first lecture this morning will actually be the elbow talk, so if you can find the elbow talk in your syllabus. Unfortunately, Dr. Beatty could not make it, so Dr. Tom Gill is stepping in and giving that elbow talk, but it will be the same PowerPoint and outline that you guys have in your handouts. The other transition is later today, instead of the sports research talk, that will be given tomorrow, and the knee talk will be given today, but we'll let you guys know as that happens. So in the first session, we're going to start off with elbow, and then the two medical issues talks will follow. I'd like to ask a quick survey here. How many people here are preparing for their board exam, that first board exam when you first become board certified? Anyone doing that? How many people here are preparing for the MOC, their maintenance of certification? And how many people are here, not necessarily for an exam, but for the CME and the general education? All right, that's good, that's interesting. All right, I'm going to turn it over to Dr. Gill, and he's going to update us on elbow. Well, good morning. I made the mistake of being enamored by the thought of Chicago pizza last night, so after our dinner, I then went out for a Gina Aziz pizza, so I have a pizza hangover this morning, so I'll try to make sure we can get through this elbow okay, but it was good on the way down. So elbow is kind of one of those talks, and it's one of those subjects that you really need to have. It's really all about anatomy, and if you know the anatomy, you can kind of figure out the rest. So we're going to concentrate a lot on anatomy. There's a lot of trauma, kind of fracture type things in this talk because of sports talks, you know, whether it's adolescent, pediatric, adult, there's a lot of fracture work, and then there's a few hot topics that we'll spend a little bit more time on that are usually on the test, and that's usually onoclateral ligament talks, single versus double incision, distal biceps, and then some of the medial epicondylitis topics, right? So those are the main three or four topics you want to kind of focus in on, but again, we're going to spend a lot of time also on the fracture things just to be comprehensive, and they do show up from time to time. So looking at the anatomy, there's kind of a complex ligamentous anatomy around the elbow, anterior bundle, posterior bundle of the medial collateral ligament, the capsule, just like in the shoulder where the answer to everything about stability in the shoulder is the anterior band of the inferior glenohumeral ligament, the answer on the test for everything about medial elbow stability, valgus stability is anterior band of the medial collateral ligament, and we'll kind of say that a few more times along the way. The other question that's going to come up a lot of times, even though I personally have never seen it, and I know it exists out there, but is lateral onoclateral ligament injuries and posterolateral rotatory instability. I can't remember a test I've taken where that hasn't been on it, but so we're going to have to, you have to just know the anatomy, and usually that comes up as, you know, you're doing a debridement for a lateral epicondylitis, and you get two posterior, you get two anterior, and you start taking down the radial collateral ligament, because that's the kind of question that you'll get in that regard. But just on the lateral side, if the radial collateral ligament, lateral collateral ligament, anterior ligament, and then the anterior and posterior capsules. Anterior anatomy around the elbow, primarily it's just remembering the lateral, so brachioradialis, extensor carpi radialis longus, and then extensor carpi radialis brevis. Those three will come up primarily with the ECRB when we talk about lateral epicondylitis, because that's where the pathology sits in that muscle. And then neurovascularly, when it comes to single incision, double incision, distal radii, distal biceps repairs, arthroscopy, it's a question of knowing the nerve anatomy, all right? So lateral side, radial nerve, more anterior, essentially the median nerve, and then the ulnar nerve, which both in pediatric injuries with medial epicondylar avulsion injuries, when you're talking about golfer's elbow, and then when you're talking about ulnar collateral ligament surgery, the ulnar nerve is going to come into play on this exam. So we're going to start kind of on the pediatric adolescent side, and then move our way up to the adult side. So if you look at the growth plates around the elbow, and that is a common area of testing on the sports exam, it's primarily the medial apophysis, and then the capitalum are the two most common ones you need to know about. But remember that most children, as far as growth anatomy, as far as fiseal anatomy, don't become mature until 18 to 25 years old. So just like we were talking about the sternoclavicular joint and having the medial epiphyseal injuries in the elbow, in kids it's less about ligamentous injury, and more about fiseal injury. Now there's a variety of different mnemonics to remember this. I won't tell you the one that I learned in medical school, but it was not Crito, I can tell you that. But it's basically, just remember, it's the capitalum, the radial head, the medial epicondyle, the trochlea, the olecranon, and then the lateral epicondyle. And it's just 1, 3, 5, 7, 9, 11. And that, and the reason as far as the years of age when they start, and as you'll see at the end, you actually do get asked about that, about the age of ossifications, unfortunately. But it's just a pretty simple 1, 3, 5, just kind of going up from there. If you look at the injuries, the medial, especially when you start talking about little league elbow, little league elbow is primarily medial apophysitis. And that's the medial epicondyle forms, starts at around age 5, doesn't fuse completely until age 15. And just like