Upper Arm, Elbow, and Forearm
Conditions
Chapter 15
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Anatomy
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Anatomy
• 3 articulations (single capsule)
– Humeroulnar (elbow joint)
• Trochlea of humerus with trochlear fossa of ulna
• Hinge joint; flexion and extension
• Close-packed position – extension
– Humeroradial
• Capitellum of humerus with proximal radius
• Gliding joint
• Lateral to humeroulnar joint
• Close-packed position – elbow 90°; forearm
supinated 5°
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Anatomy (cont.)
– Proximal radioulnar
• Head of radius with
radial notch of ulna;
joined by annular
ligament
• Pivot joint
 Radius rolls
medially and
laterally over the
ulna; pronation and
supination
• Close-packed position
– supination 5°
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Anatomy (cont.)
• Carrying angle
– Angle between humerus and ulna (arm in
anatomic position)
– 10-15° angle
– Greater in females
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Anatomy (cont.)
• Ligaments
–
Ulnar (medial) collateral
–
Radial (lateral) collateral
–
Annular
–
Accessory lateral collateral
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Anatomy (cont.)
• Bursae
– Several small
– Olecranon bursa
• Superficial
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Anatomy (cont.)
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Anatomy (cont.)
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Anatomy (cont.)
• Nerves
– Musculocutaneous
– Median
– Ulnar
– Radial
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Anatomy (cont.)
• Blood vessels
– Brachial
• Ulnar and radial
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Kinematics
• Movements
– Flexion and extension
• Humeroulnar joint and humeroradial joint
– Supination and pronation
• Proximal radioulnar
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Kinematics (cont.)
• Muscles
– Flexors
• Brachialis; biceps; brachioradialis
• Effectiveness depends on supination/pronation
position
– Extensors
• Triceps; anconeus
– Pronation and supination
• Pronator quadratus; pronator teres supinator;
biceps
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Kinetics
• Non–weight bearing but still sustains significant loads
• Extremely large muscle forces generated with forceful
throwing motions, weight lifting, and many resistance
training exercises
• Extensor moment arm < flexor moment arm
– Extensors must generate more force than flexors to
produce same amount of joint torque
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Injury Prevention
• Protective equipment
– Pads
– Braces
• Physical conditioning
– Flexibility and strength
– Focus on entire arm
• Proper skill technique
– Throwing
– Falling
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Contusions
• Susceptible due to:
–
Lack of padding
–
General vulnerability
• S&S
–
Rapid swelling – can limit ROM
• Chronic blows
–
Development of ectopic bone
• Myositis ossificans – brachialis belly; proximal
deltoid insertion
• Tackler’s exostosis
–
Painful periostitis and fibrositis may develop
• Management: standard acute; NSAIDs
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Olecranon Bursitis
• Acute and chronic
– Mechanism
• Fall on a flexed elbow
• Constantly leaning on elbow
• Repetitive pressure and friction
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Olecranon Bursitis (cont.)
– S&S
• Tender, swollen, relatively painless
• Rupture – goose egg visible
• 50% history of abrupt onset; 50% insidious onset
over a few weeks
• Motion limited at extreme of flexion – tension
increases over bursa
– Management: standard acute; NSAIDs; possible
aspiration
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Olecranon Bursitis (cont.)
• Septic bursitis
– Related to seeding from infection at a distant site
– S&S
• Traditional signs of infection (within 1 week of
symptoms)
• Skin lesion overlying bursa – 50% of cases
• Bursal tenderness – 92-100% of cases
• Peribursal cellulitis – 40-100% of cases
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Olecranon Bursitis (cont.)
• Nonseptic
– Caused by crystalline deposition disease or rheumatoid
involvement
– Associated with atopic dermatitis
– S&S
• Skin lesion – 5% of cases
• Bursal tenderness – 45% of cases
• Cellulitis – 25% of cases
• Management: physician referral
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Sprain
• Mechanism
– Fall on extended hand (hyperextension injury)
– Valgus or varus force
– More common; repetitive forces irritate and tear
ligaments, especially UCL
• Ulnar nerve may also be affected
• S&S
– Localized pain
– Point tenderness
– Instability with stress test
• Management: standard acute
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Anterior Capsulitis
• Anterior joint pain caused by hyperextension
• S&S
– Diffuse, anterior elbow pain after a traumatic
episode
– Deep tenderness on palpation (especially
anteromedial)
• Need to rule out pronator teres strain and median nerve
entrapment
• Management: immobilization for 3-5 days followed by
AROM exercises as pain allows
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Dislocation
• Proximal radial head
– Adolescents: often associated with immature annular
ligament
– Due to: longitudinal traction of an extended and
pronated upper extremity
– Inability to pronate and supinate pain free
warrants immediate physician referral
– Immobilization for 3-6 weeks in flexion is usually
necessary
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Dislocation (cont.)
