
  24. what is early management for posterior dislocation of elbow?
    • collar and cuff for 3-5 weeks
    • they are able to move within the confines of C+C
    • early management is to:
    • maintain shoulder range, wrist range and hand ROM
    • EPAs ie. IFT
    • passive rom of elbow with no pain
    • active rom as tolerated (avoid extension as it could redislocate)
    • exercises to relax brachialis and work on extension
    • soft tissue damage of triceps, massage, relax techniques, AROM, through more range.
  25. what is late management of posterior dislocation of elbow?
    • passive mobilisations to elbow
    • relax techniques to improve extension
    • gentle stretches
    • aquatic therapy
    • strengthening of muscles triceps and biceps
    • gradual return to functional activities
    • avoid carrying heavy weights for at least 6/52
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clinical patterns of elbow