Therapeutic Researsh

موضوع: Therapeutic Researsh الخميس سبتمبر 20, 2007 1:28 am

"Deformities of the elbow joint"

There are a lot of deformities concerning about the elbow joint. Bony Deformities of Elbow joint are usually resulting from previous trauma and may not be conspicuous when the elbow is flexed. There are many examples for these deformities like cubitus varus and cubitus valgus deformities with the forearm extended as straight as possible (but not hyperextended). Varus deformity (sometimes called gunstock deformity) represents a decrease in the carrying angle and is usually caused by a previous supracondylar fracture to evaluate the nature of positional changes of humeroulnar (HU) and humeroradial (HR) joints. These deformities start from early age to the elderly persons. These deformities occur in the medial, lateral, anterior and posterior of the elbow joint.

A cubitus valgus deformity is an increase in the carrying angle. The elbow seems to turn into valgus during rheumatoid destruction and excision of the radial head may speed up this process. However, totally unstable Larsen grade 5 joints may also have varus deformity owing to mutilating bone destruction. The ulna subluxates proximally in relation to the humerus, whereas the radius moves slightly anteriorly as a consequence of elbow involvement. It can be associated with chronic stretching of the ulnar nerve. Sometime s former throwing athletes, such as football quarterbacks or baseball players, will have an increase in the carrying angle on their dominant arm atrophy of the flexor carpi ulnaris in the forearm. (If you have forgotten the location of this useful muscle, flex and extend your ring and little fingers and observe the muscles that contract in the medial forearm.) Atrophy of this muscle suggests radiculopathy of the eighth cervical nerve root (C SORRY

or nerve entra ment at the elbow (cubital tunnel syndrome). Polyneuritis and trauma can produce ulnar neuropathy in addition to the entrapment syndromes
Little league elbow (LLE) is a valgus overload or overstress injury to the medial elbow that occurs as a result of repetitive throwing motions which usually occurs to the sports persons. Over the past several decades, the number of organized sports for children has grown significantly, with millions of children participating in organized athletics each year. This increase in participation has been paralleled by an increase in sports-related injuries in the pediatric population. Increased single-sport participation with year-round training, higher intensities at young ages, and longer competitive seasons are contributing factors to the increased injury rates seen in pediatric athletes. Conditioning and training errors also contribute significantly to the risk and frequency of injury but the (LLE) is considered a special case of these terms.

During the throwing motion, valgus stress is placed on the elbow. This valgus stress results in tension on the medial structures (for example, medial epicondyle, medial epicondylar apophysis, medial collateral ligament complex) and compression of the lateral structures (for example, radial head, and capitellum). Repeated stress results in overuse injury when tissue breakdown exceeds tissue repair. Recurrent microtrauma of the elbow joint can lead to (LLE), a syndrome that encompasses
(1) Delayed or accelerated growth of the medial epicondyle (medial epicondylar apophysitis)
(2) Traction apophysitis (medial epicondylar fragmentation),
(3) Medial epicondylitis.
Repetitive valgus stress generally manifest with progressive medial pain, decreased throwing effectiveness, and decreased throwing distance Repetitive medial stress can also cause attenuation and microstretching of the
ulnar collateral ligament (UCL) complex, causing mild instability over time. UCL injuries can manifest as acute ligament tears following a single valgus stress or as overuse sprains following repetitive valgus overloads. The clinical presentation is similar to LLE; however, the typical age range of the athlete is the older teenager who is skeletally mature. Suspected UCL injuries should be referred for further evaluation by a sports medicine specialist. Athletes with UCL injuries should not be allowed to pitch until they have been evaluated.
Although uncommon in children, neurological injuries such as C8-T1 radiculopathy and ulnar neuritis can manifest as medial elbow pain and should be included in the differential diagnosis.

