The Elbow and Forearm

The Elbow

 A hinge joint performing flexion, extension, pronation, and supination  Anatomy  Humerus  Lateral/Medial Epicondyle  Olecranon Fossa

The Elbow

 Anatomy  Radius  lateral bone of the forearm  Radial Tuberosity  Radial Styloid process  Ulna  Medial border of the forearm  Semilunar notch  Olecranon process

The Elbow

 Articulations  Flexion and Extension  Humeroulnar joint  Humeroradial joint  Supination and Pronation  Humeroradial joint  Superior and inferior Radioulnar joints

The Elbow

 Ligamentous support  Ulnar collateral Lig. (UCL)  Divided into sections  Anterior Oblique band  Transverse Oblique band  Posterior oblique band

The Elbow

 Ligamentous Support  Lateral Ulnar collateral Lig. (LUCL)  Radial Collateral Lig. (RCL)  Annular Ligament  Interosseus Membrane

The Elbow

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Supporting Structures

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Types

 Static Structure  Dynamic Structure

Static Structures

 Includes  Fibrous Capsule  Collateral Ligaments  Synovial membrane  Fat pads  At the Olecranon Fossa (largest)  Over the radial and coronoid fossae (2 small fat pads)

Dynamic Structures

 Supinator muscle - supports lateral joint and serves as false ligament  Other muscle around elbow joint

Cubital Fossa

 Passing within the fossa is the  Brachial artery  Median Nerve  Biceps Tendon  Musculocutaneous Nerve This is called the

Triangular Space

Carrying Angle

    The way the forearm goes outward when at ones side. Caused by the size of the trochlea.

Valgus (outward angulation) of 5-15 degrees is normal  being greater in females.

Cubitus Valgus/Varus 

Gunstock deformity

 A deformity of the elbow, resulting from condylar fracture at the elbow in which the forearm deviates toward the midline of the body when extended.

Isoceles Triangle

 Medial and lateral epicondyles, Olecranon process. Forms a triangle in flexion and lines up in extension  Boarded laterally by the Brachioradialis and medially by the pronator teres

Eating Angle

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Due to the carrying angle hand goes straight to the mouth when elbow is flexed.

Observation

  Note the carrying angle Note Cubitus valgus and/varus   excessive swelling Look for normal bony and soft tissue contours  Functional position  90 degrees of flexion with hand in neutral

Range of Motion

 AROM  Flexion - 135-145 degrees  Extension - 0-10 degrees  Supination - 90 degrees  Pronation - 80-90 degrees

Circulation

 Brachial Artery  The pulse of the brachial artery can be felt directly medial to the biceps tendon insertion

Peripheral Nerve Injuries

  Median Nerve (C6-C8,T1) innervates wrist & finger flexors & pronates forearm  Pinched or compressed as it passes under the Lig. of Struther  Weakness of the pronator teres, and motor and sensory loss Referred as

Humerus Supracondylar Process Syndrome

Peripheral Nerve Injuries

 Pronator Teres Syndrome  As the median nerve passes through the two heads of the pronator teres it can be compressed  In this case the pronator teres remains normal and the other muscles supplied by the median nerve become involved down the median nerve’s motor distribution.

 The motion of pronation is possible but weak  Tested with Pronator Teres Syndrome Test: + sign is tingling or paresthesia in the median nerve distribution of the forearm and hand

Pronator Teres Syndrome Test

     The patient stands with the elbow in 90 degrees of flexion. The practitioner then places one hand on the client's elbow for stabilization and the other hand grasps the client's hand in a handshake position. The client holds this position as the practitioner attempts to supinate the client's forearm (forcing the client to contract the pronator muscles). While holding the resistance against pronation, the practitioner extends the client's elbow If the client's pain or discomfort is reproduced, there is a good chance of median nerve compression by the pronator teres

Pronator Teres Syndrome

 Pronator Teres Syndrome Test: In 90 degrees of elbow flexion the pronator teres muscle is weaker: a positive test is indicated by tingling or parenthesis in the median nerve distribution

Peripheral Nerve Injuries

   Anterior Interosseus Nerve Pinch Deformity  Sometimes pinched or entrapped as it passes the pronator teres, leading to impairment of    Flexor pollicis longus Flexor digitorum profundus (lateral half) Pronator Quadratus Anterior Interosseous Nerve Syndrome or Kiloh-Nerin Syndrome- exhibited by pinch deformity: + sign is touching finger pulp-to-pulp instead of finger tip to finger tip AIS causes no sensory loss because the AIN is a motor nerve

Peripheral Nerve Injuries

 Ulnar Nerve (C7-C8, T1)- innervates flexors of wrist & finger, intrinsics of the fingers and thumb   Likely to be compressed or stretch in the

Cubital tunnel

Compressed by  The Cubital Tunnel  Between the two heads of the flexor carpi ulnaris muscle

Peripheral Nerve Injuries

 Radial Nerve (C5-C8, T1) innervates triceps, brachiolis, brachioradialis, supinator ,& extensor muscles of wrist and fingers  May be injured as it winds around behind the Humerus in the R

adial Groove.

 Damage can occur at time of injury or later when the nerve gets caught in the callus of fracture healing  The extensor muscle of the arm are supplied by the radial nerve and only the triceps get spared with this injury

Peripheral Nerve Injuries

 Posterior Interosseous Nerve 

Radial Tunnel Syndrome

 The PIN can be compressed as it passes b/t the two head of the Supinator in the

Arcade or Canal of Frohse.

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Compression leads to functional involvement of forearm extensor muscles and drop wrist

No sensory deficit and may mimic tennis elbow

Elbow Pathology

 Lateral Epicondylities/Radiohumeral Bursitis  Location: extensor carpi radialis brevis tendon or the extensor commounis tendon  Signs & Symptoms:  Pain & tenderness on the outer side of elbow  Pain or weakness with gripping activities  Pain with twisting motions of the wrist ( playing tennis, using a screwdriver, opening a door or jar)  Pain with lifting objects

Lateral Epicondylitis

       Causes: Chronic repetitive stress and strain to the muscles and tendons that attach the forearm muscles to the elbow Sudden change in activity level or intensity Incorrect grip Incorrect grip size of racquet (often to large) Incorrect hitting position or technique ( usually backhand; leading with the elbow Using a racket that is too heavy

Radial Head Fractures

 MOI:  FOOSH injury  Elbow Dislocation  Direct Blow to the area

Radial Head Fractures

 Three Types or Classifications:   Type I: Nondisplaced Type II Marginal radial fractures that are displaced  Type III: Comminuted Fractures involving the entire radial head

Elbow Dislocation

  Very common in children and athletes MOI: FOOSH injury  Direct blow or twisting injury to the elbow   Posterior Dislocations are most common(98%) Seldom occur in isolation – are associated with fracture of the radial head (occur in 10%), Neurovascular involvement including brachial artery and median nerve

Elbow Dislocations

 Signs and Symptoms:  Extreme pain, swelling, and inability to bend the elbow  Deformity with olecranon protruding posteriorly and inferiorly  Loss of elbow function  Severe pain when attempting to move the elbow  Numbness or paralysis in the forearm or hand below the dislocation from pinching , stretching, or pressure on the blood vessels or nerves  Decrease or absent pulse at the wrist

Olecranon Bursitis

 Inflammation of the bursa located b/t the skin and tip of the ulna  Common in contact sports such as wrestling, football, volleyball

Olecranon Bursitis

 Signs and Symptoms  Pain, tenderness, swelling, warmth, or redness over the olecranon process  Crepitaiton ( a crackling sound) on movement or touch  Fever when infected  Often painless swelling of the bursa