Loco2 (elbow anatomy, probs) PDF

Preview

Summary

Structure of the elbow and common flexor/extensor muscles origin
Inflammatory conditions affecting the elbow : Golfer’s elbow (medial epicondylitis), Olecranon bursitis, Carpal tunnel syndrome, Cubital tunnel syndrome, Osteoarthritis, Rheumatoid arthritis, Osteochondritis dessicans, Lateral ep...

Description

Learning objectives 1. Structure of the elbow and common flexor/extensor muscles origin Structure - Hinged joint made up of the humerus, ulna and radius - Humeroulnar joint between trochlea on medial aspect of the distal end of humerus and trochlear notch on proximal ulna - Humeroradial joint between capitulum on lateral aspect of the distal end of the humerus with head of the radius - Proximal radioulnar joint enables for pronation/supination Ligaments - Medial and lateral collateral - Provides main source of stability for the elbow → holds humerus and ulna tightly together - Anular - Holds radial head tight against the ulna Muscles Flexion - Biceps brachii - 2 heads: long head originates from supraglenoid tubercle of scapula, short head originates from coracoid process of scapula → inserts via a single tendon onto radial tuberosity distal to elbow joint - Brachialis (strongest flexor) - Originates from distal half of anterior surface of humerus, located deep to the biceps brachii muscle - Forms a singular tendon that inserts onto tuberosity of ulna - Coracobrachialis - Originates from the coracoid process of scapula and inserts on the middle, inner border of humerus - Raises and adducts arm as well Extension - Triceps brachii - 3 heads: long head originates from infraglenoid tubercle of scapula, medial head from lateral aspect of humerus above radial groove and medial head from medial aspect of humerus below level of the radial groove → converges on a single tendon that inserts onto olecranon of ulna - Aconeus - Small triangular muscle that lies on elbow joint, continuation of triceps - Supplied by a branch of radial Neurovascular - Recurrent and collateral branches from brachial and deep brachial arteries - Nervous supply by median, musculocutaneous and radial nerves anteriorly, ulnar nerve posteriorly

2. Inflammatory conditions affecting the elbow a. Golfer’s elbow (medial epicondylitis) - Pain and inflammation of tendons connecting forearm to elbow → overtime the acute inflammation results in degeneration of tendons - Due to repeated/excess stress of forearm muscles (forceful motions of wrist and fingers) - Pain can come on suddenly or gradually - Higher risk if: above 40, performing repetitive activity at least 2hrs a day, obese or smoker Symptoms - Pain and tenderness on medial side of elbow → may extend along inner side of forearm - Stiffness of elbow - Weakness in hands and wrists - Numbness/tingling of ring and little fingers Diagnoses - Apply pressure to affected area of ask to move elbow/wrist/fingers in various ways - Xray → rule out other causes of pain e.g fracture/arthritis - MRI → identify any tendon tears or inflammation

Treatment - Physiotherapy to strengthen forearm muscles → use light weights - Stretch before activity to warm up muscles - Fix form to avoid overload on muscles - Use the right equipment → use lighter graphite golf clubs - Rest and ice affected area - OTC medications e.g ibuprofen, naproxen sodium, acetaminophen (tylenol) - Wear golfer’s brace → counterforce to reduce tendon and muscle strain - Surgery → if signs/symptoms don’t respond to conservative treatment in 6-12 months - Frayed part of tendon is removed from bone → endoscopic/arthroscopic - TENEX procedure → US-guided removal of scar tissue in region of tendon pain

-

b. Olecranon bursitis Irritation of the olecranon bursa → fluid accumulates

Causes - Trauma → hard blow to tip of elbow can cause bursa to produce excess fluid and swell - Prolonged pressure → bursitis develops over several months - Certain occupations e.g plumbers, aircon technicians - Infection e.g scrape/puncture wound → infected bursa produces fluid, redness swelling and pain - Medical conditions e.g rheumatoid arthritis, gout, kidney failure Symptoms - Swelling → bursa stretches causing pain - Pain worsens with direct pressure/bending of elbow - Swelling can grow large enough to restrict elbow motion - Redness and warm to touch → if infected - If infection not treated immediately, can spread to other parts of the arm/move into bloodstream → can also break open to release pus Diagnoses - X-rays → look for foreign body/bone spur/calcium deposit - Fluid testing → sample of bursal fluid to diagnose whether bursitis is caused by infection or gout Treatment - Aspiration of bursa (infection) → fluid removal helps relieve symptoms and identify the antibiotic needed to fight the infection - Elbow pads for cushioning - Medications e.g ibuprofen → reduce swelling and relieve symptoms - Corticosteroid injection → if swelling and pain still there after 3-6 weeks - Stronger anti-inflammatory

