Elbow Injuries for the Primary Care Doc

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Elbow Injuries for the Primary Care Doc

• Brian Badman M.D.

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Disclosures

• Consultant
• Smith and Nephew Endoscopy
• UpEX
• DJO Surgical
• I have no conflicts with current talk or industry
  support

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Basic Anatomy
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Relevant Anatomy

• Humerus
• Ulna
• Radius

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Distal Humerus
Coronoid Fossa
Medial Epicondyle
Lateral Epicondyle
Trochlea
Capitellum
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Proximal Ulna
Greater Sigmoid Notch
Olecranon Process
Lesser Sigmoid Notch
Coronoid Process
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Proximal Radius
Head
Neck
Radial/Bicepital Tuberosity
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Joints

• Humeroulnar joint and Humeroradial
• Flexion/extension
• Radioulnar joint
• Supination/pronation

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Muscles Around ElbowSimple

• Bicep
• Triceps
• Wrist flexors
• Wrist extensors

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Wrist Flexors
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Wrist Extensors
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Forearm muscles

• Forearm flexors?medial epicondyle
• Forearm extensors?lateral epicondyle

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Flexors of the elbow

• Brachialis
• Biceps
• Brachioradialis

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Extensors of the elbow

• Triceps brachii
• Long head
• Lateral head
• Medial head

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Elbow Pronator

• Pronator teres

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Elbow Supinators

• Biceps brachii
• Supinator

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Ligaments

• Joint capsule surrounds joint
• Ulnar collateral (Tommy John)
• Radial collateral
• Annular ligament

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Other structures

• Nerves
• Ulnar, radial, median

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Palpable Landmarks

• Olecranon process
• Olecranon fossa
• Medial and lateral epicondyles
• Radial head
• Cubital TunnelUlnar N

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Stability of Elbow

• Secondary Stabilizers
• Radiohumeral Joint
• Capsule
• Musculature (dynamic)

• Primary Stabilizers
• MCL (55 _at_ 90)
• Ulnohumeral Joint
• Coronoid?50
• Olecranon

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Common Elbow Maladies
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Soft Tissue
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Olecranon Bursitis
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Etiology

• Aseptic
• Direct blow or fall?Hemarthrosis
• Gout
• Septic
• Insect Bite
• Cut/Abrasion
• Hematogenous

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Signs symptoms

• Pain
• Swelling
• Erythema/Febrile?Septic

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Treatment

• Cold
• Compression
• Aspirate
• If serous/bloody?Inject 40mg steroid compressive
  dressingelbow extension x 3 days
• If puss?Requires ID (Ortho Consult)
• Recurrent aseptic bursitis?Surgery

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Elbow Sprains
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Mechanism

• Hyperextension or a force that bends or twists
  the lower arm outward
• Valgus stress

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Signs Symptoms

• Pain
• Inability to throw or grasp an object
• POT (usually over UCL)

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Treatment

• Ice
• Compression
• Sling for support _at_ 90 degrees
• Progress to full ROM and strength

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Lateral EpicondylitisA.K.A Tennis Elbow
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Epidemiology

• 4th -5th Decade
• MF
• Repetitive wrist extension forearm
  pronation/supination
• 10-50 tennis players will develop
• ECRB Tendon primarily involved
• 2EDC

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Histology

• Angiofibroblastic hyperplasia
• No acute inflammation
• Likely begins as microtear

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Physical Examination

• TTP anterior/distal LE
• Pain worse w/ resistive wrist/finger extension

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Imaging

• Typically clinical diagnosis and not initially
  necessary
• Consider plain XR for recalcitrant
• Look for calcification
• MRI?Concern for intraarticular pathology

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Treatment

• Acute (lt4wks)
• Rest
• NSAIDS
• PT
• Massage
• U/S
• Counterforce Bracing

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Treatment (contd)

• Rehab
• ROM exercises
• stretching
• PREs
• strengthening
• Hand grasping while in supination
• Avoid pronation movements

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Treatment

• Chronic (gt4wks)
• Steroid injection
• 40mg kenalogue 1/2 cc lidocaine

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Surgery /Referral

• Must fail 6-12 months conservative mgt
• 85-90 EffectiveNirschl JBJS 1979

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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

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PRP Cont.

