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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Upper Arm, Elbow, and Forearm Conditions Chapter 15.

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Presentation on theme: "Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Upper Arm, Elbow, and Forearm Conditions Chapter 15."— Presentation transcript:

1 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Upper Arm, Elbow, and Forearm Conditions Chapter 15

2 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy

3 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy 3 articulations (single capsule) –Humeroulnar (elbow joint) Trochlea of humerus with trochlear fossa of ulna Hinge joint; flexion and extension Close-packed position – extension –Humeroradial Capitellum of humerus with proximal radius Gliding joint Lateral to humeroulnar joint Close-packed position – elbow 90°; forearm supinated 5°

4 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) –Proximal radioulnar Head of radius with radial notch of ulna; joined by annular ligament Pivot joint  Radius rolls medially and laterally over the ulna; pronation and supination Close-packed position – supination 5°

5 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Carrying angle –Angle between humerus and ulna (arm in anatomic position) –10-15° angle –Greater in females

6 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Ligaments –Ulnar (medial) collateral –Radial (lateral) collateral –Annular –Accessory lateral collateral

7 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Bursae –Several small –Olecranon bursa Superficial

8 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.)

9 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.)

10 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Nerves –Musculocutaneous –Median –Ulnar –Radial

11 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Blood vessels –Brachial Ulnar and radial

12 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics Movements –Flexion and extension Humeroulnar joint and humeroradial joint –Supination and pronation Proximal radioulnar

13 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics (cont.) Muscles –Flexors Brachialis; biceps; brachioradialis Effectiveness depends on supination/pronation position –Extensors Triceps; anconeus –Pronation and supination Pronator quadratus; pronator teres supinator; biceps

14 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinetics Non–weight bearing but still sustains significant loads Extremely large muscle forces generated with forceful throwing motions, weight lifting, and many resistance training exercises Extensor moment arm < flexor moment arm –Extensors must generate more force than flexors to produce same amount of joint torque

15 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Injury Prevention Protective equipment –Pads –Braces Physical conditioning –Flexibility and strength –Focus on entire arm Proper skill technique –Throwing –Falling

16 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions Susceptible due to: –Lack of padding –General vulnerability S&S –Rapid swelling – can limit ROM Chronic blows –Development of ectopic bone Myositis ossificans – brachialis belly; proximal deltoid insertion Tackler’s exostosis –Painful periostitis and fibrositis may develop Management: standard acute; NSAIDs

17 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Olecranon Bursitis Acute and chronic –Mechanism Fall on a flexed elbow Constantly leaning on elbow Repetitive pressure and friction

18 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Olecranon Bursitis (cont.) –S&S Tender, swollen, relatively painless Rupture – goose egg visible 50% history of abrupt onset; 50% insidious onset over a few weeks Motion limited at extreme of flexion – tension increases over bursa –Management: standard acute; NSAIDs; possible aspiration

19 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Olecranon Bursitis (cont.) Septic bursitis –Related to seeding from infection at a distant site –S&S Traditional signs of infection (within 1 week of symptoms) Skin lesion overlying bursa – 50% of cases Bursal tenderness – 92-100% of cases Peribursal cellulitis – 40-100% of cases

20 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Olecranon Bursitis (cont.) Nonseptic –Caused by crystalline deposition disease or rheumatoid involvement –Associated with atopic dermatitis –S&S Skin lesion – 5% of cases Bursal tenderness – 45% of cases Cellulitis – 25% of cases Management: physician referral

21 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprain Mechanism –Fall on extended hand (hyperextension injury) –Valgus or varus force –More common; repetitive forces irritate and tear ligaments, especially UCL Ulnar nerve may also be affected S&S –Localized pain –Point tenderness –Instability with stress test Management: standard acute

22 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anterior Capsulitis Anterior joint pain caused by hyperextension S&S –Diffuse, anterior elbow pain after a traumatic episode –Deep tenderness on palpation (especially anteromedial) Need to rule out pronator teres strain and median nerve entrapment Management: immobilization for 3-5 days followed by AROM exercises as pain allows

23 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Dislocation Proximal radial head –Adolescents: often associated with immature annular ligament –Due to: longitudinal traction of an extended and pronated upper extremity –Inability to pronate and supinate pain free warrants immediate physician referral –Immobilization for 3-6 weeks in flexion is usually necessary

24 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Dislocation (cont.) Ulnar dislocation –Younger than 20 years old –Mechanism: Hyperextension Sudden, violent unidirectional valgus force drives ulna posterior or posterolateral –Associated conditions

25 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Dislocation (cont.)

