Presentation on theme: "Musculosekeltal Diseases and Disorders: Elbow and Forearm"— Presentation transcript:
1 Musculosekeltal Diseases and Disorders: Elbow and Forearm PTP 521
2 Anteroposterior view: A Alignment:Identify the structures from a proximal to distal viewRadial head should be aligned with the capitulum but not directly in contact with itOlecranon should be centered in the olecranon fossaCarrying angle should be noted and be ~ 15 dg.Identify: Humerus, olecranon fossa, medial epicondyle, lateral epicondyle, olecranon, trochlea, capitulum, coronoid process and radial head
3 Abnormal Anteroposterior View This view will demonstrate the following pathologies, if present:Fractures of the distal humerus – supra, trans, and intercondylarFractures of the medial and lateral epicondylesFractures of the capitulum, trochlea and lateral aspect of radial headVarus and Valgus deformitiesSecondary ossification centers of the distal humerus
4 Anteroposterior view: B Bone Density: pay particular attention to the radial head for any chips/fracturesLook for Trabecular linesPay attention to the medial and lateral epicondyles for any lucencies or breaks in the margins
5 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 years.None should be open at age 13.They appear and fuse to the adjacent bones at different ages. It is important to know the sequence of appearance since the ossification centers always appear in a strict order.
6 C and S Cartilage: Soft Tissue: not seen well on an AP view Evaluated with an MRI, joint space is noted with the radial head and capitulum onlySoft Tissue: not seen well on an AP viewFat Pad Sign (Sail Sign): evidence of swelling or bleeding anterior to the elbowemedicine.medscape.com/article/imaging
7 Lateral View of the Forearm Anterior humeral lineIdentify: 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.Radiocapitulum line
8 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
9 Anterior Humeral LineLine drawn along the anterior surface of the humerus, in a lateral view, should pass through the middle third of the capitulum
10 Abnormal Lateral ViewThe lateral view will demonstrate the following pathologies, if present:Supracondylar fractures of distal humerusFractures of anterior radial head and olecranonComplex dislocations of the elbow jointDislocation of the radial headpad sign (sail sign)
11 Lateral ViewBone Density: view the radial head, trabecular lines
12 Cartilage: Soft Tissue: Able to see a joint space between the radius and the capitulumTrochlea and the coronoid processSoft Tissue:May or may not be seen in this viewEvaluate for changes in density of the tissue which may indicate swellingFat pad sign (Sail sign) can be seen in this view as well
13 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
14 AbnormalThe External Oblique view will demonstrate the following pathologies, if present:Fractures of radial head and lateral epicondyles614.photobucket.com/albums/tt228/ex_cowboy/?...
15 Internal ObliqueThis view is taken to demonstrate the coronoid process, trochlea notch, and medial trochleaForearm is pronated ~ 45 dgAbnormal: will demonstrate fractures of the medial epicondyle and the coronoid process
16 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)A properly positioned elbow with the correct tube angle will demonstrate the normal radial head aligned with the coronoid process, the medial trochlea (green arrowheads) will be seen distal to the capitulum without superimposition.Look at this view and evaluate the difference between the lateral view and the trauma lateral view - Its in the radial head position
17 Radial Head /Capitulum Trauma View The trauma view will demonstrate the followingFractures of radial head, capitulum and coronoid processAbnormalities of the humeroradial and humeroulnar joints
18 CT Imaging Utilized to determine the following abnormal pathology: Complex fractures around the elbow, particularly comminuted fracturesHealing processNon union of bonesSecondary infections
19 CT Imaging of the ElbowMRI seems to replace a lot of CT imaging because of the soft tissue around the elbowThese images are of a trochlear fracture (sorry, I couldn’t get better resolution)
20 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.
21 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 data
22 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.
