Orthopedics: Elbow Conditions and Exams
LATERAL EPICONDYLITIS
--most common overuse injury of elbow (90% of elbow tendonitis)
--inflam, microscopic tears, fibrosis of the extensor carpi radialis brevis tendon
--"tennis elbow" -- from backhand, mind you
--S/Sx: PAIN: lateral elbow, w/ gripping, resisted wrist ext, forearm supination, ext of mid finger
--pain: gradual onset, intermittent
--pt may report weakness, tenderness
--dt degeneration, tendonosis, periostitis
--at jct of common extensor and lateral epicondyle of humerus
--usu no visible swelling or inflam
--AROM and PROM usu normal
--trigger points in extensors of wrist
--PROGnosis: good with conservative care (3 months or less to good as new)
--Tx: pain control, anti-inflam, rest, avoid aggrav, exercise as tolerated, ice, ultrasound, laser, splint, manip, forearm soft tissue tx, ergonomic changes
Cozen's test (resistive) -- Pt may sit or stand, (text version) with arm at side and elbow at 90, pt makes fist, forearm is pronated, then extends and radially deviates the wrist while doc palpates lateral epicondyle and resists extension. (or from lab: waitress position and push up w/ examiner resistance)
Mill's test (stretch) -- Examiner palpates lateral epicondyle, extends elbow completely with elbow crease up, pronates forearm and flexes wrist fully (hand flops down), doc increases wrist flexion, stretching extensors and common extensor tendon. (+) = pain @ lateral epicondyle, radial nerve mb compressed.
Finger Extension Test -- Pt places hand palm down on flat surface and extends 3rd digit (middle finger). Examiner pushes down on middle finger at distal IP joint to evaluate digit strength. Stresses extensor digitorum muscle and tendon. (+) test = pain over lateral epicondyle.
MEDIAL EPICONDYLITIS
--"golfer's elbow", "pitcher's elbow", "little leaguer's elbow" (apophysitis)
--inflam in children, degenerative in adults
--with children xray for suspected avulsion in Little Leaguer's elbow
--I have this from lifting/swinging a backpack full of books one handed, and mousing R handed
--tendonosis, periostitis, apohysitis @ jct of common flexor tendon & medial epicondyle of humerus
--ETIO: overuse, overhead throw, tennis swing, golf swing, use of a hammer
--inflam, strain, fibrosis of pronator teres and flexor carpi radialis longus tendons
--S/Sx: tenderness and aching pain over medial elbow, early: pain w/ activity, relieved by rest
--S/Sx: chronic: constant pain that is worsened by activity
--usu gradual onset, no visible swelling or signs of inflam
--PROG and Tx: same as lateral
Reverse Cozen's Test (resistive) = Pt may sit or stand, examiner passively supinates forearm, flexes elbow to 120 degrees, and slightly flexes the wrist with ulnar deviation (put patient in position of patting self on same side shoulder with palm down). Patient then maintains this position while doc has a stabilizing hand on the point of the elbow, and the other hand lifting the pts palm away from the shoulder.
