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Anatomy Articulations

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Humeroulnar Humeroradial Proximal radioulnar

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Anatomy • Carrying Angle • __1_ angulation • Males: __2_ • Females: __3_

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1. Valgus 2. 11° - 14° 3.13° - 16°

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Medial Ligament Complex • Ulnar Collateral Ligament (UCL) • Anterior bundle • Taught in __1_. provides__2_ • Posterior bundle Taught in __3_ • Transverse bundle

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1. extension 2. majority of stability 3. flexion

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which structures provide restraint to valgus stress?

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joint articulations medial ligaments joint capsule

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• Radial collateral ligament Taught__1_ •___2_: primary restraint to varus stress o primary restraint to varus stress • Accessory collateral ligament. Blends with __3_ o these 2 together help stabilize prox radal ulanr joint. Less bony congruence on radial vs. ulnar side •___4_ Stabilizes proximal radioulnar joint • __5_ taught with supination • __6_ taught with pronation

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1. throughout ROM 2. Lateral UCL 3. annular ligament 4. •Annular ligament 5. Anterior 6. Posterior

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restraints to varus stress include

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joint articulations lateral ligaments and joint capsule other soft tissues

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Elbow Flexors ___1_: • Strong supinator o bc of medial insertion point on radius • __2_: Poor mechanical advantage • ___3_: Strongest elbow flexor

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1. Biceps 2. Brachialis 3. Brachioradialis

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Elbow Extensors Triceps Long Head start __1_ Medial / Lateral Heads start __2_

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1. infraglenoid tubercle 2. posterior aspect of humerus

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Extensor-Supinator Group originate at __1_ include__2(6)_

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1. lateral epicondyle 2. • Supinator • Extensor Carpi Radialis Longus • Extensor Carpi Radialis Brevis • Extensor Digitorum Communis • Extensor Digiti Minimi • Extensor Carpi Ulnaris

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flexor pronator group (important in overhead athletes) originate_1__ include__2(5)_

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1. medial epicondyle 2. Pronator Teres Flexor Carpi Radialis Palmaris Longus Flexor Carpi Ulnaris Flexor Digitorum Superficialis

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Nerves • __1_ o Anterior to lateral epicondyle o Innervate extensor-supinator group • __2_ o Posterior to medial epicondyle o Innervates Flexor Carpi Ulnaris • __3_ o Innervates flexor-pronator group

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1. Radial 2. Ulnar 3. Median

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Instability • Mechanism: o _1_ Considerations o Timing Acute, Chronic, Recurrent • Articulations involved o 3 distinct joints which involved • Direction of displacement • Anterior, Posterior, Lateral, Divergent (separate) • __2_most common • Degree of displacement • Subluxation or dislocation (spontaneously reduce or not) • Presence / Absence of __3_ • Patient Presentation • s/p __4_(usually) • _5_ complaints

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1. Fall on outstretched hand 2. Posterior & posterolateral 3. fracture 4. traumatic event 5. Ulnar, median, radial nerve

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• Simple Dislocation

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• Acute soft tissue injury • No fracture o damage to muscle capsule and ligaments but bone intact

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• Complex Dislocation

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• Multiple articulations • Fractures o greater amount of force and load

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Simple Dislocation • Management (de Haan J et al. Arch Orthop Trauma Surg. 2010) o __1_reduction • anytime with dislocation first need to reduce it more often is physician unless on athletic field etc. • Stable joint post reduction __2_AROM in pain-free ROM __3_for edema __4_helps create activation in a lot of muscles and prevent atrophy Unstable joint post reduction Immobilization (cast/brace) __5_ ↑ risk of stiffness so try to keep immobilization limited to this time period •__6_ strength for stability • more stretched ligamentous structures more going to stay like that (like salt water taffy) and need to rely more on musculature

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1. Closed 2. Immediate 3. Compression garment 4. Gripping 5. >14 days 6. Pronation/Supination

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complex dislocation • Management • Reduction of dislocation • Fixation of fractures o Common fractures • __1_ (especially bc posterior dislocation is most common • "Terrible Triad"__2_ Rehabilitation • Dependent on __3_

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1. Radial head & coronoid process 2. posterior dislocation, radial head and coronoid process fracture 3. bony healing & associated injury

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Postoperative Management of "Terrible Triad" immobilization

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Immobilized at 90° 0-10 days post op Pronation: Lateral ligaments repaired: Neutral: None/both ligaments repaired

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Postoperative Management of "Terrible Triad" 1. AROM 2. strengthening

