8977 Lecture Notes - Lecture 13: Humerus, Avulsion Fracture, Posterior Interosseous Nerve
3 Jul 2018
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ELBOW INJURIES
Common/ Less Likely/ NTBM?
Objective Examination
Standing or lying
Observe carrying angle, olecranon height, skin, swelling and deformity (muscle wasting too)
Articular/Muscular tests
AROM: flexion and extension (pronated, thumb to shoulder and supinated), supination and pronation (90degrees and full
extension), neck (look up down left right over shoulder, ear to shoulder). Do wrist + shoulder especially in flexor tendinopathy.
PROM (all movements if necessary and overpressure if not necessary to do PROM)
Resisted: flexion and extension (supinated=bicep, pronated=brachialis, thump up=brachioradialis).
Neurological tests
Upper limb tension tests: ULTT 1 (median), ULTT 2 (radial- extensor tendinopathy), ULTT 3 (ulna)
Sensation testing for upper arm and down hand
Vascular tests –pulses
Palpation
olecranon, olecranon fossa, medial epicondyle, lateral epicondyle, radial head, flexor bellies, extensor bellies, ulnar nerve
Special tests
MCL – valgus at 0 (anterior band), 30 (medial fibres) and 90 degrees (posterior band)
LCL – varus at 0 and 30 degrees
Extensors: Posterior impingement (olecranon impinging on olecranon fossa) – quick hyperextension
2kg weight test / back of chair – arm pronated
Extensor indicus – extend arm and push down on 2nd phalanx (ECRL) or 3rd phalanx (ECRB) and whole hand.
Diagnosis
Rule out less likely and NTBM. Rationalise why you have come to your conclusions.
Intervention (treatment for today and in future)
Acute phase – SPM
Tubigrip, braces (hinge or straight), tape or plaster (for fracture)
Tapping for stability and support:
Elbow ligaments - MCL or LCL, anchors then cross
Tennis elbow - to unload muscle; twist, cross or 2 piece pull
Myofascial - chronic condition; find point of relief when contracting muscle and roll tape down
Manage pain and inflammation RICE and EPAs. Ice best for acute stages and heat for chronic.
Subacute phase
Regain ROM:
PPM - which ever movement is restricted
PAM - anterior medial glide of radius at flexion-biceps and extension-supinator
MWM - lateral epicondylitis to increase strength + decrease pain-lateral glide of radius while pt grips
Stretches - extensors and flexors
Neural stretches – ULTT 1, 2 and 3. Wind up nerve and come in and out of stretch. Max 5 per day for 1 week.
Soft tissue massage
Regain control:
Push up on wall - gradually move feet outwards
Ball on wall - hold and roll
Wobbles - press onto table then flex and extend, punch theraband, water pipe
Catch and throw - rubber ball off wall, sports specific
Regain strength:
Multiangle isometrics (no movement) – self resist in any positions. Hold for a count of 5-10
Curls – weighted, theraband, water pipe, any home equipment in all different positions. Ensure wrist is neutral
Regain function/ proprioception:
Correct any poor techniques/ posture issues that lead to injury including aggravating activities
ADLs – posture sitting at desk, adjust ADLs to prevent injury occurring again
Catch and throw – small and light ball, not a tennis ball
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Document Summary
Observe carrying angle, olecranon height, skin, swelling and deformity (muscle wasting too) Arom: flexion and extension (pronated, thumb to shoulder and supinated), supination and pronation (90degrees and full extension), neck (look up down left right over shoulder, ear to shoulder). Do wrist + shoulder especially in flexor tendinopathy. Prom (all movements if necessary and overpressure if not necessary to do prom) Resisted: flexion and extension (supinated=bicep, pronated=brachialis, thump up=brachioradialis). Upper limb tension tests: ultt 1 (median), ultt 2 (radial- extensor tendinopathy), ultt 3 (ulna) Sensation testing for upper arm and down hand. Palpation olecranon, olecranon fossa, medial epicondyle, lateral epicondyle, radial head, flexor bellies, extensor bellies, ulnar nerve. Mcl valgus at 0 (anterior band), 30 (medial fibres) and 90 degrees (posterior band) Lcl varus at 0 and 30 degrees. Posterior impingement (olecranon impinging on olecranon fossa) quick hyperextension. 2kg weight test / back of chair arm pronated.
