Chapter 16 Elbow and Forearm Pathologies Copyright 2015

Clinical Anatomy § Bony anatomy § § § Medial epicondyle Trochlea Capitellum Lateral epicondyle

Clinical Anatomy § Bony anatomy § § § § Ulna Semilunar notch Olecranon process Olecranon fossa Coronoid process Coronoid fossa Radial notch Proximal radioulnar joint Radial head Bicipital tuberosity Radial shaft Radial styloid process Lister tubercle Copyright © 2015. F. A. Davis Company

Clinical Anatomy § Articulation and ligamentous anatomy § Humeroulnar joint § Flexion and extension § Modified hinge joint § Humeroradial joint § Flexion and extension § Pronation and supination § Modified hinge joint § Proximal and distal radioulnar joints § Pronation and supination § Syndesmotic joint Copyright © 2015. F. A. Davis Company

Clinical Anatomy § Articulation and ligamentous anatomy § Ligamentous support § Ulnar collateral ligament (UCL) § Anterior, transverse, and posterior bundle § Lateral collateral ligament § Radial collateral ligament (RCL) § Annular ligament § Accessory lateral collateral ligament § Interosseous membrane Copyright © 2015. F. A. Davis Company

Clinical Anatomy Elbow flexor and supinator group Copyright © 2015. F. A. Davis Company

Clinical Anatomy Nerves § Median nerve § Anterior interosseous nerve § Ulnar nerve § Arcade of Struthers § Tunnel of Guyon § Radial nerve § Superficial branch § Deep branch Copyright © 2015. F. A. Davis Company Bursa § Subcutaneous olecranon bursa § Subtendinous olecranon bursa

Clinical Evaluation of the Elbow and Forearm Past medical history § Previous history § Seasonal pain § Cervical injury § General medical health § Vascular, neurological, or systemic conditions Copyright © 2015. F. A. Davis Company History of the present condition § § § Location of the symptoms Onset of the symptoms MOI Technique Associated sounds and sensations

Clinical Examination of the Elbow and Forearm § Inspection § Functional observation § Anterior structures § Carrying angle § Cubitus valgus § Cubitus varus § Cubital fossa § Medial structures § Medial epicondyle § Flexor muscle mass Copyright © 2015. F. A. Davis Company

Cubital Fossa The cubital fossa is a triangular area demarcated by the brachioradialis muscle laterally and the pronator teres medially. The brachial artery and its two subdivisions (the radial and ulnar arteries), the median nerve, and the musculocutaneous nerve pass through this fossa. Copyright © 2015. F. A. Davis Company

Clinical Examination of the Elbow and Forearm § Inspection § Lateral structures § Alignment

Clinical Examination of the Elbow and Forearm § Inspection § Posterior structures § Bony

Clinical Examination of the Elbow and Forearm § Palpation of the anterior structures 1. 2. 3. 4. 5. 6. 7. 8. Biceps brachii Cubital fossa Brachioradialis Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Pronator quadratus Copyright © 2015. F. A. Davis Company

Clinical Examination of the Elbow and Forearm Method of approximating the superficial muscles of

Clinical Examination of the Elbow and Forearm § Palpation of the medial structures 1. 2. 3. 4. 5. Medial epicondyle Ulna Anterior band UCL Posterior band UCL Transverse band UCL Copyright © 2015. F. A. Davis Company

Clinical Examination of the Elbow and Forearm § Palpation of the lateral structures 1. Lateral epicondyle 2. Radial head 3. Radial collateral ligament 4. Capitellum 5. Annular ligament 6. Lateral ulnar collateral ligament Copyright © 2015. F. A. Davis Company

Clinical Examination of the Elbow and Forearm § Palpation of the posterior structures 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Olecranon process Olecranon fossa Triceps brachii Anconeus Ulnar nerve Extensor carpi ulnaris Extensor carpi radialis brevis Extensor carpi radialis longus Extensor digitorum Extensor digiti minimi Extensor pollicis brevis Abductor pollicis longus Radial tunnel Copyright © 2015. F. A. Davis Company

Clinical Examination of the Elbow and Forearm § Joint and muscle function assessment § Active range of motion (AROM) § Flexion and extension § Pronation and supination § Manual muscle tests (MMT) § Passive range of motion (PROM) § Flexion and extension § Pronation and supination Copyright © 2015. F. A. Davis Company