Reverse Mill's Test (stretch of medial forearm with arm extended) Pt extends elbow, supinates forearm (turns palm up) and extends wrist. Doc increases wrist extension to stretch the common flexor tendon. (This test can also be done with wrist flexed and doc pushing toward extension)
ELBOW SPRAIN AND INSTABILITY
--sprain = soft tissue stretch or rupture to ligaments of elbow joint
--instability = laxity of medial collateral or lateral collateral ligaments-->hypermobility
--medial collateral lig most often injured
--can result in ulnar nerve inflam
--grade 1 = mild strain/sprain, stable to stress tests, 1-4 weeks healing time
--grade 2 = partial lig/muscle tear, slight laxity w/ firm end feel w/ stress tests, 2 week-6mo healing
--grade 3 = severe sprain/strain, possible complete tear, will show ecchymosis, edema, dysfunction, guarding, may have muscle flaccidity, unstable join w/ laxity/empty end feel
--pain with PROM and AROM, ligaments show less pain (than muscle) with isometric contraction
--ETIO: FOOSH, elbow hyperext, valgus/varus stress, trauma (single or repetitive)
--S/Sx: elbow joint pain esp w/ ext and supinate, antalgic posture (elbow in 90 flexion), tender to palp, decreased ROM and stiffness, local swelling, erythema, ecchymosis
--S/Sx: neuro and vascular tests WNL
--may have paresthesias, (+) Tinel's sign
--DDX: hemarthorsis (vascular damage w/ severe sprain), avulsion, displaced fx, dislocation (refer), vascular and neurological signs, use imaging for severe sprains
--Tx: same as conditions above except may need short term immobilization via sling, elastic wrap, taping or splint
Valgus Stress Test = two part test in which examiner attempts to bend elbow medially. Patient's forearm is supinated for both, test at full extension (not hyperext) and with elbow flexed 30 degrees. Tests for medial collateral ligament laxity and pain.
Varus Stress Test = same as valgus except direction of examiner pressure is lateral to stress the lateral collateral ligament.
CUBITAL TUNNEL SYNDROME
--tunnel is the groove between the medial epicondyle and the ulna
--ulnar nerve entrapment and irritability due to hyypermobility, excessive valgus force on elbow, loose body or osteophyte, fascial bands, subluxation of nerve over medial epicondyle, hypertorphied synovium, tumor, ganglia, direct compression (banging your funny bone too much)
--S/Sx: aching pain with paresthesias, may radiate distally to digits 4 & 5
--weak grip, atrophy of hypothenar eminence, poor hand coordination
--(+) Tinels at elbow, (+) Froment's sign
--DDX: systemic conditions such as DM, renal dz, multiple myeloma, chronic alcoholism, malnutrition
--DDX: also consider compression dt: activities requiring repetitive flexion (sleeping with arm cranked back under head), prolonged use of vibrating tools, recurrent trauma, valgus ligament instability (medial collateral lig strain)
--DDX: fx, disloc, SOL, perineural adhesions, arthritis (local osteophytes, synovitis), cervical disc dz, cervical arthritis, TOS, pancoast tumor
--DX: EMG/NCS above and below elbow (EMG/NCS = electromyography/nerve conduction studies
--Tx: rest, modify activity, splint elbow, inti-inflam, manip/mobiliz as needed, soft tissue work as needed, excercises as tolerated to hand, wrist, elbow, shoulder
Tinel's Sign = Tapping over ulnar nerve in cubital tunnel of elbow. (+) = shooting electrical pain or paresthesia distal to tap. (24% of normal individuals have a (+) test!!)
Froment's sign = When pinching a piece of paper using thumb and index finger, pt cannot pinch with straight thumb; there is a bend in the thumb at the IP joint indicating ulnar nerve compromise (thumb adductor innervated by ulnar nerve, IP flex uses long flexor of thumb, innervated by median nerve)
Elbow Flexion Test = the best diagnostic test for cubital tunnel syndrome. Pt may be seated or standing. Pt flexes elbow past 90, supinates forward and extends wrist and holds this position for up to 5 minutes. ("Waitress" position as if carrying tray). Shoulder abduction increases closure of tunnel. (+) = discomfort or paresthesia in a minute or less, indicates ulnar compression within cubital tunnel.
