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6002 Elbow Cheat Sheet by

6002 Elbow conditions

Cubital tunnel syndrome (CTS)

- Entrapment neuropathy caused by compre­ssion the median nerve in the carpal tunnel
Aetiology (risk factors):
- Typically in 40 - 60 yrs
- 1-5% in general population
- F>M (3:1)
- Risk factors: carpal tunnel modifi­cat­ions, fluid imbalance, neurop­athic factors
- Examples: carpal disloc­ati­on/­sub­lux­ation, radius #, arthritis, cysts/­tum­ours, pregna­ncy­/me­nop­ause, obesit­y/k­idney failur­e/h­ypo­thy­roi­dism, oral contra­cep­tiv­es/­heart failur­e/d­iab­ete­s/a­lco­holism, vitamin defici­enc­y/t­oxicity
- Caused by various factors
- Involves compre­ssion & traction affecting the median n.
- Compre­ssion leads to increased pressure, obstru­ction of venous outflow, localised edema, & impaired microc­irc­ulation of the median n.
- Lesions on the myelin sheath & axon cause inflam­mation & loss of normal physio­logical functions of surrou­nding tissues
- Worsening structural integrity of the nerve exacer­bates the dysfun­ctional environment
- Repeated traction & wrist movements further injure the nerve
- Inflam­mation of any of the 9 flexor tendons passing through the carpal tunnel can compress the median nerve
- Sensory fibres are often affected before motor fibres, & autonomic nerve fibres may also be affected
Clinical presen­tation:
- Numbness, tingling, & px in the thumb, 2nd, & radial portions of the 4th digits
- Ssx worsen at night
- Variab­ility in Ssx distri­bution from wrist to shoulder
- Initially interm­ittent, worsen w/ activities like driving, reading, painting
- Nighttime exacer­bation, relieved by shacking hand/wrist
- Leads to permanent sensory loss, muscle weakness, & clumsiness
- Challenges in tasks like opening doorknobs & buttoning clothes
- Dominant hand usually affected first
Physical examin­ation:
- Sensory loss or weakness in median n. distribution
- Thenar eminence spared in sensory loss
- Diminished thumb ABD & opposition strength, thenar eminence atrophy
- Tinel's sign
- Carpal tunnel compre­ssion test
- Phalen's test
- Median n. tension test
- Motor & sensory testing
- 70-90% of mild to moderate cases respond to conser­vative care
- Some degree of recurr­ence, even after surgery
- Pts w/ CTS 2° to diabetes or wrist # have less favourable prognosis
- Nerve release
- Support brace at night
- Taping
- Brachial plexopathy
- Cx myofascial px
- Cx spondylosis
- Compar­tment syndrome
- Ischemic stroke
- Monone­uritis multiplex
- Multiple sclerosis
- Median neuropathy in the forearm
- Motor neuron disease
- Diabetic neuropathy
- Cx radiculopathy
- Overuse injury
- Traumatic brachial plexopathy
- Neuropathies
- Tendonitis
- Tenosynovitis

