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The Elbow

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

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The Elbow

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  1. The Elbow Functional Anatomy & Clinical Presentation

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

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

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

  5. Bony Anatomy • Posterior • Olecranon fossa • Olecranon • Groove for ulnar nerve

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

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

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

  9. 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

  10. Soft Tissue Anatomy • Anterior • Biceps brachii • Brachioradialus • Brachialis • Pronator Teres

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

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

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

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

  15. Soft Tissue Anatomy • Posterior • Triceps • Supinator

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

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

  18. Soft Tissue Anatomy • Medial • Wrist flexors • Originate off medial epicondyle

  19. Soft Tissue Anatomy • Lateral • Wrist extensor muscles • Originate off lateral epicondyle

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

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

  22. 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

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

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

  25. 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

  26. 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

  27. 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.

  28. 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.

  29. 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

  30. 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

  31. Elbow Dislocation • MOI? • 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

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

  33. Muscle & Tendon Injuries • Elbow flexor strains • Elbow extensor strains • Medial & lateral epicondylitis

  34. Elbow Flexor Strain • MOI? • 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

  35. 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

  36. Elbow Extensor Strain • MOI • 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.

  37. 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

  38. 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

  39. 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

  40. 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.

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

  42. 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.

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

  44. 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.

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

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