Elbow Diagnoses

Elbow Diagnoses

Function of the Elbow

The elbow serves as the essential functional link between the hand and the shoulder, allowing the hand to be brought inward toward the body and outward into the surrounding environment. It also transfers force through the upper extremity (UE) during weight bearing on the hand. The functional range of motion (ROM) required at the elbow is reported to be 30° of extension, 130° of flexion, and 50° each of pronation and supination.¹ However, because functional demands vary, the range required will differ somewhat among individuals. In general, it is easier to compensate for limited extension by moving closer to objects during reach than it is to compensate for limited flexion. Because the most common complication of elbow trauma is stiffness, it is essential that therapists treating individuals with elbow injuries be well versed in effective treatment approaches. To “push harder” or “be more aggressive” is not an effective solution and may instead cause more damage and stiffness. In addition to being mobile, the elbow must also be stable so that it can withstand the forces of daily activities. Maintaining the most effective balance between minimizing stiffness through early motion, preserving stability, and protecting healing structures is a challenge even for experienced therapists.

Clinical Pearl

Elbow stiffness is the most common complication of elbow trauma.

Elbow Anatomy

Three bones contribute to the elbow joint, the distal humerus, proximal ulna, and proximal radius (Fig. 23-1). They form the three articulations of the elbow: the ulnohumeral, radiohumeral, and proximal radioulnar joints. The distal humerus has two articular surfaces: the spool-shaped trochlea medially and the convex capitellum (also known as the capitulum) laterally. The ulnohumeral joint is the close articulation of the trochlea with the rounded trochlear notch formed by the coronoid and olecranon of the proximal ulna. In full elbow flexion the coronoid fossa on the anterior distal humerus receives the coronoid process of the anterior trochlear notch. In full extension, the olecranon fossa on the posterior distal humerus receives the olecranon process of the posterior trochlear notch. The radiohumeral joint is the articulation of the capitellum of the distal humerus with the shallow concavity on the proximal aspect of the radial head. The radial head and the radial notch of the ulna form the proximal radioulnar joint.

FIGURE 23-1 A, Anterior view of the elbow joint. B, Posterior view of the elbow joint. (From Thibodeau G, Patton K, editors: Anatomy & physiology, ed 8, St Louis, 2013, Mosby.)

Due to the oblique orientation of the trochlea of the humerus, in full extension the elbow has a valgus angle, known as the carrying angle. It has been widely reported that men have a carrying angle of approximately 5° to 10°, while women have a slightly greater carrying angle of approximately 10° to 15°. However, measured radiographically, the normal carrying angle in adults is reported to be 17.8° on average with no significant difference between men and women.²

Clinical Pearl

The most reliable way to determine if the carrying angle of an injured elbow is normal is to compare it to the individual’s uninjured elbow.

Ligaments

The three elbow articulations share a common joint capsule. The medial and lateral collateral ligament complexes of the elbow are essentially thickenings of the joint capsule. Portions of the collateral ligament complexes remain taut throughout elbow flexion and extension, making an essential contribution to static elbow stability. The medial collateral ligament complex (Fig. 23-2) has three components, the anterior bundle, posterior bundle, and the transverse ligament. This ligament complex, particularly the anterior bundle, stabilizes the elbow against valgus (abduction) forces. The lateral collateral ligament complex (Fig. 23-3) has four components, the lateral ulnar collateral ligament (LUCL), the radial collateral ligament, the annular ligament, and the accessory lateral collateral ligament. The lateral collateral ligament complex is considered to be one of the primary stabilizers of the elbow. It provides restraint from varus (adduction) forces. The LUCL, one of the four components of this ligament complex, also provides posterolateral stability to the ulnohumeral joint.

FIGURE 23-2 The medial collateral ligament complex of the elbow. (From Morrey BF, Sanchez-Sotelo J, editors: The elbow and its disorders, ed 4, Philadelphia, 2009, Saunders.)

Clinical Pearl

Edema often affects all three joints of the elbow because they share a common joint capsule.

The interosseous ligament, fibrous tissue lying obliquely between the radius and ulna, transfers forces from the radius to the ulna during weight bearing on the hand. Although not part of the elbow complex, injury to the interosseous ligament can alter the mechanics of the elbow. If the radial head is fractured or excised, the interosseous ligament is critical to load sharing. If it is disrupted, the entire force is shifted to the ulna rather than being shared between the ulna and radius.