Extensor tendin­opathy*

- Also known as tennis elbow & lateral epicon­dylitis
- Overuse injury
- Occurs due to eccentric overload of the extensor carpi radialis brevis (ECRB) tendon
- Results from repetitive strain during activities involving gripping, wrist EXT, radial deviation, & forearm supination
- Common in tennis, squash, & badminton
Aetiology (risk factors):
- Most common cause of elbow Ssx
- F=M
- More common in pts >40 yrs
- Risk factors: smoking, obesity, repetitive movement for at least 2 h daily, & vigorous activity (loads >20kg)
- Condition: degene­rative overuse process
- involves: extensor carpi radialis brevis & common extensor tendon
- Findings: granul­ation tissue, micro-­rup­ture, abundance of fibrob­lasts, vascular hyperp­lasia, instructed collagen, lack of inflam­matory cells
Clinical presen­tation:
- Px w/ an insidious onset
- Overuse Hx is common, often w/o a specific traumatic event
- Px occurs 1-3 days after unaccu­stomed activities involving repeated wrist EXT
- Triggers: new equipment use or atypical workout circumstances
- Acute injuries or strains (e.g. lifting heavy objects, hard backhand swing)
- Acute injuries may lead to chronic overuse injury
- Px is usually located over the lateral elbow
- Worsens w/ activity, improves w/ rest
- Px severity varies, from mild discomfort during activities to severe px triggered by simple tasks (e.g. picking up coffee)
Physical examin­ation:
- Point of max. tenderness usually over lateral epicondyle or slightly distal
- Discomfort may extend along the tendon, w/ tightness in connecting muscle
- Px exacer­bated by resisted wrist EXT, especially w/ EXT elbow & pronated forearm
- Resisted middle finger EXT w/ EXT elbow partic­ularly painful, indicating increased tendon stress
- Absence of radicular Ssx or numbness/tingling
- Suggests altern­ative process such as radial n. entrapment if present, though conditions can coexist
- Sponta­neous recovery within 1-2 yrs in 80-90%
- Bracing
- Forearm stretching & strengthening
- Progre­ssion to eccentric muscle streng­thening of the common extensor tendon
- Invasive techniques if conser­vative care fails
- Surgery (if no improv­ement after 6-12 months)
- Elbow bursitis
- Cx radiculopathy
- Poster­ola­teral elbow plica
- Radial n. entrapment
- Radial n. syndrome
- Occult fracture
- Capitellar osteoc­hon­dritis dissecans
- Triceps tendinitis
- Radioc­api­tellar OA
- Shingles

Flexor tendin­opathy

- Also known as medial epicon­dylitis, pronator tendin­opathy, & golfer's elbow
- Overload or overuse of the medial common flexor tendon
- Medial epicondyle is a common origin: pronator teres, flexor carpi radialis, palmar is longus, flexor digitorum superf­ici­alis, & flexor carpi ulnaris
- Innervated by median n.
- Together, they form the conjoined FX tendon (3cm long)
- This tendon crosses the medial ulnohu­meral joint & acts as a 2° stabiliser parallel to the ulnar collateral ligament
Aetiology (risk factors):
- 90% of cases are not sports related
- F>M
- 45-64 yrs
- Athlete risk factors: training errors, improper technique, equipment, lack of strength, endurance, flexibility
- Occupation risk factors: heavy physical work, excessive repeti­tion, high BMI, smoking, comorb­idi­ties, high psycho­social work demands
- General risk factors: smoking, overuse, dominant arm, DM 2
- Caused by overuse tendin­opathy from repetitive loading of wrist flexors & pronator teres
- Leads to angiof­ibr­obl­astic changes in the affected tendons
- Repetitive activity causes microtears in the tendon, resulting in tendonosis
- All muscles may be affected equally, except for palmaris longus
- Bony inflam­mation is not involved in this condition
- Microtears lead to collagen fibre remode­lling & increased mucoid ground substance
- Focal necrosis or calcif­ication can develop in the tendon
- Collagen strength decreases over time, leading to increased fragility & scar tissue formation
- Acute trauma can also cause medial epicon­dylitis from sudden violent muscle contra­ctions, though less common
Clinical presen­tation:
- Hx of acute traumatic blow or repetitive elbow use, gripping, or valgus stress
- Aching px on the medial or ulnar side of the elbow, which radiates from the epicondyle into the forearm & wrist
- Exacer­bated: forearm motion, gripping, or throwing activities (overhead throwing, tennis, golf)
- Relief: rest
- Elbow stiffness, weakness, numbness, or tingling, 1° in an ulnar n. distribution
- Chronic cases may exhibit weakness w/ grip strength
- Ulnar n. Ssx in up to 20%
Physical examin­ation:
- Acute cases: swelling, erythema, or warmth
- Chronic cases: less likely to show abnormalities
- Tender­ness: 5-10mm distal & anterior to medial epicondyle
- Pronator teres & flexor carpi radialis involvement
- Px elicited by resisted pronation or FX of wrist
- Weakness in affected arm
- ROM typically normal
- Golfer's elbow test: px during manoeuvre
- Tinel's test: +ve for ulnar neuropathy
- Valgus stress test: stressing ulnar collateral ligament (espec­ially throwing athletes)
- Good prognosis
- Conser­vative care: aims for full, painless motion at wrist & elbow
- Strength exercises w/ focus on eccentric activity
- Dry needling, shock wave therapy, etc.
- Night splinting
- Elbow taping
- Cortic­ost­eroid inject­ions, US, platel­et-rich plasma injections
- Surgery
- Neurop­athy: C6 or C7 radicu­log­pthy, CTS, ulnar/­median neurop­athy, ulnar neuritis, anterior intero­sseous n. entrap­ment, tardy ulnar n. palsy
- Ligame­ntous injury: ulnar / medial collateral ligament instab­ility, sprain, tear
- Intra-­art­icular issues: adhesive capsul­itis, arthro­fib­rosis, loose bodies
- Osseous concerns: medial epicondyle avulsion fracture, osteophytes
- Myofascial diffic­ulties: flexor / pronator strain
- Tendin­opathy: lateral epicon­dyl­itis, triceps tendonitis
- Synovitis
- Valgus extension overload
- Herpes zoster (derma­tol­ogical)

