Forearm And Elbow Pathologies Dr. Mark Davies Sjsu, Spring 2008

Elbow and Forearm Elbow and Forearm PathologiesPathologies

Mark R. Davies, MDCenter for Shoulder and Sports Disorders

Kaiser Permanente Medical GroupSanta Teresa Medical Center

San Jose, CA

Dr. James AndrewsBirmingham, Alabama

Over 900 “Tommy John” surgeries

American Sports Medicine InstituteAmerican Sports Medicine InstituteBirmingham, ALBirmingham, AL

Elbow and Forearm PathologiesElbow and Forearm Pathologies

Elbow ligamentous sprainsElbow ligamentous sprainsEpicondylitisEpicondylitisDisorders of the capitellumDisorders of the capitellumRupture of distal biceps tendonRupture of distal biceps tendonOlecranon bursitisOlecranon bursitisNeurologic injuryNeurologic injuryElbow dislocationsElbow dislocationsFracturesFractures

Elbow Ligamentous SprainsElbow Ligamentous Sprains

Medial (ulnar) collateral ligament injuryMedial (ulnar) collateral ligament injury

Lateral (radial) collateral ligament injuryLateral (radial) collateral ligament injury

Ulnar Collateral Ligament (UCL)Ulnar Collateral Ligament (UCL)

UCL is the main UCL is the main medial stabilizer of medial stabilizer of the elbowthe elbow

Anterior bundle is Anterior bundle is the primary structure the primary structure involved in throwinginvolved in throwing

UCL HistoryUCL History

Pain or instability Pain or instability with throwingwith throwing

What phase of What phase of throwing?throwing?

85% of throwers 85% of throwers with medial elbow with medial elbow instability complain instability complain of pain in the of pain in the acceleration phase acceleration phase of throwingof throwing

UCL InjuryUCL Injury

History:History:

- Acute medial pain- Acute medial pain

- Onset during throwing, inadequate - Onset during throwing, inadequate warmupwarmup

- “Pop” heard or felt- “Pop” heard or felt

- Can be one pitch or can be insidious- Can be one pitch or can be insidious

UCL InjuryUCL Injury Physical exam:Physical exam:

- Medial elbow ecchymosis- Medial elbow ecchymosis

- Ulnar nerve symptoms- Ulnar nerve symptoms

- Tender at anterior bundle- Tender at anterior bundle

- Difficult exam:- Difficult exam:

+/- instability+/- instability

Milking ManeuverMilking Maneuver

Palpation of UCLPalpation of UCL

Palpate in flexion to move flexor-pronator mass anteriorly

Complete UCL tear on MRIComplete UCL tear on MRI

Normal UCLNormal UCL

Bone Bone tunnels are tunnels are drilleddrilled

““Tommy John” SurgeryTommy John” Surgery

Graft is Graft is harvested – harvested –

PalmarisPalmaris

longuslongus

Operative TechniqueOperative Technique

Graft is passed Graft is passed and crossed in a and crossed in a figure eight patternfigure eight pattern

Operative TechniqueOperative Technique

ResultsResultsReturn to SportReturn to Sport

85 % of major league 85 % of major league

professional baseball playersprofessional baseball players

were able to returnwere able to return

Lateral EpicondylitisLateral Epicondylitis

“Tennis elbow”

Lateral EpicondylitisLateral Epicondylitis

More common by 9:1 More common by 9:1 ratio than medial ratio than medial epicondylitisepicondylitis

Degenerative process: Degenerative process: “tendinosis”“tendinosis”

Extensor Carpi Radialis Extensor Carpi Radialis Brevis (ECRB) most Brevis (ECRB) most commonly involvedcommonly involved

Lateral EpicondylitisLateral Epicondylitis

Palpate mobile wad while resisting active wrist extension

Pain at lateral epicondyle or over muscle mass usually present

No neurologic symptoms

Normal sensation

Lateral Epicondylitis Lateral Epicondylitis Conservative TreatmentConservative Treatment

Up to 90% of epicondylitis resolves Up to 90% of epicondylitis resolves spontaneouslyspontaneously Rehab focus on stretching wrist Rehab focus on stretching wrist

extensors, eccentric wrist extensorsextensors, eccentric wrist extensors Activity modificationActivity modification Anti-inflammatory medicationsAnti-inflammatory medications Counterforce bracingCounterforce bracing SteroidsSteroids

InjectedInjectedTopical –Iontophoresis / 24 Hr. Topical –Iontophoresis / 24 Hr. patchpatch

SurgerySurgery

MedialMedialEpicondylitisEpicondylitis

“Golfer’s “Golfer’s Elbow”Elbow”

