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198 Cards in this Set
- Front
- Back
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Sagittal bands
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Center EDC at MCPJ. Attaches to volar plate
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Central slip
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inserts onto base of P2. Extends PIPJ
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Terminal extensor tendon
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Confluence of radial and ulnar lateral bands, central slip of EDC, intrinsics
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Transverse retinacular ligament
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prevents dorsal subluxation of lateral bands
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Obliqure retinacular ligament
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(ligament of Landsmeer) Helps link PIPJ and DIPJ extension. Contracted in chronic boutonniere deformity
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Grayson's/ Cleland's ligaments
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Attach radial/ulnar aspects of P3 to overying skin. Grayson's- volar/ Clelands/ dorsal to nv bundle (Graysons- ground/ Clelands- ceiling)
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FDP
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Flexes DIPJ. Splits FDS at Camper's chiasma @ PIPJ
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Pulleys that prevent bowstringing
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A2/A4
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Thumb pulleys
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A1, A2, Oblique- most important. Attached to adductor.
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Finger annular pulleys
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Odd over joints. Even over digits. A2- proximal aspect of proximal phalanx. A4 middle of middle phalanx
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Digit pulleys
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A1-5, C1-3
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Contents of carpal tunnel
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9 flexor tendons (4x FDP, 4x FDS, FPL), median nerve. FPL most radial. FDS long and ring are volar
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Guyon's canal
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contains ulnar artery and nerve
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Palmaris longus prevalence
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85%
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Primary wrist flexors
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FCR: inserts on 2nd metacarpal- more expendable. FCU: inserts on pisiform- more powerful.
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1st dorsal compartment
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APL/EPB- De Quervain's. Watch for multiple slips of aPL
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2nd dorsal compartment
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ECRB/ECRL- Intersection Syndrome- radial to Lister's tubercle
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3rd dorsal compartment
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EPL- ulnar to Lister's tubercle
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4th dorsal compartment
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EDC/ EIP. EIP ulnar to index EDC
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5th dorsal compartment
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EDM- ulnar to small finger EDC. Rupture= Vaugh-Jackson syndrome
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6th dorsal compartment
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ECU
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Lumbricals
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Origin: radial aspect of FDP. Insert: radial lateral bands. Action: Relax extrinsic extensors. --> IPJ extension/ MCP flexion.
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Test for intrinsic tightness
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Test PIPJ ROM with MCPJ flexed and extended. Positive test if dec ROM with MCPJ extension
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AIN
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branch of median nerve. Innervates FPL/index/long FDP/ PQ
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Palmar cutaneous branch
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off median nerve. Between palmaris longus and FCR at wrist flexion crease
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Recurrent motor branch median nerve
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Innervates APB/OP/sup head of FPB
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Ulnar nerve
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hypothenar, interossei, ring/small FDP, lumbricals, FCU, adductor pollicis, deep head of FPB
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Martin-Gruber anastamoses
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connections between median and ulnar nerves in hand. 15% incidence
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Digital nerves vs arteries
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nerve volar to artery in fingers. Reversed in palm
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Load sharing radius/ulna
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80% radius/ 20% ulna (via TFCC) if neutral ulnar variance
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Normal alignment distal radius
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11deg volar tilt, 12mm radial height, 23deg radial inclination
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Chauffeurs Fracture
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Radial styloid (aka Hutchinson's fx)
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Interval Henry approach
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FCR and radial artery
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Arthrosis with articular stepoff
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1mm--> 90%. 2mm--> 100% (2/3 symptomatic)
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Tx EPL rupture
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EIP to EPL transfer or palmaris graft interposition
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Scaphoid blood supply
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Primary: dorsal branch radial artery. Enters distal to waist--> retrograde flow. Branch of superficial plmar br radial artery-->distal tubercle
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Scaphoid view XR
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30deg wrist extension, 20deg ulnar deviation
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False negative XR for scaphoid fx
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30%
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Nonunion rate with delayed diagnosis
