Musculosekeltal Diseases and Disorders: Elbow and Forearm
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Transcript of Musculosekeltal Diseases and Disorders: Elbow and Forearm
Musculosekeltal Diseases and Disorders: Elbow and Forearm
PTP 521
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Anteroposterior view: A
• Alignment:– Identify the structures
from a proximal to distal view
– Radial head should be aligned with the capitulum but not directly in contact with it
– Olecranon should be centered in the olecranon fossa
– Carrying angle should be noted and be ~ 15 dg.
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Abnormal Anteroposterior View
• This view will demonstrate the following pathologies, if present:
• Fractures of the distal humerus – supra, trans, and intercondylar
• Fractures of the medial and lateral epicondyles
• Fractures of the capitulum, trochlea and lateral aspect of radial head
• Varus and Valgus deformities
• Secondary ossification centers of the distal humerus
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Anteroposterior view: B
• Bone Density: pay particular attention to the radial head for any chips/fractures– Look for Trabecular lines
• Pay attention to the medial and lateral epicondyles for any lucencies or breaks in the margins
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Ossification Centers• 6 ossification centers around the
elbow joint.
• Mnemonic C-R-I-T-O-E (Capitulum - Radius - Internal or medial epicondyle - Trochlea - Olecranon - External or lateral epicondyle).
• The ages at which these ossification centers appear are highly variable and differ between individuals.
• As a general guide you could remember 1-3-5-7-9-11 years.
– None should be open at age 13.
www.radiologyassistant.nl/en/4214416a75d87
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C and S• Cartilage:
– Evaluated with an MRI, joint space is noted with the radial head and capitulum only
• Soft Tissue: not seen well on an AP view
• Fat Pad Sign (Sail Sign): evidence of swelling or bleeding anterior to the elbow
emedicine.medscape.com/article/389069-imaging
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Lateral View of the Forearm
• Identify: trochlea, capitulum, radial head, coronoid process.
• Alignment:– Line drawn through
center of humeral shaft should intersect line through shaft of radius and be ~ 90 dg.
Anterior humeral line
Radiocapitulum line
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Radiocapitulum line:
• Unless there is a dislocation of the radius, a line drawn through the center of the radius, should ALWAYS pass through the center of the capitulum.
• Bottom right: dislocation
http://www.radiologyassistant.nl/en/4214416a75d87
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Anterior Humeral Line
• Line drawn along the anterior surface of the humerus, in a lateral view, should pass through the middle third of the capitulum
http://www.radiologyassistant.nl/en/4214416a75d87
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Abnormal Lateral View
• The lateral view will demonstrate the following pathologies, if present:
• Supracondylar fractures of distal humerus
• Fractures of anterior radial head and olecranon
• Complex dislocations of the elbow joint
• Dislocation of the radial head
• pad sign (sail sign)
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Lateral View
• Bone Density: view the radial head, trabecular lines
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• Cartilage:– Able to see a joint space
between the radius and the capitulum
– Trochlea and the coronoid process
• Soft Tissue:– May or may not be seen
in this view– Evaluate for changes in
density of the tissue which may indicate swelling
– Fat pad sign (Sail sign) can be seen in this view as well
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External Oblique View• Radiohumeral joint (long
white arrow)• Capitulum, radial head (yellow
arrow)• Radial neck (orange arrow)• Radial tuberosity, coronoid
process (dark blue arrowhead)• Trochlea notch/trochlea
articulation (light blue arrowheads)
• Proximal radioulnar articulation
http://www.ceessentials.net/article29.html
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Abnormal
• The External Oblique view will demonstrate the following pathologies, if present:
• Fractures of radial head and lateral epicondyle
s614.photobucket.com/albums/tt228/ex_cowboy/?...
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Internal Oblique
• This view is taken to demonstrate the coronoid process, trochlea notch, and medial trochlea
• Forearm is pronated ~ 45 dg
• Abnormal: will demonstrate fractures of the medial epicondyle and the coronoid process
http://www.ceessentials.net/article29.html
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Radial Head/Capitulum or Trauma View
• Trauma View is when the radius is completely on top of the ulna, not overlapped.