OLECRANON BURSITIS
--aka students elbow, draftsman's elbow, miner's elbow, dart thrower's elbow
--ETIO: inflam dt infx (common), gout, trauma, repeated microtrauma
--S/Sx: focal posterior elbow swelling (soft, egg-sized lump) and stiffness
--usu little pain dt few nociceptors, may be tender to palpation
--DDX: infectious bursitis, rheumatoid arthritis, gout, pseudogout, fracture, tricps tendonitis
--DX: imaging only if fracture is suspected
--LABS: if suspect infx (CBC, WBC, synovial aspiration)
--LABS: if suspect arthritis (rheumatoid factor, ESR, CRP) or gout (uric acid)
--Tx: protect wtih elastic sleeve/padding (imp!), rest, avoid aggrav, PT, ice, anti-inflam, soft tissue, trigger pts, myofascial release
--PROG: good but slow (1-2 mo)
--If no response to Tx refer to rhematologist (needle aspiration, inflam arthropathy)
PULLED ELBOW OR NURSEMAID'S ELBOW
--subluxation or temporary displacmenet of radial head from annular ligament
--common in preschool children (2-5 yrs)
--often spontaneously reduced
--ETIO, MOI in kids: sudden traction on forearm with elbow extended and forearm pronated (lift child by one arm, swing child by arms, annular ligament gets trapped btw raidal head and capitulum, may tear)
--recurrence in children: 5-25%, consider child/sibling abuse if high %
--usu minor soft tissue injury, may be assoc w/ fracture if trauma
--ETIO: elbow dislocation/sublux rare in adults, usu assoc w/ violent trauma
--injury usu less severe than child's presentation: calm the parents
--S/Sx: pain, apprehension, guarding, crying, no play, forearm held in pronation w/ slight elbow flexion, unwilling to supinate or straighten arm, opposite hand may be splinting
--S/Sx: tender to palpation over anterior aspect of radius, no sign of trauma (no deformity, erythema, warmth, edema), spasm of forearm flexors and extensors, normal CSM
--S/Sx: relatively painless elbow flexion 30-120 degrees, more pain w/ extension past 30 degrees or supination
--Tx: if not spontaneously reduced, child is under 4, parents give permission, consider reduction techniques, have child sit on parents lap during reduction procedure (supination-flexion: press radial head and traction arm, supinate and fully flex elbow in one motion, feel/hear click w/ reduction->immediate relief, sling for a a week, ice for first 24-48 hours) (pronation reduction: hyperpronation with or without elbox flexion may be more effective, sling and ice the same)
--DDX: elbow or wrist fracture, soft tissue injury, use imaging if fracture suspected
--most common overuse injury of elbow (90% of elbow tendonitis)
--inflam, microscopic tears, fibrosis of the extensor carpi radialis brevis tendon
--"tennis elbow" -- from backhand, mind you
--S/Sx: PAIN: lateral elbow, w/ gripping, resisted wrist ext, forearm supination, ext of mid finger
--pain: gradual onset, intermittent
--pt may report weakness, tenderness
--dt degeneration, tendonosis, periostitis
--at jct of common extensor and lateral epicondyle of humerus
--usu no visible swelling or inflam
--AROM and PROM usu normal
--trigger points in extensors of wrist
--PROGnosis: good with conservative care (3 months or less to good as new)
--Tx: pain control, anti-inflam, rest, avoid aggrav, exercise as tolerated, ice, ultrasound, laser, splint, manip, forearm soft tissue tx, ergonomic changes
Cozen's test (resistive) -- Pt may sit or stand, (text version) with arm at side and elbow at 90, pt makes fist, forearm is pronated, then extends and radially deviates the wrist while doc palpates lateral epicondyle and resists extension. (or from lab: waitress position and push up w/ examiner resistance)
Mill's test (stretch) -- Examiner palpates lateral epicondyle, extends elbow completely with elbow crease up, pronates forearm and flexes wrist fully (hand flops down), doc increases wrist flexion, stretching extensors and common extensor tendon. (+) = pain @ lateral epicondyle, radial nerve mb compressed.
Finger Extension Test -- Pt places hand palm down on flat surface and extends 3rd digit (middle finger). Examiner pushes down on middle finger at distal IP joint to evaluate digit strength. Stresses extensor digitorum muscle and tendon. (+) test = pain over lateral epicondyle.