when you talk about flexor pronator injuries in adults, when we start talking about ulnar collateral injuries in throwers, this is going to be repetitive stress, valgus stress to the medial apophysis. The kids are going to present with loss of velocity and diminished effectiveness. So they'll just say, you know, it hurts to throw, I can't throw as hard, and I, you know, they can't locate. On exam, pretty typical, but rather than being tender over the ligament, so between the medial epicondyle and the sublime tubercle, they're actually going to be tender right over the medial epicondyle. Usually you do not have any kind of ulnar nerve symptoms with this, but it's just pain, as you might expect, on valgus stress. X-ray is going to be usually your mainstay, especially when you start to look at displacement, but certainly MRI is confirmatory in this regard. Unless there's significant displacement, what's significant displacement? It's going to be about 5 millimeters, just like with a little league shoulder, it's going to be rest, rest, no throw, non-operative is the key, unless they start going into the exact distance of displacement. It's controversial about the fact whether or not curve balls and breaking pitches affect the medial side of the elbow more. No one's actually proven that, although a lot of little league coaches think that might be the case, but treatment for this is going to be shoulder core, scapula strengthening, hip and trunk stability. Historically, what a lot of times the kids will say, on one throw, I felt a pop, right, and we're so used to ligaments being the things that pop, but in this case, it's the apophysis. Acutely, they don't want to bend their elbow, and they're going to be holding it in about 30 to 40 degrees of flexion. They have difficulty fully extending, and sometimes you can have a palpable defect, but it's not common. Typically, it's just going to be tenderness that you're going to feel. If you look at indications for surgery, all right, and just a good number to remember around the elbow in kids and adolescents is 5 millimeters. They're not going to tell you 2 millimeters or 3 millimeters or 4. They're going to say it's minimally displaced or it's 5 millimeters or more. If it's more than 5, that's an indication for either pinning or a screw, etc. Panner's disease. Also, you'll see this a lot in young kids that do any kind of throwing. This is an osteochondrosis of the capitellum, and typically, it's going to be between kids who are 5 and 10, and just like in the hip with leg perthes, the younger you are when you get it, the better the outcome, the better the healing, etc. You start getting older than 10 if you get panners. That's when you start getting loose body formation, catching, locking. That's when you start sometimes have to do surgical removal of loose bodies or even sometimes, you know, the oach to the capitellum. So, young panners, osteochondrosis, capitellum, non-operative. Older, loose bodies, mechanical symptoms is when you start thinking about operative for that. Unlike the medial side, this is not usually a one pitch, one throw, ow, and then having the problem. This is more insidious. It's kind of a vague type of pain. They'll just start saying, all of a sudden, my lateral side of my elbow hurts. And actually, some people, you know, if you don't stop and think about it, you might say, oh, it's lateral epicondylitis, but kids really don't get lateral epicondylitis, right? So, it's a first thought should be, could it be a problem with the capitellum? Workup, oftentimes, you see this fragmentation on plain x-ray. And treatment is, again, going to be rest, avoiding valgus stress. What does that mean? Throwing, primarily. And it can actually take up to three years. So, you have to tell the kids, tell the families that this is going to take a long time to get better. And you can kind of see some of the sclerosis, and then with a little bit of a lucency in more advanced stages of Panners. So, what about some of the fractures? Olecranon stress fractures can happen both in kids, but all, as well as adults. The olecranon apophysis appears at age nine, fuses as the second to last apophysis to form, apophysis to form, and it fuses between ages 12 and 15. If you have repetitive stress to the olecranon apophysis, you can actually have a non-union or displacement of it. And you always want to compare x-rays, any kind of pediatric, whether it's shoulder, elbow, always have bilateral x-rays to look at. The two groups that get this, throwers, but gymnasts, as well, because of the force loading with extension that they do, both on mats and beam, etc. Night pain is not uncommon. It's going to be posterior night pain, and then the kids saying they don't want to, they don't like to push open a door, they don't want to extend. X-rays and CTs can both be inconclusive, and that's why MRI, you'll start to see this edema pattern, and you have a linear sign of signal. Typically, as long as it's minimally displaced, it's going to be avoidance of the forced extension, non-operative. Indications, again, for surgery is that five millimeter number again. So no matter kind of what you're looking at, it's usually going to be about five millimeters you're cut up for operative versus non-operative, and you can use either a screw or a tension band, or anything that's going to cause compression. If you look at the more acute fractures, three different types, non-displaced, displaced, and then the unstable, which can sometimes be seen here with a montasia type fractures or dislocations. Treatment for minimally displaced, immobilizing an extension, but typically surgery with open reduction internal fixation with either a screw tension band or a plate if it's comminuted. Now, supracondylar fractures, typically less so. We're not seeing them as much on the sports front, but you'll do see them an awful lot in pediatric practices, etc., and we do see them. They