of preparation for this discussion. As you know, I mean, the elbows just, I mean, there's tons of stuff. I mean, if you just look through this topic outline, I mean, we have an hour, I have 200 slides, so don't worry, you guys have them all. I'm not gonna go over every single slide. But I hope to just sort of hone in for the rest of this talk, primarily on the key exams, the exam questions, and then any of the key pertinent things as the slides come on. But I mean, I'm gonna leave it up to you guys to look over the rest of the slides. But overused tendinopathies, compressive neuropathies, muscle strains, stress fractures, impingement syndrome, ligament injuries in throwers and non-throwers, acute fractures, elbow instability from trauma, and of course, the pediatric patients, and also elbow arthroscopy. These are, this is the categories of questions that I've seen in the exams. You guys doing now the combined, the MOC guys doing the combined sports, and yeah, because I did that for the hand, so that the hand has a combined one as well. I thought it was really good. I'm sure you guys, I'm sure this'll be a lot better. I think that, I mean, there are these major sort of topic overviews within each of the diagnoses, and you'll see that in all the handouts that I gave you guys. And really sort of pay attention to the stuff that's highlighted in yellow. Those are the points that have come up in questions in the past, and likely to come up again. So going right to it, here's a, I'd like to start off with some questions, and really sort of just, sort of hopefully blast through these. Histologic studies of surgically resected tissue in lateral precondylitis demonstrates which of the following? Go ahead. All right. We picked two. The answer here is two. And that, the angiofibroblastic tendinosis is really, it's really sort of a fancy name for chronic inflamed tissue. And it's what we all see intraoperatively. And that is sort of the key terminology that they want to, that they will be referencing in all of the answers for this particular problem. As you know, this is one of the most common elbow disorders. It's in, it's a degenerative condition in the fourth and fifth decade. And the pang is two to five centimeters distal to the lateral precondyle. And I think the key thing, and we'll go over that in a little bit, but a key thing is to distinguish lateral precondylitis from radial tunnel syndrome. And that's a question that'll come up. And also, when it comes to surgical treatment for lateral precondylitis, it's a possible effect on the lateral ulnar collateral ligament that's underneath that. And those are some of the key things. So here, again, here the key sort of text in yellow here, ECRB is the primary facilitator of this diagnosis. Angiofibroblastic hyperplasia, as we talked about. Talk about conservative treatment, obviously, in that cortical sterile injections can lead to complications. And that's key, we'll talk about that in complications here. Treatment is, there's certainly non-surgical treatment we just talked about. There's different surgical procedures. They don't tend to ask a lot about surgical procedures. But they do ask about complications. Here's somebody in this question, here's somebody who had five cortical sterile injections for tennis elbow. Now it's got lateral elbow pain, popping, instability, lateral pivot shift in positive, pushup test is positive. And of course, what we're thinking about now is the posterolateral rotatory instability. And anatomically, it's the LUCL that's directly underneath that. And if you look at the bottom, if you look at this, here's the, the ECRB comes up right in this area, but the LUCL is down just underneath it. So if the, it's just like the, it's like the Xiflex injections that we give for the hand, for dupatrans. If it gets too deep through the palmar cord, it's gonna rupture the flexor tendons underneath it. And the same thing here, you give cortical sterile injections, and if you get too much or too deep, then you're hitting the ligament. And as you know, tendon, tendonous tissue and ligaments issue, ligamentous issue are at risk for ruptures. The other thing to pay attention to is what I was referring to earlier. If you have persistent pain after tendonous elbow surgery, many times it's because the radial tunnel syndrome has been missed. And we'll talk more about that. There's this whole section, I have a whole section on radial tunnel, on peripheral neuropathy. So we'll talk more about that as we get there. But that's in the same milieu, and certainly part of the physical examination that should be looked at. Not gonna spend a whole lot of time on medial epicondylitis. It's pretty much lateral epicondylitis, the opposite. And please, this is your course, you guys are paying for this course. If anybody wants me to slow down somewhere, just raise your hand and I will slow down. And just go over some details of the slides, or raise your hand. But I didn't want to bore everybody with just reading from my slides. But there are some sort of key pearls in each of the statements in here. So one of the key things about surgical procedures is really sort of, the second bullet point here is that you can do arthroscopic tennis elbow debridement relatively easily and relatively safely. Especially if you avoid the LUCL as we had talked about earlier. It's not recommended on the forbid of conylitis, primarily because of the ulnar nerve. People do it, but it's not recommended for test-taking purposes. And there's a big debate with ulnar nerve, ulnar cubital