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Biomechanical Considerations of the Wrist Contusions, Strains, and Related Conditions Wrist Sprain Tenosynovitis Arterial Obstruction Edema Subluxations Fractures and Dislocations General Nerve Injuries and Disorders Radial Nerve Injury and Wrist Drop Median Nerve Injury and Entrapment Ulnar Nerve Injury and Claw Hand Injuries of the Hand and Fingers Etiology and Physical Approach Contusions and Lacerations Strains, Sprains, and Related Disorders Fractures and Dislocations Miscellaneous Pathologic Signs Injuries of the Nails and FingertipsChapter 23
Elbow, Wrist, and Hand Injuries
From R. C. Schafer, DC, PhD, FICC's best-selling book:
“Chiropractic Management of Sports and Recreational Injuries”
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Injuries of the Distal Arm and Elbow Physical Approach Roentgenologic Considerations Contusions and Strains Elbow Sprains Tennis Elbow Olecranon Bursitis Subluxations Fractures and Dislocations Nerve Compression Injuries Miscellaneous Pathologic Signs Injuries of the Forearm and Wrist
Chapter 23: Elbow, Wrist, and Hand Injuries
The highest incidence of elbow injury is in tennis, golf, Little League baseball, and occasionally in javelin throwing. Most forearm injuries are the result of direct blows or falls. Commonly seen are avulsion-type injuries of the elbow as a result of acute or chronic strain at a site of tendon or ligament attachment.
(1) musculotendinous,
An outline of common sports injuries about the elbow is shown in Table 23.1
This chapter discusses traumatic-related disorders of the elbow, forearm, wrist, hand, and fingers. As in all traumatic injuries, the sooner the patient is examined after injury, the more accurate the diagnosis. Swelling, spasm, tenderness, and motion limitations rapidly cloud the picture.
Injuries of the Distal Arm and Elbow
Physical Approach
Parkes divides common sports injuries involving the elbow into three categories according to their prevalence:
(2) articular, and
(3) neurovascular. Most injuries are the result of either a sudden unguarded or a repetitive overload on the joint mechanism. This is especially true if the joint is weak or inflexible.
Table 23.1. Common Sports-Related Elbow Injuries
Syndrome Typical Clinical Picture
MUSCULOTENDINOUS INJURIES
Lateral Aspect Pain on gripping, point tenderness at the
Extensor carpi radialis attachment of the common extensor tendon.
brevis strain, tendinitis Pain is aggravated by resisted hyperextension
Lateral epicondylitis of the wrist or passive wrist flexion
Lateral epicondyle spur or with the elbow extended. Some swelling is
adjacent calcium usually present.
deposition
Posteromedial radial head
subluxation
Lateral olecranon subluxation
Anterior Aspect Anterior elbow pain aggravated by use, point
Biceps-brachialis strain, tenderness over the insertion of the biceps
tendinitis, rupture tendon. Pain is increased by resisted elbow
Anterior olecranon flexion, forearm supination, and passive
subluxation elbow extension. Antecubital swelling is
Superior ulna subluxation usually present.
Avulsion at radial tuberosity
Medial Aspect Pain on throwing, forearm tennis shot, or
Strain, tendinitis, or gripping. Point tenderness at attachment of
rupture of wrist flexors common tendon to medial epicondyle. Pain is
and forearm pronators aggravated by resisted wrist flexion or
Medial epicondylitis, with passive wrist extension when the elbow is
or without avulsion extended
Medial olecranon subluxation
Posterior Aspect Pain on repetitive extension (eg, throwing,
Triceps strain, tendinitis tennis, weight lifting, gymnastics). Point
Olecranon avulsion tenderness at or just above the insertion of
(uncommon) the triceps on the olecranon process. Pain
Bursitis is aggravated by resisted extension or
Posterior olecranon passive flexion of the elbow.
subluxation
ARTICULAR INJURIES
Lateral Compartment Lateral elbow pain on throwing, gymnastics,
Traumatic damage to radial racquet sports, sometimes associated with
head, capitellum, or both joint clicking, catching, grinding.
