Chapter 23: The Elbow

Anatomy Bones Ligaments Muscle action Humerus Radius Ulna Radial collateral Ulnar collateral Annular Muscle action Flexion (biceps) Extension (triceps) Supination (supinator and biceps) Pronation (pronator teres)

Bony Anatomic Landmarks Coronoid Process Radial Head Capitellum Trochlea Lateral Humeral Epicondyle Medial Humeral Epicondyle Coronoid Fossa Radial Fossa

Anatomy Modified hinge with three articulations Ulnotrochlear Radiocapitellar Proximal radioulnar All contained within a single synovial lining

Ligament Anatomy Anterior

Ligament Anatomy Medial

Ligament Anatomy Lateral

Vascular Structures (continued) Radial artery Originates at radial head, emerges from antecubital fossa between brachioradialis and pronator teres muscles Continues laterally along forearm deep to brachioradialis muscle

Neurological Structures (continued) Ulnar nerve Courses in cubital tunnel posterior to medial epicondyle Superficial and susceptible to compression or entrapment Courses down medial forearm to hand/wrist distribution Sensory distribution is pad of little finger

Functional Anatomy Complex that allows for flexion, extension, pronation and supination 145 degrees of flexion and 90 degrees of supination and pronation Bony limitations, ligamentous support and muscular stability at the elbow help to protect it from overuse and traumatic injuries Elbow demonstrates a carrying angle due to distal projection of humerus Normal in females is 10-15 degrees, males 5 degrees Critical link in kinetic chain of upper extremity

Carrying Angle/Cubitus Valgus Formed by long axis of humerus and midline of forearm Male norms – 11-14 degrees Female norms – 13-16 degrees Larger angles are considered abnormal

Gunstock Deformity/Cubitus Varus Usually develops secondary to condylar humerus fracture

HOPS for the elbow History Observation Palpation Special tests Questions???? Related to throwing Observation Dominant arm (muscles/joint) Cubitus valgus/varus/recurvatus Triangle (epicondyles and olecranon process Palpation Bony Soft tissue Nerves (radial and ulnar) Can’t actually touch everything (general area) Special tests Very big part

Special tests Range of motion Muscle testing Joint instability Passive, active-assisted, active Muscle testing Joint instability Circulatory and neurological Nerves (sensation)

Special tests Tinel’s sign Determine ulnar nerve pathology Put athlete in slight elbow flexion Tap on the ulnar notch between the olecranon process and medial epicondyle with a reflex hammer or index finger Positive sign: athlete complains of a tingling sensation along the forearm, hand, and fingers

Valgus and varus stress test To test integrity of medial and lateral collateral ligaments of the elbow Test the same as knee collateral ligaments Make sure you have a good fulcrum What am I testing for??? (positive sign)

Valgus/Varus Stress Test Assess injury to the medial and lateral collateral ligaments, respectively Looking for gapping or complaint of pain

Lateral and medial epicondlyitis test

Resist wrist extension--lateral Resist wrist flexion--medial

Recognition and Management of Injuries to the Elbow Subject to injury due to broad range of motion, weak lateral bone structure, and relative exposure to soft tissue damage Many sports place excessive stress on joint Locking motion of some activities, use of implements, and involvement in throwing motion make elbow extremely susceptible

Etiology of Elbow Injuries