tunnel in the hand world about do we transpose or not transpose. I'm not really gonna get into that too much, but it continues to be an area of conflict in that sort of splits into, is it mostly a traction problem, or is it mostly a compression problem of the ulnar nerve around the elbow? And so if you think it's mostly a compressive problem, you're just gonna decompress alone. If you think it's a traction problem, then you're gonna decompress and transpose. There's pluses and minuses. The prospective randomized studies have looked at that and really shown no significant difference in the outcomes, whether you do a transposition or not. That being said, we have to sort of talk about these compressive sites. These are, we get asked a lot about all these compressive sites on the CAQ and the hand MOC. I didn't see a lot of this, honestly, in the sports exam questions I looked at. There weren't a whole lot of these sort of arcader struthers, the stuff that you bring out for test-taking purposes. But arcade, remember there's an arcader struthers, and for the radial nerve, there's an arcader Frosch. They're both bands. For some reason, I always think, I sort of mistakenly think of them as possible vascular leashes. And so I get that, I've always gotten it confused in my head, but both the arcades are bands. They're lateral bands. And arcader struthers is actually very far proximal to the medial condyle. It's about 12 centimeters proximal to that. So technically, if you were to do a complete ulnar nerve release, you gotta extend that incision all the way up. Most people don't do that. We talked about, you know, obviously the numbness and tingling in the fourth and fifth digits. I think it's really key to sort of look at some of the key things that occurs in athletes is you can have sort of a snapping medial head of the triceps that can be, that can have sort of some references, and you can have ulnar nerve symptoms because of that. So that's something to think about. And in these type of cases, especially in a young patient, I think in the population that sort of the young athlete that's having ulnar nerve problems, most often than not, you're gonna need to transpose just because it's either the muscle that's getting too big and irritating it as they're using their triceps muscle, or that they're hyperflexible and their nerves are normally just sort of subluxing as part of your exam. You can certainly do EMG nerve conduction test. They do come up positive for the cubital tunnel, but there are things like pronator syndrome, radial tunnel syndrome that I'm gonna talk about later. They normally are negative on the EMG nerve conduction test. So it's primarily a diagnosis based on physical examination alone. And this is a typical picture. A decompression is, we talked about decompression alone for mild injuries. You risk subluxation, that is true. In my practice now, I primarily, if it's a non-athlete and the nerve is not subluxing, I primarily go with a decompression alone and then take them through a full range of motion intraoperatively to see what happens. If the nerve just perches but doesn't sublux, I leave it alone and not risk the transposition. I've done a lot of, so these are the type of transpositions that I do not do when you actually tie down the nerve back down, but people still talk about it. The book answer and the test question answer for a revision transposition of nerve is a submuscular transposition as opposed to subcutaneous. That's the book answer. I don't agree with it, but that's the book answer. So here's another question about peripheral neuropathy. 32-year-old male softball player presents with vulvar forearm pain, throwing intermittent numbness in the radial three fingers of the hand. Exam is notable for weak thenars, sparing of the anterior osseous muscles, FPL and FTP to the index finger. EMGs are normal, and so the most likely diagnosis here, obviously we're thinking about the median nerve when it comes to the radial three fingers and also the thenar musculature, and since this is an elbow talk, it can't be carpal tunnel, but basically what we're looking at is that it's a pronator syndrome is what you would be concerned about. And this can happen in athletes just because of a lot of times how prominent their forearm musculature is. And same thing with a radial tunnel syndrome. But the median nerve dives, it's in the antecubital fossa, it really dives in between the two heads of the pronator teres. All the times I've done these, it's rarely compressed in that area. It's actually mostly compressed. What I've seen, it's usually compressed as it dives in underneath the FDS muscle. The median nerve lies in between the FDS and FTP musculature, and there's a band there that typically is the culprit. But I typically will start off in the antecubital fossa and just follow it down. And on the physical examination, I think the forearm percussion test is really what I focus on. Even if they don't have, even if they have a positive phalanx, I mean, obviously you can be a lot more specific if the phalanx test and the wrist is negative, cubital tunnels is negative, but you can have pronator syndrome with some of the other neuropathies as well, especially if your patient is a bodybuilder, has a really large forearm musculature. And the key thing with pronator is that the anterosseous muscles are spared because that comes, the anterior anterosseous muscle comes off of the median nerve, but it comes off just after it dives under the FDS and FDP muscle bellies. And again, the key thing is EMG nerve