Forearm And Elbow Pathologies Dr. Mark Davies Sjsu, Spring 2008
-
Upload
jls10 -
Category
Health & Medicine
-
view
3.343 -
download
3
Transcript of Forearm And Elbow Pathologies Dr. Mark Davies Sjsu, Spring 2008
Elbow and Forearm Elbow and Forearm PathologiesPathologies
Mark R. Davies, MDCenter for Shoulder and Sports Disorders
Kaiser Permanente Medical GroupSanta Teresa Medical Center
San Jose, CA
Dr. James AndrewsBirmingham, Alabama
Over 900 “Tommy John” surgeries
American Sports Medicine InstituteAmerican Sports Medicine InstituteBirmingham, ALBirmingham, AL
Elbow and Forearm PathologiesElbow and Forearm Pathologies
Elbow ligamentous sprainsElbow ligamentous sprainsEpicondylitisEpicondylitisDisorders of the capitellumDisorders of the capitellumRupture of distal biceps tendonRupture of distal biceps tendonOlecranon bursitisOlecranon bursitisNeurologic injuryNeurologic injuryElbow dislocationsElbow dislocationsFracturesFractures
Elbow Ligamentous SprainsElbow Ligamentous Sprains
Medial (ulnar) collateral ligament injuryMedial (ulnar) collateral ligament injury
Lateral (radial) collateral ligament injuryLateral (radial) collateral ligament injury
Ulnar Collateral Ligament (UCL)Ulnar Collateral Ligament (UCL)
UCL is the main UCL is the main medial stabilizer of medial stabilizer of the elbowthe elbow
Anterior bundle is Anterior bundle is the primary structure the primary structure involved in throwinginvolved in throwing
UCL HistoryUCL History
Pain or instability Pain or instability with throwingwith throwing
What phase of What phase of throwing?throwing?
85% of throwers 85% of throwers with medial elbow with medial elbow instability complain instability complain of pain in the of pain in the acceleration phase acceleration phase of throwingof throwing
UCL InjuryUCL Injury
History:History:
- Acute medial pain- Acute medial pain
- Onset during throwing, inadequate - Onset during throwing, inadequate warmupwarmup
- “Pop” heard or felt- “Pop” heard or felt
- Can be one pitch or can be insidious- Can be one pitch or can be insidious
UCL InjuryUCL Injury Physical exam:Physical exam:
- Medial elbow ecchymosis- Medial elbow ecchymosis
- Ulnar nerve symptoms- Ulnar nerve symptoms
- Tender at anterior bundle- Tender at anterior bundle
- Difficult exam:- Difficult exam:
+/- instability+/- instability
Milking ManeuverMilking Maneuver
Palpation of UCLPalpation of UCL
Palpate in flexion to move flexor-pronator mass anteriorly
Complete UCL tear on MRIComplete UCL tear on MRI
Normal UCLNormal UCL
Bone Bone tunnels are tunnels are drilleddrilled
““Tommy John” SurgeryTommy John” Surgery
Graft is Graft is harvested – harvested –
PalmarisPalmaris
longuslongus
Operative TechniqueOperative Technique
Graft is passed Graft is passed and crossed in a and crossed in a figure eight patternfigure eight pattern
Operative TechniqueOperative Technique
ResultsResultsReturn to SportReturn to Sport
85 % of major league 85 % of major league
professional baseball playersprofessional baseball players
were able to returnwere able to return
Lateral EpicondylitisLateral Epicondylitis
“Tennis elbow”
Lateral EpicondylitisLateral Epicondylitis
More common by 9:1 More common by 9:1 ratio than medial ratio than medial epicondylitisepicondylitis
Degenerative process: Degenerative process: “tendinosis”“tendinosis”
Extensor Carpi Radialis Extensor Carpi Radialis Brevis (ECRB) most Brevis (ECRB) most commonly involvedcommonly involved
Lateral EpicondylitisLateral Epicondylitis
Palpate mobile wad while resisting active wrist extension
Pain at lateral epicondyle or over muscle mass usually present
No neurologic symptoms
Normal sensation
Lateral Epicondylitis Lateral Epicondylitis Conservative TreatmentConservative Treatment
Up to 90% of epicondylitis resolves Up to 90% of epicondylitis resolves spontaneouslyspontaneously Rehab focus on stretching wrist Rehab focus on stretching wrist
extensors, eccentric wrist extensorsextensors, eccentric wrist extensors Activity modificationActivity modification Anti-inflammatory medicationsAnti-inflammatory medications Counterforce bracingCounterforce bracing SteroidsSteroids
InjectedInjectedTopical –Iontophoresis / 24 Hr. Topical –Iontophoresis / 24 Hr. patchpatch
SurgerySurgery
MedialMedialEpicondylitisEpicondylitis
“Golfer’s “Golfer’s Elbow”Elbow”
Pain with resisted wrist Pain with resisted wrist flexionflexionPain with resisted Pain with resisted pronationpronationTender either within Tender either within muscle belly or directly muscle belly or directly over medial epicondyleover medial epicondyle
Medial EpicondylitisMedial EpicondylitisDiagnosisDiagnosis
Medial Epicondyle Avulsion Medial Epicondyle Avulsion FracturesFractures
Result from extreme valgus loads or violent muscle contractions during the throwing motion
Commonly occur in adolescents as the medial epicondyle begins to fuse
May report a “pop”