-

Surgical → after procedure, splint will be applied to protect elbow area, skin should heal within 12-16 days post-surgery and ROM resume by 3-4 weeks - Infected bursa: doesn’t improve with antibiotics/removing fluid so remove entire bursa → bursa usually grows back as non-inflamed, normally functioning over a period of several months - Non-infected: if nonsurgical treatments don’t work → remove bursa as outpatient procedure

c. Carpal tunnel syndrome Pain/numbness in hand and arm due to median nerve being compressed Carpal tunnel narrowed or when synovium of flexor tendons swell → pressure on median nerve Risk factors: - Heredity → anatomical differences in diff people - Repetitive hand use → aggravation of tendons in wrist, causing swelling - Hand and wrist position → activities of extreme flexion/extension of hand and wrist for prolonged time - Pregnancy → causes swelling - Health conditions e.g diabetes, RA, thyroid gland imbalance -

Symptoms - Numbness/tingling in thumb/middle/ring fingers → can travel up forearm to shoulder - Usually begin gradually, night-time symptoms common Diagnoses - Tinel sign → press down/tap along median nerve at inside of wrist to see if it causes numbness/tingling - Bend and hold wrists in a flexed position - Look for thenar atrophy - Electrophysiological tests → measure how well median nerve is working and determine if there’s too much pressure on nerve, also helps to determine if you have another nerve condition or other sites of nerve compression - Nerve conduction tests: measure signals travelling in nerves to detect severity of problem - Electromyogram (EMG): measures electrical activity in muscles - Ultrasound → evaluate median nerve for signs of compression - X-rays → identify presence of arthritis/ligament injury/fracture - MRI → look for abnormal tissues that can be impacting median nerve, or if there are problems with the nerve itself e.g scarring

Treatment - Bracing/splinting → keep wrist in neutral position to reduce Pa on nerve in carpal tunnel - NSAIDs e.g ibuprofen, naproxen → relieve pain and inflammation - Nerve gliding exercises → help median nerve move more freely within confines of carpal tunnel - Steroid injections - Surgical → non-surgical doesn’t relieve symptoms, dependent on severity (recommended if long-standing with constant numbness and wasting of thenar muscles) - Carpal tunnel release: relieve Pa on nerve by cutting the transverse carpal ligament (ligament on roof of carpal tunnel) - Open: small incision in palm of hand, dividing transverse carpal ligament - Endoscopic: 1/2 smaller skin incisions (portals) and uses endoscope to see inside of hand, then use special knife to divide transverse carpal ligament d. Cubital tunnel syndrome - Ulnar nerve travels through cubital tunnel that runs under medial epicondyle (funny bone) then under muscles on inside of forearm and into hand on side of palm with little finger → innervation to little finger, and most of intrinsic hand muscles Risk factors: - Prior fracture/dislocations of elbow - Bone spurs/arthritis of elbow - Swelling/cysts near elbow joint Causes - Prolonged flexion of elbow, leaning on elbow - Nerve may slide back/forth behind medial epicondyle when elbow is bent - Fluid buildup in elbow - Direct blow to inside of elbow Symptoms - Numbness/tingling in ring and little finger - Weakening of grip and difficulty with finger coordination e.g typing - Muscle wasting in hand Diagnoses - X-rays → look for bone spurs/arthritis - Nerve conduction studies → measure signals travelling in nerves of arm and hand to determine how well it’s working Treatment - NSAIDs e.g ibuprofen → reduce swelling around nerve - Steroids not used as may cause further damage to nerve

-

-

Bracing/splinting → keep elbow in straight position Nerve gliding exercises → help ulnar nerve slide through cubital tunnel at elbow and Guyon’s canal at the wrist to improve symptoms Surgical → if non-surgical methods haven’t improved condition/ulnar nerve is very compressed/compression has caused muscle weakness/damage - Cubital tunnel release: ligament of cubital tunnel is cut and divided - Ulnar nerve anterior transposition: moving nerve to the front of the medial epicondyle to prevent it getting caught on the bony ridge and stretching when bending elbow → either lie under the skin and fat but on top of muscle (subcutaneous transposition), within the muscle (intermuscular transposition) or under the muscle (submuscular transposition) - Medial epicondylectomy: remove part of the medial epicondyle to prevent nerve getting caught on the bony ridge and stretching when bending elbow e. Osteoarthritis When cartilage surface of elbow is damaged