do show up on the test from time to time. It's going to be a fall on a flexed elbow with a hyperextension mechanism. The Gartland classification, three different types. The type threes, of course, being the most severe, complete displacement, and most of them are posteromedial, so that's ulnar nerve, start thinking about that along the way, or about a quarter of them being posterolateral. Treatment, either you can have cross pins or lateral pinning if it's minimally displaced. Radial head fractures, valgus overload or an axial load to the forearm, less common in kids, more as we start to get into the older populations. Three types you need to know about. Non-displaced, because those are all going to be non-operative. Type twos, displaced, those are typically what you're going to have surgery for, and then the threes, comminuted, and four is usually seen with a dislocation, terrible triad type thing. Oblique x-rays are going to be the best, and often sometimes you'll see the so-called sale sign, which is an effusion of the joint, a lucency behind the distal humerus. By and large, again, for the purpose of the test, all you really need to know is minimally displaced, early range of motion, sling for comfort, no surgery, displaced ORIF. The one thing you do that does come up from time to time, I've seen this on self-assessments, as well as some of the OITs that have been out there, are when you're doing an ORIF of a radial head, where's the safe zone? So if the elbow is at 90 degrees, it's the anterolaterally is a safe zone. If you have the hand, if you're trying to get exposure in neutral rotation and posterolaterally when the hand is fully supinated, and that's just where it's putting the posterior nasolabial nerve, etc. Capitella fractures, this is going to be, you know, it's more when you're over 12 years of age, because before that, it's going to be more Panners osteochondrosis of the capitellum, and you kind of need to differentiate between the two. Obviously, the Panners has a better chance of healing on its own than actually an acute fracture. Usually, it's a sheer force that you'll see. Again, the different types, it's not important, you know, whether it's specifically a type 1, 2, or 3, just how displaced is it. CT is going to be your best for seeing what to do, I'm assuring as regard to surgically, how displaced it is, and treatment is going to be usually some kind of screw type fixation, restoration of the articular surface. Coronoid fractures, because we do see a fair amount of elbow dislocations with sport, so you have to know a little bit about them. Three different types of coronoid fractures, type 1s, 2s, and 3s. One, and it's just pretty much straightforward, the tip, kind of midway down, and then at the base of the coronoid. Type 1s, pretty much always non-operative. Type 3s, oftentimes need to be surgery, need to be operated on because you're going to lose the stability of the coronoid in that situation. And then type 2 just depends on exactly how displaced it is and whether there's mechanical symptoms. Here's a picture of a coronoid tip fracture there. With just the type 1s or the tip fractures, you want to move them right away. Everything around the elbow, typically you want to treat, if it's going to be done non-operatively, with early motion so the elbow doesn't get stiff. Type 2s, it's usually more than 50% of the coronoid, early range of motion, but if it's unstable, then you're going to fix it. And then the base fractures, sometimes you have to graft, but typically, again, those are going to be treated surgically. Capitellum, we've talked about this a little bit already, but this is going to be kind of working more again towards the adult setting. X-ray, CT, MRI, but what you're looking for is displacement or loose body formation. So you'll usually, they'll show you an X-ray, they'll show you a CT scan, and they just want you to pick up, is this displaced enough that it has to be removed? Surgical options, microfracture, drilling, OATs, ORIF. All right, so now we're going to start moving a little bit more towards less trauma, a little bit more sports kind of oriented now, but both trauma and sports are going to show up on the test. So lateral epicondylitis, buzzwords. All right, so we got through the first part. The two buzzwords for lateral epicondylitis, but there's always some kind of question about this. It's localized to extensor carpi radialis brevis. Just remember, ECRB, lateral epicondylitis, and it's really not an itis or an inflammatory, it's angiofibroblastic dysplasia. Why is that important? Because when you start talking about the surgical options, you know, you have to excise this kind of tendinosis area, this hyperplastic area. And the other thing is there's no inflammatory cells. If you look at it histologically, you know, you're not seeing a lot of lymphocytes or something like that from acute inflammatory process. This is angiofibroblastic hyperplasia. Classically, it's going to be tenderness, just distal to the lateral epicondyle. Again, over the ECRB, that's why you have to know that surface anatomy of brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis. Pain with resisted wrist extension or really with the elbow straight, pushing down on the long finger, so kind of resisting long finger extension is going to also be indicative of lateral epicondylitis, decreased grip strength. There's really not, the only time you're really going to think about imaging too much is if you are starting to get to the point where you have a recalcitrant case, it's not getting better nonoperatively and you're thinking about potential surgery for it. You can look with ultrasound. Oftentimes, they'll MRI as a modality of choice. One of the questions that comes up is the indications for corticosteroid injections. I think a lot of us do them, but there's no study in the literature that will say that there is a statistically significant