ulnar collateral ligament (UCL) complex, causing mild instability over time. UCL injuries can manifest as acute ligament tears following a single valgus stress or as overuse sprains following repetitive valgus overloads. The clinical presentation is similar to LLE; however, the typical age range of the athlete is the older teenager who is skeletally mature. Suspected UCL injuries should be referred for further evaluation by a sports medicine specialist. Athletes with UCL injuries should not be allowed to pitch until they have been evaluated.
Although uncommon in children, neurological injuries such as C8-T1 radiculopathy and ulnar neuritis can manifest as medial elbow pain and should be included in the differential diagnosis.
Lateral compression of the elbow most frequently results in injuries to the capitellum and radial head. Osteochondrosis of the capitellum (known as Panner disease) generally occurs in children aged 7-12 years and manifests as dull, achy activity-related lateral elbow pain. Swelling, clicking, and decreased range of motion are uncommon associated symptoms. Panner disease tends to be a benign self-limited condition that does well over time and is treated with complete rest from inciting activities such as throwing and weightbearing on the elbow. Osteochondral injuries can also be observed in the radial head.

Osteochondritis dissecans (OCD) of the capitellum occurs in adolescents aged 13-17 years. This is a localized injury to subchondral bone that results from repetitive lateral compression of the elbow during overhead motions. These patients report a general dull elbow pain that worsens with activity, often have a flexion contracture of 15° or greater, and may have mechanical symptoms of clicking or popping. Loose body formation, residual capitellum deformity, and elbow degenerative joint disease are potential sequelae. Different treatment options are used based on the age and skeletal maturity of the patient and the type of lesion present. OCD lesions can be separated into type I, which has no displacement and no articular cartilage fracture; type II, which has evidence of articular cartilage fracture or partial displacement; and type III, which is completely displaced with loose bodies in the joint.

Posterior elbow injuries also occur as a result of throwing. During the follow-through stage of throwing, extension overload and valgus stress can result in injury of the olecranon. These athletes present with posterior elbow pain, clicking, and possible loss of elbow extension. Loose bodies and olecranon nonunion can occur in younger athletes. Older athletes may experience olecranon fractures or secondary osteophyte formation. These injuries are sometimes treated surgically.
Elbow biomechanics include flexion/extension range of motion and pronation/supination. Slight hyperextension 5-15° through flexion of approximately 150° is within normal limits
(1) Elbow Flexion and Extension. Flexion and extension are key components of the elbow range of motion needed to perform daily activities. Limited range of motion suggests degenerative joint disease or previous fracture. Limited extension is an important sign of abnormality in the elbow joint because it is the first aspect of the range of motion to be influenced. Painful extension suggests radial tunnel syndrome or lateral epicondylitis. Painful flexion suggests medial epicondylitis. For example, baseball pitchers with years of throwing experience often have relative 5-10° flexion contractures on their dominant side; however, in the young thrower, a flexion contracture can be a sign of injury.
(2) Supination and Pronation. Supination and Pronation are not as critical for activities of daily living as are flexion and extension. Impairment suggests degenerative joint disease or previous radial fracture. Pain on supination and pronation suggests fracture of the radial head. Lead-pipe rigidity to passive supination and pronation of the forearm suggests early Parkinsonism for example Pronation of 75° and supination of 85° is normal. Varus-valgus laxity of 3-4° is normal.

One should be familiar with the stages of throwing to understand the complexities of the biomechanical forces that contribute to the young thrower's risk of injury. The pitching or throwing motion can be divided into 6 stages. Medial elbow injuries are the most common type seen in throwers and occur most commonly in the cocking and acceleration phases of throwing, owing to the presence of maximum valgus extension or distraction forces.
(1) Windup begins with the pitcher balancing his weight over his rear leg with the elbow flexed and the forward leg flexed at least 90°
(2) Stride starts with the lead leg beginning to descend toward the plate and he 2 arms separate. The elbow moves from extension into flexion of 80-100°
(3) Cocking occurs when the humerus is in extreme abduction and external rotation and the elbow is flexed. The lead foots contacts the ground, the pelvis and trunk rotate, and elbow torque transfers valgus force across the elbow joint. During this phase, medial tension and lateral compression forces are applied to the elbow.
(4) Acceleration is the shortest pitching phase, lasting from maximal external shoulder rotation to ball release. In this phase, the trunk rotates as the elbow extends. Maximum elbow angular velocity is comparable during fastballs, sliders, and curveballs, but it less during the change-up pitch. Velocity comes from rotation of the trunk, shoulder, and hips. Varus torque forces during this phase act to resist the valgus extension "overload" phenomenon and can contribute to posterior elbow (olecranon) impingement.
(5) Deceleration is initiated at ball release and ends when the shoulder has reached full internal rotation. The body must decelerate the arm and dissipate forces in the elbow and shoulder.
(6) Follow-through is the final phase of the baseball pitch and ends with the pitcher reaching a balanced fielding position with full-trunk rotation and the body weight fully transferred from the rear leg to the forward leg. During follow-through, the elbow flexes into a relaxed position and crosses the body.