• Ulnar dislocation
– Younger than 20 years old
– Mechanism:
• Hyperextension
• Sudden, violent unidirectional valgus
force drives ulna posterior or
posterolateral
– Associated conditions
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Dislocation (cont.)
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Dislocation (cont.)
– S&S
• Snapping or cracking sensation
• Severe pain, rapid swelling
• Total loss of function
• Obvious deformity
• Arm held in flexion, with forearm appearing shortened
• Olecranon and radial head palpable posteriorly
• Slight indentation in triceps visible just proximal to
olecranon
• Nerve palsy
– Management: immediate immobilization in vacuum
splint; activation of EMS
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Strains
• Flexors and pronator teres
– Repetitive tensile stresses
• Extensor
– Decelerating type injury
• S&S
– Typical muscle strain S&S
– Self-limiting
• Management: standard acute
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Biceps Brachii Rupture
• Mechanism: sudden eccentric load
• S&S
– Tenderness, swelling, and ecchymosis in
antecubital fossa
– Weakness in supination and flexion
– Distal tendon not palpable
• Management: standard acute; immediate physician
referral
• Nonoperative vs. surgical repair
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Triceps Brachii Rupture
• Mechanism:
– Direct blow to posterior elbow
– Uncoordinated triceps contraction during a
fall
• 80% involve olecranon avulsion fracture
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Triceps Brachii Rupture (cont.)
• S&S
– Pain and swelling in distal attachment
– Palpable defect in the triceps tendon or a stepoff deformity of the olecranon
– Active extension weak – partial tear;
nonexistent – total rupture
• Management: standard acute; immobilize in sling;
immediate physician referral
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Compartment Syndrome
• Anterior – wrist and finger flexors
posterior – wrist and finger extensors
• Condition often secondary to other injuries
• Potential for neurovascular compromise
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Compartment Syndrome (cont.)
• S&S
– Rapid onset
– Swelling; discoloration
– Absent or diminished distal pulse
– Subsequent onset of sensory changes and paralysis
– Severe pain at rest, aggravated by passive stretching of
muscles in involved compartment
• Management: immobilization; ice and elevation; NO
compression; immediate physician referral
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Overuse Conditions
• Medial epicondylitis
– Due to repeated valgus forces during
acceleration phase of throwing motion
– Commonly involved tendons: pronator teres
and flexor carpi radialis
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Overuse Conditions (cont.)
– S&S
• Swelling, ecchymosis, and point tenderness at
humeroulnar joint or over the flexor/pronator origin
• Severe pain; aggravated by:
 Resisted wrist flexion and pronation
 Valgus stress applied at 15-20° of elbow flexion
• Ulnar nerve involved – tingling and numbness
– Management: ice; NSAIDs; sling immobilization for 2-3
weeks with wrist in slight flexion; therapeutic exercise
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Overuse Conditions (cont.)
• Lateral epicondylitis
– Due to eccentric loading of extensor muscles
(especially extensor carpi radialis brevis)
during deceleration phase of throwing motion
or tennis stroke
– Contributing factors
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Overuse Conditions (cont.)
– S&S
• Pain anterior or just distal to lateral epicondyle; may
radiate into forearm extensors during and after activity
• Repetition produces pain that becomes more severe and
↑ with resisted wrist extension
• + “coffee cup” test
• + tennis elbow test
– Management: ice; NSAIDs; rest; support
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Overuse Conditions (cont.)
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Overuse Conditions (cont.)
• Neural entrapment
– Ulnar nerve
• Vulnerable to compression and tension
• S&S
 Shocking sensation (medial elbow), radiating as if
“hitting their crazy bone.”
 + Tinel sign – ulnar groove (tingling and
numbness of medial forearm into ring and little
finger)
 Pain not present, ROM is not limited
 Grip strength may be weak
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Overuse Conditions (cont.)
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Overuse Conditions (cont.)
– Median nerve
• Compression
• Involvement of pronator teres – pronator
syndrome
• S&S
 Pain in anterior proximal forearm, and
aggravated with pronation
 Numbness in anterior forearm, middle and
index fingers, and thumb
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Overuse Conditions (cont.)
– Radial nerve
• S&S
 Aching lateral elbow pain, radiates down posterior
forearm
 Significant point tenderness over supinator muscle
 Resisted supination more painful than wrist
extension
 Extreme cases: wrist drop
– Management of neural entrapment: immediate physician
referral
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Fractures
• Epiphyseal and avulsion fractures
– Medial epicondyle growth plate sensitive to
tension stress
• Repetitive or sudden contraction of the
flexor-pronator muscle group → partial or
complete avulsion fracture of the medial
epicondyle (little league elbow)
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Fractures (cont.)