Myositis ossificans (MO)

- Benign, self-l­imiting ossifying lesion that can affect any type of soft tissue
- Most common form of hetero­trophic ossifi­cation (HO), usually within large muscles
Aetiology (risk factors):
- M>F
- 1° in young adults as result of trauma
- Metaplasia of the intram­uscular connective tissue resulting ion extra osseous bone formation (w/o inflammation)
- Histol­ogi­cally can appear similar to osteos­arcoma, thus, can lead to inappr­opriate management
3 stages:
Stage 1 (0-4 weeks):
- Following injury
- Inflam­matory cascade that preceded ossification
- Calcif­ication not apparent radiographically
Stage 2 (4-8 weeks):
- Calcif­ication becomes radiog­rap­hically seen
Stage 3:
- Peripheral bone formation
- Lamellar cortical & trabecular bone
Clinical presen­tation:
- Onset followed by trauma, repetitive trauma
- Px, joint stiffness, oedema
- Lesion causes mechanical irritation of bursa, tendon, joint
Physical examin­ation:
- Px durance longer than of a sprain/strain
- Decreased ROM
- Up to 70% of cases are asymptomatic
- Prognosis good after surgery
- Very little than can be done to accelerate the resorptive process (i.e. process of removing bone from the bruised region)
- Rest from aggrav­ating activities
- Implem­ent­ation of gentle px-free ROM exercises
- Surgical resection of mature bone once it has fully matured
- Can take 12-18 months after initial presentation
- Surgery only if there will be improv­ement in function as demons­trated by mobility, transfers, hygiene, & ADLs
- Osteos­arcoma

Olecranon bursitis / Miner's elbow

- Inflam­mation of the synovial bursa
- Suscep­tible to trauma & infection due to superf­icial location, limited vascul­arity
Aetiology (risk factors):
- M>F
- 30-60 yrs
- Underlying inflam­matory condit­ions: RA, psoriatic arthritis, gout, etc
- Chronic medical condit­ions: diabetes, alcoho­lism, HIV
- Infection usually occurs through a transc­uta­neous route due to poor vascul­arity, often from direct inocul­ation via mild trauma
- Inciting events (trauma or infect­ious), trigger reactive inflam­mation in the bursa
- Leads to the extrav­asation of protein & synovial type fluid into the affected bursa
- Conseq­uence is the develo­pment of a pronounced round swelling charac­ter­istic of this condition
- Trauma causes bleeding within bursa & release of inflam­matory mediators, increasing recurrence risk
Clinical presen­tation:
- Swelling over the olecranon process
- Initially, doesn't restrict elbow movement, setting it apart from swelling within the joint
- Swelling can progress & eventually limit elbow movement
- Charac­ter­istic appearance is round or "golf ball" shaped due to fluid confin­ement within the bursa
Physical examin­ation:
- Caused by infection shows signs of erythema & tenderness
- Systemic Ssx like fever & malaise can accompany infectious bursitis
- Fever is present in around 70% of septic bursitis cases, but its absence doesn't rule out infection entirely
- Low risk of progre­ssion to systemic infection from infectious bursitis in healthy pt
- Self-l­imiting & managed conservatively
- Elastic bandage application
- Cortic­ost­eroid injections (risk of iatrogenic infection)
- Bursectomy considered for related episodes, especially w/ underlying bone spur
- Recurrent non-in­fective bursitis w/o a spur may benefit from surgical bursa excision
- Requires antibiotics
- Aspiration & drainage are recommended
- Oral antibi­otics for 7 days (longer courses don't reduce recurrence)
- Bursectomy may be necessary
- Systemic infection warrants further evaluation & approp­riate treatment for sepsis or septic shock
- Cutaneous abscess
- Hematoma
- Olecranon fracture
- Cellulitis
- Tendon rupture
- Septic arthritis
- Gouty arthritis
- Neoplasm
- Ligament rupture