Tenderness over the Medial Aspect of the Elbow: Tenderness over the medial aspect of the elbow is an important observation. Discomfort over the medial epicondyle suggests medial epicondylitis or golfer's elbow.
Golfer's elbow is a disorder of the elbow and forearm caused by repetitive motions. The condition is also known as medial epicondylitis and involves overuse of the forearm muscles and tendons which causes pain and inflammation around the elbow joint. Golfers often suffer this condition.
* Symptoms of Golfer's elbow are:
Elbow pain
Elbow tenderness
Forearm pain
Outer-side forearm pain-the inner side is affected by Tennis Elbow
Elbow Pain worse with wrist movement
* Golfer's elbow can be treated by:
Rest
Strapping
NSAIDs
Injected local anesthetic
Injected corticosteroids

Characteristically, there will be pain on resisted palmar flexion at the wrist. It can be known by Checking for a dimple next to the radial head, which suggests a severe medial collateral ligament tear. If present, test for stability by having the patient lie supine with the arm held perpendicular (straight up in the air) and the elbow flexed about 30° to move the olecranon from its fossa. Stability can be assessed by gently moving the joint medially and laterally in both supination and pronation.
Also check for median nerve entrapment syndromes Carpal tunnel syndrome is entrapment of the nerve at the wrist. Check Tinel's sign (reproducing tingling paresthesias by tapping on the nerve in the middle of the wrist) and touching thumb to the fingertips to evaluate median nerve function. In addition, perform Phalen's maneuver by having the dorsal aspects of the hands touch to produce tingling on acute passive wrist flexion. The anterior interosseous syndrome is nerve entrapment between wrist and elbow.
The combination of thumb weakness and thenar atrophy without Tinel's sign suggests the pronator syndrome with nerve entrapment at the elbow. The patient may have a claw hand with weakness of finger flexion and weak "OK" sign and thenar atrophy.

Tenderness to palpation Over the Lateral Aspect of the Elbow:
Suggest lateral epicondylitis (tennis elbow). Tennis Elbow is condition characterized by pain in or near the lateral humeral epicondyle or in the forearm extensor muscle mass as a result of unusual strain. It occurs in tennis players as well as housewives, artisans, and violinists Pain can be demonstrated on resisted dorsiflexion of the wrist on passive pronation of forearm.
* There are a lot of reasons that cause Tennis Elbow as:
Elbow pain
Elbow tenderness
Forearm pain
Inner-side forearm pain; as the outer side is affected in Golfer's elbow.
Drugs side effect
Drugs interaction causes

To be sure check for radial nerve entrapment by looking for decreased sensation over the dorsal hand and lateral forearm. Also look for painful finger extension with the wrist flexed and pronated. Another clue of radial nerve entrapment is tingling in the radial distribution with tapping over arcade of Frohse which is present in over 60% of individuals and is located in the superior hiatus of the supinator muscle.
*Treatment used in Tennis Elbow:
Rest
Strapping
NSAIDs
Injected local anesthetic
Injected corticosteroids