Pain with resisted wrist Pain with resisted wrist flexionflexionPain with resisted Pain with resisted pronationpronationTender either within Tender either within muscle belly or directly muscle belly or directly over medial epicondyleover medial epicondyle

Medial EpicondylitisMedial EpicondylitisDiagnosisDiagnosis

Medial Epicondyle Avulsion Medial Epicondyle Avulsion FracturesFractures

Result from extreme valgus loads or violent muscle contractions during the throwing motion

Commonly occur in adolescents as the medial epicondyle begins to fuse

May report a “pop”

Tender at medial epicondyle, ecchymosis present medially

Medial Epicondyle Avulsion Medial Epicondyle Avulsion FracturesFractures

Medial Epicondyle Avulsion Medial Epicondyle Avulsion FracturesFractures

Panner’s DiseasePanner’s Disease

Osteochondrosis of Osteochondrosis of the capitellumthe capitellum

Elbow’s version of Elbow’s version of Legg-Calve-Perthes Legg-Calve-Perthes DiseaseDisease

Presents with lateral Presents with lateral elbow pain and elbow pain and perhaps stiffness in perhaps stiffness in an active youngsteran active youngster

Panner’s DiseasePanner’s Disease

Usually seen in Usually seen in children less than children less than age 10age 10

Fragmentation of Fragmentation of the capitellum the capitellum usually seen on usually seen on xraysxrays

Panner’s DiseasePanner’s Disease

Panner’s DiseasePanner’s Disease

TreatmentTreatmentOrthopedic referral appropriate as is MRIOrthopedic referral appropriate as is MRIStop offending activities - typically throwing Stop offending activities - typically throwing (baseball) or handsprings (gymnastics) (baseball) or handsprings (gymnastics) Rest elbow – may consider splinting for a few Rest elbow – may consider splinting for a few weeksweeksTypically symptoms will resolve in a few months Typically symptoms will resolve in a few months and capitellum ossification will normalize within 2 and capitellum ossification will normalize within 2 years years Long term prognosis excellent in most casesLong term prognosis excellent in most cases

Osteochondritis Dissecans (OCD) Osteochondritis Dissecans (OCD) of the Capitellumof the Capitellum

OCD is a localized lesion in which a segment of OCD is a localized lesion in which a segment of subchondral bone and articular cartilage subchondral bone and articular cartilage separates from the underlying bone separates from the underlying bone Presents with lateral elbow pain and perhaps Presents with lateral elbow pain and perhaps stiffness in an active youngsterstiffness in an active youngsterUsually seen in children older than age 12Usually seen in children older than age 12Focal area of lucency in the subchondral bone in Focal area of lucency in the subchondral bone in the anterior aspect of the capitellumthe anterior aspect of the capitellumPrognosis worsePrognosis worse

Osteochondritis Dissecans of the Osteochondritis Dissecans of the CapitellumCapitellum

Osteochondritis Dissecans of the Osteochondritis Dissecans of the CapitellumCapitellum

Physical examPhysical examLateral elbow pain with tenderness directly over Lateral elbow pain with tenderness directly over the capitellumthe capitellumSmall effusion may be noted. Small effusion may be noted. Limited range of motion is typically observed Limited range of motion is typically observed with approximately 20° of extension losswith approximately 20° of extension lossCrepitus may be present in the radiocapitellar Crepitus may be present in the radiocapitellar joint with active or passive forearm rotationjoint with active or passive forearm rotationMay also complain of locking & catching, which May also complain of locking & catching, which may indicate a loose bodymay indicate a loose body

Osteochondritis Dissecans of the Osteochondritis Dissecans of the CapitellumCapitellum

TreatmentTreatment

Orthopedic referral appropriate as is MRIOrthopedic referral appropriate as is MRI

Stop offending activities - typically throwing Stop offending activities - typically throwing (baseball) or handsprings (gymnastics) (baseball) or handsprings (gymnastics)

Rest elbow – consider splinting for a few weeksRest elbow – consider splinting for a few weeks

Treatment will depend on symptomsTreatment will depend on symptoms

Long term prognosis more guarded – may Long term prognosis more guarded – may require surgeryrequire surgery

Osteochondritis Dissecans of the Osteochondritis Dissecans of the CapitellumCapitellum

Surgical indicationsSurgical indicationsSymptomatic loose bodies Symptomatic loose bodies Articular cartilage fracture Articular cartilage fracture Displacement of the osteochondral lesion Displacement of the osteochondral lesion

Surgical management of OCD lesionsSurgical management of OCD lesionsExcision of loose bodies or partially attached lesions Excision of loose bodies or partially attached lesions Abrasion chondroplasty or subchondral drilling. Abrasion chondroplasty or subchondral drilling. Results of internal fixation of the loose fragment varyResults of internal fixation of the loose fragment varyNew techniques to harvest cartilage from the knee and New techniques to harvest cartilage from the knee and transplant into the elbow promisingtransplant into the elbow promising

Distal Biceps RuptureDistal Biceps Rupture

Usually dominant extremityUsually dominant extremity

Male (often weight lifters) Steroids?!?Male (often weight lifters) Steroids?!?

