Elbow Injuries for the Primary Care Doc

Brian Badman M.D.Brian Badman M.D.

Disclosures:

ConsultantConsultant Smith and Nephew EndoscopySmith and Nephew Endoscopy UpEXUpEX DJO SurgicalDJO Surgical

I have no conflicts with current talk or I have no conflicts with current talk or industry supportindustry support

Basic Anatomy

Relevant Anatomy

HumerusHumerus UlnaUlna RadiusRadius

Distal Humerus

Medial Epicondyle Lateral Epicondyle

Trochlea Capitellum

Coronoid Fossa

Proximal Ulna

OlecranonProcess

Greater Sigmoid Notch

Lesser Sigmoid Notch

Coronoid Process

Proximal Radius

Head

Neck

Radial/Bicepital Tuberosity

Joints

Humeroulnar joint and HumeroradialHumeroulnar joint and Humeroradial Flexion/extensionFlexion/extension

Radioulnar jointRadioulnar joint Supination/pronationSupination/pronation

Muscles Around Elbow—Simple

BicepBicep TricepsTriceps Wrist flexorsWrist flexors Wrist extensorsWrist extensors

Wrist Flexors

Wrist Extensors

Forearm muscles Forearm flexorsForearm flexorsmedial epicondylemedial epicondyle Forearm extensorsForearm extensorslateral epicondylelateral epicondyle

Flexors of the elbow

BrachialisBrachialis BicepsBiceps BrachioradialisBrachioradialis

Extensors of the elbow

Triceps brachiiTriceps brachii Long headLong head Lateral headLateral head Medial headMedial head

Elbow Pronator

Pronator teresPronator teres

Elbow Supinators

Biceps brachiiBiceps brachii SupinatorSupinator

Ligaments Joint capsule surrounds jointJoint capsule surrounds joint Ulnar collateral (Tommy John)Ulnar collateral (Tommy John) Radial collateral Radial collateral Annular ligamentAnnular ligament

Other structures

NervesNerves Ulnar, radial, medianUlnar, radial, median

Palpable Landmarks Olecranon processOlecranon process Olecranon fossaOlecranon fossa Medial and lateral epicondylesMedial and lateral epicondyles Radial headRadial head Cubital Tunnel—Ulnar NCubital Tunnel—Ulnar N

Stability of Elbow

Primary StabilizersPrimary StabilizersMCL (55% @ 90MCL (55% @ 90°)°)Ulnohumeral JointUlnohumeral Joint

• CoronoidCoronoid50%50%

• OlecranonOlecranon

Secondary Secondary StabilizersStabilizers Radiohumeral Radiohumeral

JointJoint CapsuleCapsule Musculature Musculature

(dynamic)(dynamic)

Common Elbow Maladies

Soft Tissue

Olecranon Bursitis

Etiology AsepticAseptic

Direct blow or Direct blow or fallfallHemarthrosisHemarthrosis

GoutGout SepticSeptic

Insect BiteInsect Bite Cut/AbrasionCut/Abrasion HematogenousHematogenous

Signs & symptoms

PainPain SwellingSwelling Erythema/FebrileErythema/FebrileSepticSeptic

Treatment ColdCold CompressionCompression AspirateAspirate

If serous/bloodyIf serous/bloodyInject 40mg steroid Inject 40mg steroid +compressive dressing+elbow extension x 3 days+compressive dressing+elbow extension x 3 days

If pussIf pussRequires I+D (Ortho Consult)Requires I+D (Ortho Consult)

Recurrent aseptic bursitisRecurrent aseptic bursitisSurgerySurgery

Elbow Sprains

Mechanism

Hyperextension or a force that bends or Hyperextension or a force that bends or twists the lower arm outward twists the lower arm outward

Valgus stressValgus stress

Signs & Symptoms

PainPain Inability to throw or grasp an objectInability to throw or grasp an object POT (usually over UCL)POT (usually over UCL)

Treatment

IceIce CompressionCompression Sling for support @ 90 degreesSling for support @ 90 degrees Progress to full ROM and strengthProgress to full ROM and strength

Lateral EpicondylitisA.K.A “Tennis Elbow”

Epidemiology

44thth -5 -5thth Decade Decade M=FM=F Repetitive wrist extension +forearm Repetitive wrist extension +forearm

pronation/supinationpronation/supination 10-50% tennis players will develop10-50% tennis players will develop

ECRB Tendon primarily involvedECRB Tendon primarily involved #2=EDC#2=EDC

Histology

Angiofibroblastic hyperplasiaAngiofibroblastic hyperplasia No acute inflammationNo acute inflammation Likely begins as microtearLikely begins as microtear

Physical Examination

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

Imaging Typically clinical diagnosis and not initially Typically clinical diagnosis and not initially

necessarynecessary Consider plain XR for recalcitrantConsider plain XR for recalcitrant