Posterior intero­sseous nerve entrapment

- Compre­ssion neuropathy of the posterior intero­sseous n. (branch of radial n.)
- Passes through radial tunnel (Arcade of Frohse)
- Results in paresis & paralysis of the finger & thumb EXT
- Preserves wrist EXT due to innerv­ation patterns
Aetiology (risk factors):
- M>F (2:1)
- Dominant arm
- Trauma or space-­occ­upying lesions (RA, brachial neuritis, sponta­neous compression)
- Most common site: Arcade of Frohse (proximal edge of supinator)
- Also repetitive pronat­ion­/su­pin­ation
- Nerve injury severity varies based on compre­ssion severity
3 categories of nerve injury:
- Neurop­raxia: mildest form, demyel­ina­tion, from compre­ssi­on/­tra­ction, slows conduc­tion, may cause muscle weakness, -ve Tinel sign, recovery prognosis: days to 12 weeks
- Axonot­mesis: demyel­ination & axon damage, muscle weakness, may have +ve Tinel sign
- Neurot­mesis: severe, nerve completely transe­cted, no nerve conduc­tion, surgical correction needed for recovery
Clinical presen­tation:
- Hx of trauma or fracture of the extremity
- Can be present in Monteggia fractures or radial head fractu­re-­dis­loc­ations
Physical examin­ation:
- Weakness w/ finger EXT
- When asked to make a fist, wrist may deviate radially due to extensor carpi ulna's weakness
- Depending on injury severity, may be +ve Tinel sign
- Pretty good prognosis
- Pts continue to improve months after surgery
- Athletes may return to play once full ROM & strength
- Splinting
- Physical therapy
- Activity modification
- Unsucc­essful conser­vative therapy for at least 3 months
- Radial tunnel syndrome: same sites of compre­ssion, however presents w/ forearm px w/o motor weakness
- Wartenberg syndrome: compre­ssion of superf­icial sensory radial n., no motor weakness, may present w/ parest­hesia / numbness / ill-de­fined px over the dorsal radial aspect of hand

Pronator teres syndrome (PTS)