difference between corticosteroid use or not. I know that goes against a lot of our clinical experience, but for the purpose of the test, there's not been a study that has shown that it alters the natural history. I don't think on the test, although a lot of people are doing PRP and the results are encouraging, I can't imagine that PRP at this point is going to be an answer on a standardized test for sports. So if you see PRP, I would not jump to that as your answer for a lot of the tendinosis things right now. Classically, the nonoperative thing they're going to ask you is are counterforce straps, stretching, and then anti-inflammatory medication. If you look at the systematic reviews that have been pointed out, but Nurschel initially put his surgical treatment for this. You have to go and actually fully excise that area of angiofibroblastic dysplasia. Again, that's going to be the buzz for that. Now, medial epicondylitis is very similar to lateral. So most of the same concepts for lateral epicondylitis are going to be medially as well. This time, except rather than being the ECRB, it's the flexor pronator group, commonly pronator teres, FCR, and palmaris. And again, in young, younger athletes, don't make the diagnosis of medial epicondylitis. That's more going to be medial apophysitis. Exam, tenderness over the common flexor mass, decreased grip strength. It's rare, but occasionally you can have ulnar nerve symptoms or ulnar neuritis as well. And as I mentioned from imaging, not a ton of, not a huge role for imaging here. You can look more to rule out osteophytes, loose bodies, other types, fractures, other differential things in the differential, but not to confirm medial epicondylitis. Same concepts, counterforce sprays, stretching, anti-inflammatories, PRP and corticosteroids, oftentimes not going to be the selection you're going to make by itself. It's usually more just the general, they'll say rehab, non-operative, et cetera, and it's rare to need surgery. Now, separate for just slightly different than the medial epicondylitis, you have flexor pronator strains. This is going to be more in your throwing athletes, baseball, very, very common in pitchers. It can be either from an acute event, so from one throw, more commonly repetitive microtrauma. And classically, it's going to be in kind of throwers over the age of 30. Usually it's because as the ulnar collateral ligament starts to get attenuated, the dynamic stabilizer of the flexor pronator has to do more work. So the older the athlete, the more attenuated the MCL, the more prone you are to flexor pronator problems. Also golfers, the other group that will get this type of injury. The difference, the way you differentiate it though is there shouldn't be any valgus laxity, right? So whether it's a negative milking maneuver, negative moving elbow valgus test, this should really just be isolated point tenderness over the flexor pronator and pain with either resisted finger digital inflection or wrist flexion. But you have to rule out the UCL, obviously, as the diagnosis. Non-operatively, the treatment is always going to be non-operative for this problem unless there is an evulsion of the flexor pronator mass. And if it's, if there's a tear of the flexor pronator with more than a couple, with more than a couple centimeters of retraction, you're going to end up fixing it. All right, so here's another topic that you're definitely going to be asked about on the test, which is distal bicep ruptures. So distal bicep ruptures, typically men in their 40s, oftentimes labor type jobs, physically demanding jobs, associated with higher BMIs and smoking. And it's typically going to be an eccentric load to a flexed elbow. You know, as we talked about during yesterday's talk, it's always, muscle injuries, tendon injuries, always going to be eccentric loads to muscles and tendons that are going to cause the ruptures. If you look at the radial tuberosity itself, and that's going to be important from the standpoint of whether you're doing your single incision, double incision, the differences between the two repairs, the shape of it, because where you're going to reattach the tendon makes a big difference as to the postoperative strength, both of flexion and supination. If there are two different heads of the biceps that attach for the purpose of this test, it's you know, there's a short and a long head, you can rupture them independently. You're not going to be asked about independent ruptures on the exam, just know that they exist and it has more to do with where you put your surgical fixation. Also, when you're examining for them, remember that the lacertus fibrosus, occasionally you can get fooled by it and up to almost 60% of distal biceps tears, the lacertus can still be intact. So if you're feeling for the biceps tendon, you might be feeling the lacertus instead. The lacertus is protecting the nerve vascular structures deep to it. And this, Ben, I would say more than 50% of the nerve injury questions that you get are answered right here, which is when we think about nerve injuries for distal biceps ruptures and for surgery, I always accept when I was preparing for my test that I was going to be pushing our osseous nerve. In fact, lateral antebrachial cutaneous nerve is the most commonly injured nerve around the elbow with bicep surgery. So just remember that, because that will come up at some point along the standardized testing track here, especially for this test. So that's the most commonly, then the radial sensory nerve, this more distally, and then the posterior osseous nerve. The anatomy of the posterior osseous nerve kind of varies in relation to the radial tuberosity. At the radial tuberosity, the posterior osseous nerve is closed during the transmuscular approach in the supinator. And if you look at the distance, if you're using a button-type technique and the direction that you want to drill for a button-type