Tenderness of the medial aspect of the hand with palpation between the medial epicondyle suggests cubital tunnel syndrome (ulnar nerve entrapment). The ulnar nerve can be trapped in several anatomic sites:
The arcade of Osborne (under the 2 heads of the flexor carpi ulnaris) -- the most common location;
The arcade of Struthers (a thin band extending from the medial head of the triceps muscle to the medial intermuscular septum; located approximately 8 cm proximal to the medial epicondyle); and the ulnar groove.
Also Elbow Dislocation: One of the most serious acute elbow injuries is an elbow dislocation. Typically this results from falling on an outstretched or extended arm, most commonly as a result of a contact sport or fall from a height. The patient experiences an immediate loss of range of motion in combination with acute pain over the elbow surface. The elbow may also appear deformed. In this situation the elbow joint needs to be reduced, or the joint needs to be put back in alignment. Since the patient likely needs sedation and pain management, the reduction should only be performed by a medical provider at an emergency clinic. An x-ray is also required since the climber may have also suffered a fracture of the olecranon and/or radial head in this situation.
And elbow Fracture Fractures of the elbow also cause acute pain, swelling, bruising and potential joint deformity. Elbow fractures need to be recognized and treated early to minimize long term complications such as loss of elbow range of motion and chronic stiffness. Direct trauma or a fall on an outstretched hand may indicate an olecranon (proximal ulnar) fracture. Fractures of the radius often occur over the radial head (at the elbow joint) and are associated with elbow dislocations. Pain with elbow flexion may indicate a fracture to the distal humerus. In these scenarios, an x-ray is required to determine a possible fracture. Surgery is often required for a fracture that is severely displaced. Additional damage to the nerves and blood vessels of the upper extremities may also be apparent. Patients may complain of numbness or tingling of the digits of the forearm or hand indicating potential nerve damage. Injury to the blood vessels may decrease perfusion to the forearm and hand as indicated by diminished temperature and/or a weakened or absent pulse at the wrist

Chronic Elbow Injuries: Chronic elbow injuries are typically the result of repetitive injuries, general inflammatory conditions and/or post trauma. They are recognized as greater than 2 weeks in duration. Patients often describe recurrent pain, stiffness and/or loss of elbow range of motion.

Arthritis: describes chronic joint pain. The most common forms encountered in the elbow include osteoarthritis (OA), postraumatic arthritis (PA) and rheumatoid arthritis (RA). OA is the result of calcification of cartilage in the joint spaces. Occurring most often in older age, OA is characterized by pain, stiffness and restricted range of motion. Patients with OA often experience a feeling of locking or catching in the joint which is related to loose cartilage pieces. PA often follows a history of a fracture, dislocation or cartilage injury and results in recurrent pain, stiffness and/or limited motion. RA often presents with pain and symmetrical swelling of multiple joints. Joint deformity may occur
Olecranon Bursitis: Acute or chronic swelling over the tip of the elbow with increased pain during movement is a sign of the development of olecranon bursitis. Bursitis describes the inflammation of the bursa, the connective tissue structure surrounding the joint space. Typically, blood and serous fluid collect in this subcutaneous structure. It is caused by chronic overuse of the joint, previous injury or infection. People often encounter this condition after leaning on the elbow surface for long periods of time; this condition is also known as miner’s elbow. A single, acute episode of trauma to the tip of the elbow, such as a fall on a hard surface, may precede this condition. The condition can be either inflammatory, infectious or both. The olecranon region often appears red and is warm to palpation. Initial treatment involves use of NSAIDS (non-steroidal anti-inflammatory agents, such as ibuprofen, aleve, naprosyn) to control inflammation and swelling. Fluid collection over the olecranon is easily infected with a simple abrasion, insect bite or cut. If infection is suspected, the region is aspirated to drain infected fluid and perform a bacterial culture. Further treatment with antibiotics and immobilization is required. Without treatment, more serious infections, such as osteomyelitis, bone infection, or septic arthritis can occur.
Tendinitis: There are three main forms of tendinitis, inflammation of a tendon, encountered in the elbow. These include lateral epicondylitis, often known as tennis elbow, medial epicondylitis, often known as golfer’s elbow and biceps tendinitis [3]. Each condition is usually the result of repetitive motion injuries to the elbow joint. Tendinosis, on the other hand, is a chronic condition that occurs when the tendon is never allowed adequate time to heal properly, and can linger for months to even years. Climbers who repeatedly return to the climbing wall too soon can suffer from this chronic state for life.

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موضوع: رد: Therapeutic Researsh الأحد سبتمبر 23, 2007 1:48 am

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