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1. Protected motion out of brace 10-15 days post-op 30° - 60° by week 6 post-op 2. no guidelines

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Elbow Fractures ___1_ • >50% of elbow fractures in children • Mechanism: Fall on outstretched arm • Fixation- ORIF vs Closed reduction Dependant on __2_

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1. Supracondylar Fracture 2. displacement

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Olecranon Fracture • Common in __1_ • Presentation o Disruption to __2_function o Displaced intra-articular joint fracture • Surgery to restore humeroulnar congruence o Complications • Loss of __3_ • __4_neuropathy (bc of where located) • Posttraumatic __5_ • __6_

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1.elderly 2. triceps 3. extension 4. Ulnar 5. arthritis 6. instability

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Radial Head Fracture • Common in__1_ • Mechanism of injury:_2_, __3_ to elbow or _4__injury

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1. females (20-60 yo) 2. Axial load on pronated forearm 3. Direct blow 4. Hyperflexion

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Radial Head Fracture Management Type I: __1_ (fractured not displaced. Not worried about having separation) o Type II-IV o __3_(to allow for better healing) o Surgical o ORIF (hardware to fixate fragments) o Radial head excision (too many pieces and cant get back together with hardware. Comminuted radial head fracture) o Radial head replacement

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1. Early motion 3. Immobilization in full extension 4.

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Radial Head Fracture Management Radial head excision Intact__1_ __2_ mass compensates ↓ strength post-op compared to ORIF

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1. UCL required (if torn wont do well) 2. Flexor-pronator

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Radial Head Fracture Management Radial head replacement Indications__1(3)_ Rehabilitation:_2_

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Type IV fracture UCL or RCL dysfunction & instability Coronoid fractures >50% 2. Immediate ROM

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Osetoarthritis Elbow Osteoarthritis Primary:__1_ • Presentation o Age: __2_ yo o Gender: __3_ o History: Repetitive use or UE weight bearing occupation o Onset: Insidious o Symptoms:__4_ o Radiographs: _5_

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1. Degenerative 2. 40-60 3. Male (more common) 4. End range pain. Loss of extension, painful locking (will use flexion as well but will have to be more signficant to impact ADLs) 5. Normal joint space with osteophyte formation (hard end feel like door hitting a doorstop)

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Elbow Osteoarthritis Secondary: __1_ • Presentation o Age: __2_ o Gender: __3_ o History: Prior trauma or surgery o Onset: s/p trauma o Symptoms:__4_ o Radiographs: __5_

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1. Prior Trauma 2. Any 3. Male or Female 4. End range pain. Loss of extension, painful locking (very similar to primary) 5. Joint space destruction with inflammatory arthritis.

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Elbow Osteoarthritis • Nonoperative Management (5)

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o Maximize flexibility o Mobilizations at elbow o Initiate at grade I-II o Shoulder strength o Modalities PRN

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Elbow Osteoarthritis Operative Management (4)

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• Debridement • Osteophyte excision • Contracture release • Total Elbow Arthroplasty is rare for OA • Limited longevity

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Total Elbow Arthroplasty (TEA) • Indications (Moro JK & King GJ, Clin Orthop. 2000) o(8)

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Advanced age (often make wait bc doesn't last that long) o Low physical demand (not laborer who uses a lot wont be successful) o Chronic instability o Advanced RA o Posttraumatic OA o Ankylosis of elbow o Elbow stiffness o Functional ROM loss (this is ppl that can't eat or drink wash face bc don't have ROM to do) o Pain (impacts function and QOL)

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Total Elbow Arthroplasty (TEA) complications (8)

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Loosening o Hardware failure o Proximal ulna fracture o Radial head impingement o Instability o Ulnar nerve sensory damage (pinky and half of ring all the way back to wrist) o Infection (with any open procedure and foreign material into body) o Posterior elbow dislocation (if not done right or components not sized correctly)

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type TEA o Unconstrained

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• Resurfacing or unlinked • Stability from soft tissue integrity & humeroulnar contact • Requires good bone stock & strong capsuloligamentous support • Rarely used in traumatic cases

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type TEA o Semiconstrained

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• Loose hinged or linked • Prosthesis alone provides stability • Preferred s/p trauma

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• Postoperative Management unconstrained TEA 1. acute 0-7 days 2. post acute 7+

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1. No ext. > 30 degrees. ROM with forearm pronated. Passive assist with extension. Resting splint at 90 degrees elbow flexion and pronation 2. No extension> 30 degrees until week 4. Forearm pronated position with ROM until week 6