Tender at medial epicondyle, ecchymosis present medially
Medial Epicondyle Avulsion Medial Epicondyle Avulsion FracturesFractures
Medial Epicondyle Avulsion Medial Epicondyle Avulsion FracturesFractures
Panner’s DiseasePanner’s Disease
Osteochondrosis of Osteochondrosis of the capitellumthe capitellum
Elbow’s version of Elbow’s version of Legg-Calve-Perthes Legg-Calve-Perthes DiseaseDisease
Presents with lateral Presents with lateral elbow pain and elbow pain and perhaps stiffness in perhaps stiffness in an active youngsteran active youngster
Panner’s DiseasePanner’s Disease
Usually seen in Usually seen in children less than children less than age 10age 10
Fragmentation of Fragmentation of the capitellum the capitellum usually seen on usually seen on xraysxrays
Panner’s DiseasePanner’s Disease
Panner’s DiseasePanner’s Disease
TreatmentTreatmentOrthopedic referral appropriate as is MRIOrthopedic referral appropriate as is MRIStop offending activities - typically throwing Stop offending activities - typically throwing (baseball) or handsprings (gymnastics) (baseball) or handsprings (gymnastics) Rest elbow – may consider splinting for a few Rest elbow – may consider splinting for a few weeksweeksTypically symptoms will resolve in a few months Typically symptoms will resolve in a few months and capitellum ossification will normalize within 2 and capitellum ossification will normalize within 2 years years Long term prognosis excellent in most casesLong term prognosis excellent in most cases
Osteochondritis Dissecans (OCD) Osteochondritis Dissecans (OCD) of the Capitellumof the Capitellum
OCD is a localized lesion in which a segment of OCD is a localized lesion in which a segment of subchondral bone and articular cartilage subchondral bone and articular cartilage separates from the underlying bone separates from the underlying bone Presents with lateral elbow pain and perhaps Presents with lateral elbow pain and perhaps stiffness in an active youngsterstiffness in an active youngsterUsually seen in children older than age 12Usually seen in children older than age 12Focal area of lucency in the subchondral bone in Focal area of lucency in the subchondral bone in the anterior aspect of the capitellumthe anterior aspect of the capitellumPrognosis worsePrognosis worse
Osteochondritis Dissecans of the Osteochondritis Dissecans of the CapitellumCapitellum
Osteochondritis Dissecans of the Osteochondritis Dissecans of the CapitellumCapitellum
Physical examPhysical examLateral elbow pain with tenderness directly over Lateral elbow pain with tenderness directly over the capitellumthe capitellumSmall effusion may be noted. Small effusion may be noted. Limited range of motion is typically observed Limited range of motion is typically observed with approximately 20° of extension losswith approximately 20° of extension lossCrepitus may be present in the radiocapitellar Crepitus may be present in the radiocapitellar joint with active or passive forearm rotationjoint with active or passive forearm rotationMay also complain of locking & catching, which May also complain of locking & catching, which may indicate a loose bodymay indicate a loose body
Osteochondritis Dissecans of the Osteochondritis Dissecans of the CapitellumCapitellum
TreatmentTreatment
Orthopedic referral appropriate as is MRIOrthopedic referral appropriate as is MRI
Stop offending activities - typically throwing Stop offending activities - typically throwing (baseball) or handsprings (gymnastics) (baseball) or handsprings (gymnastics)
Rest elbow – consider splinting for a few weeksRest elbow – consider splinting for a few weeks
Treatment will depend on symptomsTreatment will depend on symptoms
Long term prognosis more guarded – may Long term prognosis more guarded – may require surgeryrequire surgery
Osteochondritis Dissecans of the Osteochondritis Dissecans of the CapitellumCapitellum
Surgical indicationsSurgical indicationsSymptomatic loose bodies Symptomatic loose bodies Articular cartilage fracture Articular cartilage fracture Displacement of the osteochondral lesion Displacement of the osteochondral lesion
Surgical management of OCD lesionsSurgical management of OCD lesionsExcision of loose bodies or partially attached lesions Excision of loose bodies or partially attached lesions Abrasion chondroplasty or subchondral drilling. Abrasion chondroplasty or subchondral drilling. Results of internal fixation of the loose fragment varyResults of internal fixation of the loose fragment varyNew techniques to harvest cartilage from the knee and New techniques to harvest cartilage from the knee and transplant into the elbow promisingtransplant into the elbow promising
Distal Biceps RuptureDistal Biceps Rupture
Usually dominant extremityUsually dominant extremity
Male (often weight lifters) Steroids?!?Male (often weight lifters) Steroids?!?