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45% after 4wks vs 5% with immediate treatment
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Stable scaphoid fracture patterns
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Transverse fx, minimal comminution, impaction
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Unstable scaphoid fracture patterns
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Vertical/oblique pattern, comminution, wide displacement
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Indications for fixation scaphoid fractures
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>1mm displacement, >15deg angulation, trans-scaphoid-perilunate injuries. Proximal pole relative indication
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ORIF scaphoid nonunion w/ humpback deformity
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Opening wedge interposition graft
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Best sign of vascularized proximal pole scaphoid
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Intraoperative punctate bleeding
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Pedicle for vascularized bone graft to scaphoid
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1,2 intercompartmental supraretinacular artery
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Complication of lunate fx
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osteonecrosis
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Carpal instability dissociative vs non-dissociative
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Dissociative= Instability between carpal bones within row. Nondissociative= between rows
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DISI
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SL disruption--> scaphoid flexion/ lunate extension. PE: Watson's test. RAD: SL angle >70deg, SL interval >3mm. Cortical ring sign. Wrist arthroscopy is gold standard. Tx: Primary repair if acute, A/S and debridement if partial tear. SL reconstruction/Blatt if chronic
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SLAC stages
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1. Radial styloid. 2. Radioscaphoid joint. 3. Midcarpal. Radiolunate spared
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VISI
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LT injury. Scaphoid and lunate flex. Hx: ulnar sided wrist pain. RAD: break in Gilula's arc. SL <30deg. Arthroscopy gold standard. Tx: LT repair, FCU augmentation, LT arthrodesis. Ulnar shortening osteotomy may help with pain
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CIND midcarpal instability
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Clunking wrist, often without trauma. Dx: cineradiography. Tx: most repond to immobilization. Surg= midcarpal fusion.
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CIND radiocarpal instability
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If secondary to distal radius malunion then tx malunion. Ulnar carpal translation is secondary to extrinsic ligament rupture. Dx: >50% of lunate translated ulnarly. Tx: immediate open reduction/repair.
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Stages of perilunar disruption
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Counterclockwise from radius to ulna. 1:SL. II: SC. III:LT. IV: volar lunate dislocation
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Lesser vs greater arc
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Lesser arc: ligamentous. Greater arc: bony. (surrounding lunate)
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Acceptable alignment metacarpal neck fractures
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Index/long <20. Ring <40. Small <70
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Acceptable alignment metacarpal shaft fractures
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index/long <10. Ring/small <30. (approx 1/2 parameters for neck)
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Deforming force reverse Bennett's fracture
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ECU
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Deforming forces Bennett's fracture
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APL--> proximal/dorsal/radial displacement of base. Add pollicis--> supination/adduction of shaft. AOL keeps volar/ulnar fragment reduced
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Rolando fracture
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T/Y shaped comminuted fracture of base of thumb MC
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UCL stress examination
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Unstable in extension= UCL and volar plate rputure. Instability in flexion (<30deg= partial/ >30deg= complete)= UCL rupture
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Tx MCPJ dislocation
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Skin dimpling indicated complex dislocation (volar plate/sesamoids interposed). Reduction: flexion/volar directed force NO TRACTION!. Open reduction- dorsal/volar approach. (volar risks NV bundle)
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Deforming forces P2 fx
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Interossei--> proximal fragment flexion. Central slip-->distal fragment extension
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Sequela of volar PIPJ dislocation
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Central slip insufficiency--> boutonniere deformity
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Rotatory dislocation PIPJ
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condyle buttonholes between central slip and lateral band. Open reduction usually required
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Surgical indications for mallet finger
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volar subluxation- perc pinning. ORIF if >50% articular surface involved. Chronic mallet: direct repair vs tenodermodesis vs spiral oblique retinacular ligament reconstruction.
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Consequence of untreated mallet finger
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Swan neck deformity from attenuation of volar plate/ transverse retinacular ligaments
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PE for central slip rupture
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Elson test: flex PIPJ to 90 then pt extends DIPJ vs resistance. NML: no resistance
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Extensor tendon zones
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P3/DIPJ/P2/PIPJ/P1/MCPJ/MC/Carpus/forearm/muscle bellies
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Extensor tendon laceration over wrist/forearm
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Repair retinaculum also. Immobilize wrist in extension/MCPJ flexion for 3wks. Poor results in this zone
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Partial flexor tendon lacerations
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<25%- trim. 25-50%- epitenon repair. >50% core and epidtenon repair.