Look for calcificationLook for calcification MRIMRIConcern for intraarticular pathologyConcern for intraarticular pathology

Treatment

Acute (<4wks)Acute (<4wks) RestRest NSAIDSNSAIDS PTPT

MassageMassageU/SU/S

Counterforce BracingCounterforce Bracing

Treatment (cont’d)

RehabRehab ROM exercisesROM exercises

stretchingstretching PRE’sPRE’s

strengtheningstrengthening Hand grasping while in supinationHand grasping while in supination Avoid pronation movementsAvoid pronation movements

Treatment

Chronic (>4wks)Chronic (>4wks) Steroid injection Steroid injection

40mg kenalogue +1/2 cc lidocaine40mg kenalogue +1/2 cc lidocaine

Surgery/Referral Must fail 6-12 months conservative mgtMust fail 6-12 months conservative mgt

85-90% Effective—Nirschl JBJS 197985-90% Effective—Nirschl JBJS 1979

Platelet Rich Plasma

Autologous BloodAutologous Blood Centrifuge to separate layers and Centrifuge to separate layers and

concentrate plateletsconcentrate platelets Growth FactorsGrowth FactorsMay potentiate/stimulate May potentiate/stimulate

healinghealing May stimulate Type 1 collagen formationMay stimulate Type 1 collagen formation

–Kajikawa J Cell Physiol 2008Kajikawa J Cell Physiol 2008

PRP Cont.

Expensive $200-600Expensive $200-600 Not covered by insuranceNot covered by insurance Early results poor study quality with Early results poor study quality with

research bias (financial incentive)research bias (financial incentive)

PRP Peer Reviewed Level 1 EvidenceGosens T, Peerbooms JC, van Laar W, den Oudsten BL. Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Am J Am J

Sports MedSports Med. 2011 Mar 21. . 2011 Mar 21. Ongoing Positive Effect of Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-Year Follow-Up.Controlled Trial With 2-Year Follow-Up.

100 patients100 patients49 cortisone/51 PRP49 cortisone/51 PRP

PRP group with significant improvement PRP group with significant improvement regarding pain c/w steroid group at 2 yearsregarding pain c/w steroid group at 2 years

Medial epicondylitis

A.K.A.

Pitcher’s elbowPitcher’s elbow Racquetball elbowRacquetball elbow Golfer’s elbowGolfer’s elbow Javelin-thrower’s elbowJavelin-thrower’s elbow

Epidemiology

Less commonLess common 44thth-5-5thth decade decade M=FM=F

Mechanism

Repeated forceful Repeated forceful forearm flexionforearm flexion

Excessive throwingExcessive throwing

Microtear of Microtear of FCR/Pronator TeresFCR/Pronator Teres

Physical Examination

TTP at medial epicondyleTTP at medial epicondyle Worse w/ wrist flexion or forearm pronationWorse w/ wrist flexion or forearm pronation Weak GripWeak Grip

May be associated with ulnar neuritisMay be associated with ulnar neuritis TTP ulnar nerveTTP ulnar nerve +Tinnels thru cubital tunnel+Tinnels thru cubital tunnel

Treatment Conservative management Conservative management

NSAIDSNSAIDS PT—Massage/US/strengthening/ROMPT—Massage/US/strengthening/ROM Counterforce BraceCounterforce Brace Steroid InjectionSteroid Injection Consider EMG if associated with ulnar nerve Consider EMG if associated with ulnar nerve

sxssxs Surgical Referral—Failure of 6-12 monthsSurgical Referral—Failure of 6-12 months

Distal Bicep Rupture

Epidemiology Male predominated injuryMale predominated injury 50-60yo 50-60yo Dominant armDominant arm Traumatic event of elbow Traumatic event of elbow

flexion against resistanceflexion against resistance Often times described as Often times described as

audible pop/”gunshot”audible pop/”gunshot”

Physical Examination

Tenderness/bruising Tenderness/bruising antecubital fossaantecubital fossa

Pain to resisted bicep flexion Pain to resisted bicep flexion and forearm supinationand forearm supination

Hook TestHook TestAble to hook Able to hook tendon from lateral side with tendon from lateral side with flexionflexion

Imaging: Clinical Exam typically confirmsClinical Exam typically confirms

If not obviousIf not obviousMRIMRI Helps evaluate partial tears and extent of Helps evaluate partial tears and extent of

partial tearingpartial tearing

Management

Typically recommend surgical repairTypically recommend surgical repairOrtho Ortho referralreferral 4-6 mo recovery4-6 mo recovery Retear <2%Retear <2%

Nonoperative managementNonoperative management 40% loss flexion strength40% loss flexion strength 50% loss supination power50% loss supination power

NERVES

Cubital Tunnel Syndrome

Ulnar N compression thru medial elbowUlnar N compression thru medial elbow 22ndnd most common compressive neuropathy most common compressive neuropathy

UEUE 30-60yo30-60yo DDx: DDx:

C8/T1 cervical compressionC8/T1 cervical compression Pancoast TumorPancoast Tumor

Physical Examination Check neck and axillaCheck neck and axilla

Spurling’s signSpurling’s sign Axillary mass/tinnelsAxillary mass/tinnels

Tinnel’s thru cubital tunnelTinnel’s thru cubital tunnel Direct compression TestDirect compression Test Numbness to RF/SFNumbness to RF/SF

Semmes-Weinstein MonofilamentSemmes-Weinstein Monofilament

Intrinsic WeaknessIntrinsic Weakness Adductor PollicisAdductor Pollicis 11stst Dorsal Interosseus Dorsal Interosseus

Special Tests Fromment’s signFromment’s sign

Weakness of Adductor Weakness of Adductor Pollicus compensated by Pollicus compensated by FPLFPL

IP flexion with lateral IP flexion with lateral pinchpinch

FOX vs. RABBITFOX vs. RABBIT

Jeanne’s signJeanne’s signMP MP hyperextension w/ IP hyperextension w/ IP flexionflexion

Management

CONSIDER EMG TO DOCUMENT SEVERITYCONSIDER EMG TO DOCUMENT SEVERITY

SevereSevere Persistant PainPersistant Pain AtrophyAtrophy

Surgical ReferralSurgical Referral

Mild to ModerateMild to Moderate Night splinting Night splinting

Avoids elbow Avoids elbow hyperflexionhyperflexion

HeelboHeelbo NSAIDSNSAIDS Steroid InjectionSteroid Injection Work Ergonomic Work Ergonomic

ModificationModification

Bones

Dislocation of Elbow

Mechanism of injury

Second most frequent joint dislocationSecond most frequent joint dislocation

Fall on extended elbow with outstretched Fall on extended elbow with outstretched handhand

Majority posterior/posterolateral (90-95%)Majority posterior/posterolateral (90-95%)

Signs & Symptoms

Ulna and/or radius displaced posteriorly, w/ Ulna and/or radius displaced posteriorly, w/ olecranon process sitting posteriorlyolecranon process sitting posteriorly

Severe swelling/bleedingSevere swelling/bleeding Extreme painExtreme pain

Classification

SimpleSimple No fractureNo fracturepurely ligamentouspurely ligamentous

ComplexComplex Associated with fractureAssociated with fracture

Radial HeadRadial Headmost common fxmost common fx

Treatment Immobilize in position you find itImmobilize in position you find it Send to ERSend to ER RadiographsRadiographs

SIMPLE POSTEROLATERALDISLOCATION

Treatment—Simple

Closed ReductionClosed Reduction Long arm splint/cast x 2 weeksLong arm splint/cast x 2 weeks Progressive ROMProgressive ROM

Protect terminal extension x 6wksProtect terminal extension x 6wks

Major ComplicationMajor ComplicationExtension LossExtension Loss

Reduction Maneuver

Gentle tractionGentle traction Anterior directed force Anterior directed force

on olecranonon olecranon Gradual flexionGradual flexion

COMPLEX ELBOWDISLOCATION W/ RADIAL NECK FRACTURE

Radial Head

Treatment--Complex

Splint in situSplint in situNo reduction No reduction Exception: NV compromiseException: NV compromise

Ortho ReferralOrtho ReferralSurgerySurgery

Radial Head Fractures Most Common Adult elbow fractureMost Common Adult elbow fracture MechanismMechanismFOOSHFOOSH

PE:PE: Pain/Effusion ElbowPain/Effusion Elbow Commonly associated with wrist painCommonly associated with wrist pain Pain with forearm rotationPain with forearm rotation Check for mechanical clickCheck for mechanical click

Radial Head Fractures

RadiographsRadiographs Can be subtleCan be subtle Look for fat pad signLook for fat pad sign

FAT PADSIGN

Mason Classification

IINondisplacedNondisplaced

IIII<30% head and <30% head and >2mm displacement>2mm displacement

IIIIIIComminutedComminuted

Treatment

IINonoperativeNonoperative Sling for comfortSling for comfort ROM 3-4 daysROM 3-4 days Possible Aspiration Possible Aspiration

HematomaHematoma Repeat XR 2wksRepeat XR 2wks ComplicationComplication

Extension/Supination Extension/Supination LossLoss

Inject Joint 3monthsInject Joint 3months

IIIIDebatableDebatable Ortho ReferralOrtho Referral

No Mechanical SxNo Mechanical Sx ConservativeConservative

• Early ROMEarly ROM

• Close XR F/UClose XR F/U

Mechanical SxMechanical Sx Possible SURGERYPossible SURGERY ORIFORIF

Treatment--Continued

IIIIIIOrtho ReferralOrtho Referral SurgerySurgery

ORIFORIF RADIAL HEAD RADIAL HEAD

REPLACEMENTREPLACEMENT

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