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Elbow Injuries for the Primary Care Doc

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Presentation on theme: "Elbow Injuries for the Primary Care Doc"— Presentation transcript:

1 Elbow Injuries for the Primary Care Doc
Brian Badman M.D.

2 Disclosures: Consultant Smith and Nephew Endoscopy UpEX DJO Surgical
I have no conflicts with current talk or industry support

3 Basic Anatomy

4 Relevant Anatomy Humerus Ulna Radius

5 Distal Humerus Coronoid Fossa Medial Epicondyle Lateral Epicondyle
Trochlea Capitellum

6 Proximal Ulna Greater Sigmoid Notch Olecranon Process Lesser Sigmoid
Coronoid Process

7 Proximal Radius Head Neck Radial/Bicepital Tuberosity

8 Joints Humeroulnar joint and Humeroradial Flexion/extension
Radioulnar joint Supination/pronation

9 Muscles Around Elbow—Simple
Bicep Triceps Wrist flexors Wrist extensors


11 Wrist Flexors

12 Wrist Extensors

13 Forearm muscles Forearm flexorsmedial epicondyle
Forearm extensorslateral epicondyle

14 Flexors of the elbow Brachialis Biceps Brachioradialis

15 Extensors of the elbow Triceps brachii Long head Lateral head
Medial head

16 Elbow Pronator Pronator teres

17 Elbow Supinators Biceps brachii Supinator

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

19 Other structures Nerves Ulnar, radial, median

20 Palpable Landmarks Olecranon process Olecranon fossa
Medial and lateral epicondyles Radial head Cubital Tunnel—Ulnar N

21 Stability of Elbow Secondary Stabilizers Primary Stabilizers
Radiohumeral Joint Capsule Musculature (dynamic) Primary Stabilizers MCL 90°) Ulnohumeral Joint Coronoid50% Olecranon

22 Common Elbow Maladies

23 Soft Tissue

24 Olecranon Bursitis

25 Etiology Aseptic Direct blow or fallHemarthrosis Gout Septic
Insect Bite Cut/Abrasion Hematogenous

26 Signs & symptoms Pain Swelling Erythema/FebrileSeptic

27 Treatment Cold Compression Aspirate
If serous/bloodyInject 40mg steroid +compressive dressing+elbow extension x 3 days If pussRequires I+D (Ortho Consult) Recurrent aseptic bursitisSurgery

28 Elbow Sprains

29 Mechanism Hyperextension or a force that bends or twists the lower arm outward Valgus stress

30 Signs & Symptoms Pain Inability to throw or grasp an object
POT (usually over UCL)

31 Treatment Ice Compression Sling for support @ 90 degrees
Progress to full ROM and strength

32 Lateral Epicondylitis A.K.A “Tennis Elbow”

33 Epidemiology 4th -5th Decade M=F
Repetitive wrist extension +forearm pronation/supination 10-50% tennis players will develop ECRB Tendon primarily involved #2=EDC

34 Histology Angiofibroblastic hyperplasia No acute inflammation
Likely begins as microtear

35 Physical Examination TTP anterior/distal LE
Pain worse w/ resistive wrist/finger extension

36 Imaging Typically clinical diagnosis and not initially necessary
Consider plain XR for recalcitrant Look for calcification MRIConcern for intraarticular pathology

37 Treatment Acute (<4wks) Rest NSAIDS PT Massage U/S
Counterforce Bracing

38 Treatment (cont’d) Rehab ROM exercises stretching PRE’s strengthening
Hand grasping while in supination Avoid pronation movements

39 Treatment Chronic (>4wks) Steroid injection
40mg kenalogue +1/2 cc lidocaine

40 Surgery /Referral Must fail 6-12 months conservative mgt
85-90% Effective—Nirschl JBJS 1979

41 Platelet Rich Plasma Autologous Blood
Centrifuge to separate layers and concentrate platelets Growth FactorsMay potentiate/stimulate healing May stimulate Type 1 collagen formation Kajikawa J Cell Physiol 2008


43 PRP Cont. Expensive $200-600 Not covered by insurance
Early results poor study quality with research bias (financial incentive)

44 PRP Peer Reviewed Level 1 Evidence
Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Am J Sports Med Mar 21. Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-Year Follow-Up. 100 patients49 cortisone/51 PRP PRP group with significant improvement regarding pain c/w steroid group at 2 years