Symptoms - Pain -

“grating”: loss of normal smooth joint surface “Locking”: loose pieces of cartilage/bone that dislodge from joint and become trapped between moving joint surfaces → blocking motion Loss of ROM Joint swelling → occurs later as disease progresses

Diagnoses - X-rays → show arthritic changes Treatment - Steroid injections for pain relief - Viscosupplementation → injecting HLA into joint to improve quality of joint fluid - Surgical - Arthroscopy: removing any loose bone/cartilage fragments or inflammatory/degenerative tissue in the joint, smoothes out irregular surfaces and remove bone spurs - Joint replacement

-

-

f. Rheumatoid arthritis Autoimmune condition where synovium is attacked → thickening of synovium which can eventually destroy the cartilage and bone within the joint - Tendons/ligaments holding the joint together weaken and stretch → lose shape and alignment Swelling of joint lining, invading surrounding tissues and producing chemical subst. that attack and destroy joint surface

Symptoms - Swelling/pain/stiffness in joint even when not being used - Warmth around joint - Deformities and contractures of joint - Nodules/lumps around the elbow - Weakness due to anemia Diagnoses - Look for swelling/warmth around joint, painful motion, lumps under skin, joint deformities/contractures (can’t fully stretch/bend) - Blood test → look for rheumatoid factor Treatment - Aspirin/ibuprofen to reduce inflammation, disease-modifying drugs e.g methotrexate - Exercise/therapy - Joint replacement surgery

-

-

g. Osteochondritis dessicans Small segment of bone begins to separate from surrounding region due to a lack of blood supply → small piece of bone and cartilage covering it begins to crack and loosen Usually in children and adolescents

Diagnoses - X-rays → evaluate size and location of the lesion - MRI and US → evaluate extent to which overlying cartilage is affected Treatment - Observation and activity changes → most lesions will heal on their own - Crutches/splinting - Surgical → if nonsurgical treatments fail, lesion is separated from surrounding bone and cartilage and moving around within joint, lesion is very large (>1cm) - Drilling into lesion to create pathways for new blood vessels to nourish affected area → healing of surrounding bone - Holding lesion in place with internal fixation e.g screws - Grafting → regenerate healthy bone and cartilage in damaged area

3. Lateral epicondylitis (tennis elbow) - Inflammation of tendon joining forearm muscles of lateral epicondyle Causes - Overuse → damage to extensor carpi radialis brevis (stabilises wrist when elbow straightened) which weakens it - Occupation e.g painters/plumbers - Age → 30-50 - Unknown → insidious Symptoms - Pain/burning on medial side of elbow → worsens with forearm activity - Weak grip strength Symptoms develop gradually → begins mildly and slowly worsens overtime Diagnoses - X-rays → rule out arthritis of elbow - MRI → determine if you have possible herniated disk or arthritis in neck - EMG → rule out nerve compression - Maudley’s test → examiner resists extension of 3rd digit, stressing the extensor digitorum muscle and tendon while palpating lateral epicondyle - Positive: pain over lateral epicondyle Treatment → 80-95% with nonsurgical - Rest and recovery for several weeks - NSAIDs e.g ibuprofen/aspirin - Physiotherapy → strengthen muscles of forearm - Brace → centered over back of forearm by resting muscles and tendons, doesn’t full contraction of muscles - Transcutaneous electrical nerve stimulation (TENS) → small electrical impulses delivered to area of body where pads are attached - Reduce pain signals going to spinal cord and brain, relieving pain and relaxing muscles - Stimulate production of endorphins (body’s natural painkillers) - Extracorporeal shock wave therapy → soundwaves sent to elbow, creating “microtrauma” that promote healing process - Equipment check → proper fitting etc - Surgery → nonsurgical doesn’t help after 6-12months, involves removing diseases muscle and reattaching healthy muscle back to bone - Open: make incision over elbow - Arthroscopic: similar to open Rehab after surgery: Immobilised arm with splint for 1 week → light exercises to stretch elbow and restore flexibility 2 months after surgery...