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Flexor tendon repair mechanics
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Dorsal sutures stronger than volar. Strength proportional to number of core sutures. Epitenon repair--> 10-50% increased strength. Repair fails at suture knots
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Time of greatest risk of ruptures s/p flexor tendon repair
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3wks. Usually at suture knots
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Postop flexor tendon repair in children
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Cast x 4wks for kids < 6yo
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FDP injuries
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Leddy classification: 1: tendon only--> retraction. 2: small avulsion fragment- retracted to A4 pulley. 3: large bony fragment- stays outside sheath. Repair type I <7-10 days/ type II <6wks. Advancement >1cm--> quadrigia
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FPL laceration
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Repair--> higher rate of rerupture. Zone I: distal to IPJ. Zone II: P1. Zone III: Beneath thenar muscles
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Flexor tendon repair rehabilitation protocols
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Kleinert: dynamic splinting. Active extension/ passive flexion. Duran: contralateral hand performs passive flexion.
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ECU subluxation
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Occurs with forced hypersupination/ulnar deviation. Tx: Acute: LAC in pronation/slight radial deviation. Chronic: repair/recon of retinaculum +/- groove deepening. 50% incidence of concomitant TFCC tear
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Ulnar variance w/ wrist position
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Positive when Pronated. Negative when supinated
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Components of TFCC
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Dorsal /volar radioulnar ligaments. Articular disk. Meniscus homologue. ECU sheath. UCL. Origins of TL/LT ligaments
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Germinal matrix
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Proximal to nail fold.
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Sterile matrix
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Beneath nail plate. Contributes keratin to increase nail thickness.
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Hyponychium
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Between distal nail bed and skin of fingertip. Acts as barrier
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Eponychium
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Distal margin of proximal nail fold. = cuticle
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Paronychia
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lateral margins of nailbed
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Tx subungal hematoma
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<50% nail surface- perforate nail. >50% nail surface- nail removal
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Fingertip soft tissue injury <1cm2
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Allowable to heal by secondary intention
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Best flap for volar oblique fingertip injury
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Cross finger flap
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Thenar flap indications
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volar index or long digit injuries. Risk: PIPJ contractures
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Homodigital island flap
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Pedicle on digital artery. Preserves innervation.
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Heterodigital island flap
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From ulnar aspect of long or ring finger to cover thumb
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Moberg advancement flap
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Entire volar surface of thumb shifted w/ nv bundle. Uses: transverse or volar oblique thumb injuries
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First dorsal metacarpal artery kite flap
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Uses: dorsal thumb injury
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Indications for flap coverage
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Exposed: bone stripped of periosteum, tendon stripped of paratenon, cartilage, hardware
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Axial pattern flaps
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single named arteriovenous pedicle. More predictable blood supply, greater mobility, more resistance to infection
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Random pattern flap
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depend on microcirculation for viability
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Z-plasty principles
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Limbs of equal angles. 60deg angle--> 75% lengthening
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Gracilis flap artery
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medial femoral circumflex artery
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Latissimus flap artery
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Thoracodorsal artery
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Serratus anterior flap artery
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Serratus branch of subscapular artery
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Causes of flap failure
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Early: arterial (most common). Late: venous
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Indications for replantation
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1. multiple digits. 2. thumb amputation. 3. Wrist/proximal amputations. 4. pediatric . 5. (relative) distal to FDS insertion
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Warm ischemia time
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6hrs- proximal to carpus// 12hrs distal to carpus