technique, it's going to be the distance between the nerve and the button is increased if you aim your guide pin between 0 and 20 degrees, so more towards the radiocapitellar joint, okay? And it's decreased if you aim towards the ulna. The hook test is, and Sean O'Driscoll published it, it was 100%, you know, sensitive and specific. So simply, you know, this is one of the classic photos of that. Chris Amad had done this picture where you just put a hanger, you know, on a distal biceps, but it really is that simple from a diagnostic standpoint. MRI is going to be your modality of choice for not only to confirm the fact that the tendon is torn, but also to determine the degree of retraction, and it may or may not influence the type of repair that you want to do. If you're looking at single incision versus double incision, obviously trying to restore the anatomy and recover full strength, and the two techniques are a little bit different with regard to the amount of strength that you recover. In one systematic review, the safety with bone tunnel and button methods was reported to be safer than anchors or screw methods. This, although in the systematic review, two incision method was supposedly better for lateral antebrachial cutaneous. That's actually, as I'll get to first and get to the answer for the test, is going to be more injuries to the lateral antebrachial cutaneous with a single incision than a double incision. I'm going to say that's in your handout coming up in a minute as well. Now, what about kind of the degree of differences in strength and supination? So if you're doing just a kind of a single incision, you're doing just an anterior repair of the tendon, often with a suture anchor type technique or a button, the tendon tends to be placed more anteriorly so you don't have the lever arm, say, of a two incision, so you have decreased supination strength with single versus double incision. Does that make sense? All right, so detached in the front versus if you're getting around the back when this contracts, you're going to have more powerful supination strength. So if you do a single incision technique, anterior incision, define the tendon, you have to protect the lateral antebrachial cutaneous nerve and then supinate the forearm and expose the tuberosity. You want to be careful where you're putting your retractors, especially on the lateral side from a standpoint of disturbing the interosseous membrane. If you look at nonoperative versus operative treatments, they're never going to want you for the purpose of the exam to do nonoperative treatment for a distal biceps, all right, unless they say, you know, it's a two-year injury, no complaints of pain or strength, proximal retraction, what are you going to do? But it's really rare. Typically, they're going to want you to and the reason is you have a 40% loss of supination and at least a 20 degree loss of flexion if you leave it nonoperative treatment of a distal biceps injury. So here is these two bullets are the ones you have to remember. Just circle these in your handout or this is the classic type of question that comes up. Single incision, the risks are increased risk of posterior interosseous nerve but especially, so increased risk of nerve injury, lateral antebrachial cutaneous first as well as posterior interosseous. Two incision, the risk of a two incision is heterotopic ossification, loss of motion. So just remember those two things because that will come up in some, at some level. Triceps, we touched on this a bit previously but echemosis, deformity but most commonly, it's going to be offensive lineman, typically the type of picture, steroid use. Tenderness on exam, you have a flex sign right here where a little avulsion of the part of the olecranon where the triceps is attaching. That's usually a pathognomonic for a triceps injury. Partial tears, you can treat nonoperatively but for most full thickness triceps tears, they want you to fix it. So elbow dislocations, a lot of super simple elbow dislocations in sports medicine, usually posterior is the most common. You can have the other types as well but posterior is the most common. You have to check wrist as well. So distal radiolunar joint, proximal radiolum joint, especially for a divergent type of dislocation. And always, of course, think about neurovascular injury. Compartment syndrome as well of the forearm, things to worry about. Imaging, always starting with x-ray, looking for loose bodies, looking for coronoid fractures, looking for the direction of the injury. Usually it's a rotatory stress type of injury that's going to lead to your dislocation. Treatment, simple dislocation is going to be closed reduction and early range of motion in the safe zone. What's the safe zone? It's usually about 30 degrees of flexion to about 100, 110 degrees of flexion. And when you're doing your reduction, you can kind of get a feel for exactly where the elbow is stable, where it's not stable. But you want to do early motion so it doesn't get stiff but you just want to prevent, just restrict zero to 30 degrees of extension. So again, just very brief immobilization. Terrible triad, elbow dislocation, radial head fracture, coronoid fracture. And these have the worst outcomes with regard to post-traumatic osteoarthritis, with regard to recurrent instability and joint stiffness. Montasia fracture dislocations could be proximal third of the ulna with associated radial head dislocation, much more common in kids. Usually it's an anterior dislocation of the radial head that you're going to see. All right, imaging, kind of the standard types. But don't forget, you want to get wrist views as well, ruling out distal radial ulnar joint injuries, scaphoid fractures, et cetera. Pretty rare are you going to do just closed reduction and leave it alone. Typically it's going to be reduction of the radial head with ORIF of the ulna. It's kind of, it's not common to do an UCL