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• Postoperative Management seimiconstrained TEA 1. acute 0-7 days 2. post acute 7+

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1. Extension splint (x3 days) passive assist with extension. Active assist flexion 2. AAROM begins. Day splint at 90 degrees elbow flexion until week 6. Extension splint at night until week 12

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Varus Instability Radial (Lateral) Collateral Ligament Insufficiency Elbow dislocation Varus elbow stress __1_ O'Driscoll SW. Clin Orthop. 2000 __2_ causes (someone in medical field does it to them) Over-aggressive __3_ surgery Savoi FH et al. Hand Clin. 2009 • ? Corticosteroid injection (some evidence suggest multiple will weaken attachemtn point of tendon into bone and why limit # do at one spot) Kalainov DM & Cohen MS. JBJS. 2005

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1. UE weight bearing (crutch use 2. Iatrogenic 3. lateral tendinopathy

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• Varus restraint • __1_ • Common __2_ origin • __3_capsule

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1. RCL (radial collateral ligament) (keeping in mind LUCL bc of oblique nature provides most stability) 2. extensor 3.posterolateral

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varus instability pt presentation (4)

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o Vague elbow discomfort o Lateral elbow pain o Mechanical symptoms with supination o Clicking, snapping, clunking

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varus instability physical exam o RCL Insufficiency o Varus Stress o 0° o Between 5° - 30°:__1_ o PLRI _2_(stands for_ o PLRI test of elbow/Pivot Shift of elbow • move into unstable position and will __3_. Most pts don't allow you to do this bc replicating there instability where will sublux or dislocate

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1. olecranon out of fossa 2. (push lateral rotary instability) 3. feel or hear a clunk

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Differential Diagnosis • PLRI vs. RCL insufficiency o posterior lateral rotary insufficiency vs radial collateral • need to tease these things out ___(4)

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• Lateral epicondylalgia • Wrist extensor tendinopathy vs laxity • Radial Tunnel Syndrome • Cervical Spine referral

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Varus Instability • Nonoperative Management (3)

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• Protect healing structures • Hinged brace with forearm in pronation (4-6 weeks) Avoid any varus load at elbow o no pushing pulling or carrying things • Potential benefit of strengthening o Wrist extensors o can help stability if stronger

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Radial (Lateral) Collateral Ligament Reconstruction • Indicated with ___ • Arthroscopic & open procedures have similar outcomes

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chronic instability

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Radial (Lateral) Collateral Ligament Reconstruction • Acute Phase (weeks __1_) 2. guidelines (6)

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1. 0-4 2. o Immobilization at 90° flexion with slight pronation & wrist extension for up to 2 weeks o Neutral shoulder rotation to limit lateral joint gapping o Modalities for pain control/edema o Hand/finger AROM (usually right away to help rid of fluid and get some muscle contractions) o Isometrics: triceps, biceps & shoulder musculature in brace o Manual scapular exercises

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Radial (Lateral) Collateral Ligament Reconstruction • Postoperative Phase (weeks__1_) 2. guidelines (7)

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1. 4-6 2. Elbow AROM in pronation (in brace) multiple x/day o Avoid supination due to varus stress o Grade I-II elbow mobilizations o Hand/finger AROM o Gripping exercises in pronation o Isometrics: triceps, biceps & shoulder musculature in brace o Manual scapular exercises

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Radial (Lateral) Collateral Ligament Reconstruction • Intermediate Phase (weeks __1_) 2. guidelines (6)

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1. 6-12 2. o AROM of elbow o Avoid PROM elbow extension & supination (too much load on reconstructued tissues) o Active supination with full flexion only o Grade III-IV mobilizations at elbow o Shoulder & core exercises o Maintain precautions at elbow • make sure they understand what happens at elbow with some shoulder exercises

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Radial (Lateral) Collateral Ligament Reconstruction • Advanced Phase(weeks _1__) 2. guidelines (8)

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1. 12-16 2. o Wean from brace o Strengthening in brace should be pain-free o Should have normal ROM o Progress functional activity o Avoid extension, supination & varus o Elbow strengthening begins o Low reactivity (only. Need to have little to no pain little to no swelling and no increased activation of sx with activities doing) o Begin with elbow flexors while in pronation

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Radial (Lateral) Collateral Ligament Reconstruction • Return to Sport Phase(weeks __1_) 2. guidelines (4)

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1. 16+ 2. o Upper quarter flexibility should be normal o Progress strengthening o Incorporate balance o Incorporate core stabilization o more checking in at this phase not coming in regularly