Mean age of 50 (reported 18 to 72)Mean age of 50 (reported 18 to 72)
Biceps Rupture - MechanismBiceps Rupture - Mechanism
Often a single traumatic eventOften a single traumatic event
Unexpected eccentric extension force Unexpected eccentric extension force applied to an arm at 90 degrees of applied to an arm at 90 degrees of flexionflexion
“Popeye” muscle
Rupture of Distal Biceps Rupture of Distal Biceps TendonTendon
AROM/PROM may be WNL but RROM AROM/PROM may be WNL but RROM limited due to pain with elbow flexion and limited due to pain with elbow flexion and forearm supinationforearm supination
Almost always treated surgically followed Almost always treated surgically followed by progressive ROM and strengthening by progressive ROM and strengthening programprogram
Olecranon BursitisOlecranon Bursitis
Typically due to direct Typically due to direct traumatraumaUsually easily treated Usually easily treated with rest, modalities with rest, modalities compression, and compression, and NSAIDsNSAIDsIf persists, may be If persists, may be aspirated – risk of aspirated – risk of infectioninfection
Neurologic InjuryNeurologic Injury
Ulnar nerveUlnar nerve At elbow (cubital tunnel) or wristAt elbow (cubital tunnel) or wrist
Median nerveMedian nerve At elbow or wrist (carpal tunnel)At elbow or wrist (carpal tunnel)
Radial nerveRadial nerve Least involved with overuseLeast involved with overuse
Sensory ExaminationSensory Examination
RadialRadial First dorsal webspace of handFirst dorsal webspace of hand
UlnarUlnar Pad of pinky fingerPad of pinky finger
MedianMedian Pad of index fingerPad of index finger
Tinnel’s TestTinnel’s Test
Gentle percussion of the ulnar nerve Gentle percussion of the ulnar nerve above or within the cubital tunnel above or within the cubital tunnel should not elicit pain in the normal should not elicit pain in the normal elbowelbow Pain or paresthesias into the ring and Pain or paresthesias into the ring and
small fingers with tapping over the small fingers with tapping over the ulnar nerve in the cubital tunnel is ulnar nerve in the cubital tunnel is considered a positive testconsidered a positive test
Elbow DislocationsElbow Dislocations
Typically results from hyperextension, trochlea Typically results from hyperextension, trochlea levered over coronoid processlevered over coronoid process
Vast majority are posterior with most common Vast majority are posterior with most common direction being posterolateraldirection being posterolateral
Involve injury to most ligamentous structures, Involve injury to most ligamentous structures, and potential for injury to neurovascular and potential for injury to neurovascular structures – if stable post-reduction, treat structures – if stable post-reduction, treat conservatively and if unstable, treat surgicallyconservatively and if unstable, treat surgically
Posterior Elbow DislocationPosterior Elbow Dislocation
FracturesFractures
HumerusHumerus
RadiusRadius
UlnaUlna
Humerus FracturesHumerus Fractures
Supracondylar Supracondylar fracturefracture
Supracondylar Supracondylar fracture with posterior fracture with posterior elbow dislocationelbow dislocation
Humerus FracturesHumerus Fractures
Most common in Most common in children/adolescents from children/adolescents from fall on flexed elbow or fall on flexed elbow or hyperextension hyperextension mechanismmechanismDeformity present if Deformity present if displaced, often missed displaced, often missed on initial evaluation if on initial evaluation if nondisplacednondisplacedOften requires surgery if Often requires surgery if displaceddisplaced
Ulnar FracturesUlnar Fractures
Olecranon process Olecranon process fracturesfractures If stable/nondisplaced, If stable/nondisplaced,
short immobiliazation short immobiliazation period (45-90 degrees period (45-90 degrees of flexion)of flexion)
If displaced, ORIF with If displaced, ORIF with longer immobilization longer immobilization period and early ROM period and early ROM if toleratedif tolerated
Radial FracturesRadial Fractures
Radial head Radial head fracturefracture
Radial neck Radial neck fracturefracture
Most treated non Most treated non operativelyoperatively
Thank you!!!Thank you!!!