23 Can you name the anatomy? (Don’t click until you are ready to answer) A = cornoid process, ulnaB = coronoid fossa, humerusC = olecranon processD = olecranon fossa
24 Midsagittal plane CTDemonstrates 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.
25 MRI Imaging Demonstrates the following pathology: Bone Contusion Abnormalities of the ligaments, tendons and musclesLateral epicondylitisBicipital tendonitisUlnar collateral ligament injuryRadial collateral ligament injuryBone ContusionCapsular rupturesJoint effusionsSynovial CystsHematomasOsteochondritis DissecansEpiphyseal fractures in children
27 Axial View What is the anatomy of 1-5? 1= Biceps Brachii 2= Brachialis 3= Brachial artery4= Humerus5= Triceps
28 CFT: common flexor tendon CET: common extensor tendonRCL: radial collateral ligamentUCL: ulnar collateral ligament
29 CORMPGRCoronal PlaneSequence: MPGR (Multiplanar Gradient Recalled) This is an echo pulsed sequenceThis image demonstrates the humerus, ulna, radius is not in the picture just yetRadial collateral ligUlnar collateral ligmedial
30 CORPD Coronal View Proton Density Here you can see the radius as well as the ulna, humerus, olecranon
31 US ImagingNormal anterior elbow appearance at the humeroradial joint (wide short arrow) with the fat pad at the radial fossa demonstrated (thin arrow).
32 Normal distal biceps tendon (arrows) with insertion deep to vein (longitudinal)
33 Normal lateral common extensor tendon origin (arrows) with normal hyper- echogenicity of the longitudinal tendon
34 Normal medial epicondyle, common flexor tendon origin (large arrows on hyperechoic longitudinal tendon ) and ulnar collateral ligament (small arrows on hypoechoic ligament).
35 Normal ulnar nerve at the joint in longitudinal (left) and transverse (right) planes (arrows).
36 Musculoskeletal Injury BoneFracturesArthritic DisordersBruiseOtherMuscleStrain and InflammationRuptureTrigger PointsTendontendonosisstrainNerveEntrapmentLigamentSprain and InflammationCapsule and JointArthritis: OA and RAOsteochondrosisDislocationsOther - BursitisSystems that refer pain to areaOther joints that refer pain to area
37 Fractures: Musculoskeletal Practice Pattern 4G Fractures of the Distal Humerus1. Suprachondylar fractures: extra- articularMost common fracture in children- 65%Uncommon fracture in adultsLeft arm more than right – protective response98% occur with arm extended and wrist dorsiflexedPossible neurovascular complications: ~22% neuro and 10% vascularPossible permanent impairment and deformityMcKinnis LN, 2005
38 Gunstock DeformityCommon complication of a suprachondylar fracture
39 SX: Signs: purple discoloration of hand, severe pain in forearm muscles initiallyparesthesias as the dysfunction progressesSigns:cool pale extremity with altered pulsepain on passive stretchswelling initiallynumbness distal to the ischemic region
40 2. Transcondylar: intracapsular but extraarticular fracture Common in elderly3. Epicondylar Fractures: extra-articular4. Condylar FracturesMcKinnis LN, 2005
41 5. Intercondylar Fractures T intercondylar, Y Intercodylar Medial or Lateral Condyle6. Intra-Articular FracturesCompressive forces across the elbowMcKinnis LN, 2005
42 Volkmann's Ischemia Compartment Syndrome Prolonged ischemia of the forearm musclesmuscle necrosisreplacement of tissue with fibrous tissuesevere deformities of the hand and wristparalysis of muscles.Three stages: mild, moderate and severeCauses:Arterial injury caused by an open laceration,Arterial disruption secondary to a severely displaced fracture or dislocation
43 Fractures of the Radial Head: Mason Classification System Type INon-displaced fractureOften missed on x-rayPositive posterior fat pad signRX: minimal immobilization, early ROM
44 Radial Head Fracture Type II Displaced fracture Separation or angulations of the fracture fragmentRX: ORIF, early motion
45 Radial Head Fractures Type III Comminuted fracture of the entire head Children ages 4-14RX: ORIF and early motion
46 Radial Head Fractures Type IV Comminuted fracture Dislocation of the elbowUsually cause some functional limitationRX: radial head resection
47 Fractures of the Coronoid Process RX:Open reduction generally necessaryConcern for elbow instabilityClassified: Regan-MorreyType I: tip of coronoidType II: less than 50% coronoid tipType III: more than 50% of the coronoidboneandspine.com/wp-content/uploads/2009/02/c...