Osteochondral fractures Tenderness and swelling over radiocapitellar
Compression osteochondritis joint. Grating on forced forearm supination
of capitellum (youth) and pronation (often), and reduced range of
Osteochondritis of elbow extension.
radial head
Superior ulnar subluxation
Loose body formation
Medial Compartment Medial elbow pain and swelling aggravated by
Capsular tear valgus stress (eg, throwing, weight lifting),
Calcium deposition point tenderness below medial epicondyle
Coronoid process spur near humeral-ulnar joint, and possible
Ulnar nerve entrapment sensitive ulnar nerve. Pain is aggravated by
passive wrist extension or active flexion.
Posterior Compartment Posterior pain on elbow extension, often
Olecranon tip spur with a catching or locking sensation; point
Olecranon hypertrophy tenderness in the olecranon fossa; reduced
Loose body formation range of extension.
Olecranon fatigue fracture
Posterior olecranon
subluxation
NEUROVASCULAR INJURIES
Ulnar Nerve Entrapment Paresthesiae and weakened motor power in 4th
Cubital tunnel syndrome and 5th fingers, point tenderness in cubital
tunnel.
Pronator Teres Syndrome Anterior elbow pain, usually radiating into
Median nerve entrapment thumb, index finger, and middle finger.
Forearm cramps (sometimes), and tenderness
over pronator teres. Pain is aggravated by
resisted forearm pronation and passive
supination. Possible thumb abduction weakness
and sensory loss in the 1st, 2nd, and 3rd
digits.
Musculocutaneous Nerve Weak elbow flexion, absent biceps reflex,
Entrapment biceps and brachialis atrophy, and numbness/
tingling and numbness along the radial-volar
aspect of the forearm.
Radial Nerve Entrapment Elbow pain along the lateral extensor muscle
(Uncommon) group. Tenderness along the radial nerve
anteriorly about the radial head, but not
over the lateral epicondyle as in tennis
elbow. Pain is aggravated by passive forearm
supination and pronation and forced extension
of the wrist and 3rd finger. Weakness
and stiffness of the extensor-supinator
muscles are usually exhibited.
Brachial Artery Impingement Signs of vascular insufficiency; eg,
Supracondylar fracture progressively increasing pain, pain on passive
Posterior or posterolateral extension of the fingers, median nerve
dislocation paresthesia.
A review of pertinent neurologic, orthopedic, and peripheral vascular manuevers, reflexes, and tests relative to the elbow and forearm is shown in Table 23.2.
Biernacki's sign Medial epicondyle test Bikele's test Mill's test Brachioradialis reflex Muscle strength grading Cogwheel sign Periosteoulnar reflex Cozen's test Periosteoradial reflex Elbow abduction stress test Kaplan's test Elbow adduction stress Radial reflex Elbow extension stress test Range of motion tests Elbow flexion stress test Strumpell's pronation sign Elbow pronation stress test Tinel's elbow test Elbow supination stress test Tinel's sign Erb's sign Triceps reflex Light touch/pain tests Ulnar reflex
Roentgenologic Considerations
As a consequence of avulsion injury, bone fragments may be seen in the area of the epicondyles or olecranon process, and epicondyle spurs may point to chronic stress. Standard projections are A-P, lateral, and oblique views. An intra-articular bone fragment may sometimes be only elicited by tomography, and comparative views of the sound limb are frequently necessary.
Soft Tissues. Displacement of fat pads is often found at the elbow after injury. It can occur in any injury that distends the joint capsule. A pad appears as a thin strip of radiolucent fat density. The anterior fat pad is normally seen on lateral views, but the posterior humeral pad is hidden by the epicondyles' posterior extensions. However, the posterior pad will become visible at the posterior edge of the humerus on lateral views if effusion causes displacement of the pad. The most important complication is ischemia of the forearm, which may cause an irreversible contracture deformity.
Growth Centers. Normal ossification of distal humeral epiphyses is not an even process, especially during the periods of rapid growth and development; thus knowledge of secondary ossification centers of the elbow is necessary in dealing with children or teenagers. One or more bony centers may remain uneven in density and irregular on the margins, especially the trochlea and olecranon epiphyses. Because of this irregularity, careful differentiation must be made from osteochondrosis and epiphysitis. The trochlear center is irregularly mineralized and always develops from several small foci. The lateral epicondyle does not fuse directly with the humerus as the medial epicondyle does; rather, it fuses first with the neighboring epiphyseal ossification center, the capitellum, then the fused mass joins the end of the shaft of the humerus. After injury, the position of various centers must be evaluated for possible displacement, laceration, and incarceration into the joint.