• Humeroradial joint (white arrow)
• Radial head (dark blue arrow)
• Capitulum (orange arrow) radial notch of the ulnar and radioulnar joint (yellow arrow)
• Neck of the radius (light blue arrow)
http://www.ceessentials.net/article29.html
Look at this view and evaluate the difference between the lateral view and the trauma lateral view - Its in the radial head position
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Radial Head /Capitulum Trauma View
• The trauma view will demonstrate the following– Fractures of radial head,
capitulum and coronoid process
– Abnormalities of the humeroradial and humeroulnar joints
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CT Imaging
• Utilized to determine the following abnormal pathology:
• Complex fractures around the elbow, particularly comminuted fractures
• Healing process
• Non union of bones
• Secondary infections
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CT Imaging of the Elbow
• MRI seems to replace a lot of CT imaging because of the soft tissue around the elbow
• These images are of a trochlear fracture (sorry, I couldn’t get better resolution)
www.jortho.org/2008/5/3/e5/index.htm
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• These two CT images demonstrate the radioulnar articulation.
• On the left is a coronal image of the elbow showing the radioulnar joint (A) and on the right the head of the humerus (C) and ulna (B) that form the joint. www.ceessentials.net/article29.html
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• On the left is a sagittal cut through the elbow
• On the right a coronal cut through the elbow.
• Both pictures demonstrate the humeroradial joint formed by the capitulum of the humerus (A) and the head of the radius (B).
• Reconstructions from axial datawww.ceessentials.net/article29.html
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• Humeroradial Joint
• 3D volume rendered image demonstrating the humeroradial joint (A).
• The sagittal CT image demonstrates this articulation formed by the articulation (B) fovea of the head of the radius, and (C) capitulum of the humerus. www.ceessentials.net/article29.html
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Can you name the anatomy?(Don’t click until you are ready to answer)
A = cornoid process, ulnaB = coronoid fossa, humerus
C = olecranon processD = olecranon fossa
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Midsagittal plane CT• Demonstrates the positions of
the anterior (B) and posterior (A) fat pads.
• If these fat pads are elevated following trauma, it may indicate intra-articular hemorrhage secondary to fracture of the radial head or neck.
• Sail sign as seen on the radiographs.
www.ceessentials.net/article29.html
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MRI Imaging
• Demonstrates the following pathology:– Abnormalities of the
ligaments, tendons and muscles
• Lateral epicondylitis• Bicipital tendonitis• Ulnar collateral ligament
injury• Radial collateral ligament
injury
– Bone Contusion– Capsular ruptures– Joint effusions– Synovial Cysts– Hematomas– Osteochondritis
Dissecans– Epiphyseal fractures in
children
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MRI Imaging
• Axial view, T1 weighted– Humerus– Ulna– Tendons– Ligaments – image black– Nerves– Vascular– Muscles
lateral medial
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Axial View
• What is the anatomy of 1-5?
• 1= Biceps Brachii• 2= Brachialis• 3= Brachial artery• 4= Humerus• 5= Triceps
http://anatomy.med.umich.edu/radiology/xray/arm_mri_zoom.html
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• CFT: common flexor tendon
• CET: common extensor tendon
• RCL: radial collateral ligament
• UCL: ulnar collateral ligament
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CORMPGR
• Coronal Plane• Sequence: MPGR
(Multiplanar Gradient Recalled) This is an echo pulsed sequence
• This image demonstrates the humerus, ulna, radius is not in the picture just yet
• Radial collateral lig• Ulnar collateral lig
medial
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CORPD
• Coronal View• Proton Density
• Here you can see the radius as well as the ulna, humerus, olecranon
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US Imaging
• Normal anterior elbow appearance at the humeroradial joint (wide short arrow) with the fat pad at the radial fossa demonstrated (thin arrow).
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• Normal distal biceps tendon (arrows) with insertion deep to vein (longitudinal)
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• Normal lateral common extensor tendon origin (arrows) with normal hyper- echogenicity of the longitudinal tendon
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• Normal medial epicondyle, common flexor tendon origin (large arrows on hyperechoic longitudinal tendon ) and ulnar collateral ligament (small arrows on hypoechoic ligament).
www.gehealthcare.com/.../products/cme_msk.html
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• Normal ulnar nerve at the joint in longitudinal (left) and transverse (right) planes (arrows).
