Elbow Injuries - Dr Brian L Badman | Orthopedic Shoulder
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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 flexorsmedial epicondyle
Forearm extensorslateral 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
• Coronoid50%
• Olecranon
Secondary
Stabilizers
Radiohumeral
Joint
Capsule
Musculature
(dynamic)
Common Elbow Maladies
Soft Tissue
Olecranon Bursitis
Etiology
Aseptic
Direct blow or
fallHemarthrosis
Gout
Septic
Insect Bite
Cut/Abrasion
Hematogenous
Signs & symptoms
Pain
Swelling
Erythema/FebrileSeptic
Treatment
Cold
Compression
Aspirate
If serous/bloodyInject 40mg steroid
+compressive dressing+elbow extension x 3
days
If pussRequires I+D (Ortho Consult)
Recurrent aseptic bursitisSurgery
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
MRIConcern 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 FactorsMay 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 patients49 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 TestAble to hook
tendon from lateral side
with flexion
Imaging:
Clinical Exam typically confirms
If not obviousMRI
Helps evaluate partial tears and extent of
partial tearing
Management
Typically recommend surgical
repairOrtho 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 signMP
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 fracturepurely ligamentous
Complex
Associated with fracture
Radial Headmost 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 ComplicationExtension 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 situNo reduction
Exception: NV compromise
Ortho ReferralSurgery
Radial Head Fractures
Most Common Adult elbow fracture
MechanismFOOSH
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
INondisplaced
II<30% head and
>2mm displacement
IIIComminuted
Treatment
INonoperative
Sling for comfort
ROM 3-4 days
Possible Aspiration
Hematoma
Repeat XR 2wks
Complication
Extension/Supination
Loss
Inject Joint 3months
IIDebatable
Ortho Referral
No Mechanical Sx
Conservative
• Early ROM
• Close XR F/U
Mechanical Sx
Possible SURGERY
ORIF
Treatment--Continued
IIIOrtho Referral
Surgery
ORIF
RADIAL HEAD
REPLACEMENT
Thank You Terre Haute Medical
Community!!!