45 Medial epicondylitis

46 A.K.A. Pitcher’s elbow Racquetball elbow Golfer’s elbow
Javelin-thrower’s elbow

47 Epidemiology Less common 4th-5th decade M=F

48 Mechanism Repeated forceful forearm flexion Excessive throwing
Microtear of FCR/Pronator Teres

49 Physical Examination TTP at medial epicondyle
Worse w/ wrist flexion or forearm pronation Weak Grip May be associated with ulnar neuritis TTP ulnar nerve +Tinnels thru cubital tunnel

50 Treatment Conservative management NSAIDS
PT—Massage/US/strengthening/ROM Counterforce Brace Steroid Injection Consider EMG if associated with ulnar nerve sxs Surgical Referral—Failure of 6-12 months

51 Distal Bicep Rupture

52 Epidemiology Male predominated injury 50-60yo Dominant arm
Traumatic event of elbow flexion against resistance Often times described as audible pop/”gunshot”

53 Physical Examination Tenderness/bruising antecubital fossa
Pain to resisted bicep flexion and forearm supination Hook TestAble to hook tendon from lateral side with flexion

54 Imaging: Clinical Exam typically confirms If not obviousMRI
Helps evaluate partial tears and extent of partial tearing

55 Management Typically recommend surgical repairOrtho referral
4-6 mo recovery Retear <2% Nonoperative management 40% loss flexion strength 50% loss supination power


57 Cubital Tunnel Syndrome
Ulnar N compression thru medial elbow 2nd most common compressive neuropathy UE 30-60yo DDx: C8/T1 cervical compression Pancoast Tumor

58 Physical Examination Check neck and axilla
Spurling’s sign Axillary mass/tinnels Tinnel’s thru cubital tunnel Direct compression Test Numbness to RF/SF Semmes-Weinstein Monofilament Intrinsic Weakness Adductor Pollicis 1st Dorsal Interosseus

59 Special Tests Fromment’s sign
Weakness of Adductor Pollicus compensated by FPL IP flexion with lateral pinch FOX vs. RABBIT Jeanne’s signMP hyperextension w/ IP flexion

60 Management CONSIDER EMG TO DOCUMENT SEVERITY Severe Mild to Moderate
Persistant Pain Atrophy  Surgical Referral Mild to Moderate Night splinting Avoids elbow hyperflexion Heelbo NSAIDS Steroid Injection Work Ergonomic Modification

61 Bones

62 Dislocation of Elbow

63 Mechanism of injury Second most frequent joint dislocation
Fall on extended elbow with outstretched hand Majority posterior/posterolateral (90-95%)




67 Signs & Symptoms Ulna and/or radius displaced posteriorly, w/ olecranon process sitting posteriorly Severe swelling/bleeding Extreme pain

68 Classification Simple No fracturepurely ligamentous Complex
Associated with fracture Radial Headmost common fx

69 Treatment Immobilize in position you find it Send to ER Radiographs


71 Treatment—Simple Closed Reduction Long arm splint/cast x 2 weeks
Progressive ROM Protect terminal extension x 6wks Major ComplicationExtension Loss

72 Reduction Maneuver Gentle traction
Anterior directed force on olecranon Gradual flexion


74 Treatment--Complex Splint in situNo reduction
Exception: NV compromise Ortho ReferralSurgery

75 Radial Head Fractures Most Common Adult elbow fracture MechanismFOOSH
PE: Pain/Effusion Elbow Commonly associated with wrist pain Pain with forearm rotation Check for mechanical click

76 Radial Head Fractures Radiographs Can be subtle Look for fat pad sign

77 Mason Classification INondisplaced
II<30% head and >2mm displacement IIIComminuted

78 Treatment IIDebatable INonoperative Ortho Referral Sling for comfort
ROM 3-4 days Possible Aspiration Hematoma Repeat XR 2wks Complication Extension/Supination Loss Inject Joint 3months IIDebatable Ortho Referral No Mechanical Sx Conservative Early ROM Close XR F/U Mechanical Sx Possible SURGERY ORIF

79 Treatment--Continued

80 Thank You Terre Haute Medical Community!!!

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