conduction tests in pronator syndrome are negative. We talk about some of the different surgical decompression sites, and I tend not to operate on these until they've had at least six months of therapy. A lot of them will resolve on its own. And my hesitancy in operating on these is because the conflicting nature of, some people just don't believe in pronator or radial tunnel because they always have negative EMG nerve conduction tests, so conservative treatment is what I usually go with early on. Here's another question on nerves. Patient had a corticosteroid injection for lateral epicondylitis, had good relief for four months, and then presented with recurrent lateral pain, underwent partial lateral epicondylectomy for tennis elbow. The elbow pain has resolved, but now continues to have pain with the proximal forearm area, pain with resisted wrist extension and resisted long finger extension, but the strength is normal. The most likely reason for the continued pain is what we just talked about, is that some patients, you can have lateral epicondylitis and radial tunnel at the same time. You take care of the tennis elbow, but the radial tunnel's now still there. And the pain is really right over the mobile WOD. So if you really sort of push down on the mobile WOD, that's the area where the exquisite area of tenderness is for radial tunnel. And the pain with resisted long finger extension and wrist extension is really not specific to radial tunnel, as you know. So here's radial tunnel. We talked about the compression size. Here's the other RK that tends to, that I always read up upon before I take any tests, but there's the Arcata-Frosch is really in the proximal aspect of the supinator. It's really another ridge, a fibrous ridge as the nerve, the posterior osseous nerves dives into the supinator muscle. I also found that the Leisure Henry, these recurrent vessels can be a problem because the radial nerve before, as it dives into the superficial radial nerve and before it gets into the posterior osseous nerve, there's usually a lot of vessels from the radial artery that comes over and can have a compressive effect. Most of these, if they're positive, and most of the time when I take them to surgery, again, I wait six months, I do six months of therapy. And before I think about surgical release. In my patient population, if you do six months of therapy, about 40% of the patients will get better. In the remaining 60%, surgical decompression will be better in 75% of them. So here's some of the key things about radial tunnel. It can mimic lateral pericondylitis, and it's part of the problem for failed lateral pericondylitis surgery. We talked about the physical examination. Diagnostic injection is something that sometimes I will do. Most of the time, I just wait the six months, and to me, that's more of the diagnostic aspect of things. Sterile injections for radial tunnel has not been shown to be effective, even temporarily. It may be effective in terms of just localizing where the pain is. If you inject into the radial tunnel area, it can certainly get a little better. Of course, gotta be a little cautious. There's some art, obviously, there's a lot of vasculature around there, and so just be a little cautious with your injections. We talked about the decompression sites, but Arcata-Frosch and Lisa Henry, those are the two areas that I focus on the most for radial tunnel. Okay, moving on to the next topic. Muscle strain or tendon, how am I doing on speed? It's okay? No issues? Good. Muscle strain or tendon ruptures. These are ones that are not, this is no longer the medial pericondylitis or the lateral pericondylitis. This is now distal to those areas. This particular one, you can get flexor pronator strain, and it's just distal to the medial pericondyle, and it can be exacerbated by resisted flexion and pronation of the wrist. MRIs can elucidate some edema in the flexor pronator mass, and it can also look at UCLs. And I think this is key here. The indication for surgery is if you have significant retraction of the muscle on the MRI, and that's important. It's essentially signifying a pretty big, significant rupture, as opposed to partial tear. So really, social indication for this particular problem, especially if you're thinking about primary treatment, is really any type of retraction of the flexor pronator mass on the MRI. Of course, distal biceps tendon rupture, some of the most common things that I do in terms of tendon work in the elbow. And most of the patients here are active laborers that I see. Here's another, here's a question on this. What's the most common complication associated with treatment of distal biceps rupture, as shown in these images? So you can see the endobutton here in the radial tuberosity. So we know that this was a single incision technique. And with a single incision technique, you need to do a lot more retracting in order to sort of get your exposure and get the drill through. And so you're looking at some type of nerve traction type of injury. And really, there's only two nerves here, posterior osteous nerve injury and lateral anapracheal cutaneous nerve. And honestly, both are at risk for this procedure. They're both right there. I mean, I think they're looking at the most common one just because the most common one is the one where you have to just sort of elevate up the entire sort of mobile wad. And that elevation is where the lateral anapracheal cutaneous nerve sits. And you have to do it. I mean, I do this all the time, but you just, you don't, you kind of have