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Cold ischemia time
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12hrs- proximal to carpus// 24hrs distal to carpus
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Sequence for replantation
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1. bone. 2. extensor tendon. 3. flexor tendon. 4. artery. 5. vein. 6. nerve. 7. skin. Structure by structure technique fastest. Artery first in limb replantation
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Replantation temperature monitoring
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Drop of 2deg C in 1hr or below 30deg C= decreased perfusion
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Replantation failure
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Early (<12hrs)- arterial thrombosis from persistent vasospasm. Tx: release dressing, dependent position, heparin, stellate ganglion block. Late (>12hrs)- venous congestion/thrombosis. Tx: release dressing, elevate, leeches, heparin soaked pledgets
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Most predictive factor in replantation success
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mechanism of injury
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Ring avulsion injuries
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type 1: soft tissue- tx soft tissue procedures. Type 2: circulation compromised- tx w/ revascularization. Type 3: complete degloving- tx w/ amputation
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Vascular arch
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Ulnar dominant and primary to superficial arch/ radial primary to deep arch and princeps pollicis. Complete arch present in 80%
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Cold stimulation testing
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Time to return to normal temp after cold water immersion. Normal: 10minutes
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Three phase bone scan
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Phase 1: info similar. Phase II: show dec perfusion in vasospastic disorders. Phase III: skeletal images
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Hypothenar hammer syndrome
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Most common post-traumatic vascular occlusive condition of UE. Thrombosis/ aneurysm distal ulnar artery. Sx: cold intolerance/ pain/ ulnar n comp in Guyon's canal.
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UE emoblic disease
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Primarily cardiac in origin. Also subclavian origin in TOS. Tx: embolectomy if large vessel. Thrombolytics if small vessels
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Raynaud's
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Sx: triphasic color changes. F>M. Tx: CCB/digital sympathectomy if severe/ smoking cessation/cold avoidance
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Forearm compartments
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Mobile wad/dorsal/volar
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Hand compartments
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adductor pollicis/ thenar/hypothenar/ 4 dorsal and 3 volar interossei. Release: 2 dorsal incisions for interossei, 1 thenar and 1 hypothenar incision. If releasing digits: radial incision for thumb/small, ulnar incision for all others
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Volkman's ischemic contracture
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FDP/FPL most vulnerable and most affected. If severe--> claw hand deformity
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Tx frostbite injury
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Rapid rewarming @40-44deg
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NCS Findings Compressive neuropathy
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Demyelination: decreased velocity/ increased latency (over 3.5msec sensory/4.5msec motor). Axonal loss: decreased amplitude. EMG: fibrillation at rest/ positive sharp waves/complex repetitive discharges
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Transverse carpal ligament attachments
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Scaphoid tuberosity/ Trapezium/ Pisiform/ hook of hamate
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Results steroid injxn CTS
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80% benefit. 22% symptom free at 12mo (40% if duration of sx less than 1yr w minor NCS changes)
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Variations of recurrent motor branch of median nerve
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extraligamentous 50%/ subligamentous 30%/ transligamentous 20%
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results of endoscopic carpal tunnel release
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faster return to work/better pt satisfaction, equal long term results. Higher complication rates- related to experience. Most common complication- incomplete release TCL
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Site of compression median nerve
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1. supracondylar process. 2. ligament of Struthers (bet supracondylar process and medial epicondyle). 3. bicipital aponeurosis. 4. bet heads of PT. 5. FDS aponeurosis. AIN also can be compressed by bicipital bursa/ Gantzer's muscle (accessory head FPL)
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Sites of compression ulnar nerve
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1. arcade of Struthers (fascial hiatus intermuscular septum- 8cm prox to medial epicondyle). 2. medial head of triceps. 3. medial epicondyle. 4. Osborne's ligament (roof of cubital tunnel). 5. anconeus epitrochlearis. 6. FCU aponeurosis.
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Persistent elbow pain s/p decomp ulnar nerve
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r/o neuroma MABCN
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Surgery w/ best results cubital tunnel
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anterior submuscular transposition
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Causes ulnar tunnel syndrome
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Compression in Guyon canal. Most 2/2 ganglion cyst. Also hook of hamate nonunion/ulnar artery thrombosis/ palmaris brevis hypertrophy/anomalous muscles.