Pitching Injuries. Avulsion and displacement of the medial epicondyle may complicate supracondylar fracture, or they may occur in association with softtissue trauma alone. Biceps spasm after 5 min of pitching strongly suggests an avulsion. Finger numbness following pitching suggests a scalenus anticus syndrome from a cervical or 1st rib condition. Avulsion and displacment of the epicondyle are common between 7 and 17 years of age and vary from slight epicondylar separation to complete avulsion and displacement into the elbow joint. Displacement and fragmentation of the medial condyle in youthful baseball pitchers (Little Leaguer's elbow) is increasing in incidence.
It has been estimated that two of every three professional baseball pitchers have an elbow abnormality. Arm and forearm hypertrophy is typical. Hypertrophy of the humerus is invariably demonstrated in roentgenography, and traction spurs and loose bodies of bone within the elbow joint are frequent. Most loose bodies are found in the olecranon fossa, near the epicondyle, and near the tip of the coronoid process --where ulnar nerve irritation is likely. In 50% of professional pitchers, flexion contracture of the elbow is present. In addition to pitching, outfield throwing and batting mishaps account for similar injuries.
Contusions and Strains
Traumatic Inflammation of the Elbow. There may be an injury to the upper radioulnar articulation by sudden overpronation or oversupination followed by pain over the articulation with limitation of rotation. Normally, the olecranon bursa will not be palpable; in bursitis, it will feel boggy and thick. Trigger points are commonly found just below the horizontal midline of the antecubital fossa over the proximal radius and ulna. When the joint proper is involved, motion is limited chiefly in extension and may persist indefinitely. An associated injury to the brachialis anticus muscle with contracture is common. In children, a strip of periosteum may be torn from the anterior humerus, followed by bone formation and blocked joint motion. Local myositis ossificans may also develop in the tendon of the brachialis anticus. Some cases will be complicated by ulnar neuropraxia.
Management. During the early stage, rest in a sling for 3-4 days is required for the acute symptoms to subside. Thereafter, physical therapy with passive and progressive active exercises are recommended. Diathermy is especially helpful in absorption of joint effusion. Rarely is joint aspiration necessary.
Distal Bicipital Strain. Strains of the bicipital attachment to the ulna are not common. They occur in elbow hyperextension injuries and in overenthusiastic weight-lifting efforts. The course of the tendon will be tender on palpation. Management consists of rest in a sling for a few days along with standard sprain therapy.
Elbow Sprains
Intra-articular or extra-articular injuries to the elbow without fracture are not uncommon and are peculiarly resistant to treatment. There may be a primary or secondary injury to the upper radioulnar articulation by sudden overpronation or oversupination, followed by pain over the articulation and limited rotation. Overlooking radial-head dislocation is a common orthopedic pitfall.
DIFFERENTIATION
Forced joint movement beyond full extension, abduction, or adduction causes ruptures within the capsular apparatus and its contained reinforcing ligaments from their attachment to the humerus, radius, and ulna. The capsule is tender and frequently distended with blood. Movement in the direction of injury aggravates the pain, and there is some restriction at extreme ranges.
Hyperextension Sprain. Hyperextension sprains strongly mimic posterior dislocation of the elbow. Swelling and tenderness will be found at the joint capsule posteriorly, bicipital tendon, olecranon fossa, lateral and medial collateral ligaments, and attachments of the flexors and extensors at the medial condyle. Pain is relieved by flexion and increased on attempted extension. If the joint proper is involved, extension is chiefly limited, and it may persist for weeks or years.
Hyperabduction Sprain. Tenderness is found below the lateral epicondyle, indicating sprain of the ulnar collateral ligament. Pain is increased by forcing the elbow into valgus stress.
Hyperadduction Sprain. Tenderness is exhibited below the medial epicondyle, indicating sprain of the radial collateral ligament. Pain is increased by forcing the elbow into varus stress.
Ligamentous Stability Test. To judge stability of medial and lateral collateral ligaments of the elbow, hold the patient's wrist with one hand and cup your stabilizing hand under the patient's distal humerus. As the patient is directed to slightly flex his elbow, (1) push medially with your active hand and laterally with your stabilizing hand, then (2) push laterally with your active hand and medially with your stabilizing hand. With your stabilizing hand, note any joint gapping during either the valgus or varus stress maneuver.