to get all, you know, when you're doing the endobutton technique, you got to get everything all lined up. Everything's done. So when you're doing that final sort of retraction and you're gonna put some tension on the nerve, you're ready for all your drills. You're not, somebody's not holding that while you're futzing around on the side, getting the stuff ready. So lateral anapracheal cutaneous nerve irritation. Here's another one. Patient returns for his post-op visits following a single incision, very muscular, complaining inability to extend his thumb and fingers. So that's a different, that's a different picture now. Inability to extend his thumb and his fingers. He can extend his wrist, but cannot extend the thumb MCP joints. And that now is the other nerve that I said were at risk. And so it's not the lateral anapracheal cutaneous, which is the most common one that's at risk. But now this is actually a more severe injury where somebody had knocked out the posterior osteous nerve. And the way to avoid that is maximal supination, which is kind of what you need to do anyways to get that drill through. And so you kind of, you know, it's, but oftentimes I have my assistant really, really not just supinating, but really hyper supinating that to get the tuberosity in view and also get the nerve out of the way. This is a question primarily about what is the consequence of a ruptured biceps tendon when not repaired? And so we know that biceps tendon does flexion and supination and, you know, supination is the one we always hear about. So when you're looking at that, when you're looking at these results, right off the bat, A's out. B has pretty equal loss of supination and loss of flexion. E has more loss of flexion than supination. So those two answers are gonna be out. So you're really looking at C and D as your possible choices and it happens to be D. It's just, there isn't a full 80% loss of supination. But as you can see, a lot of these things, if you don't quite remember some of the specific numbers, you can sort of narrow it down to a couple of different answers here. A male laborer suffers a right elbow injury and basically this guy had a distal biceps rupture and underwent a two incision repair. Six months later, he's got limited forearm rotation. And so this is one of the other risk factors of the two incision technique for biceps tendon reattachment, which is a synostosis right here. I think we've gone over a lot of these, but the key is that there's a hypovascularity zone about two centimeters just as the tendon's inserting into the radial tuberosity. And that is the etiology of why this particular area is at risk. And as with any of these tendon ruptures, it's a eccentric contraction type of thing. It's just the eccentric contraction, meaning something is, you're flexing your biceps in one direction and then the weight is pulling it in the equal and opposite direction. You can certainly palpate for biceps deformity. The way I like to do that is usually with the hook test. Remember the hook test is really trying to, when the patient is trying to supinate and flex the elbow, you're really trying to hook your finger around. So you start with the patient in pronation before you do the hook test. And you put your finger right over the antecubital fossa. And as you supinate, you're gonna feel, and yeah, you can do it on yourself right now. You can feel your biceps tendon popping in to your finger as you supinate your form. And the person who has a ruptured biceps tendon really obviously will not have much of a prominence in that distal biceps tendon. In fact, it will be a little bit lax. So we talked about that. The MRI is pathognomonic and really has a good, and I get the MRI just to know, I don't really necessarily need to get the MRI if it's like an acute obvious pop and it's two weeks out. But if it's six weeks out, I like to get an MRI. I need to know where, how far retracted this is. And of course, this is not one where you wanna just wait on the MRI and have them come back. You really wanna send them to an MRI urgently because you don't want it to become a chronic problem. Because usually by the time they see you, it's already at least a week. I don't know about your practice, but it's hard for me to see patients within a week. So it's a week out already. And then you get another MRI. If you get an MRI, you're looking for retraction. It can delay you unnecessarily. And of course, we wanna always try to avoid sort of that's chronic and trying to avoid a grafting. I think that's just, I've done it, just makes it a lot harder. Actually, I found that most of the time, even with the really retracts five, six centimeters on the MRI and about six weeks out, when you repair that, it's pretty tight. It's about, you're repairing about 80 degrees flex to hold it, but they actually do well. You get a good repair and they stretch out nicely. So here's the thing about the 30% of flexion and a 40% of supination. And this is a key, this is sort of a key thing. Non-operative treatment is really relatively high risk. You're losing this degree of flexion and supination. You're losing endurance. And you have really surgical outcome is 90% good to excellent. So that's one of the few things that we have that really has a dramatic difference between non-operative and operative treatment. Now, these are not partial ruptures. These are complete ruptures. We talked about the distal biceps, the complications for the surgical treatment. These are the different surgical treatment options. I find that they don't ask too