AT 359
Chapter 23 - The Elbow

ANATOMY:
-Humerus
-Radius
-Ulna

JOINTS
-Humeroulnar - trochlea of humerus joins with trochlear notch of ulna
-Humeroradial - radial head joins with capitulum of humerus
-Radioulnar - radial head joins with radial notch of ulna

LIGAMENTS
-Annular - holds radial head to ulna
-Medial (Ulnar) Collateral - provides stability against valgus forces
-Lateral (Radial) Collateral - provides stability against varus forces

BURSAE
-olecranon bursa most commonly affected, especially in quarterbacks

MUSCLES

NERVE SUPPLY
Elbow muscles are innervated by C5-T1 nerve roots

BLOOD SUPPLY
Brachial artery becomes ulnar and radial arteries at elbow

Isosceles Triangle - imaginary triangle made up of 3 points
        1)Lateral epicondyle
        2)Medial epicondyle
        3)Olecranon process

Carrying Angle
    -Cubitus Valgus - carrying angle is increased
    -Cubitus Varus - carrying angle is decreased;  gunstock deformity can develop from
            supracondylar fx
    -Cubitus Recurvatus - increased hyperextension
  

SPECIAL TESTS

ELBOW INJURIES
    -Contusions
            -elbow does not have effective padding
            -RICE, protective padding

    -Olecranon Bursitis
            -injury/inflammation to the olecranon bursa which is over olecranon process
            -MOI is blow to olecranon process (common in quarterbacks)
            -s/s: gross deformity over posterior elbow (looks like a water balloon underneath
                    the skin, pain, stiffness
            -treatment: RICE, stress compression all of the time (neoprene sleeve is good)

    -Ulnar Collateral Ligament Sprain
            -typically caused by repetitive movements such as throwing, swinging, etc.
            -s/s: pain on medial aspect of elbow, MCL is tender, can have positive Tinel's
                    sign/ulnar nerve involvement because of location by cubital tunnel, laxity
            -treatment: conservative measures are used first: RICE, NSAIDs, rehab;  if
                    unresolved, surgery may be necessary (Tommy John) which can take 6
                    months to heal

    -Lateral Epicondylitis
            -common in sports with repeated extension movements such as tennis
            -also known as "Tennis Elbow"
            -microtrauma occurs at extensor muscle tendon at lateral epicondyle
            -s/s: aching pain in lateral epicondyle region while playing, weakness in hand and
                    wrist, limited ROM
            -treatment: RICE, NSAIDs, analgesics, rehab exercises; deep friction massage
                    may also be helpful; elbow strap or sleeve is helpful on return to playing

    -Medial Epicondylitis
            -common is sports with repeated wrist flexion and valgus stress forces on elbow
                    -ex: baseball, golf, etc.
            -also known as "Golfer's" or "Pitcher's" or "Little League" elbow
            -s/s: pain around medial epicondyle on forceful wrist flexion or extension, swelling
            -treatment: same as for lateral epicondylitis but in extreme cases may require
                    immobilization in an arm sling for a week

    -Osteochondritis Dissecans
            -impairment of the blood supply to the anterior bony surfaces can lead to
                    framentation/separation of bone and cartilage
            -osteochondritis dissecans in children <10 years is called "Panner's Disease"
            -s/s: sudden pain and locking of elbow, swelling, creptitation, decrease ROM
            -treatment: restrict activity for 6-12 weeks, NSAIDs, if not resolved, surgery is 
                    indicated to remove fragments

    -Little League Elbow
            -occurs in about 20% of young pitchers
            -caused more by the number of pitches thrown, not the type of pitches
            -can have avulsion injuries, osteochondrosis, stress fx's, traction apophysitis, etc.
            -s/s: gradual onset, tightness, weakness in triceps, locking/catching, decrease
                    ROM with pronation and supination
            -treatment:  RICE, NSAIDs, analgesics, stop throwing until pains gone and ROM
                    is full, stretching, strengthening, possible surgery

    -Cubital Tunnel Syndrome
            -caused any of these four things:
                    1)traction injury from valgus force
                    2)irregularities within the tunnel
                    3)subluxation of the ulnar nerve
                    4)compression of ligament on nerve
            -s/s: pain on medial aspect of elbow, tender over cubital tunnel, paresthesia or
                    numbness in 4th and 5th fingers
            -treatment: RICE, immobilization for 2 weeks, NSAIDs, avoid elbow valgus and
                    hyperextension forces, surgical decompression may be necessary

    -Elbow Dislocations
            -MOI is usually fall on outstretched arm with rotation
            -almost always dislocated posterior
            -s/s: severe pain, gross deformity (big lump on posterior elbow), disability
            -can have radial and median nerve involvement as well
            -always assess blood flow (capillary refill and radial pulse)
            -myositis ossificans is associated with this condition - causes extension loss
            -treatment: ice, splint in position found, put in sling and get to hospital; must be
                    reduced quickly to prevent more damage from occurring especially blood
                    flow related problems

    -Elbow Fx's
            -MOI is usually fall on outstretched arm
            -s/s: swelling, pain, muscle spasm
            -treatment: ice, splint and refer to doctor

    -Volkmann's Contracture
            -caused by lack of blood flow to lower arm (brachial or radial)
            -common with a humeral supracondylar fx or dislocation
            -increased pain when extending fingers followed by cessation of pulse
            -constant monitoring of pulse should be done

Web Sites for further study/learning:
www.worldortho.com - World Ortho

www.medmedia.com/med.htm - Wheeless' Textbook of Orthopaedics

www.sportsmed.org - American Orthopaedic Society for Sports Medicine

www.medfacts.com - MedFacts Sports Doc

www.orthonet.com - OrthoNet

www.physsportsmed.com/issues/may_96/nirschl.htm - Physician & Sports Medicine - Elbow Injuries

www.swmed.edu/home_pages/library/consumer/elbow.htm - Elbow Injuries

www.orthobionics.com/elbow/index.htm - Braces & Supports for Tennis Elbow & Elbow Pain

www.medlineplus.nlm.nih.gov/medlineplus/elbowinjuries - MEDLINEplus: Elbow Injuries & Disorders