or any kind of ligamentous reconstruction at the same time. Now, posterolateral rotatory instability, again, this is a topic that does come up very commonly with your sports elbow questions. So we'll just spend a second on it because not many of us see it a whole lot. Typically it can occur, it's a post-traumatic injury. It's usually not a repetitive overuse injury. It's either traumatic or iatrogenic. The mechanism is a valgus load hyper supination with axial compression. And on exam, you're going to have lateral tenderness over the joint line. The, as Driscoll described, the posterolateral rotatory pivot shift test or drawer test is the diagnosis of choice. X-ray ultrasound, but really it's MRI that's going to be your mainstay for diagnosis. Oftentimes, you're going to, the majority of times you're going to start nonoperative treatment for this injury. But surgical reconstruction, whether you do an overlay or docking, they're not going to ask you what type of reconstruction to do. Just persistent posterolateral rotatory instability. It's a lateral ulnar collateral ligament reconstruction would be the answer for that. Okay, ulnar collateral. This is going to be, again, one of the hot topics for the test when it comes to elbow. So as we talked a little bit about it in the beginning, just looking at the anatomy, it's a complicated anatomy. You've got the anterior band, you've got the posterior band, you've got the joint capsule. And remember that the UCL is most active and most important as you start to flex the elbow. So just remember that with late cocking, early acceleration, that's where the stress on the thrower becomes. Because in more extension, the MCL provides about 30% of stability. As you flex more, the UCL is over half of the stability of the elbow. What's the other stability? Well, the bony anatomy, the flexor pronator group, the muscles, et cetera. So ulnar collateral, most active in flexion. Three parts, anterior, posterior, transverse ligament. And again, anterior band of the ulnar collateral is the primary stabilizer of the elbow from 20 to 120 degrees. And that's why it's important because then when you're doing your moving elbow valgus test, which is also the exam of choice for UCL injuries, that's the range of motion that you're testing in. You don't do it in full extension. You don't do it in hyperflexion. You do it from 20 to 120 degrees for the moving elbow valgus. As we talked about, we can just look at the biomechanics of throwing, this is what's placing the ulnar collateral at risk, rapid extension from 125 to 25, huge angular velocity. It's going to be the more flexed you are, the more the ulnar collateral ligament gets strained and that leads to valgus extension overload. What is valgus extension overload? Well, it's going to be compression laterally, tension medially. So when that happens, you're going to get injury to the ulnar collateral medially. You get compression of the radiocapitella joint. And then as you kind of gap open medially, you get postural medial olecranon osteophytes, which then leads to valgus extension overload symptoms, which is typically pain with forced extension. And the other thing to keep in mind is when you see these postural medial osteophytes and pain, oftentimes that's because you have an incompetent ulnar collateral ligament, which is leading to it. So it's kind of a chicken and egg type of thing as far as which leads to which. But always think of UCL incompetency when you see postural medial osteophytes in the elbow. As far as how much you take off, if you take off more than three millimeters, it's going to lead to increase stress and your tension in your ligament. So just like, you know, distal clavicle, you don't want to take more than two centimeters because of the CC ligaments. And if you are resecting osteophytes, you don't want to take more than three millimeters where you can potentially injure your ulnar collateral ligament. Exam of test, exam test of choice is the moving valgus stress test, most sensitive, most specific from ulnar collateral injury. But don't forget about the ulnar nerve as well. You want to have, make sure that you don't have ulnar neuritis because that's going to probably play into, if you do a reconstruction, are you going to transpose the nerve, are you going to decompress it, what are you going to do? The imaging test of choice is an MRI specifically looking for the T sign, all right. So if you look at the ulnar collateral ligament from the medial epicondyle to the sublime tubercle, if you're doing an arthrogram, you'll have leakage of dye from the joint distally and approximately it forms this T that you see right here. You can also stress under a fluoroscan and look for medial joint line gapping. Two to three centimeters is an aggressive number. It's usually more, you know, eight to ten millimeters that you're going to see when you start to have ulnar collateral ligament injuries. So especially in younger kids, but really for anyone, if it's a partial tear, if you're going to treat a UCL nonoperatively, it's a minimum of three months, Art Rettig kind of did this today, but it's a minimum of three months of no throw, rest, et cetera. And then there's a variety of different surgical techniques. But if you look at the study that Art published on this, he couldn't really correlate anything pre-op, degree of tearing, age, et cetera on who's going to do well nonoperatively and who's going to do well. And the progression just goes from anti-inflammatory, splinting, you're not going to do a ton of splinting because you don't want them to get stiff. It's really just restriction from throwing. And then slowly progress to begin playing catch at three months and looking to try to return by four to five if it's going to be successful. All right, so neurologic conditions. Ulnar neuritis, cubital tunnels we talked about often goes with ulnar collateral injuries, but can it happen in