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Biceps Tendon Tear (Distal)

  • Cause/Pathophysiology

    • Failure of the distal biceps tendon

    • Frequently results from forceful concentric flexion of the elbow (lifting) or excessive eccentric load 

  • History and symptoms

    • Mechanism of injury

    • + pop or pull in front of elbow

    • + antecubital pain

  • Exam Findings

    • + biceps deformity in complete rupture, +/- with partial

    • Palpable tendon defect

    • Pain and decreased strength with elbow flexion and supination

  • Imaging/Diagnostic Studies

    • MRI or ultrasound

  • Treatment

    • Surgical repair is the standard

    • Exceptions could include low demand and/or high risk patients

  • Common ICD-10 Codes

    • S46.299A

 

 

 

 

 

 

 

Cubital Tunnel Syndrome

  • Cause/Pathophysiology

    • Compressive/stretch injury to the ulnar nerve at the elbow

    • Frequently results from repeated flexion of the elbow

  • History and symptoms

    • +/- Pain, numbness, tingling in ring and small fingers

    • +/- Pain posterior medial elbow in ulnar groove

  • Exam Findings

    • +/-  Tinel's over ulnar groove

    • TTP over ulnar nerve in ulnar groove

    • +/- altered sensation ring and/or small finger

    • +/- intrinsic muscle wasting

    • +/- grip, finger adduction strength

  • Imaging/Diagnostic Studies

    • Imaging negative​

    • EMG/NCS diagnostic

    • If concern that symptoms may be cervical, cervical X-Rays and MRI may play a role in work-up

  • Treatment

    • First Line

      • NSAIDs or steroid​

      • Elbow extension splint at night (towel or pillow wrapped around elbow, elbow pad turned backwards)

      • +/- PT for neural glide stretches

    • Surgery - ulnar nerve transposition

  • Common ICD-10 Codes

    • G56.20

 

Lateral Epicondylitis (Tennis Elbow)

  • Cause/Pathophysiology

    • Repetitive use injury

    • Acute inflammation or chronic micro-damage to extensor tendons at the lateral epicondyle

  • History and symptoms

    • Pain with gripping, lifting, or turning

  • Exam Findings

    • TTP over lateral epicondyle

    • Pain with resisted wrist extension, especially with the elbow in extension

    • Pain with gripping

    • +/- pain with resisted supination

  • Imaging

    • ​X-Rays - generally negative​​

    • MRI may be helpful prior to surgery, if conservative treatment fails

  • Treatment

    • Inflammation reduction: NSAIDs, steroids, cortisone injection, ice

    • Physical therapy

    • Cock-up wrist brace - in my opinion works better than tennis elbow strap

    • Tennis elbow strap

  • Common ICD-10 Codes

    • M77.10

 

 

Medial Epicondylitis (Golfer's Elbow)

  • Cause/Pathophysiology

    • Repetitive use injury

    • Acute inflammation or chronic micro-damage to flexor tendons at the medial epicondyle

  • History and symptoms

    • Pain with gripping, lifting, or turning

  • Exam Findings

    • TTP over medial epicondyle

    • Pain with resisted wrist flexion, especially with the elbow in extension

    • Pain with gripping

    • +/- pain with resisted pronation

  • Imaging

    • ​X-Rays - generally negative​​

    • MRI may be helpful prior to surgery, if conservative treatment fails

  • Treatment

    • Inflammation reduction: NSAIDs, steroids, cortisone injection, ice

    • Physical therapy

    • Cock-up wrist brace - in my opinion works better than tennis elbow strap

    • Tennis elbow strap used backwards

  • Common ICD-10 Codes

    • M77.00

Nursemaid's Elbow

  • Cause/Pathophysiology

    • Pediatric dislocation/subluxation of the radial head from under the annular ligament