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Varus instability Posterolateral Rotary Insufficiency • Postoperative Phase (weeks __1_) •2. guidelines (4)

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1. 0-2 2. Immobilization at 45° - 90° flexion with slight pronation • Gripping activities • Shoulder isometrics • Manual scapular exercises

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Varus instability Posterolateral Rotary Insufficiency • Intermediate Phase (weeks__1_) 2. guidelines (40

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1. 2-6 2. • Progression of brace with extension block • Week 2: 60° • Week 4: 45° • Week 6: 30° • Extension performed with pronation • Active supination allowed with elbow flexion >90° (not in extension) • Avoid PROM of extension & supination

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Varus instability Posterolateral Rotary Insufficiency • Advanced Phase (weeks__1_) 2. guidelines (7)

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1. 6-16 2. • Wean from brace • Strengthening in brace should be pain-free • Should have normal ROM • Progress functional activity • Avoid extension, supination & varus • Elbow strengthening begins at week 10 • Low reactivity required (progressed well and no flare ups with things done, little pain and swelling)

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Varus instability Posterolateral Rotary Insufficiency • Return to Sport Phase (weeks _1_) 2. guidelines (2)

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1. 16+ 2. o Normalize flexibility o Initiate full strengthening of elbow

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valgus instability • _1_Insufficiency • Acute • ___2 • Insidious • Chronic overuse (throwers

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1. Ulnar (Medial) Collateral Ligament 2. Fall on outstretched hand 3.

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valus instability pt presentation (5)

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• Overhead Athlete Repetition of throwing High forces associated with Elbow extension Valgus stress ↑ with shoulder ER Pronation of supinated forearm Force during acceleration phase of throwing exceeds failure rate of UCL of cadaver specimens

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valgus instability pt presentation • C/O __1_ • Tender _2_ • Traumatic Associated injury__3(2) • Subjective: __4_

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1. medial elbow pain 2. at ulnar insertion of UCL • 2cm distal to medial epicondyle 3. Pronator flexor group, Radial head fracture (more of concern with trauma) 4. Heard or felt "pop" (if pitching ball will go wild pitch and if try to throw again wont be pretty) • Info related to throwing

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physical exam valgus instability Physical Exam ROM Examination "Instability" when __1_ • more complaints __2_ Valgus Stress Test Forearm _2__ Full Extension Flexed 5° - 30° (+) __4_

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1. forearm pronated vs. supinated 2. pronated 3. pronated 4. Greater laxity

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Milking Maneuver Shoulder __1_ Elbow__2_ Greatest__3_laxity (this position is greatest) Valgus force at elbow (+) if __4_

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1. adducted & ER 2. flexed to 70° 3. UCL 4. medial elbow pain

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Moving Valgus Stress Test (O'Driscoll SW et al. AJSM. 2005) Shoulder __1_ Elbow taken from__2_ (+) __3_ Sensitivity = 100% Specificity = 75

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1. abducted to 90° 2. full flexion & quickly extended to 30° flexion with valgus force 3. Medial elbow pain between 120° & 70°

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Valgus instability Differential Diagnosis (7)

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• Medial tendinopathy • Valgus extension overload syndrome • Postero-medial impingement • Ulno-humeral compression • Radio-capitellar overload syndrome • Elbow OA • Ulnar neuritis

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Little Leaguer's Elbow __1_ Children _2__ Adolescent Fleisig GS et al. Curr Sports Med Rep. 2009 <25 pitches ↑ Risk of elbow injury 21% 75-99 pitches ↑ Risk of elbow injury 35%

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1. Apophysitis & fragmentation 2. Avulsion of medial epicondyle

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Nonoperative Management valus instability • Successful in __1_ • Initial phase_2(3)_ • • Strengthening phase • 3(4)

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1. non-throwing athletes 2. Immobilization • Control inflammation • Avoid overhead activity 3. Flexor-pronator group (need to think about wrist flexors and pronators) • Kinetic chain approach • Core & shoulder strength (need to think prox stability) • Address GIRD

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Operative Management valgus instability • Primary repair:_1_ • Reconstruction • ↑ Success rate (Vitale MA & Ahmad CS. AJSM. 2008) • __2_graft • __3_ procedure • Docking technique o most common to have reconstruction vs. repair o difference btw techniques is # tunnels • Rehabilitation (long) 4. guidelines (4)

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1. Suture ligament to bone 2. Palmaris longus 3. "Tommy John" 4. o Protection for 2 weeks o Strength after 4-6 weeks o Interval throwing at 4 months o Competition after 9-12 months

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