Muscles

The muscles that cross the elbow provide it with active power and dynamic stability. Biceps brachii, brachialis, and brachioradialis are the primary elbow flexors. Biceps brachii is the primary supinator of forearm with supinator acting as an additional, weaker supinator. Triceps is the primary elbow extensor. Pronator teres is the primary forearm pronator with pronator quadratus in the distal forearm acting as another, weaker pronator. The other muscles crossing the elbow joint serve as secondary movers and contribute to dynamic joint stability.

Nerves and Blood Vessels

The muscles that move the elbow are innervated by the musculocutaneous, radial, and median nerves. The musculocutaneous nerve innervates biceps brachii and brachialis. The radial nerve innervates brachioradialis, triceps, and supinator. The median nerve innervates pronator teres. The median, ulnar, and radial nerves and the brachial artery all lie close to the elbow joint and as a result are susceptible to injury in elbow fractures and dislocations. The ulnar nerve is particularly susceptible to injury as it passes posterior to the medial epicondyle through the cubital tunnel.

Clinical Pearl

Abnormal stress on the ulnar nerve can result from an elbow injury, a direct blow, or prolonged direct pressure (such as, when leaning on the elbow or prolonged or repetitive elbow flexion) that stretches the nerve. Numbness and tingling in the small finger and ulnar aspect of the ring finger and grip weakness can be signs and symptoms of ulnar neuritis or compression of the ulnar nerve in the cubital tunnel.

Elbow Biomechanics

Motion at the elbow occurs in two axes: flexion-extension and pronation-supination. The elbow acts as a hinge during flexion-extension. However, rather than occurring in a single plane, flexion-extension is accompanied by slight rotation and medial-lateral motion, which results in the carrying angle of the elbow. Normal elbow ROM is approximately 0° extension to 140° flexion. Because flexion is limited by soft tissue approximation, end range is variable. Hyperextension of up 10° is observed more commonly in women. During pronation-supination, the radius rotates around the ulna. Normal forearm ROM is approximately 85° pronation and 90° supination. ROM varies among individuals, and a variety of normal values are reported in the literature.

Clinical Pearl

Determination of normal elbow and forearm ROM for an individual is best made by comparison to the uninvolved UE rather than to published norms.

Stability at the elbow is provided by both static and dynamic constraints. The osseous structures provide static stability. The highly congruent ulnohumeral joint is the primary stabilizer of the elbow. The radial head also acts as a stabilizing structure. The joint capsule, medial collateral ligament complex, and lateral collateral ligament complex provide additional static stability. The muscles that cross the elbow, when contracted, contribute dynamic stability to the elbow.

Elbow Fractures

The elbow is a complex joint, vulnerable to fracture from falls on an outstretched hand as well as from direct trauma. Elbow fractures are frequently challenging to treat, often requiring operative intervention. The most common complication of elbow fracture is stiffness. Failure to regain elbow ROM can result in significant functional impairment. To minimize this risk, it is important that mobilization begin early. The necessary stability to safely allow early mobilization of displaced and unstable elbow fractures requires operative management.

Radial Head Fractures

Radial head fractures are the most common elbow fracture in adults. The most common mechanism of injury is falling onto an outstretched hand with the forearm pronated. These fractures can also result from falling directly onto the elbow. The most common complication of both stable, non-operatively managed radial head fractures and those requiring operative stabilization is elbow flexion contracture, the loss of full elbow extension.

Clinical Pearl

In the presence of radial head fracture, the forearm and wrist should also be carefully evaluated, because there may be associated injuries to the interosseous ligament and the distal radioulnar joint, known as an Essex-Lopresti lesion.

Olecranon Fractures

Olecranon fractures are another relatively common elbow fracture in adults. These fractures usually result from a fall onto a bent elbow or a direct blow. The olecranon is particularly vulnerable to direct trauma due to its location just below the skin where it has minimal protective soft tissue coverage. The majority of olecranon fractures are displaced with a tendency to be widely separated because of the pull of the triceps insertion. Most olecranon fractures require operative management. Severe, unstable olecranon fractures are usually associated with trauma to other structures and can be very complex and challenging to treat.

Clinical Pearl

The ulnar nerve is susceptible to injury in olecranon fractures due to its adjacent location.