– S&S
• Initial phase – aching during performance, but no
limitations of performance or residual pain
• Progression – aching pain during activity limits
performance, and a mild postexercise ache
• Localized tenderness
– Management
• Initial phase: standard acute; activity modification
• Performance limitations – physician referral
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Fractures (cont.)
• Stress fractures
– Ulna diaphysis – intensive weight lifting
– Bilateral distal radius and ulna – young individuals who
lift heavy weights
• Osteochondritis dissecans
– Complication of repetitive stress to skeletally immature
elbow
– Lateral compressive forces during throwing motion
damage radial head, capitellum, or both
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Fractures (cont.)
– S&S
• Pain with activity, improves with rest
• Occasional clicking or locking of elbow
• Swelling and tenderness over radiocapitellar joint
• Grating during passive pronation and supination
• Limited full extension
• Management: physician referral
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Fractures (cont.)
• Supracondylar fractures
– Fall on outstretched hand
• Volkmann’s contracture:
 Complication from supracondylar fractures
 Ischemic necrosis of forearm muscles
 Damage to brachial artery or median nerve
from fractured bone ends
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Fractures (cont.)
• Olecranon
– Direct blow
– Triceps tension pulls bone fragment superiorly
– Intra-articular fracture – does not respond to
conservative treatment, requires surgical
intervention
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Fractures (cont.)
• Radial head
– Valgus stress tears UCL → compression and shearing
on radial head
– S&S
• Swelling lateral to the olecranon
• Point tenderness radial head
• Flexion and extension may or may not be limited;
passive pronation and supination is painful and
restricted
• Possible associated valgus instability of the elbow
or axial instability of the forearm
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Fractures (cont.)
• Ulna (forearm fracture)
– Direct blow
– Also known as “nightstick” fracture
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Fractures (cont.)
• Fracture management
– Neurologic and circulatory assessment
• Radial nerve damage
 Weak forearm supination; elbow, wrist, or
fingers extension
 Sensory changes – dorsum of hand
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Fractures (cont.)
• Median nerve
 Weak wrist and finger flexion
 Sensory changes – palm of hand
• Ulnar nerve
 Weak ulnar deviation and finger
abduction/adduction; sensory changes – ulnar
border of the hand
– Assess pulse at wrist or assess capillary refill
– Apply vacuum splint; transport immediately to nearest
medical facility
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Assessment
• History
• Observation/inspection
– Carrying angle
– Position of function
• Palpation
• Physical examination tests
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Range of Motion (ROM)
• Active range of motion (AROM)
– Elbow
• Flexion/extension
• Pronation/supination
– Wrist
• Flexion/extension
• Passive range of motion (PROM)
– Elbow flexion – tissue approximation
– Elbow extension – bone to bone
– Supination and pronation – tissue stretch
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ROM (cont.)
• Normal ranges
– Elbow flexion: 140-150°
– Elbow extension: 0-10°
– Supination: 90°
– Pronation: 90°
– Wrist flexion: 80-90°
– Wrist extension: 70-90°
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ROM (cont.)
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ROM (cont.)
• Resisted range of motion (RROM)
– Elbow flexion
– Elbow extension
– Supination
– Pronation
– Wrist flexion
– Wrist extension
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ROM (cont.)
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Stress Tests
• Ligamentous instability
– Valgus stress
– Varus stress
– Perform at multiple angles (full extension → 20-30°
flexion)
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Special Tests
• Common extensor tendinitis (lateral epicondylitis)
– Resisted extension and radial deviation of wrist
– Passive stretching of wrist extensors
– Resisted extension of extensor digitorum communis in
middle finger with wrist extended
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Special Tests (cont.)
• Medial epicondylitis
• Tinel’s sign for ulnar neuritis
• Elbow flexion for ulnar neuritis
• Pronator teres syndrome
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Special Tests (cont.)
• Pinch grip test
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Neurologic Tests
• Myotomes
– Scapular elevation – C4
– Shoulder abduction – C5
– Elbow flexion and/or wrist extension – C6
– Elbow extension and/or wrist flexion – C7
– Thumb extension and/or ulnar deviation – C8
– Abduction and/or adduction of fingers – T1
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Neurologic Tests (cont.)
• Reflexes
– Biceps – C5-C6
– Brachioradialis – C6
– Triceps – C7
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Neurologic Tests (cont.)
• Dermatomes
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Neurologic Tests (cont.)
• Cutaneous patterns
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Rehabilitation
• Restoration of motion
– Use of opposite hand
to supply load
– UBE
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Rehabilitation (cont.)
• Restoration of proprioception and balance
– Closed-chain exercises
• Muscular strength, endurance, and power
– Open-chain exercises
– PNF-resisted exercises
• Cardiovascular fitness
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