Other Elbow Stress Tests. Besides elbow abduction and adduction, stability and range of motion should also be tested in extension, flexion, pronation, and supination. These motions should be carefully attempted when the elbow joint is as relaxed as possible. Pain or motion restriction will be found if contrac- tures, acute tendinitis, and/or acute joint pathology are present. If negative, the tests should be repeated against patient resistance. Pain or instability will then be found if sprain, acute or chronic tendinitis, and/or chronic joint pathology are present.
MANAGEMENT
During the acute hyperemic stage, structural alignment, cold, firm compression, rest in a sling, positive galvanism, ultrasound, vitamin C, manganese glycerophosphate, rest and possibly elevation are indicated. Swelling and joint limitation usually subside in 2-4 days. After 48 hr, passive congestion may be managed by contrast baths, light massage, gentle passive manipulation, sinusoidal stimulation, ultrasound, and a mild range of motion exercise can be initiated. Great care must be taken throughout management that treatment (eg, vigorous manipulation) does not induce further reaction. Injuries of the proximal radial articulation and annular ligament, key components in pronation and supination, are often frustrating to manage.
During the stage of consolidation, local moderate heat, moderate active exercise, moderate range of motion manipulation, and ultrasound are beneficial. In the stage of fibroblastic activity, deep heat, deep massage, vigorous active exercise with and without weights, negative galvanism, ultrasound, and active joint manipulation speed recovery and inhibit postinjury effects. An elbow "cinch-strap" is a helpful but annoying support during competitive activity to prevent overextension. When myositis ossificans becomes a complication, surgical removal of the bony mass may be required.
Tennis Elbow
"Tennis elbow" is a painful condition of traumatic origins which occurs about the external epicondyle of the humerus. The term incorporates a group of conditions, especially epicondylitis or radiohumeral bursitis. It is caused by repeated violent elbow extension combined with sharp twisting supination or pronation of the wrist against resistance. The result is severe contraction of the extensor-supinator muscles of the forearm. The clinical picture is one of synovitis, subperiosteal hematoma, fibrositis, or partial rupture of the fibrous origin of muscles and ligaments at the affected epicondyle, with some associated periostitis. Radial nerve entrapment may be involved. If the medial epicondyle is sore, the flexor-pronator muscles and medial ligaments are affected. The lateral epicondyle area is affected seven times more often than the medial epicondyle.
Bowerman reports that strain of the lateral epicondylar area is actually more common in golf than in tennis. In fact, the disorder commonly referred to as "tennis elbow" is a misnomer in that it has a higher incidence in golf, badminton, squash, rowing, manual labor, and even violin playing than tennis. It is not uncommon in bowlers and professional chess players.
Roentgenologic Considerations. X-ray features in the elbow may include softtissue calcification at the margin of the lateral joint, lateral epicondyle and capitellum erosion and fragmentation, and spur development at the coronoid process of the ulna. A medial slope deformity of the lateral condyle of the humerus is frequently related. Strenuous unilateral use of the active upper extremity (eg, tennis) often leads to hypertrophy of muscle and bone in the forearm and hands as compared to the nondominant side in young players. Increased radial length and width is frequently found.
Typical Signs. Hasemeir describes the typical symptomatic picture as pain over the outer or inner side of the elbow, distal to the affected epicondyle. Pain may be severe and radiate when the patient extends his arm. The pain is usually sharp and lancinating on exertion, but it may be dull, aching, and constant. Squeezing an object with the fingertips is usually painful (writer's cramp). Tenderness, heat, and swelling are found over the affected epicondyle, and limited passive movement on extension may be found. This is the result of microscopic and macroscopic tears at the common origin of the extensor and flexor muscle groups -- occurring as a consequence to overstress of tendon fibers. The supinator has its tendinous orgin just behind the common extensor tendon. Grip strength as well as supination and pronation strength are affected.
Cozen's Test. With the patient's forearm stabilized, instruct him to make a fist and extend his wrist. Grip the elbow with your stabilizing hand and grip the top of the patient's fist with your active hand and attempt to force the wrist into flexion against resistance. A sign of tennis elbow is a severe sudden pain at the lateral epicondyle area.
Mills' Test. The patient is instructed to make a fist, flex forearm, fully flex fingers and wrist, pronate forearm, and then attempt to extend forearm against resistance. This stretches the extensor and supinator muscles attaching to the lateral epicondyle. Pain at the elbow during this maneuver is an indication of radiohumeral epicondylitis.
