ELBOW Acadimya 1.4

8/3/2019 ELBOW Acadimya 1.4

http://slidepdf.com/reader/full/elbow-acadimya-14 1/23

Dr Youssef masharawi1

The Elbow Complex







Anterior view of the course of the median nerve.Note the path of the nerve between the two heads

of the pronator teres muscle .




• Anterior view of the

course of the radialnerve. Note the positionof the deep branch of theradial nerve (posterior

interosseous nerve) as itpasses through thearcade of Frohse at theproximal margin of thesuperficial head of thesupinator muscle .







1. Radiohumeral joint• ArthrologySynovial pivot/hinge joint.• Ligaments

Radial collateral ligamentAnnular ligament• KineticsJoint is designed primarily for flexion and extension but

must allow the radial head to spin during pronation andsupination.the head of the radius is in full contact in full flexion as the

head of the radius enters the radial fossa of the

humerus.Only half of the head makes contact on full extension.• InnervationAbundant from the radial nerve and its branches,

musculocutaneous and some supply from median nerve.




2. Humeroulnar joint

• Arthrology

Synovial hinge joint.

• LigamentsMedial collateral ligament

Arcuate ligament

• KineticsConsidered a hinge joint; flexion and extension

sagittal motion.

• InnervationSupplied by the ulnar nerve, median nerve,

musculocutaneous and radial nerves.




3. Superior Radioulnar joint

• ArthrologySynovial pivot joint.

• LigamentsAnnular ligamentQuadrate ligament• Kinetics

The adult radial head is oval in shape allowing the axis ofthe radius to displace laterally during pronation;

Also during pronation the radius rotates, and the radialhead tilts laterally and distally.

• InnervationBranches of median, ulnar, musculocutaneous and readial

nerves.




Valgus stability

• In extension, valgus stability is providedby the medial collateral ligament, anteriorcapsule and bony articulation.

• In flexion 54% of the stability is providedby the MCL alone.

• The anterior oblique portion of the MCL isthought to be a particularly importantstabilizer.




Varus stability • In extension, varus stability is provided by the capsule

(32%), the bony articulation (54%) and the lateralcollateral ligament (14%).

• In flexion more stability is provided by the articulation(78%).

• In distraction most of the resistance was capsular (78%).

• Disruption of the lateral collateral ligament complex postdislocation or after chronic varus microtrauma .

• Elbow not often subject to varus stress.

• Straight varus instability is not as apparent as the

posterolateral rotatory instability that alwaysaccompanies disruption of the LCL.




Posterolateral stability

• Fall onto outstretched hand producing a valgusstress with hypersupination under axial

compression.• Disrupts the LCL (ulnar band) first with

spontaneous reduction of subluxation, further

stress disrupting medial ligament complex(posterior band first then anterior band) and theanterior capsule.

• Stages of disruption range from subluxation to

complete dislocation.• Other causes include: Lateral release for tennis

elbow (LUCL disruption), radial head excision.




Carrying angle:

• Initially it was defined as the angle formed by thelong axis of the humerus and the long axis of theulna. An average angle of 10-15 degrees for

men and slightly higher for women wasdescribed.

• This angle has since been measured using the

humerus or the ulna as the fixed referencesystem.

• A third system is more dynamic and measures

the abduction/adduction angle of the ulna withrespect to the humerus. In this case the carryingangle progressively decreases with flexion.




Activities Commonly Associated with

Overuse Elbow Injuries• Posterior dislocation: Posterolateral rotatory

instability

• Racquet sports: Pronator syndrome, tricepstendinosis, olecranon stress fracture, lateraltennis elbow, radial tunnel syndrome, golfer's

elbow, ulnar nerve entrapment• Rowing: Radial tunnel syndrome

• Skiing: Ulnar nerve entrapment

• Swimming: Radial tunnel syndrome• Weight lifting: Biceps tendinosis, triceps

tendinosis, anterior capsule strain, radial tunnel

syndrome, ulnar nerve entrapment




Causes of Overuse Elbow Pain

• Anterior elbow:

Biceps tendinosisPronator syndromeAnterior capsule strain

• Posterior elbow:

Triceps tendinosis

Olecranon impingementOlecranon stress fractureOlecranon bursitis




Causes of Overuse Elbow Pain

• Lateral elbow:

Lateral tennis elbowRadial tunnel syndromeRadiocapitellar chondromalacia

Posterolateral rotatory instability

• Medial elbow:

Medial tennis elbow (golfer's elbow)Ulnar collateral ligament sprainUlnar nerve entrapment




• A complete examination of the elbow

includes the neck, shoulder and wrist.• The most common overuse injury of the

elbow is lateral tennis elbow.










Normal tendon structure• parallel collagen

fibers attached to thebone )




Tendinopathy.

Due to damage, someof the normal collagenfibers have been

replaced by scartissue, which hassimilar structure but is

not as strong .




Tendonitis.Secondary to the damage

within the tendonsubstance, inflammatorychanges have developedaround the tendon.

Anti-inflammatorymedication (includingtablets and cortisone

injections) can helprelieve pain, but do not help heal the tendondamage .




Healing tendon.• The scar tissue within the

tendon is starting to re-organize and preservesome structural strength.

• The best way to makethis happen is torepeatedly load thetendon below itsthreshold of damage.

• Overload is dangerous,but complete rest meansthat the healing won'toccur either .




• The goal of any tendino-pathyis a healed tendon, where new

collagen fibers have grownand the tendon is now asstrong as the original and is nolonger painful.

• The tendon is usually a littlewider and less elastic, buthighly functional.

• In the vast majority oftendinopathy cases, healinglike this is possible .

ELBOW Acadimya 1.4

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