Transcript Elbow Injuries - Dr Brian L Badman | Orthopedic Shoulder

Elbow Injuries for the Primary
Care Doc
Brian Badman M.D.
Disclosures:

Consultant
 Smith and Nephew Endoscopy
 UpEX
 DJO Surgical

I have no conflicts with current talk or
industry support
Basic Anatomy
Relevant Anatomy
Humerus
 Ulna
 Radius

Distal Humerus
Coronoid Fossa
Medial Epicondyle
Trochlea
Lateral Epicondyle
Capitellum
Proximal Ulna
Greater Sigmoid Notch
Olecranon
Process
Lesser Sigmoid
Notch
Coronoid Process
Proximal Radius
Head
Neck
Radial/Bicepital Tuberosity
Joints
Humeroulnar joint and Humeroradial
 Flexion/extension
 Radioulnar joint
 Supination/pronation

Muscles Around Elbow—Simple
Bicep
 Triceps
 Wrist flexors
 Wrist extensors

Wrist Flexors
Wrist Extensors
Forearm muscles
Forearm flexorsmedial epicondyle
 Forearm extensorslateral epicondyle

Flexors of the elbow
Brachialis
 Biceps
 Brachioradialis

Extensors of the elbow

Triceps brachii
 Long head
 Lateral head
 Medial head
Elbow Pronator

Pronator teres
Elbow Supinators
Biceps brachii
 Supinator

Ligaments
Joint capsule surrounds joint
 Ulnar collateral (Tommy John)
 Radial collateral
 Annular ligament

Other structures

Nerves
 Ulnar, radial, median
Palpable Landmarks
Olecranon process
 Olecranon fossa
 Medial and lateral epicondyles
 Radial head
 Cubital Tunnel—Ulnar N

Stability of Elbow

Primary Stabilizers
 MCL (55% @ 90°)
 Ulnohumeral Joint
• Coronoid50%
• Olecranon

Secondary
Stabilizers
 Radiohumeral
Joint
 Capsule
 Musculature
(dynamic)
Common Elbow Maladies
Soft Tissue
Olecranon Bursitis
Etiology
Aseptic
 Direct blow or
fallHemarthrosis
 Gout
 Septic
 Insect Bite
 Cut/Abrasion
 Hematogenous

Signs & symptoms
Pain
 Swelling
 Erythema/FebrileSeptic

Treatment




Cold
Compression
Aspirate
 If serous/bloodyInject 40mg steroid
+compressive dressing+elbow extension x 3
days
 If pussRequires I+D (Ortho Consult)
Recurrent aseptic bursitisSurgery
Elbow Sprains
Mechanism
Hyperextension or a force that bends or
twists the lower arm outward
 Valgus stress

Signs & Symptoms
Pain
 Inability to throw or grasp an object
 POT (usually over UCL)

Treatment
Ice
 Compression
 Sling for support @ 90 degrees
 Progress to full ROM and strength

Lateral Epicondylitis
A.K.A “Tennis Elbow”
Epidemiology
4th -5th Decade
 M=F
 Repetitive wrist extension +forearm
pronation/supination
 10-50% tennis players will develop
 ECRB Tendon primarily involved
 #2=EDC

Histology



Angiofibroblastic hyperplasia
No acute inflammation
Likely begins as microtear
Physical Examination
TTP anterior/distal LE
 Pain worse w/ resistive wrist/finger extension

Imaging
Typically clinical diagnosis and not initially
necessary
 Consider plain XR for recalcitrant
 Look for calcification
 MRIConcern for intraarticular pathology

Treatment

Acute (<4wks)
 Rest
 NSAIDS
 PT
 Massage
 U/S
 Counterforce Bracing
Treatment (cont’d)

Rehab
 ROM exercises
 stretching
 PRE’s
 strengthening
 Hand grasping while in supination
 Avoid pronation movements
Treatment

Chronic (>4wks)
 Steroid injection
 40mg kenalogue +1/2 cc lidocaine
Surgery /Referral

Must fail 6-12 months conservative mgt

85-90% Effective—Nirschl JBJS 1979
Platelet Rich Plasma
Autologous Blood
 Centrifuge to separate layers and
concentrate platelets
 Growth FactorsMay potentiate/stimulate
healing
 May stimulate Type 1 collagen formation
–Kajikawa J Cell Physiol 2008

PRP Cont.
Expensive $200-600
 Not covered by insurance
 Early results poor study quality with
research bias (financial incentive)

PRP Peer Reviewed Level 1
Evidence
Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Am J
Sports Med. 2011 Mar 21. Ongoing Positive Effect of
Platelet-Rich Plasma Versus Corticosteroid Injection in
Lateral Epicondylitis: A Double-Blind Randomized
Controlled Trial With 2-Year Follow-Up.