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Musculoskeletal Injury
Bone
Fractures
Arthritic Disorders
BruiseOther
Muscle
Strain and Inflammation
Rupture
Trigger Points
Tendon
tendonosis
strain
Nerve
Entrapment
Ligament
Sprain and Inflammation
Rupture
Capsule and Joint
Arthritis: OA and RA
Osteochondrosis
Dislocations
Other - Bursitis
Systems that refer pain to area
Other joints that refer pain to area
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Fractures: Musculoskeletal Practice Pattern 4G
Fractures of the Distal Humerus1. Suprachondylar fractures: extra-articular
• Most common fracture in children- 65%• Uncommon fracture in adults• Left arm more than right – protective response• 98% occur with arm extended and wrist
dorsiflexed• Possible neurovascular complications: ~22%
neuro and 10% vascular• Possible permanent impairment and deformity
McKinnis LN, 2005
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Gunstock Deformity
• Common complication of a suprachondylar fracture
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• SX: – purple discoloration of hand, – severe pain in forearm muscles initially– paresthesias as the dysfunction progresses
• Signs: – cool pale extremity with altered pulse – pain on passive stretch – swelling initially – numbness distal to the ischemic region
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2. Transcondylar: intracapsular but extraarticular fracture
• Common in elderly
3. Epicondylar Fractures: extra-articular
4. Condylar Fractures
McKinnis LN, 2005
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5. Intercondylar Fractures – T intercondylar, Y
Intercodylar Medial or Lateral Condyle
6. Intra-Articular Fractures– Compressive forces
across the elbow
McKinnis LN, 2005
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Volkmann's Ischemia
Compartment Syndrome • Prolonged ischemia of the forearm muscles
– muscle necrosis – replacement of tissue with fibrous tissue – severe deformities of the hand and wrist – paralysis of muscles. – Three stages: mild, moderate and severe
• Causes: – Arterial injury caused by an open laceration, – Arterial disruption secondary to a severely displaced
fracture or dislocation
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Fractures of the Radial Head: Mason Classification System
• Type I• Non-displaced fracture• Often missed on x-ray• Positive posterior fat pad
sign • RX: minimal
immobilization, early ROM
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Radial Head Fracture
• Type II• Displaced fracture• Separation or
angulations of the fracture fragment
• RX: ORIF, early motion
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Radial Head Fractures
• Type III• Comminuted fracture of
the entire head• Children ages 4-14• RX: ORIF and early
motion
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Radial Head Fractures
• Type IV• Comminuted fracture • Dislocation of the elbow• Usually cause some
functional limitation• RX: radial head
resection
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Fractures of the Coronoid Process
• RX:– Open reduction generally
necessary– Concern for elbow
instability
• Classified: Regan-Morrey– Type I: tip of coronoid– Type II: less than 50%
coronoid tip– Type III: more than 50%
of the coronoid
boneandspine.com/wp-content/uploads/2009/02/c...
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Fractures of the Olecranon
• MOI: fall onto the flexed elbow
• MOI: Boxer’s elbow: avulsion fracture of the olecranon
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Monteggia Fracture
• Dislocation of radial head – most common lateral or anterolateral, posterior rare
• Fracture of ulnar metaphysis or diaphysis
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Badu Classification of Monteggia FracturesType Description Frequency, % 3
I Fracture of the middle or proximal third of the ulna and anterior dislocation of the radial head
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II Fracture of the middle or proximal third of the ulna and posterior dislocation of the radial head
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III Ulnar fracture distal to the coronoid process with lateral radial head dislocation
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IV Fracture of the proximal or middle third of the ulna with an anterior dislocation of the radial head and fracture of the proximal third of the radius
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Resnick D. Physical injury: extraspinal sites. In: Diagnosis of Bone and Joint Disorders. 3rd ed. 1992.