much about these things. They ask more about complications as we talked about. And this is a good, this is just sort of a good visualization of where, so the PIN is right here as it comes under the supinator. That's also the arcade of Frosch is right there where the PIN sort of dives right into the, underneath the supinator. And of course, the biceps tendon is going right underneath here to the radial tuberosity. And here's the other nerve that's at risk. The LABC is right here. And so when you're retracting that, you can tent this, pull too much traction on that nerve. The key to the two-incision technique is when you're coming on the posterior side, you want to maximally pronate in order to avoid the PIN, versus on the single-incision side, you want to maximally supinate in order to avoid the PIN. So just in terms of reference and where it is, this is something that they can ask about and they will. They love, what I notice in looking over your questions, they love all the nerve prob, all the nerve stuff. They love all the nerve injuries that can happen with these, any type of elbow surgery. Okay, so this is a weightlifter. Basically has a palpable defect of the insertion of the triceps. Paying an inability to fully extend, defective insertion of the triceps. What's appropriate management here? Well, with a completely ruptured triceps, really you have no choice. There's really not even an option to treat this conservatively. Unlike the biceps tendon, there's an option, but surgical treatment is so much better. There's really not recommended to treat this conservatively. So open and surgical repair with suture reattachments, what we're talking about. This is important risk factor with anabolic steroids and, of course, any type of steroid injection in the region. You know, people give steroid injections wherever there's pain, and so just be cognizant of how many steroid injections you've given. I tend to not inject anywhere more than twice, period, lifetime, lifetime, unless patients really understand that they're okay with risking either tendon or ligamentous rupture. I think the MRI is pretty pathognomonic. I'm going sort of moving through that. We're about halfway. I'm not quite halfway there. Stress fractures and pinch man syndrome, obviously elbow valgus injuries in the throwers is very important. Most of the moments are generated really in the late cocking phase and early acceleration. That's the time of maximal tension on your MCL, and you're looking at possibility of posterior medial osteophytes when you have the tension with the thrower's elbow on the medial side, compression on the lateral side, and then you get shifting of the olecranon posterior medially right in here as a result of that repetitive force. This is obviously common in throwers. There's usually a flexion contracture because the throwers will not want to reproduce that posterior medial elbow impingement with extension. The path of anatomy we talked about, and I think this is important, that if you notice primarily patients come in of posterior medial impingement, you want to check out the onocladal ligament on the medial side of the elbow to make sure that that isn't the cause of everything. You can see this on the CT scan, and I think it's critical to do imaging before thinking about any type of surgical intervention. Surgery is actually very helpful for these patients. They do very well. The issue with surgery is that once you resect it, here's the problem. The resection really helps with the impingement problem, and they can extend their elbow a lot better. They don't have the impingement pain with elbow extension, but now you've put the strain back on the UCL, and so you really want to be cognizant of a UCL injury that may or may not be causing the whole posterior medial osteophyte. Let's go to questions here. Here's another question. Basically there's a CT scan. A professional baseball pitcher has had elbow pain for the last six months despite rest, so already has had conservative treatment. I think that some of the key thing in this question is this represents some type of conservative treatment for six months. Management now should be. The CT scan clearly shows a stress fracture in the olecranon here, and it's really about surgical fixation, and so you're really looking at questions three or four. I think the answer here is compression screw, although I think these obviously would do just as well with tension band wires, because I think what they're looking at is that there really isn't a lot of displacement. It's a non-displaced injury, but I think this can heal with either a screw or a tension wire banding. It's just that the tension wire banding tends to be a little bit more prominent on the proximal posterior elbow area. This can happen with throwers, gymnasts, or weightlifters, and again think about the extension bounce test. That can be very painful. If you hyperextend their elbow, it can be very painful. And also pain with resistive triceps activity. I'm going to move through this a little quicker now. I think we talked about most of these things. Radiocapitella plica syndrome is certainly something that's popularized by Odryscula, and it's really an MRI confirmation and arthroscopic excision as a treatment. And I think the key is really sort of this flexion pronation test. So you really need to engage that radiocapitella plica. You want to put the form in maximum pronation, sort of locking in the radiocapitella joint, and then move the elbow up, and where it usually catches is near 90 degrees. So it's not