Functional Anatomy & Clinical Presentation The Elbow Functional Anatomy & Clinical Presentation

Elbow Anatomy What movements occur at the elbow? What type of joint is the elbow?

Bony Anatomy Upper Arm Humerus Forearm Ulna (medial) Radius (lateral)

Bony Anatomy Anterior Supracondylar ridge Lateral epicondyle Medial epicondyle Radial head Coronoid fossa Capitulum Trochlea

Bony Anatomy Posterior Olecranon fossa Olecranon Groove for ulnar nerve

Ligaments Annular ligament 360 degrees around radial head Keeps the radial head in contact with the radial notch of the ulna

Ligaments Ulnar Collateral Ligament Medial side of elbow Connects medial epicondyle to coranoid & olecranon processes

Ligaments Radial (Lateral)Collateral Ligament Lateral side of elbow Connects the lateral epicondyle to the annular ligament

Bony Palpations Supracondylar ridge Lateral epicondyle Radial (lateral) collateral ligament Radial head/annular ligament Radius Olecranon process Olecranon fossa Medial epicondyle Proximal end of ulna Ulna Ulnar groove Ulnar collateral ligament

Soft Tissue Anatomy Anterior Biceps brachii Brachioradialus Brachialis Pronator Teres

Soft Tissue Anatomy Biceps Bracii Origin Insertion Action Shoulder Radius Action Flexes forearm, supinates forearm

Soft Tissue Anatomy Brachioradialus Origin Insertion Action Lateral supracondylar ridge Insertion Styloid process of radius Action Flexes forearm

Soft Tissue Anatomy Brachialis Origin Insertion Action Anterior, distal humerus Insertion Coronoid process of ulna Action Flexes the elbow

Soft Tissue Anatomy Pronator Teres Origin Insertion Action Medial epicondyle of humerus Coronoid process of ulna Insertion Middle of lateral surface of shaft of ulna Action Pronates the elbow

Soft Tissue Anatomy Posterior Triceps Supinator

Soft Tissue Anatomy Triceps Origin Insertion Action Shoulder (3 origins) Insertion Olecranon process of ulna Action Extends elbow

Soft Tissue Anatomy Supinator Origin Insertion Action Lateral epicondyle of humerus Insertion Proximal, lateral shaft of radius Action Supinates the elbow

Soft Tissue Anatomy Medial Wrist flexors Originate off medial epicondyle

Soft Tissue Anatomy Lateral Wrist extensor muscles Originate off lateral epicondyle

Soft Tissue Anatomy Lateral Anconeus Origin Insertion Action Posterior part of lateral epicondyle of humerus Insertion Later olecranon process, posterior ulna Action Extends forearm (helps triceps last few degrees)

Soft Tissue Palpations Anterior Biceps brachii Brachialis Brachioradialis Pronator teres Posterior Triceps Supinator Medial Wrist flexor muscles UCL Lateral RCL Wrist extensor muscles

Range of Motion Assesses the motion of the joint bilaterally (compared to the other side) Active Range of Motion (AROM) vs Passive Range of Motion (PROM) Normal joint motion @ elbow Flexion: 150 - 160 Extension: 0 Pronation: 70 Supination: 85

Measuring R.O.M. Moving arm Goniometer Fulcrum Stationary arm

Measuring R.O.M. Elbow Flexion Fulcrum Stationary arm Moving arm Lateral epicondyle Stationary arm Midline of humerus Moving arm In line with radial styloid process

Resisted Range of Motion (RROM) Elbow Flexion Put elbow in flexion Place one hand one the shoulder being tested Other hand on the anterior forearm

RROM Elbow Extension Pt is seated Elbow slightly flexed One hand supports the elbow Other hand applies pressure to the proximal wrist\ Trying to push the arm into flexion

RROM Pronation Pt is seated Palm is facing down One hand stabilizes below the forearm Other “shakes patient’s hand”, tries to make hand supinate.

RROM Supination Pt is seated Palm is facing up One hand stabilizes below the forearm Other “shakes patient’s hand”, tries to make hand pronate.

Injuries of the Elbow Bone Injuries MOI? Forcing arm into bending Fall on an outstretched hand Importance of prompt treatment? Damage to blood vessels and nerves could cause cell death. Epiphyseal & avulsion fractures Ulnar dislocations

Epiphyseal & Avulsion Fractures More common on the medial epicondyle or the olecranon. Growing athletes are more likely to have an epiphyseal fracture. S/S Epiphyseal – pain, swelling, loss of motion Avulsion – severe pain and deformity

Elbow Dislocation MOI? Most common dislocation? Fall on an outstretched hand Violent hyperextension Severe blow to the lateral elbow http://www.youtube.com/watch?v=r9rywfbwC8E Most common dislocation? Posterior S/S (What is observed?) Gross deformity Olecranon process extends posteriorly Swelling, bruising

Elbow Dislocation Potential complications? Treatment/management Damage to the median & radial nerves Damage to blood vessels Treatment/management Splint as you found it Send to emergency room for relocation.

Muscle & Tendon Injuries Elbow flexor strains Elbow extensor strains Medial & lateral epicondylitis

Elbow Flexor Strain MOI? S/S Often includes both the shoulder & elbow (biceps) Excessive resistance elbow & shoulder flexion S/S Depends on grade… (think of sprains and strains chart) Grade 1? Grade 2? Grade 3? Pain over anterior elbow and the biceps tendon

Elbow Flexor Strain Evaluation will find… Weakness Extra discomfort with elbow flexion AROM, RROM PROM? (pain decreases with PROM) Grades 1 & 2 RICE, rehabilitation Grade 3 Refer to physician/ER

Elbow Extensor Strain MOI Pain with active elbow extension Same as flexor strain Trying to break a fall Pain with active elbow extension Be sure to check for avulsion fractures at the olecranon process.

Medial & Lateral Epicondylitis Chronic inflammation of either the medial or lateral epicondyles. Lateral Epicondylitis (Tennis Elbow) Inflammation of the extensor tendons. S/S Minimal swelling over lateral epicondyle Pain will also be present

Medial Epicondylitis AKA Little League Elbow Result of repetitive throwing Inflammation of the wrist flexors Pitch counts in Little League? S/S Same as lateral epicondylitis

UCL/RCL Sprains Ulnar collateral ligament is more prone to injury MOI? UCL – valgus force (force from the lateral side) RCL – varus force (force from the medial side) S/S Pain Swelling Possibly joint laxity Special tests

Scenario 1 A basketball player goes up for a lay up and has his feet taken out from under him, and tries to catch himself with an outstretched hand. He falls to the floor and does not get up, but is holding his elbow in pain. When you get there you notice that his olecranon process is protruding posteriorly and there is already a considerable amount of swelling.

Scenario 1 Answer Posterior Dislocation Splint as you found it, and refer to ER

Scenario 2 A wrestler is trying to escape from a move. His hand is planted on the mat when his opponent strikes the lateral side of his elbow. He feels a small pop on the medial side, but finishes the match. After the match he approaches you with pain in both his medial and lateral elbow. He has a moderate amount of swelling over his medial epicondyle and has some laxity with a valgus stress test.

Scenario 2 Answer UCL Sprain (Grade 2) Follow up with physician Discontinue activities PRICES

Scenario 3 A tennis player approaches you with elbow pain. You notice a minimal amount of swelling over her lateral epicondyle. While palpating you notice that most of her pain is over the lateral epicondyle and into the wrist extensors. She does not remember doing anything to that elbow, but says it has been bothering her for about a week.

Scenario 3 Answer Lateral Epicondylitis Tape for relief Ice after practice NSAIDS