Musculoskeletal card 12

Case Study 2-Elbow
1. Identify the Pathology
· Fracture of R radial head, this is a common injury from falls onto an outstretched hand as this action forces the elbow into valgus which in turn forces the head of radius against the capitulum
· Treated with open reduction and internal fixation (O.R.I.F) which is a method of surgically repairing the fractured bone using plates and screws to stabilize the joint
· Elbow was then put into a back slab
2. Relevant anatomy of the elbow joint
Bony points
· Lower end of humerus
· At elbow joint a crease occurs during flexion, medial to this line is the medial epicondyle and lateral to this line is the lateral epicondyle
· With the elbow in extension, the Olecranon Process can be found posteriorly, directly between the two epicondyles. During flexion, these points form an equilateral triangle
· Lateral and inferior to the olecranon process, with the elbow in full extension, you can feel the joint between the radial head and capitulum of the humerus
Joints-the elbow is made up of 3 joints
· Unlotrochlear joint (elbow joint) is between the olecranon process and the medial condyle of the humerus. This joints is constrained and only allows flexion and extension.
· Radiocapitellar joint is between the radial head and lateral condyle of the humerus. This joint is less constrained and allows flexion, extension and rotation of the forearm.
· Radioulnar joint is between the radial head and proximal ulna. It is the least constrained joint allows forearm rotation.

Ligament-stabilize the elbow joint
· Elbow joint is constrained by the medial collateral ligament which has well defined anterior, posterior and transverse bundles
· Other ligaments include the lateral collateral ligament, radial collateral ligament, lateral ulnohumeral ligament and other accessory collateral ligament
· Radioulnar joint is constrained by the annular ligament
Nerves
· Ulnar nerve passes proximally and passes behind the medial epicondyle
· Posterior interosseous nerve wraps around the radial neck



3. Common symptoms and site of pain
· Pain on lateral side of elbow
· Swelling at the elbow joint
· Reduced ROM in flexion and extension with pain
· Inability or difficulty rotating the forearm
· Pain increased with passive movements
· Point tenderness over radial head

4. What you would expect from this patient in a subjective assessment
· Fear of movement of elbow
· Stiffness of joint after removal of plaster (back slab)
· Pain on palpation of elbow joint
· Pain on flexion and extension of joint
· Possible oedema due to weak muscles not able to provide pumping action for veins
· Limited ROM due to swelling, stiffness, and weakened muscles, joint may be able to complete full ROM of passively unless fracture affected joint surface in which case full ROM may never be recovered
· Loss of power due to weakened muscles from inactivity

5. Objective assessment
Visual observation
• Shape of joint caused by deformities, nodules etc
• Swelling
• Discolouration
• Posture-position of arm
• Overall position of person
• Are they using the involved limb?
• Is the arm in an abnormal position?
• Do the shoulders look symmetrical?
• Skin color
• Skin temperature
• Any signs of trauma?
• Carrying angle
ROM
• Active and passive
• Flexion/extension-tests the elbow joint and capsule
• Pronation/supination-tests superior radio-ulna joint
• Wrist flexion/extension with elbow fully extended
• Radial deviation of wrist
• Ulnar deviation of wrist
• Pronation of wrist
• Supination of wrist
Resisted tests-power tests-can be done using through range resistance or mid-way resistance
• Elbow flexion/extension
• Pronation/supination
• Wrist flexion/extension
• Palpation
Special tests-Don’t know if we need these or not but just in case...
Forearm compression test
• The examiner uses both of his or her hands to squeeze the pt’s radius and ulna together, being certain to test proximally, intermediately, and distally.
• Pain indicates a positive test for forearm long bone fracture (radius or ulna).
Transverse stress test
— The examiner grasps the pt’s radius and attempts to translate it distally and proximally, effectively stressing the bone along its long axis.
— The test should be repeated with the ulna.
— Obvious sharp pain indicates a positive test for forearm long bone fracture.
Percussion test
— The examiner simply percusses the bones of the forearm, paying special attention to bony landmarks.
— This should include the radius, ulna, olecranon process, and the medial and lateral epicondyles.
— Sharp pain indicates a positive test for forearm long bone fracture.
6. Explain to examiner what you would expect to see if the model had the real symptoms
• Results of the special test should all be positive for the radius, as although the fracture has healed (bony union visible on x-ray) the joint will still be painful
• ROM tests should show reduction in ROM actively due to pain and lack of patient lack of confidence in the join, but passively the joint should have full ROM as the fracture has healed
• Power tests should show that the left arm is stronger than the right arm due to muscle atrophy
• Pain on flexion and extension of elbow joint