isolation as well? The cubital tunnel, fibro-osseous canal, and just to remember the anatomy, you have, it's bordered by the epicondyle, the proximal ulna, and then Osborne's ligament in the retinaculum itself. Classically, repetitive valgus stress with throwing, with gymnastics. And the compression sites proximally, the arcated struthers, the two heads of the FCU, the intermuscular septum, you can get either osteophytes or ganglions as well. Tunnel sign over the cubital tunnel, very sensitive for it, but, and then numbness or weakness in the ulnar nerve distribution, but the main thing is EMG with a drop by 10 meters per second in the nerve conduction velocities. There's not a huge role for imaging or MRI except if you're going to look for a mass lesion or a cystic lesion compressing the nerve. Classically, it's going to be, in this case, it's the one time when especially night splinting, you are going to splint around the elbows for ulnar neuritis. Not much corticosteroid is not, usually not going to be something you're going to answer on the test. It's more just going to be anti-inflammatory splinting. And then if you are going to do a surgical treatment, they shouldn't really be asking transmuscular versus subcutaneous versus in situ because hand surgeons and elbow surgeons can't agree on that either. But it's just a, unless you're doing an ulnar clavicle reconstruction at the same time. Oops, sorry. Pronator syndrome, pronator syndrome is entrapment of the median nerve with symptoms that increase with force or resisted pronation of the forearm. The median nerve can also get trapped near the ligament struthers at the lacertus. Remember, the lacertus sits right over the nerve vascular structures anteriorly. Between the two heads of the teres or by the flexor digitorum superficialis. And it's most common in women in their 50s. It's usually a vague type of complaint that the patients are going to have. Not a specific traumatic injury. Presenting with thenar muscle weakness. It's rare to get kind of sensory types of, sensory type of symptoms when you're that proximal on the median nerve. And usually EMGs are inconclusive. On x-ray you're looking for osteophytes. But MRI can sometimes find the source of entrapment. But again, typically this is going to be a non-operative method of management. Now the different types of radial neuropathies. This is important to figure out because this is another question that will come up a fair amount. Is the difference between posterior interosseous nerve neuropathies versus radial tunnel syndrome. They're different. All right, so posterior interosseous nerve, you have motor weakness but no pain. All right, so weakness on wrist extension. Weakness on digital extension. But patients don't have pain. Radial tunnel is the one that gets confused with lateral epicondylitis a lot. All right, so radial tunnel is more pain but no weakness. So it just depends where the nerve is being compressed. And then you have Warrenburg syndrome which is just an isolated compression of the dorsal sensory branch. And you can, different places that you can get compressed are listed there. If you look at the anatomy of the radial tunnel, this is like the quadrilateral space and triangular space that we talked about yesterday in the shoulder. Boundaries are the common, the mobile wad laterally. So brachioradialis, ECRL, ECRB. Medially by the brachialis and the biceps. And then deep is going to be the joint capsule. Who gets posterior interosseous nerve compression syndromes? Bodybuilders, weightlifters, laborers, et cetera. And remember that the posterior interosseous nerve provides innervation to the extensor compartment. So not much of a sensory component, all motor. Oftentimes you can have, you have radial deviation of the wrist and you might have some extensor atrophy. Imaging is really typically not helpful in this regard. And you want to have conservative treatment for minimum of three months, oftentimes up to a year. It's going to be rare that they're going to want you to go or don't answer early surgery for this problem unless they say it's been a year. So we're not getting better. And if you do surgery, it's going to be released from the arcator froge, the distal edge of the supinator, the fiber spans superficially to the radiocapitellar joint. Radial tunnel syndrome, as we talked about, it's a subset that we can often misdiagnosis with lateral epicondylitis. And you have similar difficulties to making the diagnosis as you do with the PIN neuropathies. Imaging, not so helpful for it. Conservative, conservative for these neuropathies. And with surgical decompression, if it's not getting better. All right, and then just one of the last topics here we'll do is elbow contractures. As in the shoulder, where you're trying to differentiate between an intraarticular and an extraarticular source of your contracture, that's going to be important around the elbow as well. So do you have capsular, is this a capsular problem? Intraarticular adhesions, do you have loose bodies limiting your motion? Or is it extrinsic? Do you have heterotopic bone from a two-incision distal biceps repair? Do you have soft tissue contractures from a fracture that was treated from one of your surgical approaches? Or do you start getting a lot of osteophytes peripherally? And then obviously ischemic contractures can also cause it. Diagnosis, the contractures are often, you know, if you just look, you don't really notice unless you have both arms out if someone has a subtle loss of extension. So it can be severe, it can be subtle. You have to check, compare to the opposite side. X-rays are important to look for these loose bodies. CT scan, looking for olecranon osteophytes, loose bodies back in the olecranon fossa. Here you're looking for surgically remediable problems. Or is it something like this where you have an osteophyte in the coronoid fossa that's blocking your flexion? Braces, they're