MEDIAL EPICONDYLITIS
--"golfer's elbow", "pitcher's elbow", "little leaguer's elbow" (apophysitis)
--inflam in children, degenerative in adults
--with children xray for suspected avulsion in Little Leaguer's elbow
--I have this from lifting/swinging a backpack full of books one handed, and mousing R handed
--tendonosis, periostitis, apohysitis @ jct of common flexor tendon & medial epicondyle of humerus
--ETIO: overuse, overhead throw, tennis swing, golf swing, use of a hammer
--inflam, strain, fibrosis of pronator teres and flexor carpi radialis longus tendons
--S/Sx: tenderness and aching pain over medial elbow, early: pain w/ activity, relieved by rest
--S/Sx: chronic: constant pain that is worsened by activity
--usu gradual onset, no visible swelling or signs of inflam
--PROG and Tx: same as lateral
Reverse Cozen's Test (resistive) = Pt may sit or stand, examiner passively supinates forearm, flexes elbow to 120 degrees, and slightly flexes the wrist with ulnar deviation (put patient in position of patting self on same side shoulder with palm down). Patient then maintains this position while doc has a stabilizing hand on the point of the elbow, and the other hand lifting the pts palm away from the shoulder.
Reverse Mill's Test (stretch of medial forearm with arm extended) Pt extends elbow, supinates forearm (turns palm up) and extends wrist. Doc increases wrist extension to stretch the common flexor tendon. (This test can also be done with wrist flexed and doc pushing toward extension)
ELBOW SPRAIN AND INSTABILITY
--sprain = soft tissue stretch or rupture to ligaments of elbow joint
--instability = laxity of medial collateral or lateral collateral ligaments-->hypermobility
--medial collateral lig most often injured
--can result in ulnar nerve inflam
--grade 1 = mild strain/sprain, stable to stress tests, 1-4 weeks healing time
--grade 2 = partial lig/muscle tear, slight laxity w/ firm end feel w/ stress tests, 2 week-6mo healing
--grade 3 = severe sprain/strain, possible complete tear, will show ecchymosis, edema, dysfunction, guarding, may have muscle flaccidity, unstable join w/ laxity/empty end feel
--pain with PROM and AROM, ligaments show less pain (than muscle) with isometric contraction
--ETIO: FOOSH, elbow hyperext, valgus/varus stress, trauma (single or repetitive)
--S/Sx: elbow joint pain esp w/ ext and supinate, antalgic posture (elbow in 90 flexion), tender to palp, decreased ROM and stiffness, local swelling, erythema, ecchymosis
--S/Sx: neuro and vascular tests WNL
--may have paresthesias, (+) Tinel's sign
--DDX: hemarthorsis (vascular damage w/ severe sprain), avulsion, displaced fx, dislocation (refer), vascular and neurological signs, use imaging for severe sprains
--Tx: same as conditions above except may need short term immobilization via sling, elastic wrap, taping or splint
Valgus Stress Test = two part test in which examiner attempts to bend elbow medially. Patient's forearm is supinated for both, test at full extension (not hyperext) and with elbow flexed 30 degrees. Tests for medial collateral ligament laxity and pain.
Varus Stress Test = same as valgus except direction of examiner pressure is lateral to stress the lateral collateral ligament.
CUBITAL TUNNEL SYNDROME
--tunnel is the groove between the medial epicondyle and the ulna
--ulnar nerve entrapment and irritability due to hyypermobility, excessive valgus force on elbow, loose body or osteophyte, fascial bands, subluxation of nerve over medial epicondyle, hypertorphied synovium, tumor, ganglia, direct compression (banging your funny bone too much)
--S/Sx: aching pain with paresthesias, may radiate distally to digits 4 & 5
--weak grip, atrophy of hypothenar eminence, poor hand coordination
--(+) Tinels at elbow, (+) Froment's sign
--DDX: systemic conditions such as DM, renal dz, multiple myeloma, chronic alcoholism, malnutrition
--DDX: also consider compression dt: activities requiring repetitive flexion (sleeping with arm cranked back under head), prolonged use of vibrating tools, recurrent trauma, valgus ligament instability (medial collateral lig strain)
--DDX: fx, disloc, SOL, perineural adhesions, arthritis (local osteophytes, synovitis), cervical disc dz, cervical arthritis, TOS, pancoast tumor
--DX: EMG/NCS above and below elbow (EMG/NCS = electromyography/nerve conduction studies
--Tx: rest, modify activity, splint elbow, inti-inflam, manip/mobiliz as needed, soft tissue work as needed, excercises as tolerated to hand, wrist, elbow, shoulder
Tinel's Sign = Tapping over ulnar nerve in cubital tunnel of elbow. (+) = shooting electrical pain or paresthesia distal to tap. (24% of normal individuals have a (+) test!!)