48 Fractures of the Olecranon MOI: fall onto the flexed elbowMOI: Boxer’s elbow: avulsion fracture of the olecranon
49 Monteggia FractureDislocation of radial head – most common lateral or anterolateral, posterior rareFracture of ulnar metaphysis or diaphysis
50 Badu Classification of Monteggia Fractures TypeDescriptionFrequency, % 3IFracture of the middle or proximal third of the ulna and anterior dislocation of the radial head65IIFracture of the middle or proximal third of the ulna and posterior dislocation of the radial head18IIIUlnar fracture distal to the coronoid process with lateral radial head dislocation16IVFracture 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 radius1Resnick D. Physical injury: extraspinal sites. In: Diagnosis of Bone and Joint Disorders. 3rd ed. 1992.
51 Galeazzi Fracture Fracture of distal shaft of radius Dislocation of distal radial ulnar joint
53 Soft Tissue Injuries of the Elbow Lateral EpicondylitisMedial EpicondylitisTriceps TendonitisBiceps StrainMyositis Ossificans
54 Lateral Epicondylitis Adults 35 years or older: occupation or hobby involves repetitive extension of the wrist i.e. carpenter, electrician, tennis, baseball, or golfEtiology: unknown: cumulative trauma causes inflammatory process at ECRB originDifferential Diagnosis: Posterior Interosseous Syndrome and C6-7, T 4 syndromes
55 SX of Lateral Epicondylitis: Gradual onsetPain over lateral epicondylePain associated with grippingMay have some shoulder, neck pain associated with it
56 Signs of Lateral Epicondylitis: ROM: full, passive movement into extension, may be painful at end rangeLimited wrist flexion combined with finger flexion at end rangeStrength: painful resisted wrist extension and radial deviationJoint Play: full and pain freePalpation: tender over the lateral epicondyleSpecial tests: + Cozens test, + Mill’s test, - Middle Digit Extenstion Test
57 Medial Epicondylitis Golfer’s elbow Symptoms Pain on medial side of elbowInvolved in repetitive flexion activities of wrist finger flexion and active pronation
58 Signs of Medial Epicondylitis: Palpation: direct over the medial epicondyleResisted movement: resisted flexion of the fingers increases pain but is strong, may have a loss of strength with gripping activitiesObservation: swelling/erythema on medial aspect
59 Triceps Tendonitis:1) Onset: sudden, severe strain as the arm is fully extended or with a sudden snapping of the elbow into extension2) Signs: pain with resisted elbow extension – may be strong or weakpain with PROM of elbow flexion and shoulder flexion – passive stretch of the muscle
60 Biceps Muscle Strain: 1) Onset: athletic activity, very strong elbow flexion forcehyperextension 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
61 2) SX: depends on the degree of the strain 3) Signs: depends on the degree of the strain
62 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 immobilizationSX: pain with elbow flexion and extensionSigns: palpable area on muscle, warm to touch, bony end feel, limitation of range, + radiograph
63 Medial and Lateral Ligamentous structures of the elbow
64 Posterolateral Rotary Instability MOI:Rotational displacement of the ulnaRadius subluxes or dislocates posteriorSx: catching, clicking and lockingPainApprehension with elbow supinated and fully extendedSigns: lateral pivot-shift is most sensitiveForces: : axial compression, external rotation and valgus (lateral to medial) force
65 Three stagesStage I: Lateral Ulnar Collateral Ligament disruptionStage II:Anterior and posterior disruptionPerched dislocation
66 Stage III:III A: all soft tissue except Ulnar collateral lig (medial side) is disruptedIII B: UCL disruptedIII C: Entire distal humerus stripped of soft tissue
67 Ligament SprainMedial (Ulnar) Collateral Ligament sprain (little league elbow): Articular damage to the radiohumeral and ulnohumeral joint with repeated stressesMOI: adolescent involved with overhead throwing activities.FOOSH injuryThe compressive forces at the radiohumeral joint and distraction forces on the medial aspect of the elbow will overstretch and injure the ligament.
