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.

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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

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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

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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 1-3-5-7-9-11 years.

– None should be open at age 13.

www.radiologyassistant.nl/en/4214416a75d87

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C and S• Cartilage:

– 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/389069-imaging

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Lateral View of the Forearm

• 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.

Anterior humeral line

Radiocapitulum line

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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

http://www.radiologyassistant.nl/en/4214416a75d87

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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

http://www.radiologyassistant.nl/en/4214416a75d87

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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)

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Lateral View

• Bone Density: view the radial head, trabecular lines

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• Cartilage:– 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

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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

http://www.ceessentials.net/article29.html

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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/?...

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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

http://www.ceessentials.net/article29.html

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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)

http://www.ceessentials.net/article29.html

Look at this view and evaluate the difference between the lateral view and the trauma lateral view - Its in the radial head position

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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

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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

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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)

www.jortho.org/2008/5/3/e5/index.htm

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• 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. www.ceessentials.net/article29.html

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• 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 datawww.ceessentials.net/article29.html

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• Humeroradial Joint

• 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. www.ceessentials.net/article29.html

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Can you name the anatomy?(Don’t click until you are ready to answer)

A = cornoid process, ulnaB = coronoid fossa, humerus

C = olecranon processD = olecranon fossa

www.ceessentials.net/article29.html

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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.

www.ceessentials.net/article29.html

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MRI Imaging

• Demonstrates the following pathology:– 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

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MRI Imaging

• Axial view, T1 weighted– Humerus– Ulna– Tendons– Ligaments – image black– Nerves– Vascular– Muscles

lateral medial

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Axial View

• What is the anatomy of 1-5?

• 1= Biceps Brachii• 2= Brachialis• 3= Brachial artery• 4= Humerus• 5= Triceps

http://anatomy.med.umich.edu/radiology/xray/arm_mri_zoom.html

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• CFT: common flexor tendon

• CET: common extensor tendon

• RCL: radial collateral ligament

• UCL: ulnar collateral ligament

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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

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CORPD

• Coronal View• Proton Density

• Here you can see the radius as well as the ulna, humerus, olecranon

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US Imaging

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

www.gehealthcare.com/.../products/cme_msk.html

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

www.gehealthcare.com/.../products/cme_msk.html

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

www.gehealthcare.com/.../products/cme_msk.html

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

www.gehealthcare.com/.../products/cme_msk.html

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

www.gehealthcare.com/.../products/cme_msk.html

Musculoskeletal Injury

Bone

Fractures

Arthritic Disorders

BruiseOther

Muscle

Strain and Inflammation

Rupture

Trigger Points

Tendon

tendonosis

strain

Nerve

Entrapment

Ligament

Sprain and Inflammation

Rupture

Capsule and Joint

Arthritis: OA and RA

Osteochondrosis

Dislocations

Other - Bursitis

Systems that refer pain to area

Other joints that refer pain to area

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Fractures: Musculoskeletal Practice Pattern 4G

Fractures of the Distal Humerus1. 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

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Gunstock Deformity

• Common complication of a suprachondylar fracture

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• SX: – 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

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2. Transcondylar: intracapsular but extraarticular fracture

• Common in elderly

3. Epicondylar Fractures: extra-articular

4. Condylar Fractures

McKinnis LN, 2005

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5. Intercondylar Fractures – T intercondylar, Y

Intercodylar Medial or Lateral Condyle

6. Intra-Articular Fractures– Compressive forces

across the elbow

McKinnis LN, 2005

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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

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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

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Radial Head Fracture

• Type II• Displaced fracture• Separation or

angulations of the fracture fragment

• RX: ORIF, early motion

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Radial Head Fractures

• Type III• Comminuted fracture of

the entire head• Children ages 4-14• RX: ORIF and early

motion

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Radial Head Fractures

• Type IV• Comminuted fracture • Dislocation of the elbow• Usually cause some

functional limitation• RX: radial head

resection

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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...

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Fractures of the Olecranon

• MOI: fall onto the flexed elbow

• MOI: Boxer’s elbow: avulsion fracture of the olecranon

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Monteggia Fracture

• Dislocation of radial head – most common lateral or anterolateral, posterior rare

• Fracture of ulnar metaphysis or diaphysis

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Badu Classification of Monteggia FracturesType Description Frequency, % 3

I Fracture of the middle or proximal third of the ulna and anterior dislocation of the radial head

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II Fracture of the middle or proximal third of the ulna and posterior dislocation of the radial head

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III Ulnar fracture distal to the coronoid process with lateral radial head dislocation

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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.

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Galeazzi Fracture

• Fracture of distal shaft of radius

• Dislocation of distal radial ulnar joint

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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

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Soft Tissue Injuries of the Elbow

• Lateral Epicondylitis

• Medial Epicondylitis

• Triceps Tendonitis

• Biceps Strain

• Myositis Ossificans

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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

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SX of Lateral Epicondylitis:

• Gradual onset• Pain over lateral epicondyle• Pain associated with gripping• May have some shoulder, neck pain associated

with it

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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

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Medial Epicondylitis

• Golfer’s elbow• Symptoms

– Pain on medial side of elbow– Involved in repetitive flexion activities of wrist

finger flexion and active pronation

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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

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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

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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

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

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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

www.uwec.edu

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Medial and Lateral Ligamentous structures of the elbow

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Posterolateral Rotary Instability

• MOI: – Rotational displacement

of the ulna– Radius subluxes or

dislocates posterior

• Forces: : axial compression, external rotation and valgus (lateral to medial) force

• Sx: catching, clicking and locking

• Pain• Apprehension with

elbow supinated and fully extended

• Signs: lateral pivot-shift is most sensitive

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• Three stages– Stage I: Lateral Ulnar

Collateral Ligament disruption

• Stage II:– Anterior and posterior

disruption– Perched dislocation

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• 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

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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.

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Little League Elbow

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• 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

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• Radiology: – Osteochondritis

Dissecans of the Capitulum

• Note fracture of the condlye on the ulnar aspect of the elbow

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• SX: pain/swelling on the medial aspect of the elbow

• Patient c/o pain with throwing or pushing motions

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Signs:

• 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

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Joint Dysfunctions of the Elbow

Dislocations

Osteoarthritis

RA

Osteochondritis Dessicans

http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=239&topcategory=Arm

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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

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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

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Posterior:

a. straight posterior

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b. posterolateral - c. posteromedial d. Divergent

What soft tissue structures may be involved with each one of these type of dislocations?

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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

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Anterior Dislocation

• Rare 1-2% of the population

• Ulnar collateral ligament involved, what other structures?

• Fractures of radial head may occur

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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

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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

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Osteoarthritis of the Elbow

• Fill in signs and symptoms

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Rheumatoid Arthritis

http://uwmsk.org:8080/EvasMSKTF/stories/storyReader$509

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Elbow Replacement

http://www.orthop.washington.edu/uw/elbowreplacement/tabID__3376/ItemID__61/PageID__5/Articles/Default.aspx

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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

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Panners Disease

• Younger child, no ossification of growth plates

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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

89http://www.physsportsmed.com/issues/1999/02_99/hall.htm

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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

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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

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• 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

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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

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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