Distal Humeral Fractures

Fractures of the distal humerus are relatively uncommon, accounting for only 2% of all fractures. They occur most frequently in young males and in females over 80 years of age. In younger individuals, distal humeral fractures are usually associated with higher velocity injuries, such as motor vehicle and sports-related accidents. In the elderly with poor bone stock, they can occur from a simple fall onto an outstretched hand.³

Timelines and Healing

To minimize the risk of elbow stiffness following an isolated elbow fracture, gentle active motion in the stable range is usually initiated within the first week following injury or surgery. While early motion is highly desirable, fracture stability is the prerequisite. Isolated elbow fractures that are stable and non-displaced are usually referred to therapy several days after injury. Displaced or unstable fractures are treated operatively to restore bony alignment and stability; this is to ideally allow controlled motion within the first week following surgery. Open fractures must be treated operatively to clean the wounds and minimize the risk of deep infection, to restore alignment and stability, and to allow early mobilization.

During the healing process, fractures must be protected from excessive or uncontrolled forces that could disrupt alignment and lead to malunion or nonunion. Strengthening exercises are not initiated until there is evidence of fracture consolidation, usually 8 to 12 weeks following the injury or surgery. Return to all previous activities is allowed when the fracture has fully consolidated and normal or near normal strength has been regained, 3 to 6 months following injury.

Non-Operative Treatment

Elbow fractures that are stable and well aligned are usually referred to therapy within the first few days following injury. Unstable and poorly-aligned fractures are treated operatively and then referred to therapy. The initial goal of therapy is to restore motion while protecting the elbow from harmful stresses that could compromise fracture alignment and healing. A removable thermoplastic orthosis is the most common means of protective immobilization. The orthosis is removed, usually within the first week, for initiation of gentle active and active-assisted elbow and forearm motion in the arc that does not compromise stability. Educate your patient in precautions, such as any initial restrictions to the arc of motion necessary to protect fracture stability and the avoidance of weight bearing and lifting with the involved UE. Active motion of the digits, wrist, shoulder, and shoulder girdle should be performed to preserve the motion of these uninvolved joints. Elevation, cold packs, light compression wraps, and light massage are useful for the control of pain and edema. In addition to preventing digit stiffness, active digit motion helps to minimize edema in the hand and entire UE.

The rate of treatment progression is dependent on fracture healing. Discuss the degree of fracture stability with the referring physician before proceeding. Once the physician determines that there is evidence of fracture union and sufficient stability, introduce gentle passive motion, joint mobilization, and soft tissue mobilization with the goal of restoring full motion. Scar management for operatively-managed fractures should begin once the surgical incision is fully healed. As healing progresses, encourage gradual return to use of the involved UE for light functional activities. The protective orthosis is discontinued except for sleep, travel, and other circumstances that might put the elbow at risk.

Following fracture consolidation, instruct your patient in resistive exercises to strengthen the involved UE. The ultimate goal of therapy and best outcome is restoration of the previous level of function with a mobile, stable, and pain-free elbow. If your patient reaches a plateau before achieving end range motion, a static progressive orthosis or serial static orthosis may be required to address joint stiffness (see “The Stiff Elbow” section later in this chapter).

Operative Treatment

The goal of surgery is to restore alignment and stability to the displaced or unstable elbow fracture. When achieved, elbow motion can be initiated within a few days, minimizing the risk of joint stiffness. However, stability must never be sacrificed for the sake of mobility. Motion is initiated once the referring physician has determined that sufficient stability has been restored through surgery or fracture healing.

Complications of elbow fractures are more common when there is articular involvement. In addition to stiffness, the most common postoperative complications of elbow fractures are infection, malunion, nonunion, ulnar neuropathy, and arthrosis.

Displaced radial head fractures with comminution or mechanical block to forearm rotation require operative treatment. The presence of one or more associated injuries at the elbow including capitellum fracture, olecranon fracture, ligamentous injuries, and elbow dislocation, is also an indication for operative treatment. Approximately one in three radial head fractures is associated with another injury.⁴ Options for the operative treatment of radial head fractures include internal fixation with plate and screws, radial head excision, and radial head replacement. Comminuted fractures are treated with radial head excision or replacement. Displaced fractures with mechanical block to forearm rotation are treated with internal fixation or radial head excision. Note that due to important stabilizing function of the radial head, it must be replaced rather than excised in radial head fractures with associated injuries that compromise elbow stability.