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Zones of ulnar tunnel
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I: proximal to bifurcation (sens/motor). II: surrounds deep motor branch (m). III: surrounds superficial sensory branch (s). Ganglia/hamate fx- zones I/II. Ulnar artery thrombosis- zone III.
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Sites of compression PIN
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1. recurrent leash of Henry. 2. fascial band at radial head. 3. edge of ECRB. 4. arcade of Frohse (proximal edge of supinator). 5. distal edge of supinator. Arcade of Frohse most common.
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Radial tunnel syndrome
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Lateral elbow/radial forearm pain w/out motor/sensory dysfunction. Pain w/ resisted long figer extension and resisted supination. Maximal tenderness 1.5cm anterior/distal to lateral epicondyle. Usually nml EMG/NCS. Marginal results surgical tx.
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Wartenberg syndrome
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aka Cheiralgia paresthetica. Compressive neuropathy sup sens br radial nerve. Compressed between brachioradialis/ECRL during pronation.
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Suprascapular nerve entrapment
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Posterolateral shoulder pain. Post trauma/traction injury with overhead. NCS helpful. Suprascap notch--> SS/IS. Spinoglenoid notch-->IS only.
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Adson's test
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Hyperextend neck/rotate to affected side--> decreased pulse w/ inhalation.
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Most predictive factor for peripheral nerve recovery
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age <20. Also: stretch/clean wounds/ early direct repair improves prognosis.
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Classification peripheral nerve injury
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1. Neurapraxia/ First degree- demyelination/ temporary conduction block- recovery in days/weeks. 2. Axonotmesis/2nd degree- axonal injury- regen in weeks-months. 3. Neurotmesis- third degree- endoneurium injured-poor regen. 4. 4th degree- perineurium injured- neuroma incontinuity. 5. 5th degree- severed nerve. no recovery w/out surgery.
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Nerve repair
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Best w/in 10-14 days. No benefit from epineural vs fascicular repair techniques. Gaps over 2.5cm require grafting. Collagen tubes good for gaps under 4mm.
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Timing of surgery for brachial plexus injury
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Immediate- penetrating/iatrogenic injuries. Early (3wks-3mo)-high energy mechanism and complete injuries. 3-6mo observation if low energy or GSW. Best results within 3mo. Repair/recon after 6mo- poor results. Muscle fibrosis after 18-24 months. Priorities: elbow flexion/ shoulder stabilization/ hand function
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Oberlin transfer
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ulnar nerve fascicle to FCU transfer into musculocutaneous nerve.
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Correction thumb in palm deformity
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Release/lengthen AdP/1st dorsal IO/ FPB/ FPL + Z-plasty 1st webspace. Tendon transfers to augment thumb extension/abduction.
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Correction clenched fist deformity
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Fractional or Z-plasty lengthening + neurectomy of motor branch of ulnar nerve.
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Restoration wrist extension in CP
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Green transfer- FCU to ECRB around ulnar border of forearm.
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Timing tendon transfers
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Need: tissue equilibrium/passive ROM/ adequate donor site strength. i.e. resolution of spasticity in tetraplegia.
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Radial nerve injury tendon transfers.
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PT to ECRB- restores wrist extension. FCU or FCR to EDC II-V. FDSIII to EPL/EIP. FDS IV to EDC III-V. PL to EPL/ FDS to radial lateral band for thumb extension.
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Tendon transfers for intrinsics
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restore intrinsics. 1. ECRL to lateral band. 2. EDQ/EIP to lateral band. 3. MCPJ capsulodesis
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Characteristics tendon transfers
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1. expendable donor. 2. single function tx. 3. preserve wrist tenodesis. 4. keep one flexor/extensor. 5. synergistic tx easier to rehab. 6. will lose one grade muscle strength. 7. straight line of pull best. 8. adhesions most common cause of failure
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PIPJ arthrodesis
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40deg index- increase by 5deg w/ each digit ulnarly
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PIPJ arthroplasty
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poor outcomes in index finger. Expect 60deg arc of motion.
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MCPJ arthrodesis
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25deg index- increase by 5deg w/ each digit ulnarly
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Vaughn-Jackson syndrome
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progressive attritional rupture of extensor tendons. Starts w/ EDM and progresses radially. Secondary to prominent distal ulna.Occurs in RA.