- Compre­ssion of the median n. by the pronator teres muscle in the forearm
- Innerv­ation: C6-7
Aetiology (risk factors):
- Rare & often overlooked & mistaken for CTS
- M>F
- Especially common in pts w/ additional fibrous bands
- PTS can occur due to: local trauma, compre­ssion w/ Schwanoma (rare tumour), & pts undergoing antico­agu­lation therapy & renal dialysis
Quick & repetitive grasping or pronation movements can lead to PT muscle hypert­rophy & entrapment of the median n.
Clinical presen­tation:
- Px in volar forearm region
- Weakness may be significant
- Muscle wasting rare, but mild weakness in: flexor pollicis longus (FPL), abductor pollicis brevis (APB), some involv­ement of flexor digitorum profundus (FDP) in 2nd & 3rd digits
- PT commonly spared due to early innerv­ation
Physical examin­ation:
- Reprod­uction: resisted pronation + FX of elbow
- +ve Tinel sign over proximal edge of PT
- +ve Phalen test over PT muscle in 50%
Variable sensory loss:
- Involving palm or mimicking CTS
- Including thenar eminence, thumb, index, middle, & ring fingers
- Good prognosis
- Light duty in 3-6 weeks (conse­rvative care speeds up)
- Surgical cases: light duty in 6-8 weeks, regular duty in 10-12 weeks
- Rest, activity modifi­cation, NSAIDs, physical therapy
- Pts may usually continue work unless prominent motor or sensory deficits are present
- Surgery considered after fail of >6 weeks of conser­vative care
- AIN s.
- Ligament entrapments
- MN entrapment of hypert­rophied lacertus fibrosis (bicipital aponeurosis)
- Brachial plexus injury
- Cx radicu­lopathy

Pulled elbow

- Also Nursemaid elbow or radial head sublux­ation
- Common injury in young children
- Radial head sublux­ation caused by axial traction resulting in px & inability to supinate forearm
Aetiology (risk factors):
- 1-4 yrs
- 20% of upper extremity injuries in children
- Less common in >5 yrs because annular ligament streng­thens w/ age
- F>M
- Recurrence rate: 20%
- Trauma: axial traction on pronated forearm + elbow EXT
- Lifted­/swung by arms or pulling child's arm to prevent fall
- Displa­cement of the annular ligament leads to discomfort & px during arm movement
- Longit­udinal traction (e.g. baby rolling onto their arm) can also lead to radial head sublux­ation (<6 months old)
Clinical presen­tation:
Child's behaviour:
- Often nervous & may support affected arm protec­tively w/ opposite hand
- Arm held in complete or almost complete EXT + pronation
- Refusal to move the arm & becoming upset during examination
- Generally no px unless the arm is manipulated
Caregivers may report:
- Arm pulled upwards by the wrist or swung around by the arms prior to Ssx onset
- No known trauma or awareness of the incident causing the injury
- Onset of Ssx after FOOSH (less common)
Physical examin­ation:
- Tenderness at radial head
- Resistance to forearm pronation, supina­tion, FX, & EXT
- Absence of ecchym­osis, erythema, edema, or signs of trauma
- Intact circul­ation, sensation, & motor ability distal to the elbow
- Possible lack of cooper­ation w/ the exam
- Sponta­neous reduction: radial head may sponta­neously reduce before exam, reassu­rance to parents after exam is usually sufficient
Closed reduction (brief but potent­ially painful):
- Px resolves post-r­edu­ction (within minutes)
- Techniques for reduction: hyperp­ron­ation (prefe­rred) & supination/FX
- Arm function should be regained post-r­edu­ction; imaging if not
- Referral to orthop­aedic surgeon if arm not used post-reduction
- No splinting or sling required
Post-t­rea­tment instru­ctions:
- Avoid activities causing axial traction to arm to prevent recurrence
- Excellent prognosis post-r­edu­ction
- Elbow fracture
- Fractured wrist
- Green stick fracture
- Hand injury
- Monteggia fracture
- Syprac­ondylar fracture
- Soft tissue damage of hand

Medial collateral ligament sprain*

- Stretching or tearing of ligaments, due to abnormal or excessive forces applied to a joint
- Classified in 3 grades
Grade 1:
- Mild stretching of the ligament complex w/o joint instab­ility
Grade 2:
- Partial rupture of the ligament complex w/o joint instab­ility
Grade 3:
- Complete rupture of the ligament complex w/ instab­ility of the joint
Causes of MCL injury:
- Overst­retched in a single incident, e.g. unnatural bending or twisting of elbow
- Repetitive ligament stretc­hing, e.g. overhead throwing activities
Outcome of MCL injury:
- Increased valgus stress
- Grade 1-2: 2-6 weeks & high-end sports in 8 weeks
- Grade 3 ruptures: signif­icantly longer rehabi­lit­ation depending on whether surgical interv­ention was required & how much damage is present


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