Most olecranon fractures require open reduction and internal fixation. A posterior approach is typically used. The type of internal fixation is chosen depending on the individual characteristics of the fracture. Options include Kirschner wires, tension band wiring, compression screws, and plate fixation. With appropriate management, outcomes of olecranon fractures are typically good to excellent.⁵ In addition to the complications common to all elbow fractures, hardware on the posterior aspect of the elbow is not always well tolerated. Chronic irritation can result in olecranon bursitis and may require excision of the hardware.⁶

Distal humeral fractures that are comminuted, displaced, involve the trochlea or capitellum, or have neurovascular involvement require operative treatment. There is a higher risk of complications in high-energy mechanisms of injury, open fractures, and non-operatively managed fractures. In addition to the complications common to all elbow fractures, heterotopic ossification, bone in nonosseous tissues, may develop following fractures of the distal humerus. Although these fractures are frequently challenging to manage, the majority heal within 12 weeks without significant complications.³ Most are stabilized surgically with open reduction and internal fixation with plates and screws. A posterior surgical approach is most commonly used for visualization of the fracture. The triceps is split or elevated and reflected, or an olecranon osteotomy is performed. Following an olecranon osteotomy, the olecranon is reattached with Kirschner wires and screws or plating.⁷ An anterior ulnar nerve transposition is sometimes performed during surgery for fracture repair to lessen the likelihood of postoperative ulnar neuropathy. Elderly individuals with complex distal humerus fractures and osteoporotic bone present a particular challenge to the surgeon. Total elbow arthoplasty may be necessary in these individuals if screws cannot obtain adequate bony purchase for fracture fixation.⁸

Questions to Discuss with the Physician

• Which bone was fractured, and what was the nature of the fracture? Ask for the radiology report.

• Were there any associated injuries?

• Was the fracture treated surgically, and if so, how? Ask for the operative note.

• Is the fracture stable enough to begin active motion?

• Are there any movement limitations or other precautions?

• What are the preferred type, position, and wearing schedule for the protective orthosis?

As the Patient Progresses

• When can the protective orthosis be discontinued?

• When can passive motion be initiated?

• When can the use of static progressive orthoses be initiated (if necessary to increase motion)?

• When can resistive exercises be initiated?

What to Say to Clients

About Stable Elbow Fractures

“You may be surprised to start motion exercises so soon after breaking a bone, but elbow stiffness is the most common problem after an injury like yours. Your fracture is stable enough now to safely do the gentle exercises that I’m going to teach you. They will help you maintain and improve your elbow motion.”

About the Home Exercise Program

“You’ll get more benefit from doing your motion exercises slowly and fully than from doing lots of them quickly. It’s best to do the exercises throughout the day. For example, do a set when you first get up in the morning, another at lunch, another after work, and a last set before bed. It’s normal to feel tighter in the morning and looser later in the day. When your elbow feels stiff, breathe deeply and relax as you slowly move your elbow as far as it will go. Forceful or quick motions will tend to make all your muscles contract and fight the movement you’re trying to do.”

Clinical Pearl

When the elbow is viewed from behind in 90° of flexion, the medial and lateral epicondyles of the distal humerus and the tip of the olecranon of the ulna should form an inverted equilateral triangle. With the elbow in full extension, these landmarks should form a straight line.

Evaluation Tips

• When assessing motion, strength, sensibility, and edema, compare the measurements to those of the patient’s uninvolved UE to determine what is normal for that individual.

• Do not measure passive range of motion (PROM) or strength until cleared by the referring physician.

• Ask your patient to complete a self-report questionnaire at initial evaluation, re-evaluation, and discharge. These measures are useful for tracking and reporting progress as well as for highlighting functional problems that may require attention in therapy. The Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire and the Patient-Rated Elbow Evaluation (PREE) are self-report measures commonly used for elbow injuries. The DASH documents UE function, whereas the PREE documents pain and function and is specific to the elbow. Although both are scored from 1 to 100, 100 on the DASH represents maximum functional disability, whereas 100 on the PREE represents least pain and best function.

Diagnosis-Specific Information That Affects Clinical Reasoning

Radial head fractures that are non-displaced or minimally displaced are treated non-operatively, unless there is a mechanical block to forearm rotation. These fractures have a favorable prognosis as long as motion is begun early. Active motion is usually initiated within the first several days following injury. Be sure to emphasize elbow extension, because this motion is most frequently lost after radial head fracture. Immediate mobilization has been shown to result in less pain and better elbow function at 1-week follow-up as compared to motion initiated 5 days following radial head fracture; although results were similar with respect to pain, ROM, and function at 4-week follow-up.⁹ Non-displaced and minimally displaced radial head fractures treated non-operatively do not require as long of a period of protective immobilization as other elbow fractures and radial head fractures treated operatively. The use of a sling or orthosis for comfort during the first week is usually sufficient. Not all individuals with non-operatively managed radial head fractures require repeated therapy visits to achieve good results. However, to minimize the risk of elbow flexion contracture, it is important to provide a structured therapy program to individuals who are reluctant to move or who are stiff after several weeks of performing a home exercise program.