Kaplan's Test. This is a two-phase test.(1) The seated patient is given a hand dynamometer and instructed to extend the involved upper limb straight forward and squeeze the instrument as hard as possible. Induced pain and grip strength are noted.
(2) The test is then repeated as before except that this time the examiner firmly encircles the patient's forearm with both hands (placed about 1-2 inches below the antecubital crease). Induced pain and grip strength are noted. If the second phase of the test shows increased reduced pain and increased grip strength when the muscles of the proximal forearm are compressed, lateral epicondylitis is indicated.Management. For adjustment procedure, see posteromedial subluxation of the radial head. Seek signs of possibly associated cervical, upper dorsal, and 1st rib subluxations. Rest with sling, cold packs, immobilization of wrist and elbow, diathermy, and ultrasound are the common adjunctives utilized. Treatment is similar to that of sprain. Underwater ultrasound is recommended by many. Return to activity immediately upon fading of symptoms invites recurrence. Squeezing a rubber ball helps in recuperation. Graduated restoration to painless function under competitive conditions is vital before full activity is resumed. Strengthening of the wrist extensors is important.
Vapocoolant Technique in Grade I and II Strains and Sprains. Place the patient in the sitting position with the elbow slightly flexed and abducted. Isolate trigger areas and site of major pain in the arm, elbow, and forearm, and spray sites. At the same time, ask the patient to extend his elbow and then slowly return it to the relaxed position. Repeat the spraying and active movement three or four times. Have the patient indicate with his finger the major source of pain. As the pain shifts position, spray the affected area. Once relief has been obtained in flexion-extension, add forearm pronation and supination in extension, spraying painful sites as necessary between movements. Have the patient attempt movements against resistance, and spray the painful area if necessary. Once relief is obtained, correct any subluxations isolated, apply an ace bandage or "tennis elbow" support, and instruct the patient in home exercises for 1-2 min each half hour during waking hours. Begin resistance and stretching exercises as soon as logical.
VARIATIONS
Golfer's Elbow. A severe opposite strain at the origin of the flexor pronator muscles at the medial epicondyle and strain of the medial ligament is sometimes called "golfer's elbow". Subperiosteal hematoma and periostitis are often involved. Poor warmup is usually the underlying cause in golf (or bowling), but taking a divot too deep during chipping is the initiating factor. Treatment is the same as that for tennis elbow, but the adjustment is reversed. That is, the wrist and fingers are extended and the forearm supinated while the elbow is fully extended.
Medial Epicondyle Test. On the side of involvement, the patient is instructed to flex the elbow about 90° and supinate the hand. If severe pain arises over the medial epicondyle when the patient in this position attempts to extend the elbow against resistance, medial epicondylitis (golfer's elbow) is suggested.
Baseball Elbow. This is the same condition in chronic form seen with baseball pitchers caused by elbow extension and snapping pronation or supination as the pitcher throws a "slider" or "breaking curve". Degenerative changes are more common on the medial epicondyle, thus indicating pronator strain. It can be considered an elbow "whiplash" injury where the olecranon impinges the fossa at the distal humerus. Stress fracture or traumatic epiphysitis is often associated in adolescents. Loose bodies from cartilage flaking, trochlea osteophytes, medial ligament ossicles, and olecranon chips are frequently related.
Javelin Elbow. When the javelin is thrown, the olecranon pivots medially in the trochlea and its tip is forced against the edge of the fossa during the extreme forearm pronation and elbow extension. This may result in repeated sprain from amateur "round house" throws, complicated by fracture fragments, calcification, and spur development along the course of the medial collateral ligament of the elbow. Transient ulnar nerve paralysis and "Little League" symptoms are early indications. In some cases, a "golfer's elbow" syndrome is seen from flexor-origin strain.
Olecranon Bursitis
Mobility of the upper extremity is provided by this a fluid-filled bursa which is exposed when the elbow is fixed on a firm surface. It is subject to direct impact hemorrhage, abrasion, contusion, laceration, and puncture, as well as from common indirect mechanisms, all of which may cause chronic inflammation, thickening of synovium, and formation of excessive fluid. The mechanism of injury is usually one of repetitive direct injury, constant friction of extensor tendons as in tennis elbow, and/or repetitious local injuries with synovial irritation. Local pain, tenderness, swelling, and movement restrictions are exhibited. Incidence is high in basketball and indoor racket sports from falls on a hard floor. Secondary infection readily converts the inflammation into an abscess.