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Mannerfelt syndrome
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FPL and/or FDP attritional rupture from scaphoid osteophyte. Occurs in RA.
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Differentiate extensor tendon rupture from sagittal band rupture and subluxation
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Sagittal band: able to maintain extension/ can't actively extend.
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Caput ulnae syndrome
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End stage DRUJ instability in RA secondary to synovitis. ECU subluxates ulnar/volar. Ulnar head subluxates dorsally--> pressure on extensor tendons. Tx: Darrach/Sauve-Kapandji/resection hemiarthroplasty/ ulnar head replacement.
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Still disease
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transient arthritis + fever/anemia/HSM/uveitis/lymphadenitis. RF-. 1/4 get chronic arthritis
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Polyarticular JRA
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>5 joints. Symmetric. Most progress.
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Pauciarticular JRA
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<5 joints. Asymmetric. More large joints/ LE. ANA/HLA-B27 positive.
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Psoriatic arthritis
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seronegative spondyloarthropathy. Nail pitting/sausage digits. Pencil in cup DIPJ.
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SLE
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rheumatoid-like presentation. MCPJ deviated ulnar and subluxated volarly. XR usually nml. Arthrodesis better than arthroplasty (joint laxity)
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Scleroderma
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Raynaud's/ PIPJ flexion contractures/pulp atrophy/calcinosis cutis/absorption of tufts on XR. Tx: periadventitial digital sympathectomy for refractory Raynaud's. Fusion for fixedcontractures. Excise calcific despoits.
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Kienbock disease
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ON of lunate. Associated with negative ulnar variance. MRI: diffusely dark on T1/T2. Inc signal on T2 indicated revascularization. Tx: if nml XR- cast x 3mo. If XR findings: op tx. If ulnar neg- radial shortening osteotomy. If ulnar postive- capitate shortening + capitohamate fusion. vasc bone graft w/ 4-5 intercompartmental supraretinacular artery.
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Preiser disease
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ON of scaphoid. Cast immobilization effective in 20%. Tx w/ drilling/curettage/vasc bone grafting/ PRC/fusion
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Histo changes Dupuytren's
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Myofibroblasts predominant cell. Increase type III vs type I collagen. Inc free radicals.
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Spiral cord
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Contributions from pretendinous and spiral bands, lateral digital sheet, Grayson's ligament. Contributes to PIPJ contracture. Displaces nv bundle volarly/centrally.
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Indications for operation Dupuytren's
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>30deg MCPJ contracture/any PIPJ contracture/ positive tabletop test.
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Surgical tx Dupuytren's
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1. Regional palmar fasciotomy= procedure of choice. Segmental aponeurectomy just as effective. Total palmar fasciotomy not favored- high complication rate. Open plam technique of McCash- best for older pts- open wounds reduces hematoma/allows early motion w/ lowest rate of complications. Dermatofasciectomy for recurrent cases or Dupuytren's diathesis. Recurrence most common complication (50%)
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Giant cell tumor tendon sheath
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Contains giant cells, xanthoma cells, hemosiderin. High risk recurrence
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Human bite infections
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streptococcus/ s. aureus/ eikenella. Tx: Unasyn/ PCN (eikenella- resistant to cephalosporins.)
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Dog/cat bites
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alpha hemolytic strep/ pasteurella/ s. aureus/ anaerobes. Tx: unasyn/augmentin.
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Onychomycosis
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Trichophyton rubrum. Tx: ketoconazole/itraconazole PO- pulse dosing 1wk per month. Resistant cases- griseofulvin.
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Chronic paronychia refractory to abx
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Consider candida. More common in diabetes. May require marsupialization
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Kanavel signs
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1. flexed resting posture. 2. fusiform swelling. 3. `tenderness to sheath. 4. pain w/ passive extension
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Parona's space
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Potential space between PQ and FDP- allows horseshoe abscess
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Sporothrix schenckii
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ascending nodular lymphangitis- us after thorn injury. Tx: potassium iodine
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Transverse absence of UE
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congenital amputations. Usually at proximal forearm. Isolated. Secondary to vascular insult to apical ectodermal ridge.