100 patients49 cortisone/51 PRP

PRP group with significant improvement
regarding pain c/w steroid group at 2 years
Medial epicondylitis
A.K.A.
Pitcher’s elbow
 Racquetball elbow
 Golfer’s elbow
 Javelin-thrower’s elbow

Epidemiology
Less common
 4th-5th decade
 M=F

Mechanism

Repeated forceful
forearm flexion

Excessive throwing

Microtear of
FCR/Pronator
Teres
Physical Examination
TTP at medial epicondyle
 Worse w/ wrist flexion or forearm pronation
 Weak Grip


May be associated with ulnar neuritis
 TTP ulnar nerve
 +Tinnels thru cubital tunnel
Treatment
Conservative management
 NSAIDS
 PT—Massage/US/strengthening/ROM
 Counterforce Brace
 Steroid Injection
 Consider EMG if associated with ulnar
nerve sxs
 Surgical Referral—Failure of 6-12 months

Distal Bicep Rupture
Epidemiology
Male predominated
injury
 50-60yo
 Dominant arm
 Traumatic event of
elbow flexion against
resistance
 Often times described as
audible pop/”gunshot”

Physical Examination

Tenderness/bruising
antecubital fossa

Pain to resisted bicep
flexion and forearm
supination

Hook TestAble to hook
tendon from lateral side
with flexion
Imaging:

Clinical Exam typically confirms

If not obviousMRI
 Helps evaluate partial tears and extent of
partial tearing
Management

Typically recommend surgical
repairOrtho referral
 4-6 mo recovery
 Retear <2%

Nonoperative management
 40% loss flexion strength
 50% loss supination power
NERVES
Cubital Tunnel Syndrome
Ulnar N compression thru medial elbow
 2nd most common compressive neuropathy
UE
 30-60yo
 DDx:
 C8/T1 cervical compression
 Pancoast Tumor

Physical Examination

Check neck and axilla





Tinnel’s thru cubital tunnel
Direct compression Test
Numbness to RF/SF


Spurling’s sign
Axillary mass/tinnels
Semmes-Weinstein Monofilament
Intrinsic Weakness


Adductor Pollicis
1st Dorsal Interosseus
Special Tests

Fromment’s sign




Weakness of Adductor
Pollicus compensated
by FPL
IP flexion with lateral
pinch
FOX vs. RABBIT
Jeanne’s signMP
hyperextension w/ IP
flexion
Management


CONSIDER EMG TO DOCUMENT SEVERITY
Mild to Moderate
 Night splinting
 Avoids elbow
hyperflexion
 Heelbo
 NSAIDS
 Steroid Injection
 Work Ergonomic
Modification

Severe


Persistant Pain
Atrophy
 Surgical Referral
Bones
Dislocation of Elbow
Mechanism of injury

Second most frequent joint dislocation

Fall on extended elbow with outstretched
hand

Majority posterior/posterolateral (90-95%)
Signs & Symptoms
Ulna and/or radius displaced posteriorly, w/
olecranon process sitting posteriorly
 Severe swelling/bleeding
 Extreme pain

Classification
Simple
 No fracturepurely ligamentous
 Complex
 Associated with fracture
 Radial Headmost common fx

Treatment
Immobilize in position you find it
 Send to ER
 Radiographs

SIMPLE POSTEROLATERAL
DISLOCATION
Treatment—Simple
Closed Reduction
 Long arm splint/cast x 2 weeks
 Progressive ROM
 Protect terminal extension x 6wks


Major ComplicationExtension Loss
Reduction Maneuver



Gentle traction
Anterior directed force
on olecranon
Gradual flexion
COMPLEX ELBOW
DISLOCATION W/ RADIAL NECK FRACTURE
Radial Head
Treatment--Complex

Splint in situNo reduction
 Exception: NV compromise

Ortho ReferralSurgery
Radial Head Fractures
Most Common Adult elbow fracture
 MechanismFOOSH


PE:
 Pain/Effusion Elbow
 Commonly associated with wrist pain
 Pain with forearm rotation
 Check for mechanical click
Radial Head Fractures

Radiographs
 Can be subtle
 Look for fat pad sign
FAT PAD
SIGN
Mason Classification

INondisplaced

II<30% head and
>2mm displacement

IIIComminuted
Treatment

INonoperative





Sling for comfort
ROM 3-4 days
Possible Aspiration
Hematoma
Repeat XR 2wks
Complication


Extension/Supination
Loss
Inject Joint 3months

IIDebatable

Ortho Referral

No Mechanical Sx

Conservative
• Early ROM
• Close XR F/U

Mechanical Sx


Possible SURGERY
ORIF
Treatment--Continued

IIIOrtho Referral

Surgery


ORIF
RADIAL HEAD
REPLACEMENT
Thank You Terre Haute Medical
Community!!!