26 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Dislocation (cont.) –S&S Snapping or cracking sensation Severe pain, rapid swelling Total loss of function Obvious deformity Arm held in flexion, with forearm appearing shortened Olecranon and radial head palpable posteriorly Slight indentation in triceps visible just proximal to olecranon Nerve palsy –Management: immediate immobilization in vacuum splint; activation of EMS

27 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains Flexors and pronator teres –Repetitive tensile stresses Extensor –Decelerating type injury S&S –Typical muscle strain S&S –Self-limiting Management: standard acute

28 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Biceps Brachii Rupture Mechanism: sudden eccentric load S&S –Tenderness, swelling, and ecchymosis in antecubital fossa –Weakness in supination and flexion –Distal tendon not palpable Management: standard acute; immediate physician referral Nonoperative vs. surgical repair

29 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Triceps Brachii Rupture Mechanism: –Direct blow to posterior elbow –Uncoordinated triceps contraction during a fall 80% involve olecranon avulsion fracture

30 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Triceps Brachii Rupture (cont.) S&S –Pain and swelling in distal attachment –Palpable defect in the triceps tendon or a step- off deformity of the olecranon –Active extension weak – partial tear; nonexistent – total rupture Management: standard acute; immobilize in sling; immediate physician referral

31 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Compartment Syndrome Anterior – wrist and finger flexors posterior – wrist and finger extensors Condition often secondary to other injuries Potential for neurovascular compromise

32 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Compartment Syndrome (cont.) S&S –Rapid onset –Swelling; discoloration –Absent or diminished distal pulse –Subsequent onset of sensory changes and paralysis –Severe pain at rest, aggravated by passive stretching of muscles in involved compartment Management: immobilization; ice and elevation; NO compression; immediate physician referral

33 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions Medial epicondylitis –Due to repeated valgus forces during acceleration phase of throwing motion –Commonly involved tendons: pronator teres and flexor carpi radialis

34 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont.) –S&S Swelling, ecchymosis, and point tenderness at humeroulnar joint or over the flexor/pronator origin Severe pain; aggravated by:  Resisted wrist flexion and pronation  Valgus stress applied at 15-20° of elbow flexion Ulnar nerve involved – tingling and numbness –Management: ice; NSAIDs; sling immobilization for 2-3 weeks with wrist in slight flexion; therapeutic exercise

35 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont.) Lateral epicondylitis –Due to eccentric loading of extensor muscles (especially extensor carpi radialis brevis) during deceleration phase of throwing motion or tennis stroke –Contributing factors

36 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont.) –S&S Pain anterior or just distal to lateral epicondyle; may radiate into forearm extensors during and after activity Repetition produces pain that becomes more severe and ↑ with resisted wrist extension + “coffee cup” test + tennis elbow test –Management: ice; NSAIDs; rest; support

37 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont.)

38 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont.) Neural entrapment –Ulnar nerve Vulnerable to compression and tension S&S  Shocking sensation (medial elbow), radiating as if “hitting their crazy bone.”  + Tinel sign – ulnar groove (tingling and numbness of medial forearm into ring and little finger)  Pain not present, ROM is not limited  Grip strength may be weak

39 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont.)