usually going to catch in extension. It usually catches a little bit more, a little bit higher. Going on to throwers injuries, the sublime tubercle is off of the, really sort of a process right off the coronoid process on the medial side. And it's the key insertion site, as you know, of the anterior bundle of the medial collateral ligament also is the most significant part of the MCL complex. We talked about this already, what portion of the pitching phase creates the largest tensile force, and it's really sort of late caulking slash early acceleration, but the answer here would be late caulking. This is a good one. During caulking acceleration phase of the overhead pitch, there are several static and dynamic. Static, we're talking about ligaments, dynamic, we're talking about muscles. What are the dynamic restraints? The dynamic structures found to be most important during this phase are, so it's really what's on the, and obviously on the ulnar side here, it's the flexor pronator mass. So if you look at these answers, you can kind of get rid of a couple of them right off the bat. There's two of them talking about the extensors, well there's really no significant extensors over here on this side to help stabilize that medial side of the elbow. So then you're really looking at some of the, one of these two, superficialis and FCU or superficialis and FCR. And obviously the FCU would be closer to the ulnar side of the elbow than the FCR, and that happens to be the right answer. But any of these extensors really sort of throw you off because the extensor is on the other side and really doesn't help with the medial side of the elbow. I'm going to go forward a little bit, we're running a little behind. Last about the sublime, the moving valgus test, there's Chris. And you can get the sublime tubercle looking like this with chronic injury. So when you see this on the x-ray, that's your sublime tubercle hypertrophied from chronic stress to the area. The laxity of the elbow can be diagnosed with this three millimeters of gapping. You can also see that on elbow arthroscopy as well. Of course it's also important to note this, that 85% of UCLs are abnormal in MR imaging, even in patients that are quote unquote, in patients that are healthy. I'm moving forward a little bit. The reconstructive techniques, you can do the flexure pro down, the flexure split, and then the FCU and FDS are dynamic stabilizers, as we talked about, so you want to be careful about really disrupting the FCU and FDS when you're performing this surgery because those muscles are going to be needed to help protect your ligamentous repair afterwards. So because of that, I prefer to do sort of the muscle, the inner muscular splitting technique where you stay anterior as much as you can. The inner nervous plane between the median ulnar nerve, that also happens to be sort of where that is. The FCU is obviously innervated by the ulnar nerve and the poster half of the FDS is also innervated by the ulnar nerve, the flexures to the ring and small fingers. Talked about a lot of these. How we doing? Are we okay? Too fast? Okay. I'm just trying to hit all the key points here. Here's another key question. Six weeks history of pain and stiffness when throwing. Now has a decrease in maximum velocity. You have tenderness over the medial collateral ligament. MRI shows signal in the anterior band without a full thickness tear. So clearly they're looking for some type of conservative treatment option. What is the most appropriate treatment? So this is where you can do flexor pronator strengthening and gradual return. We talked about this, the muscle splitting approach for UCL reconstruction. We talked about the interval between the ulnar and median nerve. This is a javelin player. Has increasing discomfort in the right elbow, loss of distance. Application valgus force, illicit pain from 70 to 120. What structure is primarily responsible for the patient's symptoms? And as we know, the anterior bundle, I mean, it's almost, when in doubt, click the anterior bundle. That seems to be the one that they always want the answer to. And we talked about this, excessive resection of a posterior olecranon osteophyte can now put stress on the medial collateral ligament complex, which then would give you valgus instability. We talked about LUCL injury. On the other side, we're now switching gears, going to the other side of the elbow, being at risk for lateral aconitis surgery. You can examine for that with the posterior lateral rotary apprehension test or the drawer test. You can sort of do the drawer test at the same time you're doing the apprehension test. As you're going from extension to flexion, you can also pull up or pull the elbow sort of anteriorly, the way that you would do an anterior drawer test for a knee exam. The pushup test is where you really feel that instability in the posterior lateral corner when you're trying to lift up from a chair or when you're doing a pushup. And of course, the key is sort of repairing back down into the supinator crest on the ulnar side of the ulna. And the other thing that's key is you want to pronate the form while you're tensioning this to maintain the tightness of your repair. And underwent lateral aconitis elbow arthroscopy using an anterior lateral portal. There's a section on elbow arthroscopy. But if you're getting loss of digital extension, it's really the radial nerve that you've injured. This is having continued feelings of instability and catching in his elbow when using his arms to rise from a chair. So that's the