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

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Presentation on theme: "Elbow Injuries for the Primary Care Doc Brian Badman M.D."— Presentation transcript:

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

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

3 Basic Anatomy

4 Relevant Anatomy Humerus Humerus Ulna Ulna Radius Radius

5 Distal Humerus Medial Epicondyle Lateral Epicondyle Trochlea Capitellum Coronoid Fossa

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

7 Proximal Radius Head Neck Radial/Bicepital Tuberosity

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

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

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11 Wrist Flexors

12 Wrist Extensors

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

14 Flexors of the elbow Brachialis Brachialis Biceps Biceps Brachioradialis Brachioradialis

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

16 Elbow Pronator Pronator teres Pronator teres

17 Elbow Supinators Biceps brachii Biceps brachii Supinator Supinator

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

19 Other structures Nerves Nerves  Ulnar, radial, median

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

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

22 Common Elbow Maladies

23 Soft Tissue

24 Olecranon Bursitis

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

26 Signs & symptoms Pain Pain Swelling Swelling Erythema/Febrile  Septic Erythema/Febrile  Septic

27 Treatment Cold Cold Compression Compression Aspirate 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 Recurrent aseptic bursitis  Surgery

28 Elbow Sprains

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

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

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

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

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

34 Histology Angiofibroblastic hyperplasia No acute inflammation Likely begins as microtear

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

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

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

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

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

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

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

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

44 PRP Peer Reviewed Level 1 Evidence Gosens TGosens 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. Peerbooms JCvan Laar Wden Oudsten BL Gosens TPeerbooms JCvan Laar Wden Oudsten BL  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 Pitcher’s elbow Racquetball elbow Racquetball elbow Golfer’s elbow Golfer’s elbow Javelin-thrower’s elbow Javelin-thrower’s elbow

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

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

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

50 Treatment Conservative management 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 Surgical Referral—Failure of 6-12 months

51 Distal Bicep Rupture

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

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

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

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

56 NERVES

57 Cubital Tunnel Syndrome Ulnar N compression thru medial elbow Ulnar N compression thru medial elbow 2 nd most common compressive neuropathy UE 2 nd most common compressive neuropathy UE 30-60yo 30-60yo DDx: 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  1 st Dorsal Interosseus

59 Special Tests Fromment’s sign 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 Jeanne’s sign  MP hyperextension w/ IP flexion

60 Management CONSIDER EMG TO DOCUMENT SEVERITY CONSIDER EMG TO DOCUMENT SEVERITY Severe  Persistant Pain  Atrophy  Surgical Referral Mild to Moderate 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 Second most frequent joint dislocation Fall on extended elbow with outstretched hand Fall on extended elbow with outstretched hand Majority posterior/posterolateral (90-95%) Majority posterior/posterolateral (90-95%)

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

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

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

70 SIMPLE POSTEROLATERAL DISLOCATION

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

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

73 COMPLEX ELBOW DISLOCATION W/ RADIAL NECK FRACTURE Radial Head

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

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

76 Radial Head Fractures Radiographs Radiographs  Can be subtle  Look for fat pad sign FAT PAD SIGN

77 Mason Classification I  Nondisplaced II  2mm displacement III  Comminuted

78 Treatment I  Nonoperative I  Nonoperative  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 III  Ortho Referral III  Ortho Referral  Surgery  ORIF  RADIAL HEAD REPLACEMENT

80 Thank You Terre Haute Medical Community!!!


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