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Galeazzi Fracture
• Fracture of distal shaft of radius
• Dislocation of distal radial ulnar joint
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Muscle and Tendon Dysfunctions
• Overuse Injuries– 1. Risk Factors: Intrinsic and Extrinsic– 2. Types: Lateral epicondylitis, Medial epicondylitis, Triceps tendonitis, Bicipital Tendonitis, bursitis, ligamentous injuries
• Trauma
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Soft Tissue Injuries of the Elbow
• Lateral Epicondylitis
• Medial Epicondylitis
• Triceps Tendonitis
• Biceps Strain
• Myositis Ossificans
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Lateral Epicondylitis
• Adults 35 years or older: occupation or hobby involves repetitive extension of the wrist i.e. carpenter, electrician, tennis, baseball, or golf
• Etiology: unknown: cumulative trauma causes inflammatory process at ECRB origin
• Differential Diagnosis: Posterior Interosseous Syndrome and C6-7, T 4 syndromes
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SX of Lateral Epicondylitis:
• Gradual onset• Pain over lateral epicondyle• Pain associated with gripping• May have some shoulder, neck pain associated
with it
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Signs of Lateral Epicondylitis:• ROM: full, passive movement into extension, may be
painful at end range• Limited wrist flexion combined with finger flexion at
end range• Strength: painful resisted wrist extension and radial
deviation• Joint Play: full and pain free• Palpation: tender over the lateral epicondyle• Special tests: + Cozens test, + Mill’s test, - Middle
Digit Extenstion Test
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Medial Epicondylitis
• Golfer’s elbow• Symptoms
– Pain on medial side of elbow– Involved in repetitive flexion activities of wrist
finger flexion and active pronation
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Signs of Medial Epicondylitis:
• Palpation: direct over the medial epicondyle• Resisted movement: resisted flexion of the
fingers increases pain but is strong, may have a loss of strength with gripping activities
• Observation: swelling/erythema on medial aspect
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Triceps Tendonitis:
1) Onset: sudden, severe strain as the arm is fully extended or with a sudden snapping of the elbow into extension
2) Signs: pain with resisted elbow extension – may be strong
or weak pain with PROM of elbow flexion and shoulder
flexion – passive stretch of the muscle
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Biceps Muscle Strain:
1) Onset: athletic activity, – very strong elbow flexion force – hyperextension force leading to elongation and
stretch. • need to be aware of possible anterior posterior joint
capsule impingement.
– Biceps rupture: may have a history of repeated corticosteroid injections
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2) SX: depends on the degree of the strain 3) Signs: depends on the degree of the strain
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Myositis Ossificans• Common complication of
trauma to the elbow, muscle ossifies and can
bridge the elbow joint.
• Cause: contusion to the brachialis muscle from a posterior dislocation or a suprachondylar fracture.
• May also be caused by too vigorous stretching after an injury and elbow immobilization
• SX: pain with elbow flexion and extension
• Signs: palpable area on muscle, warm to touch, bony end feel, limitation of range, + radiograph
www.uwec.edu
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Medial and Lateral Ligamentous structures of the elbow
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Posterolateral Rotary Instability
• MOI: – Rotational displacement
of the ulna– Radius subluxes or
dislocates posterior
• Forces: : axial compression, external rotation and valgus (lateral to medial) force
• Sx: catching, clicking and locking
• Pain• Apprehension with
elbow supinated and fully extended
• Signs: lateral pivot-shift is most sensitive
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• Three stages– Stage I: Lateral Ulnar
Collateral Ligament disruption
• Stage II:– Anterior and posterior
disruption– Perched dislocation
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• Stage III:– III A: all soft tissue
except Ulnar collateral lig (medial side) is disrupted
– III B: UCL disrupted
– III C: Entire distal humerus stripped of soft tissue
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Ligament Sprain
Medial (Ulnar) Collateral Ligament sprain (little league elbow): – Articular damage to the radiohumeral and ulnohumeral joint
with repeated stresses
– MOI: adolescent involved with overhead throwing activities. • FOOSH injury
– The compressive forces at the radiohumeral joint and distraction forces on the medial aspect of the elbow will overstretch and injure the ligament.
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Little League Elbow
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• Articular damage to the capitulum,
• Ligamentous instability of the medial elbow
• Tardy nerve palsy
– may see medial muscle hypertrophy.
– In adolescents whose growth plate has not yet ossified, it may cause on avulsion injury of the medial epicondyle.