Mean age of 50 (reported 18 to 72)Mean age of 50 (reported 18 to 72)

Biceps Rupture - MechanismBiceps Rupture - Mechanism

Often a single traumatic eventOften a single traumatic event

Unexpected eccentric extension force Unexpected eccentric extension force applied to an arm at 90 degrees of applied to an arm at 90 degrees of flexionflexion

“Popeye” muscle

Rupture of Distal Biceps Rupture of Distal Biceps TendonTendon

AROM/PROM may be WNL but RROM AROM/PROM may be WNL but RROM limited due to pain with elbow flexion and limited due to pain with elbow flexion and forearm supinationforearm supination

Almost always treated surgically followed Almost always treated surgically followed by progressive ROM and strengthening by progressive ROM and strengthening programprogram

Olecranon BursitisOlecranon Bursitis

Typically due to direct Typically due to direct traumatraumaUsually easily treated Usually easily treated with rest, modalities with rest, modalities compression, and compression, and NSAIDsNSAIDsIf persists, may be If persists, may be aspirated – risk of aspirated – risk of infectioninfection

Neurologic InjuryNeurologic Injury

Ulnar nerveUlnar nerve At elbow (cubital tunnel) or wristAt elbow (cubital tunnel) or wrist

Median nerveMedian nerve At elbow or wrist (carpal tunnel)At elbow or wrist (carpal tunnel)

Radial nerveRadial nerve Least involved with overuseLeast involved with overuse

Sensory ExaminationSensory Examination

RadialRadial First dorsal webspace of handFirst dorsal webspace of hand

UlnarUlnar Pad of pinky fingerPad of pinky finger

MedianMedian Pad of index fingerPad of index finger

Tinnel’s TestTinnel’s Test

Gentle percussion of the ulnar nerve Gentle percussion of the ulnar nerve above or within the cubital tunnel above or within the cubital tunnel should not elicit pain in the normal should not elicit pain in the normal elbowelbow Pain or paresthesias into the ring and Pain or paresthesias into the ring and

small fingers with tapping over the small fingers with tapping over the ulnar nerve in the cubital tunnel is ulnar nerve in the cubital tunnel is considered a positive testconsidered a positive test

Elbow DislocationsElbow Dislocations

Typically results from hyperextension, trochlea Typically results from hyperextension, trochlea levered over coronoid processlevered over coronoid process

Vast majority are posterior with most common Vast majority are posterior with most common direction being posterolateraldirection being posterolateral

Involve injury to most ligamentous structures, Involve injury to most ligamentous structures, and potential for injury to neurovascular and potential for injury to neurovascular structures – if stable post-reduction, treat structures – if stable post-reduction, treat conservatively and if unstable, treat surgicallyconservatively and if unstable, treat surgically

Posterior Elbow DislocationPosterior Elbow Dislocation

FracturesFractures

HumerusHumerus

RadiusRadius

UlnaUlna

Humerus FracturesHumerus Fractures

Supracondylar Supracondylar fracturefracture

Supracondylar Supracondylar fracture with posterior fracture with posterior elbow dislocationelbow dislocation

Humerus FracturesHumerus Fractures

Most common in Most common in children/adolescents from children/adolescents from fall on flexed elbow or fall on flexed elbow or hyperextension hyperextension mechanismmechanismDeformity present if Deformity present if displaced, often missed displaced, often missed on initial evaluation if on initial evaluation if nondisplacednondisplacedOften requires surgery if Often requires surgery if displaceddisplaced

Ulnar FracturesUlnar Fractures

Olecranon process Olecranon process fracturesfractures If stable/nondisplaced, If stable/nondisplaced,

short immobiliazation short immobiliazation period (45-90 degrees period (45-90 degrees of flexion)of flexion)

If displaced, ORIF with If displaced, ORIF with longer immobilization longer immobilization period and early ROM period and early ROM if toleratedif tolerated

Radial FracturesRadial Fractures

Radial head Radial head fracturefracture

Radial neck Radial neck fracturefracture

Most treated non Most treated non operativelyoperatively

Thank you!!!Thank you!!!