The Elbow

The ElbowFunctional Anatomy & Clinical PresentationElbow AnatomyWhat movements occur at the elbow?

What type of joint is the elbow?Bony AnatomyUpper ArmHumerus

ForearmUlna (medial)Radius (lateral)

Bony AnatomyAnterior

Supracondylar ridgeLateral epicondyleMedial epicondyleRadial headCoronoid fossaCapitulumTrochlea

Bony AnatomyPosterior

Olecranon fossaOlecranonGroove for ulnar nerve

LigamentsAnnular ligament

360 degrees around radial headKeeps the radial head in contact with the radialnotch of the ulna

LigamentsUlnar Collateral Ligament

Medial side of elbowConnects medial epicondyle to coranoid & olecranon processes

LigamentsRadial (Lateral)Collateral Ligament

Lateral side of elbowConnects the lateralepicondyle to the annularligament

Bony PalpationsSupracondylar ridgeLateral epicondyleRadial (lateral) collateral ligamentRadial head/annular ligamentRadiusOlecranon processOlecranon fossaMedial epicondyleProximal end of ulnaUlnaUlnar grooveUlnar collateral ligament

Soft Tissue AnatomyAnteriorBiceps brachiiBrachioradialusBrachialisPronator Teres

Soft Tissue AnatomyBiceps BraciiOriginShoulderInsertionRadiusActionFlexes forearm, supinates forearm

Soft Tissue AnatomyBrachioradialusOriginLateral supracondylar ridgeInsertionStyloid process of radiusActionFlexes forearm

Soft Tissue AnatomyBrachialisOriginAnterior, distal humerusInsertionCoronoid process of ulnaActionFlexes the elbow

Soft Tissue AnatomyPronator TeresOriginMedial epicondyle of humerusCoronoid process of ulnaInsertionMiddle of lateral surface of shaft of ulnaActionPronates the elbow

Soft Tissue AnatomyPosteriorTricepsSupinator

Soft Tissue AnatomyTricepsOriginShoulder (3 origins)InsertionOlecranon process of ulnaActionExtends elbowSoft Tissue AnatomySupinatorOriginLateral epicondyle of humerusInsertionProximal, lateral shaft of radiusActionSupinates the elbowSoft Tissue AnatomyMedialWrist flexorsOriginate off medial epicondyle

Soft Tissue AnatomyLateralWrist extensor musclesOriginate off lateral epicondyle

Soft Tissue AnatomyLateralAnconeusOriginPosterior part of lateral epicondyle of humerusInsertionLater olecranon process, posterior ulnaActionExtends forearm (helps triceps last few degrees)

Soft Tissue PalpationsAnteriorBiceps brachiiBrachialisBrachioradialisPronator teresPosteriorTricepsSupinatorMedialWrist flexor musclesUCLLateralRCLWrist extensor muscles

Range of MotionAssesses 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 @ elbowFlexion: 150 - 160Extension: 0Pronation: 70Supination: 85

Measuring R.O.M.GoniometerFulcrumMoving armStationary armMeasuring R.O.M.Elbow FlexionFulcrumLateral epicondyle

Stationary armMidline of humerus

Moving armIn line with radial styloid process

Resisted Range of Motion (RROM)Elbow FlexionPut elbow in flexionPlace one hand one the shoulder being testedOther hand on the anterior forearm

RROMElbow ExtensionPt is seatedElbow slightly flexedOne hand supports the elbowOther hand applies pressure to the proximal wrist\Trying to push the arm into flexion

RROMPronationPt is seatedPalm is facing downOne hand stabilizes below the forearmOther shakes patients hand, tries to make hand supinate.RROMSupinationPt is seatedPalm is facing upOne hand stabilizes below the forearmOther shakes patients hand, tries to make hand pronate.

Injuries of the ElbowBone InjuriesMOI?Forcing arm into bendingFall on an outstretched handImportance of prompt treatment?Damage to blood vessels and nerves could cause cell death.

Epiphyseal & avulsion fracturesUlnar dislocationsEpiphyseal & Avulsion FracturesMore common on the medial epicondyle or the olecranon.

Growing athletes are more likely to have an epiphyseal fracture.

S/SEpiphyseal pain, swelling, lossof motionAvulsion severe pain anddeformity

Elbow DislocationMOI?Fall on an outstretched hand Violent hyperextension Severe blow to the lateral elbowhttp://www.youtube.com/watch?v=r9rywfbwC8E Most common dislocation?PosteriorS/S (What is observed?)Gross deformityOlecranon process extends posteriorlySwelling, bruisingElbow DislocationPotential complications?Damage to the median & radial nervesDamage to blood vessels

Treatment/managementSplint as you found itSend to emergency room for relocation.

Muscle & Tendon InjuriesElbow flexor strains

Elbow extensor strains

Medial & lateral epicondylitisElbow Flexor Strain MOI?Often includes both the shoulder & elbow (biceps)Excessive resistance elbow & shoulder flexion

S/SDepends on grade (think of sprains and strains chart)Grade 1?Grade 2?Grade 3?

Pain over anterior elbow and the biceps tendon

Elbow Flexor StrainEvaluation will findWeakness Extra discomfort with elbow flexionAROM, RROMPROM? (pain decreases with PROM)Grades 1 & 2RICE, rehabilitationGrade 3Refer to physician/ERElbow Extensor StrainMOISame as flexor strainTrying to break a fall

Pain with active elbow extension

Be sure to check for avulsion fractures at the olecranon process.Medial & Lateral EpicondylitisChronic inflammation of either the medial or lateral epicondyles.

Lateral Epicondylitis (Tennis Elbow)Inflammation of the extensor tendons.

S/SMinimal swelling over lateral epicondylePain will also be presentMedial EpicondylitisAKA Little League ElbowResult of repetitive throwingInflammation of the wrist flexors

Pitch counts in Little League?

S/SSame as lateral epicondylitis

UCL/RCL SprainsUlnar collateral ligament is more prone to injuryMOI?UCL valgus force (force from the lateral side)RCL varus force (force from the medial side)

S/SPainSwellingPossibly joint laxitySpecial testsScenario 1A 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 AnswerPosterior DislocationSplint as you found it, and refer to ERScenario 2A 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 AnswerUCL Sprain (Grade 2)

Follow up with physicianDiscontinue activitiesPRICESScenario 3A 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 AnswerLateral Epicondylitis

Tape for reliefIce after practiceNSAIDS