69 Articular damage to the capitulum, Ligamentous instability of the medial elbowTardy nerve palsymay 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
70 Radiology: Osteochondritis Dissecans of the Capitulum Note fracture of the condlye on the ulnar aspect of the elbow
71 SX: pain/swelling on the medial aspect of the elbow Patient c/o pain with throwing or pushing motions
72 Signs: Tender with varus stress if the radiohumeral joint is involved Valgus instability with ligamentous stress testTender with varus stress if the radiohumeral joint is involvedPainful axial compression with the radius on the humeralJoint tender over the MCL ligamentSevere cases will get locking of the elbow due to capitulum fragments
73 Joint Dysfunctions of the Elbow DislocationsOsteoarthritisRAOsteochondritis Dessicans
74 Elbow Dislocations MOI: FOOSHDirect TraumaMVADescribed by the direction the ulna and radius have been displaced relative to the humerusMost common typesPosterior or Posterolateral direction
75 Perched Dislocation Not a true dislocation Subluxation of the joint Less ligamentous damageHumerus is PERCHED on top of the coronoid process of the ulna
77 b. posterolateral -c. posteromediald. DivergentWhat soft tissue structures may be involved with each one of these type of dislocations?
78 Additional injuries to soft tissue Anterior capsule ruptureRadial collateral ligament damageBrachial muscle injuriesExtensor tendon injuriesRadial head and neck fracturesTear of brachial arteryNerve injuriesAvulsion/entrapment of medial epicondyle
79 Anterior Dislocation Rare 1-2% of the population Ulnar collateral ligament involved, what other structures?Fractures of radial head may occur
80 Dislocations Physical Exam: gross deformity of the elbow Anatomical triangle is disruptedElbow held in 45 dg flexionForearm appears shorter (posterior) and olecranon is more prominent posteriorboneandspine.com/.../10/dislocation-elbow.jpg
81 Subluxations of the Radius Nursemaids ElbowMOI: axial force on the armSX: pain, child will refuse to move the armRelocation, no immobilization needed
86 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 activityControversy: Panners disease encompasses entire capitellum and occurs at a younger age (5-16)MOI: Vascular insufficiency from repetitious lateral compression at the humeroradial joint
87 Panners DiseaseYounger child, no ossification of growth plates
88 12- 15 year old: Osteochondritis Dissecans Leading cause of permanent disability to the young pitching athleteRepetitive lateral compression at the radiocapitellar joint during late cockingLoose body formation in joint
90 Signs, Symptoms & Interventions SX: pain present over lateral and anterior elbowPain increase with deep palpation, pronation and supinationROM: extension limited by 20 dg or moreIntervention: Rest, gentle stretchingNO loose bodies: may drill bone to restore vascular supplyLOOSE bodies: may need arthroscopic surgery to remove the loose bodies
91 Bursitis: 12 bursae about the elbow with 3 of clinical significance 1) Olecranon bursae allows smooth gliding ofthe skin on the triceps Onset: traumatic, inflammatory (gout),prolonged pressure
92 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 tricepsClassic inflammatory responses with redness, temp. increases, edema, and pain
93 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 tendonResisted movements of elbow flexion and supination are painful
94 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