The Elbow



Sports Medicine

Unit 18

Elbow

Bones

1

a.

b.

I. What movements does the elbow perform?

a. Flexion

b.

c. Pronation

d.

II. Muscles in motion

a. FLEXION

i. (supinated)

ii. Brachialis (pronated)

iii. (neutral)

iv. Prime movers depends on position of the forearm

b. EXTENSION

i.

a. Primary mover

ii. Anconeus

a. Secondary mover

c. SUPINATION

i.

a. Primary mover

ii. Biceps brachii

a. Secondary mover

iii. Brachioradialis

a. Secondary mover

b. Also pronates forearm from a supinated position

d. PRONATION

i.

ii. Pronator quadratus

iii. Primary movers

III. Tendons

a. Biceps

b. Triceps

c.

d.

Joints

e. Humeroulnar joint

i.

ii. Allows for flexion and extension

f. Humeroradial joint

i. Humerus and radius

ii.

iii.

IV. Ligaments

a. Medial – resists _________________ stress

i. (UCL)

ii. three bands

a. anterior oblique band

a. medial epicondyle to coronoid process

b. restrains against valgus stress

b. transverse band

a. medial epicondyle to coronoid process

c. posterior oblique band

a. medial epicondyle to olecranon process

b. Lateral – resists ________________ stress

i. (LCL)

ii. Main lateral stabilizer

a. Middle of the lateral epicondyle to ulnar tuberacle

c. __________________collateral ligament

i. Thickened capsule

ii. Lateral epicondyle to annular ligament

iii. Maintain close relationship between humeral head and radial head

d. _________________ ligament

i. Encircles the radial head

ii. Permits internal/external rotation of radius on ulna

e. Interosseous membrane

i. Dense band of fibrous connective tissue

ii. Obliquely between radius to the ulna

iii. Transmits forces

iv. Attachment point for muscles

Assessment of the elbow

f. History

i. Past history

ii.

iii. When and where does it hurt?

iv. Motions that increase or decrease pain

v.

vi. Sounds or feelings?

vii. How long were you disabled?

viii. Swelling?

ix. Previous treatments?

g.

i. Deformities and swelling?

ii.

a. Cubitus valgus versus cubitus varus

iii. Flexion and extension

a. Cubitus recurvatum

iv. Elbow hyperextension?

h.

i. Be sure to check sites of pain and deformity

ii. Assess epicondyles, olecranon, distal aspect of humerus and proximal aspect of ulna

iii. __________________ – muscles, tendons, joint capsules and ligaments surrounding joint

i.

i. Methods to assess elbow and forearm injuries include:

a. ROM test for elbow flexion

b. ROM test for elbow extension

c. ROM test for elbow supination

d. ROM test for elbow pronation

e. Manual muscle tests

a. Flexion strength test

b. Extension strength test

c. Supination strength test

d. Pronation strength test

V. _________________________ of elbow/forearm injuries

a. Vulnerable to a variety of acute and chronic injuries

b. _________________ gear is always recommended to reduce severity of injury

c. Chronic injury reduction

i. _______________________ (baseball, tennis)

ii. Utilize proper mechanics

iii. Use ___________________ that is appropriate for skill level

iv. Maintain appropriate levels of strength, flexibility, and endurance for activity

VI. Injuries

a. Fractures

b. Dislocations and subluxations

c. Contusions

d. Sprains

i. Valgus stress test for the elbow

ii. Varus stress test for the elbow

e. Impingement

i. Tinel’s sign

f. Synovitis and bursitis

g. Biceps brachii rupture

h. Epicondylitis

i. Volkmann’s contracture

VII. Common Injuries

a.