Management. Treat with cold, compression, and elevation for 1-2 days. Refer for aspiration if necessary, but crisscross taping in elbow extension usually brings quick relief. In mild-moderate cases, an elastic ankle support can be worn with the heel opening placed on the antecubital fossa. Recurrent swelling is common, and protective elbow padding is necessary long after symptoms subside.
Subluxations
Most subluxations in the elbow area will offer dramatic relief upon correction. Generally, correction is made with a quick, short thrust to minimize the pain (and time) of relocation. It is essential that the patient's muscles be relaxed or correction will be inhibited and extremely painful. Naturally, quick thrusts are contraindicated in arthritic and sclerotic conditions or if adhesions are advanced.
POSTERIOR-MEDIAL RADIAL HEAD SUBLUXATION
This "pulled elbow" injury results from the radial head being jerked from the annular ligament, presenting symptoms of pain and tenderness in the area of the radial head. It was once called "Nursemaid's elbow", frequently found after young children were quickly lifted up by their extended forearm. Motion is severely limited in pronation and supination, but flexion and extension are normal. The arm is held in a pronated position, and pain is fairly localized at the elbow. X-ray films are negative. Incidence is high in judo, especially with the young. This type subluxation is commonly associated with tennis elbow or wrist trauma, lateral elbow pain, and restricted anterolateral radial-head motion.
Adjustment. When manipulation is indicated, the physician holds the affected elbow with one hand in such a manner that his thumb rests on the back of the head of the radius. With the other hand, the doctor holds the patient's hand and moves the arm into a position of slight flexion of the elbow, full forearm pronation, and full flexion of the wrist. This manipulation (Mills' movement) consists in fully extending the elbow while maintaining pronation and flexion of the wrist. The movement is made gently, but quite sharply; thus, it is essential that the patient's muscles be relaxed. The manipulation causes no pain to a normal elbow, but there is sharp pain when a tennis elbow is "freed" that is quickly followed by relief. Evaluate the integrity of the pronator quadratus, biceps brachii, brachioradialis, wrist extensors, and supinator. Treat as a severe sprain, and offer rest in a flexion sling for several days.
Alternative Adjustment Procedure. To re-establish the slipped radial head, grasp the hand of the seated patient and extend the wrist. Support the elbow firmly with your contact hand. Flex the elbow to a right angle. Maintain axial compression along the radius, and firmly alternate forearm supination and pronation in a "screwing" manner until the head of the radius slips back into position. A click can usually be felt and heard on replacement.
MEDIAL OLECRANON SUBLUXATION
Subluxation of the olecranon medially is often seen in association with ulna nerve paresthesias, wrist or elbow trauma, medial elbow pain, triceps dyskinesia, decreased distance between olecranon and medial epicondyle, and restricted lateral olecranon joint motion.
Adjustment. Face cephally on the affected side of the supine patient. The patient's arm is moderately abducted, and the elbow is extended. Your medial semi-extended contact hand is cupped on the medial aspect of the olecranon, while your stabilizing hand grasps the back of the patient's forearm. The elbow is brought into full extension, and a short thrust is made from the medial to the lateral with the contact hand while the stabilizing hand applies lateral to medial pressure. Evaluate the intregrity of the lateral and medial triceps.
Alternative Adjustment Procedure. Doctor and patient positions are as above. Abduct the arm and extend the patient's elbow. Firmly grasp the medial olecranon with the 1st and 2nd fingers of your contact hand, and stabilize the patient's distal forearm with your other hand. A short, brisk, pronating, medial to lateral pull and elbow extension is made with your contact hand as your stabilizing hand supinates the lower forearm.
LATERAL OLECRANON SUBLUXATION
This type of subluxation is related to elbow or wrist trauma, lateral elbow pain, triceps dyskinesia, decreased distance between olecranon and lateral epicondyle, and restricted medial olecranon motion.
Adjustment. Face caudally on the affected side of the prone patient. Abduct the arm, extend the elbow, and internally rotate the extremity. Make a soft pisiform contact with your medial hand on the lateral aspect of the olecranon, and stabilize the patient's lower forearm with your other hand. A short, brisk, thrust is made caudally to shift the olecranon medially as your stabilizing hand pronates the lower forearm. Evaluate the integrity of the lateral and medial triceps.