pushup test, which the following procedures needs to be performed at a minimum in order to reestablish stability. The patient had a dislocation, obviously lateral and posterior. So you're looking at recreation of the LUCL. I have about 15 minutes left, and I don't want to go over. Is it OK if I skip the fracture section? Huh? No. No. OK. What? I said more arthroscopy. More arthroscopy. Let me go through the fracture section really quickly. Olecranon fractures really, if they're displaced or loss of triceps, really need to be repaired. We talked about tension wire banding and screws. Radial head fractures. There's definitely some, you know, if you have a sale sign, that's a little dark area on the lateral side of the elbow x-ray where there's no fracture there. But there's sort of a dark, redolucent area in front of the distal humerus, really indicative of some bleeding. This is the Mason classification for radial head fractures. Type 1 is minimally displaced. Type 2 is marginally displaced. Type 3 is comminuted. So usually with a type 2, you can sort of aspirate and then assess for a block to see whether or not that articular defect is significant. And 3, a lot of times, most people now, if you're a young patient, you want to try to recreate as much as you can. But I am doing more and more radial head replacements now. Capitellum fractures certainly can happen. It's much rarer. But if it's displaced, it needs to be fixed. Moving on to the next section. Elbow instability. This is sort of a great question. This patient had a posterior dislocation of the elbow reduced and shows during the exam that 40 to 100 degrees of motion is stable. So what should you put them in afterwards? A hinge brace at 40 to 100 degrees. So keep them braced but moving, but within the range of motion that's stable. So this is the treatment. I highlighted that in yellow there. Of course, if you have a terrible triad dislocation, these usually need some type of surgical intervention because you're looking at coronary fracture, radial head fracture, and MCL injury. Okay. Last two sections. I have 11 minutes. Not bad. Injury in the skeleton mature, and then the last section is the elbow arthroscopy. 17-year-old baseball player injured his dominant throwing arm sliding in third base, immediate pain on the medial aspect of the elbow, painful apprehension, radiographs are here. And the treatment for that would be an ORIF. So you can have meat apophysitis in patients that are younger. In this patient, this is a 17-year-old, so really we're not talking apophysitis anymore. In this patient. But that certainly can slow down sort of your little league pitchers, and something to think about and palpate for. You get medial epicondyle tenderness, obviously, but no laxity. And that's the key between distinguishing between medial apophysitis for the little league pitcher versus an MCL laxity problem. And for the question we looked at, the 17-year-old, we're really looking at a medial epicondyle avulsion injury like this. And there's going to be pain with resistive flexion, because you're now pulling on that piece with your flexor pronator mass that's inserted in the medial epicondyle there. And also worry about ulnar nerve entrapment. And this is, with a displaced medial epicondyle like this, this is an absolute indication for surgery. Especially if there's an incarcerated fragment of ulnar nerve symptoms. Okay, here's some questions. 12-year-old gymnast, elbow pain for four weeks, denies trauma to the elbow, range of motion 15 degrees, loss of elbow extension, normal flexion, normal pronation and supination. X-rays shows a 3 to 7 millimeter radiolucency around the capitellum. T1-weighted MRI shows a single solitary lesion in the capitellum. T2 images shows no signal around the lesion. Without T2, the point of the T2 is if there's fluid around that fragment, then it may be unstable. So that's the key with that question. They're looking for, is this fragment stable or unstable? Is this lesion stable or unstable? So in this case, this is a single solitary lesion in the capitellum that's stable. Second is, conservative treatment and get back to gymnastics when she is asymptomatic. Okay, let's get to, so here's one where it is unstable. Take a look at this. There's definitely some fluid around that fragment. So you want to, in this case, you want to worry about this fragment. This fragment may be unstable. And this is one where you can see through the elbow arthroscopy. Okay, elbow arthroscopy. I think some of the pearls is really sort of pre-insufflation joint distension is really key here. And these are really more sort of practical tips as to how to do this. I mean, you know, there's just tons of nerves around the elbow when you're doing elbow arthroscopy. And so you should never sort of go right into the joint with your knife. Like you can with the, you know, when you're doing knee scopes, you can do that. You can literally be in the joint with your knife. You're sticking your blade right in there. You just don't want to do that for the elbow. And they have tons of questions on nerve complications here based on portals. So let's go over this. So here's one right off the bat, 24-year-old volleyball player, right elbow pain for six months, acute locking the elbow, x-ratios fragments, now incarcerated, undergoes elbow arthroscopy and removal of the loose bodies. Postoperatively, he's unable to extend his wrist, thumb, IP joint, and finger MCP joints. So what nerve did we damage here? Radial, right? So the radial nerve's damaged. Now the question