– Complete ligamentous rupture is usually associated with acute trauma
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• Radiology: – Osteochondritis
Dissecans of the Capitulum
• Note fracture of the condlye on the ulnar aspect of the elbow
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• SX: pain/swelling on the medial aspect of the elbow
• Patient c/o pain with throwing or pushing motions
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Signs:
• Valgus instability with ligamentous stress test
• Tender with varus stress if the radiohumeral joint is involved
• Painful axial compression with the radius on the humeral
• Joint tender over the MCL ligament
• Severe cases will get locking of the elbow due to capitulum fragments
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Joint Dysfunctions of the Elbow
Dislocations
Osteoarthritis
RA
Osteochondritis Dessicans
http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=239&topcategory=Arm
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Elbow Dislocations
• MOI:– FOOSH– Direct Trauma– MVA
• Described by the direction the ulna and radius have been displaced relative to the humerus
• Most common types– Posterior or Posterolateral direction
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Perched Dislocation
• Not a true dislocation
• Subluxation of the joint
• Less ligamentous damage
• Humerus is PERCHED on top of the coronoid process of the ulna
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Posterior:
a. straight posterior
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b. posterolateral - c. posteromedial d. Divergent
What soft tissue structures may be involved with each one of these type of dislocations?
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Additional injuries to soft tissue
• Anterior capsule rupture• Radial collateral ligament damage• Brachial muscle injuries• Extensor tendon injuries• Radial head and neck fractures• Tear of brachial artery• Nerve injuries• Avulsion/entrapment of medial epicondyle
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Anterior Dislocation
• Rare 1-2% of the population
• Ulnar collateral ligament involved, what other structures?
• Fractures of radial head may occur
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Dislocations
• Physical Exam: gross deformity of the elbow
• Anatomical triangle is disrupted
• Elbow held in 45 dg flexion
• Forearm appears shorter (posterior) and olecranon is more prominent posterior boneandspine.com/.../10/dislocation-elbow.jpg
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Subluxations of the Radius
• Nursemaids Elbow– MOI: axial force on the arm– SX: pain, child will refuse to move the arm– Relocation, no immobilization needed
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Osteoarthritis of the Elbow
• Fill in signs and symptoms
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Rheumatoid Arthritis
http://uwmsk.org:8080/EvasMSKTF/stories/storyReader$509
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Elbow Replacement
http://www.orthop.washington.edu/uw/elbowreplacement/tabID__3376/ItemID__61/PageID__5/Articles/Default.aspx
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Osteochondritis Dissecans and osteochondrosis (Panner’s Disease) • Described by some as different stages, same entity
related to age of individual and direction and level of activity
• Controversy: Panners disease encompasses entire capitellum and occurs at a younger age (5-16)
• MOI: Vascular insufficiency from repetitious lateral compression at the humeroradial joint
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Panners Disease
• Younger child, no ossification of growth plates
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12- 15 year old: Osteochondritis Dissecans
• Leading cause of permanent disability to the young pitching athlete
• Repetitive lateral compression at the radiocapitellar joint during late cocking
• Loose body formation in joint
89http://www.physsportsmed.com/issues/1999/02_99/hall.htm
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Signs, Symptoms & Interventions
• SX: pain present over lateral and anterior elbow
• Pain increase with deep palpation, pronation and supination
• ROM: extension limited by 20 dg or more
• Intervention: Rest, gentle stretching
• NO loose bodies: may drill bone to restore vascular supply
• LOOSE bodies: may need arthroscopic surgery to remove the loose bodies
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Bursitis:
12 bursae about the elbow with 3 of clinical significance
1) Olecranon bursae allows smooth gliding of the skin on the triceps
Onset: traumatic, inflammatory (gout), prolonged pressure
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• Signs: painless swelling of the bursae on the posterior aspect of the elbow (goose egg)
• Nearly full AROM and PROM into elbow flexion secondary to compression of the bursae by the triceps
• Classic inflammatory responses with redness, temp. increases, edema, and pain
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2) Bicipital Radial Bursitis:• Bursae is between the radial tuberosity and the insertion of
the biceps tendon.
• Allows smooth gliding of the tendon on the bone. SX: pain in the antecubital fossa, radiating up the biceps tendon Signs: – palpation: deep at the radial tuberosity and insertion of the biceps
tendon– Resisted movements of elbow flexion and supination are painful
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3) Radiohumeral Bursitis:
• Deep to the common extensor tendons, attaches to the lateral epicondyle.
• Aids in the gliding of the extensor tendons over the radiocapitellar bones/ capsule of the elbow complex.
• Frequently is diagnosed as lateral epicondylitis with signs and symptoms similar to the lateral epicondylitis