Some olecranon fractures with minimal or no displacement can be treated non-operatively. The elbow is immobilized full-time in a cast or orthosis at 60° to 90° of flexion and neutral forearm rotation for 1 to 2 weeks. Therapy should then be initiated to minimize the risk of elbow stiffness.

Most distal humeral fractures require operative treatment. However, some non-comminuted, stable fractures with minimal or no displacement can be treated with closed reduction followed by immobilization in a cast or orthosis. To minimize the risk of stiffness, gentle motion must be started after no more than 2 weeks of full-time mobilization. If the distal humerus is not stable enough to tolerate motion after this period of initial immobilization, it is best treated surgically to achieve the necessarily stability to allow early motion.⁶ When treating a patient referred to you following surgery for a distal humerus fracture, initiate elbow motion exercises with passive or gravity-assisted extension and active flexion. Depending on the type of surgical exposure that was used, either the triceps mechanism or the olecranon osteotomy may require protection for the first 6 weeks or so. Therefore, check with the surgeon before beginning active elbow extension and passive elbow flexion.

Tips from the Field

• You will usually fabricate a thermoplastic posterior elbow orthosis to provide protection and support to the recently fractured elbow. Braces, casts, and slings are sometimes used as alternatives to orthoses.

• Most isolated elbow fractures are immobilized with the elbow in 90° of flexion with the forearm in neutral rotation. Olecranon fractures that are managed non-operatively or have tenuous fracture fixation may require immobilization in more extension to minimize the pull of the triceps at its insertion on the olecranon.

• Instruct your patient to remove the orthosis several times daily for active motion exercises unless contraindicated due to instability. Daily removal of the orthosis for hygiene is usually permissible, although initially wearing it covered with a plastic bag or cast cover while showering or bathing offers greater protection.

• Even with optimal treatment, regaining full or at least functional motion following elbow fracture can be challenging. If your patient’s elbow motion plateaus, fabricate or provide a static progressive or serial static orthosis once the fracture has healed sufficiently (see “The Stiff Elbow” section).

Motion Exercises

• Unless contraindicated, it is often most comfortable for your patient to begin elbow flexion and extension in supine with the upper arm supported on a pillow or folded towel alongside their torso. Progress to other gravity-assisted positions, such as elbow extension while seated and elbow flexion in supine with the shoulder flexed at 90°.

• Instruct your patient to gently support the involved UE with their uninvolved hand while performing gentle motion exercises to increase comfort and control.

• It is common to compensate for limited forearm ROM by leaning to the side or substituting shoulder motion. Minimize this by having your patient support the upper arm against their torso while they pronate and supinate the forearm. Maintaining erect posture may be easier initially if forearm rotation is performed bilaterally.

• Longer holds at end range are more effective for increasing motion than performing a greater number of fast repetitions.

• An early means of increasing motion is through active-assisted “place and hold” exercises in which the joint is placed at its end range position followed by an active holding of the position.

• Precondition soft tissues with moist heat to make active and passive motion exercises more comfortable and effective.

Strengthening Exercises

• When the physician determines that there has been sufficient fracture healing, begin strengthening with isometric exercises and progress to isotonic exercises. In addition to addressing strength deficits of triceps and the elbow flexors, also address any strength deficits of the shoulder girdle, shoulder, wrist, and hand.

• Be sure not to overlook triceps, which tend to be weak following elbow injury. An effective exercise for initiating activation and strengthening of the triceps is elbow extension in supine with the shoulder flexed at 90°.

Clinical Pearl

Most individuals will be more comfortable if you include their wrist when you fabricate the protective orthosis. Make sure that they perform active wrist motion each time they remove the orthosis to prevent loss of wrist motion.

Precautions and Concerns

• Adhere to precautions related to your patient’s fracture, surgery, and phase of healing, and be sure that your patient understands them. Don’t sacrifice stability for the sake of mobility.

• Progress treatment based on the healing of your patient’s fracture as determined by their referring physician and on their individual response to therapy.

• Passive motion and stretching should be performed slowly and gently. Forceful passive motion may damage rather than lengthen soft tissues.

• Be alert for symptoms of ulnar neuritis, such as numbness or tingling in the small finger and ulnar aspect of the ring finger, and if present, report them to the referring physician.

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Tags: Fundamentals of Hand Therapy Clinical Reasoning and Treatment Gu

Sep 9, 2016 | Posted by admin in MANUAL THERAPIST | Comments Off

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