Froment's sign = When pinching a piece of paper using thumb and index finger, pt cannot pinch with straight thumb; there is a bend in the thumb at the IP joint indicating ulnar nerve compromise (thumb adductor innervated by ulnar nerve, IP flex uses long flexor of thumb, innervated by median nerve)
Elbow Flexion Test = the best diagnostic test for cubital tunnel syndrome. Pt may be seated or standing. Pt flexes elbow past 90, supinates forward and extends wrist and holds this position for up to 5 minutes. ("Waitress" position as if carrying tray). Shoulder abduction increases closure of tunnel. (+) = discomfort or paresthesia in a minute or less, indicates ulnar compression within cubital tunnel.
OLECRANON BURSITIS
--aka students elbow, draftsman's elbow, miner's elbow, dart thrower's elbow
--ETIO: inflam dt infx (common), gout, trauma, repeated microtrauma
--S/Sx: focal posterior elbow swelling (soft, egg-sized lump) and stiffness
--usu little pain dt few nociceptors, may be tender to palpation
--DDX: infectious bursitis, rheumatoid arthritis, gout, pseudogout, fracture, tricps tendonitis
--DX: imaging only if fracture is suspected
--LABS: if suspect infx (CBC, WBC, synovial aspiration)
--LABS: if suspect arthritis (rheumatoid factor, ESR, CRP) or gout (uric acid)
--Tx: protect wtih elastic sleeve/padding (imp!), rest, avoid aggrav, PT, ice, anti-inflam, soft tissue, trigger pts, myofascial release
--PROG: good but slow (1-2 mo)
--If no response to Tx refer to rhematologist (needle aspiration, inflam arthropathy)
PULLED ELBOW OR NURSEMAID'S ELBOW
--subluxation or temporary displacmenet of radial head from annular ligament
--common in preschool children (2-5 yrs)
--often spontaneously reduced
--ETIO, MOI in kids: sudden traction on forearm with elbow extended and forearm pronated (lift child by one arm, swing child by arms, annular ligament gets trapped btw raidal head and capitulum, may tear)
--recurrence in children: 5-25%, consider child/sibling abuse if high %
--usu minor soft tissue injury, may be assoc w/ fracture if trauma
--ETIO: elbow dislocation/sublux rare in adults, usu assoc w/ violent trauma
--injury usu less severe than child's presentation: calm the parents
--S/Sx: pain, apprehension, guarding, crying, no play, forearm held in pronation w/ slight elbow flexion, unwilling to supinate or straighten arm, opposite hand may be splinting
--S/Sx: tender to palpation over anterior aspect of radius, no sign of trauma (no deformity, erythema, warmth, edema), spasm of forearm flexors and extensors, normal CSM
--S/Sx: relatively painless elbow flexion 30-120 degrees, more pain w/ extension past 30 degrees or supination
--Tx: if not spontaneously reduced, child is under 4, parents give permission, consider reduction techniques, have child sit on parents lap during reduction procedure (supination-flexion: press radial head and traction arm, supinate and fully flex elbow in one motion, feel/hear click w/ reduction->immediate relief, sling for a a week, ice for first 24-48 hours) (pronation reduction: hyperpronation with or without elbox flexion may be more effective, sling and ice the same)
--DDX: elbow or wrist fracture, soft tissue injury, use imaging if fracture suspected