Clinical Examination of the Elbow and Forearm § Passive range of motion Copyright ©

Passive Range of Motion § Elbow: Ulnohumeral and radiohumeral joint capsular patterns and end-feels § Capsular pattern: Flexion, extension § Extension: Hard § Flexion: Soft § Elbow: Superior radioulnar joints § Capsular pattern: Supination and pronation equally § Radioulnar supination: Firm § Radioulnar pronation: Hard or firm Copyright © 2015. F. A. Davis Company

Passive Range of Motion § Forearm: Distal radioulnar joint § Capsular pattern: Supination and pronation equally § Radioulnar supination: Firm § Radioulnar pronation: Firm Copyright © 2015. F. A. Davis Company

Clinical Examination of the Elbow and Forearm § Joint stability tests § Stress testing

Valgus Stress Test Copyright © 2015. F. A. Davis Company

Varus Stress Test Copyright © 2015. F. A. Davis Company

Clinical Examination of the Elbow and Forearm § Neurological testing § Innervated by the brachial plexus § Injury may disturb sensory or motor function in elbow, forearm, and hand § Upper quarter screen Copyright © 2015. F. A. Davis Company

Pathologies and Related Special Tests § Elbow dislocations § MOI: Axial force through the forearm with the elbow flexed § Extremely painful § Obvious deformity § “Terrible triad of the elbow” § Swelling can be rapid, masking deformity Copyright © 2015. F. A. Davis Company

$Pathologies and Related Special Tests § Fracture about the elbow § Supracondylar fracture §$

Pathologies and Related Special Tests § Fracture about the elbow § Supracondylar fracture § MOI: Hyperextension or fall on flexed elbow § Olecranon process fracture § MOI: Falling on flexed elbow § Radial head fracture § MOI: Longitudinal compression (FOOSH) § Forearm fracture § Open or closed, simple or complex, degree of angulation, rotation or displacement Copyright © 2015. F. A. Davis Company

Pathologies and Related Special Tests § Elbow sprains § Ulnar collateral ligament § Valgus extension overload § Elbow posterolateral rotatory instability § Radial collateral ligament § MOI: Varus force Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Moving Valgus Stress Test Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Posterolateral Rotatory Instability Test (Pivot Shift) Copyright © 2015. F. A.

Pathologies and Related Special Tests § Epicondylalgia § Lateral epicondylalgia § Inflammation or repetitive stress at the lateral epicondyle § Swelling § TTP § Pain with active wrist extension § “Tennis elbow” § Medial epicondylalgia § TTP on medial epicondyle § “Little Leaguer’s elbow” § Neuropathy of the ulnar nerve Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Lateral Epicondylalgia (“Tennis Elbow” Test) Copyright © 2015. F. A. Davis

Pathologies and Related Special Tests § Distal biceps tendon rupture § Most common in males over 40 years of age § MOI: Eccentric loading of the biceps brachii when the elbow is flexed to 90 § Complete or partial § Signs and symptoms § Pain § “Pop” within elbow § Palpable defect § Usually treated with a surgical repair Copyright © 2015. F. A. Davis Company

Selective Tissue Test: Hook Test for Distal Biceps Tendon Rupture Copyright © 2015. F.

Pathologies and Related Special Tests § Nerve pathology § Ulnar nerve pathology § Radial

On-Field Evaluation of Elbow and Forearm Injuries On-field history On-field inspection § Position of the arm § Type of force involved § Alignment of forearm and wrist § Posterior triangle of the elbow Copyright © 2015. F. A. Davis Company

On-Field Evaluation of Elbow and Forearm Injuries On-field palpation On-field joint and muscle function tests § Alignment of the elbow § Collateral ligaments § Radius and ulna § AROM § MMT § PROM On-field neurological tests § Assessment of forearm and hand Copyright © 2015. F. A. Davis Company

On-Field Management of Elbow and Forearm Injuries § Elbow dislocations § Management § Activate EMS § Immobilize in the position found in § Monitor distal pulse § Rule out injury to GH joint, proximal humerus, and wrist § Immediately transport athlete to medical facility for further evaluation and treatment Copyright © 2015. F. A. Davis Company

On-Field Management of Elbow and Forearm Injuries § Fractures about the elbow § Management § Monitor distal pulse § Immobilize elbow, forearm, and wrist § Treat for shock § Immediately transport athlete to medical facility for further evaluation and treatment Copyright © 2015. F. A. Davis Company