is, so now what is the most likely complication? They're not, you know, they went a step further. They're not asking what nerve's injured. They're now asking you, well, what portal is mostly at risk? Well, is the radial nerve at risk with the medial portals or the lateral portals? Lateral, on the lateral side. So now you can sort of, you got to sort of come right to the anterolateral portal. And then the key thing is understanding where the displacement is. Is the radial nerve most at risk proximally or distally in the anterolateral portal? And we're going to go over this. I'll show the pictures, but this is why I like to just throw the question up there so you know this is what we're dealing with in terms of the question you need to answer. But the nerve gets a little bit closer with flexion of the elbow because of where the radial nerve lies. And we're going to look at that. But basically the answer here would be sort of B, where the elbow is held, where it's the anterolateral portal with the elbow inflection moving proximally. So before we go to the anteromedial, I'll come back to that. That's anteromedial. Here's the anterolateral portal. So here's a great look at sort of some of the markings. Here's your lateral epicondylitis, lateral epicondyle, radial head, and olecranon. These are some of the key portals that's used during elbow arthroscopy. And the one we're talking about and the one they're asking about is the anterolateral portal right here. And usually I place it about one to two centimeters proximal and about one centimeter anterior to the lateral epicondyle, right where this mark is. And just to show you, this is where the radial nerve is. And so this is what they're asking about. The radial nerve comes around and is in between the brachialis muscle and the brachioradialis muscle here, relatively anteriorly here. And then it's going to go underneath the supinator, so near the proximal radius. And so as you move more distal with your portal, anterolateral portal, you're going to come closer and closer to the radial nerve. So that's the question that they're asking you about. Primarily is what, you know, back to that question we looked at. It's really, well, where is that radial nerve relative? Let's go back to the question now after looking at that. Okay, so we know it's the radial nerve that they want. The question is, well, which one are these? Is it proximal placement? No, not really. We looked at the picture. So now we can narrow it down to just these two. All right, so is it distal placement of the anterolateral with the elbow inflection, right? So as you flex, your portal is going to come closer to the distal aspect of the radial nerve rather than extension, which actually will move it a little bit further away. I mean, the question is asked in such a way that I think it's more about the distal part. You can make the argument, well, if you extend it, then that radial nerve actually comes closer to where your portal is as well. But in this case, they're really talking about the distal aspect, because as in most of the questions I've noticed, they're all about the distal aspect of the radial nerve as it enters into the supinator. Let's talk about the anterior medial portal while we're here. The anterior medial portal is relatively safe. I mean, you certainly want to stay in front or anterior to the medial condyle. And your median nerve is actually usually fairly anterior in the antecubital fossa. You have some room to play with here. What you do need to worry about is the medial antebrachial cutaneous nerve. So if you just use blunt dissection, you usually should be able to get down there without causing injury to that nerve. Of course, the key point is here. This next picture is key. So this is a patient who had an anterior transposition. Well, if you had an anteriorly transposed ulnar nerve, that is right where the anterior medial portal is supposed to be. And the star represents where that portal would be inserted. So if somebody had a transposed ulnar nerve, that's a contraindication to having a medial portal there. Is that sort of the key thing to sort of look at when it comes to that portal? Let's look at the posterior portals. Some of the posterior portals, and these two in particular, really are the workhorse. The one that tends to be safest is the posterior one, which is about three centimeters proximal to the tip of the olecranon midline. The thing that they will ask you about for this portal is it's relatively, although it's not that close to the ulnar nerve. The ulnar nerve in this area lies just posterior to the intermuscular septum in the medial side of the form, and it's a couple of centimeters away from the midline. The other one that's good is this one right here, which is the posterior lateral portal. And it's really sort of about just lateral to where you can palpate for the triceps tendon about two to three centimeters proximal to the olecranon. The risk factor to that, and we're going to show you some of the, here's the key nerve picture right here. So here's your posterior central portal that we talked about. And that's close to the ulnar nerve. And then here's your posterior lateral portal where you're just close to the posterior anabrachial cutaneous nerve. My time is up. We talked about the ulnar nerve transposition with the submuscular ulnar nerve transposition. Thank you.

elbow injuries

treatment

overused tendinopathies

compressive neuropathies

muscle strains

stress fractures

impingement syndrome

ligament injuries

acute fractures

elbow instability