going to be more helpful post-op than they are pre-op for a lot of the elbow contracture problems that you have. And it really depends as far as what type of surgery you do, arthroscopic, anterior approach, posterior approach, that's where you want the 3-D CTs, that's where you want your imaging. Where is the most of the pathology that you're trying to get to? Olecranon bursitis is probably the most common sports-related bursitis you're going to see around the elbow. It can prevent warm, swollen, painful. As a general rule, don't stick needles, don't aspirate or inject steroid for an answer to how to treat this early on. You don't want to seed the bursa unless you're worried about an infection, you're trying to rule it out, or unless it's so big and people are having really severe pain. But for non-infectious olecranon bursitis, it's usually not so painful, it's just annoying when they rest on the olecranon tip. Treatment, again, if you're trying to rule out gout, if you're trying to rule out infection, you can aspirate. But for the purpose of the test, they're not going to say give a steroid injection to olecranon bursitis. And then we won't spend too much time on, just to be complete, a little bit of elbow OA here. It's, as far as, typically from a sports population, you're going to see this in the post-traumatic setting. Elbow arthroplasty is usually reserved now for people over 60 and most commonly, the people that were having elbow arthroplasty for elbow arthritis was the rheumatologic disorders, rheumatoid, but with all the advances now with the medical management of rheumatoid, just the number of total elbows being done is much, much lower. It does come up occasionally, certainly on OITEs and some of the self-assessments that I've seen, just the things to remember. There's two types of total elbows. There's the unlinked or non-constrained. The problem with that one is better motion but can cause instability. Or the linked, semi-constrained, the problem with those is they can loosen. So, not unlike in a knee, the more constrained the knee replacement, the increased risk of loosening. I did have a question on radiocapitellar plicas on one of my exams. These are lateral and posterolateral folds in the elbow. Typically, they'll say throwing the athlete feels a snap or a pop with repetitive motion on the lateral side of the elbow. That's the classic history for a plica problem in the elbow. It's used, this is something that you can treat with a corticosteroid injection, anti-inflammatory medication. The indications for, and you can reproduce the symptoms with passive elbow flexion extension with a forearm pronated. That's what's going to bring the plica into play. Ultrasound, this is one case where ultrasound is probably the best diagnostic modality to rule out this versus a loose body or something else as the cause of the problem. And when conservative management fails, arthroscopic excision is the treatment of choice. So, just a couple of questions to run through here. Eight-year-old baseball player, medial elbow pain. As soon as you see pediatric pain, you think little league elbow, medial apophysitis. Kids are not going to get post-lateral instability. They're not going to get triceps tendon injuries, right? They don't get tendon injuries. They get olecranon apophysial injuries, but not tendon injuries and most of the kids are not getting compartment syndrome. So, it's medial apophysitis. Collegiate baseball player, posterior elbow pain. So, posteriorly, it's rare to have triceps injuries in throwers. It's usually going to be, if it's young, it's going to be an apophysitis. If it's an older or adult thrower, it's going to be an olecranon stress fracture. All right, it's very, actually it's not uncommon. It's a fairly common injury in professional throwers. So, the pain continues to worsen, new x-rays. Even if it doesn't show a fracture, if they say, if they give you this vignette and then they say, what's the next step in treatment if an x-ray doesn't show anything? It should be an MRI to rule out a stress reaction, stress fracture, edema, olecranon problem there. So, I told you that this kind of comes up. What age does the olecranon apophysis appear? 1, 3, 5, 7, 9, 11, right? Olecranon is the fifth one. So, the fifth one is age 9. What's the terrible triad? It's going to be, again, elbow dislocation, coronoid fracture, radial head fractures. And this is, this does come up. What is the difference between posterior neurostious nerve syndromes and radial tunnel? So, remember, the difference is one of them is motor, but not sensory. One's more sensory, not motor. The posterior neurostious nerve is a motor nerve. So, the difference is the posterior neurostious nerve causes motor weakness, but not pain. And then, which x-ray is going to be the best for identifying minimally displaced radial head fractures? Well, RadiocapitellaView, if it's got radial in the name of the x-ray, that's going to be the answer for a radial head. And a divergent elbow dislocation, more rare, again, posterior is the most common, but the divergent is going to be a proximal radial ulnar dislocation. All right, so, again, just elbow is a little bit like, you know, it's not as bad as the brachial plexus, but just review your ligamentous anatomy and your nerve anatomy before the test. And ulnar collateral, single versus double incision for distal biceps, epicondylitis, people with, another question that comes up a lot is, you know, someone has recalcitrant lateral epicondylitis, has surgery, tries to get back, has increasing pain, not getting better, what happened? It's usually iatrogenic injury to the lateral ligamentous complex during the debridement. Okay, and that's usually, those are the main questions that you're going to get for the sports exam. Thank you.

elbow issues

lecture

Dr. Tom Gill

injuries

pediatric patients

athletes

diagnosis

treatment options

fractures