ANTERIOR OLECRANON SUBLUXATION
Subluxation of the olecranon anteriorly is seen in relation to hyperextension sprains and restricted posterior olecranon motion.
Adjustment. Stand on the affected side and obliquely face the sitting patient. Moderately abduct the arm, and flex the elbow. Place your contact hand on the dorsal aspect of the patient's distal forearm. Cup your stabilizing hand deep within the antecubital fossa, and wrap your thumb around the forearm. Make a short, brisk thrust with your contact hand towards the patient's shoulder, using your stabilizing hand as a fulcrum to bring the olecranon out of its depressed position. Evaluate the integrity of the biceps brachii, brachialis, brachioradialis, and triceps.
POSTERIOR OLECRANON SUBLUXATION
This type of subluxation is associated with elbow or wrist trauma, epicondyle and bursa tenderness, triceps dyskinesia, and restricted anterior olecranon movement.
Adjustment. Stand on the affected side of the sitting patient so that you are facing caudally. Abduct the patient's arm, extend the elbow, and slightly externally rotate the forearm. Cup the patient's elbow with your medial stabilizing hand, and place your thumb and index finger against the epicondyles for leverage. With your contact hand, grasp the volar aspect of the patient's lower forearm. A short, brisk, thrust is made towards the floor on the distal forearm as your stablizing fingers apply counterpressure upward. Evaluate the integrity of the triceps and biceps.
SUPERIOR ULNA SUBLUXATION
Subluxation of the ulna superiorly is related to elbow or wrist trauma. It is often a consequence of a falling person catching himself with an outstretched hand, resulting in the ulna being jammed upward against the humerus.
Adjustment. The patient sits next to a narrow table, leans forward to slightly forward-abduct his arm, and extends his forearm horizontal to the table's surface. The elbow should never be fully extended as this will subject the tip of the olecranon process to injury. Stand on the opposite side of the table and face the patient. With your contact hand, grasp the ulnar aspect of the patient's lower forearm and slightly rotate it externally. Cup your other hand against the patient's lower anterior humerus and extend your elbow to stabilize the patient's arm. Apply traction with your contact hand, and then make a short, quick pull to bring the ulna towards your body. Evaluate the integrity of the triceps and wrist flexors and extensors.
Alternative Adjustment Procedure. Stand on the affected side of the supine patient. Abduct his arm, and flex his elbow. Grasp the patient's lower forearm with both hands, with emphasis on the ulnar aspect, and place your knee in the patient's antecubital fossa for stabilizing. Traction is applied, followed by a strong upward pull.
Fractures and Dislocations
The radial head at the elbow transmits the force of a fall on the hand to the shoulder; thus explaining why the radial head is a common site of fracture in the elbow area. Subtle impaction fractures of the distal humerus and radial head are not uncommon and often can only be witnessed on x-ray film after a week or two. Acute signs are local swelling, tenderness about the radial head, and severe pain increased on pronation or supination. Severe displacement is not typical.
Olecranon fractures result from a fall on the elbow or excessive triceps action. Displacement may be severe because of the strong pull of the triceps. Olecranon stress fractures are seen in overuse throwing injuries (eg, baseball, javelin).
ASSESSMENT
If obvious deformity and crepitus are not present, check range of motion, and determine radial pulse. Assess sensation by light touch and distal motion function by having the patient appose thumb and forefinger. Elbow fractures and dislocations should be reduced by an orthopedist; splint in "as is" position, sling, and refer. Delay in referral can easily result in massive heterotopic bone formation. Myositis ossificans, nerve damage, brachial arterial compression, contractures, abnormal carrying angle, and joint stiffness may complicate recovery from any severe elbow injury. Poorly reduced supracondylar fractures, resulting in cubitis valgus, readily lead to ulnar neuritis.
ROENTGENOLOGIC CONSIDERATIONS
Elbow dislocations are usually the result of excessive hyperextension where the olecranon and radial head are displaced posteriorly. Severe soft-tissue damage is associated, usually resulting in subperiosteal hematoma. Comminuted or marginal fracture fragments from the radial head are frequently related with elbow dislocations. In uncomplicated cases, gentle forward traction on the forearm with the humerus stabilized can be conducted to ease pain prior to referral. Roentgenography is required to analyze possible complications prior to considering even simple dislocation reduction.