i. Cause of Injury

a. Superficial location makes it extremely susceptible to injury (acute or chronic) --direct blow

ii. Signs of Injury

a. Pain,

b. Swelling will appear and w/out usual pain and heat

a. Contusion

i. Cause of Injury

1. Vulnerable area due to ______________________

2. Result of direct blow or repetitive blows

ii. Signs of Injury

1. _________________ (rapidly after irritation of bursa or synovial membrane)

iii. Care

1. Treat w/_______________ immediately for at least 24 hours

2. If severe, refer for X-ray to determine presence of fracture

3. In acute conditions, ice

4. Chronic cases require protective therapy

5. If swelling fails to resolve, aspiration may be necessary

6. Can be padded in order to return to competition

b. Elbow Sprains

i. Cause of Injury

1. Elbow hyperextension or a ________________ force (often seen in the cocking phase of throwing

ii. Signs of Injury

1. Pain along _____________ aspect of elbow

2. Inability to grasp objects

3. Point tenderness over the MCL

iii. Care

1. Conservative treatment begins w/ RICE elbow fixed at 90 degrees in a sling for at least 24 hours

2. Coach should be concerned with gradually regaining elbow full ROM

3. Athlete should _____________________

4. Gradual progression involving an increase in number of throws while range and strength return

c. Lateral Epicondylitis (________________________)

i. Cause of Injury

1. Repetitive ____________________to insertion of extensor muscles of lateral epicondyle

ii. Signs of Injury

1. Aching pain in region of lateral epicondyle after activity

2. Pain worsens and ____________________ and hand develop

3. Elbow has decreased ROM; pain w/ resistive wrist extension

iii. Care

1. RICE, NSAID’s and analgesics

2. ROM exercises and PRE, deep friction massage, hand grasping while in supination, avoidance of pronation motions

3. Mobilization and stretching in pain free ranges

4. Use of a counter force or neoprene sleeve

5. Proper mechanics and equipment instruction is critically important

d. ___________________________ Epicondylitis (Little league elbow)

i. Cause of Injury

1. Repeated forceful flexion of wrist and extreme valgus torque of elbow

ii. Signs of Injury

1. Pain produced w/ forceful flexion or extension

2. _______________ and mild swelling

3. Passive movement of wrist seldom elicits pain, but active movement does

iii. Care

1. Sling, rest, cryotherapy or heat through ultrasound

2.

3. Curvilinear brace below elbow to reduce elbow stressing

4. Severe cases may require splinting and complete rest for 7-10 days

e. Ulnar Nerve Injuries

i. Cause of Injury

1. Pronounced cubital valgus may cause deep friction problem

2.

3. Traction injury from valgus force, irregularities w/ tunnel, subluxation of ulnar nerve due to lax impingement, or progressive compression of ligament on the nerve

ii. Signs of Injury

1. Generally respond with ___________________________

iii. Care

1. Conservative management – avoid aggravating condition

2. Surgery may be necessary if stress on nerve can not be avoided

f. Dislocation of the Elbow

i. Cause of Injury

1. High incidence in sports caused by _____________________________________________________________________________

ii. Signs of Injury

1. Swelling, severe pain, _________________

2. May be displaced backwards, forward, or laterally

3. Complications w/ median and radial nerves and blood vessels

4. Rupture and tearing of ___________________ will usually accompany the injury

iii. Care

1. Immobilize and refer to physician for reduction

2. Following reduction, elbow should remain splinted in flexion for 3 weeks, then rehab

g. Fractures of the Elbow

i. Cause of Injury

1.

2. Fracture can occur in any one or more of the bones

3. Fall on outstretched hand often fractures humerus above condyles or between condyles

ii. Signs of Injury

1. May or may not result in visual deformity

2. Hemorrhaging, swelling, muscle spasm

iii. Care

1. Ice and sling for support – ______________________

h. Elbow Osteochondritis Dissecans

i. Cause of Injury

1. Impairment of blood supply to anterior surface resulting in degeneration of articular cartilage, and bone creating loose bodies within the joint

ii. Signs of Injury

1. Sudden pain, locking; range usually returns in a few days

2. Swelling, pain and crepitation may also occur

iii. Care

1. If repeated locking occurs, loose bodies may be removed surgically

2. Without removal, arthritis may develop

i. Volkmann’s Contracture

i. Cause of Injury

1. Associate w/ humeral supracondylar fractures, causing muscle spasm, swelling, or bone pressure on brachial artery, inhibiting circulation to forearm

2. Can become permanent – muscle contraction/paralysis

ii. Signs of Injury

1. Pain in forearm - increased w/ passive extension of fingers

iii. Care

1. Immediate referral is necessary

2. Time is of the essence

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