40 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont.) –Median nerve Compression Involvement of pronator teres – pronator syndrome S&S  Pain in anterior proximal forearm, and aggravated with pronation  Numbness in anterior forearm, middle and index fingers, and thumb

41 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont.) –Radial nerve S&S  Aching lateral elbow pain, radiates down posterior forearm  Significant point tenderness over supinator muscle  Resisted supination more painful than wrist extension  Extreme cases: wrist drop –Management of neural entrapment: immediate physician referral

42 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures Epiphyseal and avulsion fractures –Medial epicondyle growth plate sensitive to tension stress Repetitive or sudden contraction of the flexor-pronator muscle group → partial or complete avulsion fracture of the medial epicondyle (little league elbow)

43 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) –S&S Initial phase – aching during performance, but no limitations of performance or residual pain Progression – aching pain during activity limits performance, and a mild postexercise ache Localized tenderness –Management Initial phase: standard acute; activity modification Performance limitations – physician referral

44 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Stress fractures –Ulna diaphysis – intensive weight lifting –Bilateral distal radius and ulna – young individuals who lift heavy weights Osteochondritis dissecans –Complication of repetitive stress to skeletally immature elbow –Lateral compressive forces during throwing motion damage radial head, capitellum, or both

45 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) –S&S Pain with activity, improves with rest Occasional clicking or locking of elbow Swelling and tenderness over radiocapitellar joint Grating during passive pronation and supination Limited full extension Management: physician referral

46 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Supracondylar fractures –Fall on outstretched hand Volkmann’s contracture:  Complication from supracondylar fractures  Ischemic necrosis of forearm muscles  Damage to brachial artery or median nerve from fractured bone ends

47 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Olecranon –Direct blow –Triceps tension pulls bone fragment superiorly –Intra-articular fracture – does not respond to conservative treatment, requires surgical intervention

48 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Radial head –Valgus stress tears UCL → compression and shearing on radial head –S&S Swelling lateral to the olecranon Point tenderness radial head Flexion and extension may or may not be limited; passive pronation and supination is painful and restricted Possible associated valgus instability of the elbow or axial instability of the forearm

49 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Ulna (forearm fracture) –Direct blow –Also known as “nightstick” fracture

50 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Fracture management –Neurologic and circulatory assessment Radial nerve damage  Weak forearm supination; elbow, wrist, or fingers extension  Sensory changes – dorsum of hand

51 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont.) Median nerve  Weak wrist and finger flexion  Sensory changes – palm of hand Ulnar nerve  Weak ulnar deviation and finger abduction/adduction; sensory changes – ulnar border of the hand –Assess pulse at wrist or assess capillary refill –Apply vacuum splint; transport immediately to nearest medical facility

52 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment History Observation/inspection –Carrying angle –Position of function Palpation Physical examination tests

53 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Range of Motion (ROM) Active range of motion (AROM) –Elbow Flexion/extension Pronation/supination –Wrist Flexion/extension Passive range of motion (PROM) –Elbow flexion – tissue approximation –Elbow extension – bone to bone –Supination and pronation – tissue stretch

54 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) Normal ranges –Elbow flexion: 140-150° –Elbow extension: 0-10° –Supination: 90° –Pronation: 90° –Wrist flexion: 80-90° –Wrist extension: 70-90°

55 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.)

56 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) Resisted range of motion (RROM) –Elbow flexion –Elbow extension –Supination –Pronation –Wrist flexion –Wrist extension

57 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.)

58 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Stress Tests Ligamentous instability –Valgus stress –Varus stress –Perform at multiple angles (full extension → 20-30° flexion)

59 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests Common extensor tendinitis (lateral epicondylitis) –Resisted extension and radial deviation of wrist –Passive stretching of wrist extensors –Resisted extension of extensor digitorum communis in middle finger with wrist extended

60 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Medial epicondylitis Tinel’s sign for ulnar neuritis Elbow flexion for ulnar neuritis Pronator teres syndrome

61 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Tests (cont.) Pinch grip test

62 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests Myotomes –Scapular elevation – C4 –Shoulder abduction – C5 –Elbow flexion and/or wrist extension – C6 –Elbow extension and/or wrist flexion – C7 –Thumb extension and/or ulnar deviation – C8 –Abduction and/or adduction of fingers – T1

63 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) Reflexes –Biceps – C5-C6 –Brachioradialis – C6 –Triceps – C7

64 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) Dermatomes

65 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) Cutaneous patterns

66 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Rehabilitation Restoration of motion –Use of opposite hand to supply load –UBE

67 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Rehabilitation (cont.) Restoration of proprioception and balance –Closed-chain exercises Muscular strength, endurance, and power –Open-chain exercises –PNF-resisted exercises Cardiovascular fitness


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