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Radial dysplasia associated syndromes
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Holt-Oram, TAR, Fanconi anemia, VACTERL
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Correction radial dysplasia
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Early: Therapy for ROM. Centralization between 6 and 12 months if full ROM elbow
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Ulnar dysplasia
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not associated w/ syndromes. Other msk abnormalities common.
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Cleft hand
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Often bilateral and familial. Cleft closure and thumb web construction priorities. Perform cleft closure first. Remove transverse bones early- can widen gap.
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Clinodactyly
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congenital curvature in radioulnar plane. Type III- severe angulation- If delta phalanx- has C-shaped physis. May resect if digit long- o/w opening wedge osteotomy to correct.
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Congenital trigger thumb
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most resolve spontaneously- release bet 6 and 12 mo.
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Congenital clasped thumb
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deficient active thumb extension. Supple- weak/absent EPL/EPB- tx w/ tendon tx. Rigid- hypolastic extensors/MCPJ contracture/UCL deficiency/thenar hypoplasia. Tx: capsular release/AdP/FPB/1st dorsal IO release. Webspace deepening
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Syndactyly
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Most common congenital hand anomaly. Failure of apoptosis. AD w/ variable expression. Release at 1yo/ if rays unequal length- 6mo/ if acrosyndactyly- as neonate. Release one side at a time. Pland and Apert syndromes have syndactyly.
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Preaxial polydactyly associated anomalies
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Holt-Oram, Fanconi anemia, Flackfan-Daimond anemia, cleft palate. Usually not syndromic in caucasians
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Postaxial polydactyly
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African-Americans. In Caucasians- genetic workup required. Remove by 1yo
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Central polydactyly
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Assoc w/ syndactyly. Early surgery to prevent angular deformity.
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Macrodactyly
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nonhereditary congenital digital enlargement. Static or progressive. Best outcome for amputation in very large digits. Also can : epiphyseal ablation/osteotomies/nerve stripping
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Thumb hypoplasia
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If CMC intact- tx w UCL stabilization/web deepening/extensor recon. If CMC not intact- tx w pollicization.
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Madelung deformity
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disrupted volar ulnar physis of distal radius--> excessive radial inclination and radiopalmar tilt. SX: ulnocarpal impaction/ dec forearm rotation/ median nerve compression. Osteotomy if symptomatic.
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Force borne across elbow joint
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60% radiocapitellar/ 40% ulnohumeral
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Normal elbow anatomy
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Distal articular surface angled 30deg anterior/ 6deg valgus ROM: 0-150 +80 pro-sup/ Functional ROM: 30-130 + 50 pro-sup.
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Elbow MCL anatomy
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Anterior/posterior/transverse bundles. Anterior bundle (medial epicondyle to sublime tubercle) primary restraint to valgus stress. Posterior bundle restraint to valgus stress at full extension.
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Elbow LCL anatomy
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RCL/ LUCL/ accessory collateral ligament/ annular ligament. LUCL (lateral epicondyle to crista supinatoris of prox ulna)- primary restraint to varus and external rotation stress
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Lateral epicondylitis
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Tendinopathy of ECRB.Angiofibroblastic hyperplasia on histo. Tx: steroids of questionable benfit. Nonop tx x 12mo. Remove friable abnormal tendon. Continued sx us due to incomplete removal tendinosis.
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Mason classification
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I: non-displaced. II: >2mm displacement or mechanical block. III: comminuted. IV: associated elbow dislocation
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Safe zone for radial head fixation
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110 degree arc where radial head non-articular
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ORIF vs replacement
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If three+ fragments then ORIF has high failure rate/ poor results--> consider replacement.
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Terrible triad of elbow
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1. Dislocation. 2. radial head fracture. 3. coronoid fracture.
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Posterolateral rotatory instability
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incompetence of LUCL. Dx: lateral pivot shift test- sup/axial load/valgus while flexing elbow. Tx: LUCL reconstruction.
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