    • Usually results from a traction and rotation

  • History and symptoms

    • Usually under 4 years of age, but can happen in older kids

    • MOI

    • Pain/crying with manipulation of the arm

    • May not be able to be consoled

    • Observed splinting or disuse

  • Exam Findings

    • Elbow usually held in slightly flexed position with the palm down in pronation

    • TTP over radial head

    • Pain with elbow motion and forearm rotation

  • Imaging​

    • X-Rays - usually negative, helpful in ruling out fracture

  • Treatment

    • Manual reduction maneuver

    • No other treatment necessary for single occurrence

  • Common ICD-10 Codes

    • S53.033A

Olecranon Bursitis

  • Cause/Pathophysiology

    • Olecranon bursa inflamed, +/- fluid filled

    • Repetitive pressure on olecranon​

    • Trauma

    • Infectious

    • Gouty

  • History and symptoms

    • +/- trauma​

    • +/- frequent pressure on elbow (resting on armrest)​

    • +/- pain

    • Usually focal painless swelling, unless septic which is usually painful

  • Exam Findings

    • Focal well defined swelling over olecranon​

    • +/- erythema

    • +/- TTP

    • Gouty may be firm due to tofi

  • Imaging​

    • X-Rays negative

  • Treatment

    • Aseptic

      • First Line​

        • RICE​

        • NSAIDs

        • Elbow pad/craddle

      • Second Line

        • Aspiration +/- cortisone injection​

    • Septic

      • Aspirate and send for Gram stain, cultures & sensitivities

      • Immobilization and antibiotics​

      • If no quick improvement, may need formal irrigation and debridement

  • Common ICD-10 Codes

    • M70.20

Osteoarthritis

  • Cause/Pathophysiology

    • Degenerative wear of articular cartilage​

    • Post-traumatic

  • History and symptoms

    • Gradually worsening pain and/or decrease in ROM​​​

  • Exam Findings

    • +/- effusion​

    • +/- TTP in joint space

    • +/- loss of ROM

  • Imaging​

    • X-Ray - decreased joint space, osteophytosis

  • Treatment

    • First Line

      • NSAIDs​

      • PT - limited benefit

    • Second Line

      • Intra-articular cortisone injection​

    • Surgery

      • Total Elbow Arthroplasty​

      • Arthroscopy - limited to no benefit

  • Common ICD-10 Codes​

    • M19.029

 

 

FRACTURES 

Olecranon fracture

  • Cause/Pathophysiology

    • Fall on the point of the elbow

  • History and symptoms

    • MOI 

    • Pain and inability to move

  • Exam Findings

    • Swelling

    • +/- ecchymosis

    • TTP

    • +/- palpable defect

    • Inability to actively extend the elbow

  • Imaging

    • X-Ray​

    • CT if evaluating complex intra-articular involvement

  • Treatment

    • Vast majority ORIF

    • Conservative treatment in cast for some completely non-displaced fractures

  • Common ICD-10 Codes​

    • S52.033A - intraarticular displaced

    • S52.036A - intraarticular non-displaced

    • S52.023A - extra-articular displaced

    • S52.026A - extra-articular non-d

Radial Head/Neck

  • Cause/Pathophysiology

    • FOOSH

    • Usually an impaction type injury

  • History and symptoms

    • MOI

    • Patient may not present right away

    • Pain increases with extension and supination activities

  • Exam Findings

    • +/- swelling

    • TTP over radial head

    • Lack of full extension and supination in most cases

  • Imaging

    • X-Ray - usually all that is necessary​, look for bony injury, posterior fat pad, and anterior "sail sign"

    • CT to evaluate any significant intra-articular deformity

  • Treatment​

    • Most conservative with sling/splint 1week ​

    • Early ROM

    • Possible surgery if significantly displaced intra-articular involvement or significant neck angulation

  • Common ICD-10 Codes

    • S52.123A​ - head

    • S52.133A - neck

Supracondylar Humerus

  • Cause/Pathophysiology

    • Trauma

    • Most frequently a pediatric injury resulting from a playground equipment fall

  • History and symptoms

    • MOI

    • Pain

    • Parent may notice disuse

  • Exam Findings

    • +/- swelling

    • +/- deformity

    • TTP over distal humerus and epicondyles

    • +/- motion abnormality

  • Imaging

    • X-Ray - May be subtle or occult

      • ​Look for bony injury, posterior fat pad, and anterior "sail sign"

    • CT to evaluate any significant intra-articular deformity

  • Treatment​

    • Nondisplaced -

      • Posterior long arm splint for a few days to allow swelling to subside some

      • LA cast 3-4 weeks, some orthopedists prefer up to 6 weeks​

    • Displaced - Closed reduction and casting, CRPP, or ORIF

  • Common ICD-10 Codes

    • S42.416A - non-displace​d

    • S42.413A - displaced

 
 
 
 
 
 
 
 
 
 

Possible Location of Distal Biceps Tendon Rupture Tenderness/Symptoms

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Possible Location of Cubital Tunnel Syndrome Tenderness/Symptoms - Medial Elbow

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Possible Location of Lateral Epicondylitis Tenderness/Symptoms 

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Possible Location of Medial Epicondylitis Tenderness/Symptoms 

Medial epicondylitis symptoms

Possible Location of Nursemaid's Elbow Tenderness/Symptoms 

Radial head symptoms

Possible Location of Olecranon 

Tenderness/Symptoms 

Olecranon Bursitis - Lateral

Possible Location of Elbow Osteoarthritis 

Tenderness/Symptoms - Anterior

Anterior OA symptoms

Possible Location of Olecranon Fracture Symptoms

Olecranon fracture

Possible Location of Radial Head/Neck Fracture

Tenderness/Symptoms - Anterior

Radial head symptoms

Possible Location of Supracondylar Distal Humerus

Tenderness/Symptoms  - Anterior

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