• Expensive 200-600
• Not covered by insurance
• Early results poor study quality with research
  bias (financial incentive)

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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

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Medial epicondylitis
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A.K.A.

• Pitchers elbow
• Racquetball elbow
• Golfers elbow
• Javelin-throwers elbow

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Epidemiology

• Less common
• 4th-5th decade
• MF

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Mechanism

• Repeated forceful forearm flexion
• Excessive throwing
• Microtear of FCR/Pronator Teres

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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

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Treatment

• Conservative management
• NSAIDS
• PTMassage/US/strengthening/ROM
• Counterforce Brace
• Steroid Injection
• Consider EMG if associated with ulnar nerve sxs
• Surgical ReferralFailure of 6-12 months

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Distal Bicep Rupture
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Epidemiology

• Male predominated injury
• 50-60yo
• Dominant arm
• Traumatic event of elbow flexion against
  resistance
• Often times described as audible pop/gunshot

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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

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Imaging

• Clinical Exam typically confirms
• If not obvious?MRI
• Helps evaluate partial tears and extent of
  partial tearing

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Management

• Typically recommend surgical repair?Ortho
  referral
• 4-6 mo recovery
• Retear lt2
• Nonoperative management
• 40 loss flexion strength
• 50 loss supination power

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NERVES
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Cubital Tunnel Syndrome

• Ulnar N compression thru medial elbow
• 2nd most common compressive neuropathy UE
• 30-60yo
• DDx
• C8/T1 cervical compression
• Pancoast Tumor

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Physical Examination

• Check neck and axilla
• Spurlings sign
• Axillary mass/tinnels
• Tinnels thru cubital tunnel
• Direct compression Test
• Numbness to RF/SF
• Semmes-Weinstein Monofilament
• Intrinsic Weakness
• Adductor Pollicis
• 1st Dorsal Interosseus

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Special Tests

• Fromments sign
• Weakness of Adductor Pollicus compensated by FPL
• IP flexion with lateral pinch
• FOX vs. RABBIT
• Jeannes sign?MP hyperextension w/ IP flexion

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Management

• CONSIDER EMG TO DOCUMENT SEVERITY

• Severe
• Persistant Pain
• Atrophy
• ? Surgical Referral

• Mild to Moderate
• Night splinting
• Avoids elbow hyperflexion
• Heelbo
• NSAIDS
• Steroid Injection
• Work Ergonomic Modification

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Bones
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Dislocation of Elbow
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Mechanism of injury

• Second most frequent joint dislocation
• Fall on extended elbow with outstretched hand
• Majority posterior/posterolateral (90-95)

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Signs Symptoms

• Ulna and/or radius displaced posteriorly, w/
  olecranon process sitting posteriorly
• Severe swelling/bleeding
• Extreme pain

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Classification

• Simple
• No fracture?purely ligamentous
• Complex
• Associated with fracture
• Radial Head?most common fx

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Treatment

• Immobilize in position you find it
• Send to ER
• Radiographs

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SIMPLE POSTEROLATERAL DISLOCATION
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TreatmentSimple

• Closed Reduction
• Long arm splint/cast x 2 weeks
• Progressive ROM
• Protect terminal extension x 6wks
• Major Complication?Extension Loss

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Reduction Maneuver

• Gentle traction
• Anterior directed force on olecranon
• Gradual flexion

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COMPLEX ELBOW DISLOCATION W/ RADIAL NECK FRACTURE
Radial Head
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Treatment--Complex

• Splint in situ?No reduction
• Exception NV compromise
• Ortho Referral?Surgery

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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

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Radial Head Fractures

• Radiographs
• Can be subtle
• Look for fat pad sign

FAT PAD SIGN
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Mason Classification

• I?Nondisplaced
• II?lt30 head and gt2mm displacement
• III?Comminuted

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Treatment

• II?Debatable
• Ortho Referral
• No Mechanical Sx
• Conservative
• Early ROM
• Close XR F/U
• Mechanical Sx
• Possible SURGERY
• ORIF

• I?Nonoperative
• Sling for comfort
• ROM 3-4 days
• Possible Aspiration Hematoma
• Repeat XR 2wks
• Complication
• Extension/Supination Loss
• Inject Joint 3months

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Treatment--Continued

• III?Ortho Referral
• Surgery
• ORIF
• RADIAL HEAD REPLACEMENT

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Thank You Terre Haute Medical Community!!!