Especially within the adolescent player, trochlea, capitellum, and epicondyle growth centers may be enlarged, fragmented, displaced, or prematurely fused. Epiphyseal lines cause the most errors in interpretation of this area. Epiphyseal cartilage may be lacerated and the ossification centers displaced, sometimes into the articular cavity.
The most common fracture is a line running from the anterior to the posterior surface of the humeral shaft (supracondylar) with the proximal fragment shifted anteriorly. Fractures in the area of the elbow usually involve the joint. In the order of frequency, the most common fractures are supracondylar, fractures of the humerus, olecranon, head of the radius, and coronoid process. A fracture line between the condyles (intercondylar) or through one or both of the condyles (diacondylar) may be seen. Fracture of the ulnar shaft with dislocation of the radial head (Monteggia injury) and fracture of the radial head may also be presented.
Nerve Compression Injuries
RADIAL NERVE COMPRESSION AT THE ELBOW
This nerve compression syndrome features pain and disturbed sensation in the area of distribution of the superficial branch, thus frequently confused with De Quervain's disease. If the deep branch is involved, pain is at or below the lateral epicondyle.
Examination. On palpation, the nerve trunk is tender near the origin of the extensor muscles, and active extension of the fingers initiates or aggravates pain. If the elbow is extended and the 3rd finger is actively extended against resistance, pain is especially increased because the extensor carpi radialis inserts at the base of the 3rd metacarpal.
Management. If conservative therapy fails to afford relief, exploratory surgery is indicated.
MUSCULOSPIRAL CONTUSION
The course of the radial nerve in the musculospiral groove along the lateral aspect of the distal-third humerus is relatively superficial and not infrequently receives a contusion. The clinical picture ("dead arm") is one of sudden radiating pain throughout the distal radial distribution and extensor paralysis. Damage is rarely permanent, and symptoms usually ease within a few minutes.
Management. Local ice massage and nerve-contusion management will usually be adequate. If symptoms persist, neurologic consultation is necessary.
ULNAR NERVE COMPRESSION AT THE ELBOW
This nerve compression disorder is often called cubital tunnel syndrome or tardy ulnar nerve palsy. It is the result of trauma or compression of the ulnar nerve at the elbow when the medial ligament ruptures during elbow dislocation. It may also be involved if the medial epicondyle becomes fractured. This consequence is disability and pain along the ulnar aspect of the forearm and hand. Early signs are inability to separate the fingers and disturbed sensation of the 4th and 5th digits. Interosseous atrophy is usually evident, and light pressure on the cubital tunnel initiates or aggravates pain. Nerve conduction studies help to confirm the diagnosis.
Management. The cause is often repetitive trauma, and response to conservative therapy is poor unless the source of irritation can be removed. Surgery may stop progressive neuropathy, but it does not guarantee return of normal neurologic function.
Miscellaneous Pathologic Signs
Tinel's Elbow Test. The groove between the olecranon process and the medial epicondyle is tapped with the pointed end of a reflex hammer. A hypersensitive response is seen in ulnar neuritis or neuroma.
Strumpell's Pronation Sign. The patient is asked to extend the elbows, project the arms forward, and supinate the hands. If the patient is unable to keep an affected limb from drifting into pronation during active flexion or elevation of the arms from this position, it is said to be a sign (pathologic reflex) of an upper motor lesion (eg, hemiplegia).
Biernacki's Sign. Deep pressure over the ulnar nerve behind the elbow normally causes pain, even in a patient with a high pain threshold. A lack of response suggests a lesion of the fibers carrying deep pressure impulses or a lesion in the posterior columns of the spinal cord. Some authorities feel this sign is pathognomonic of tabes dorsalis.
Cogwheel Sign. If during passive elbow flexion and extension, the muscles feel taut (lead pipe rigidity) and the motion is felt like a series of irregular and jerky catches and releases (cogwheel motion), a lesion in the extrapyramidal system of the basal ganglia is indicated (eg, paralysis agitans).
Erb's Sign. If during the application of a galvanic current to a nerve or muscle motor point produces a tonic muscle contraction (tetanic reaction) rather than the normal single "make and break" response, hyperexcitability of the peripheral nerve is indicated (eg, as in tetany).