I delivered this talk to a group of hand and arm therapists. Find out more about hand and arm problems at http://www.noelhenley.com Ozark Orthopaedic: Henley C Noel MD 3317 North Wimberly Drive, Fayetteville, AR 72703 (479) 521-2752 ‎

2. The Elbow
Anatomy, Injury, and
Rehabilitation Implications
C. Noel Henley, MD
February 24, 2009

3. Goals

4. Goals
• To review some elbow anatomy and
relevance to surgical approach and therapy

5. Goals
• To review some elbow anatomy and
relevance to surgical approach and therapy
• To review some specific elbow disorders/
injuries

6. Goals
• To review some elbow anatomy and
relevance to surgical approach and therapy
• To review some specific elbow disorders/
injuries
• To review some aspects of the stiff elbow

7. Surgical Anatomy

8. Surgical Anatomy
• Approaches

9. Surgical Anatomy
• Approaches
- posterior (“universal”)

10. Surgical Anatomy
• Approaches
- posterior (“universal”)
- medial/lateral

11. Surgical Anatomy

12. Surgical Anatomy
• Posterior

13. Surgical Anatomy
• Posterior
- midline posterior incision

14. Surgical Anatomy
• Posterior
- midline posterior incision
- circumferential access

15. Surgical Anatomy
• Posterior
- midline posterior incision
- circumferential access
- leaves options open for future
procedures

16. Surgical Anatomy
• Posterior
- midline posterior incision
- circumferential access
- leaves options open for future
procedures
- lower chance for cutaneous nerve injury

20. Surgical Anatomy

21. Surgical Anatomy
• Cutaneous nerves

22. Surgical Anatomy
• Cutaneous nerves
- lateral antebrachial cutaneous nerve

23. Surgical Anatomy
• Cutaneous nerves
- lateral antebrachial cutaneous nerve
- medial antebrachial cutaneous nerve

24. Surgical Anatomy
• Cutaneous nerves
- lateral antebrachial cutaneous nerve
- medial antebrachial cutaneous nerve
- posterior antebrachial cutaneous nerve

25. lateral antebrachial
cutaneous nerve

26. medial antebrachial
cutaneous nerve

27. posterior
antebrachial
cutaneous nerve

28. Surgical Anatomy

29. Surgical Anatomy
• Posterior approach

30. Surgical Anatomy
• Posterior approach
- distal humerus fracture

31. Surgical Anatomy
• Posterior approach
- distal humerus fracture
- medial, lateral structures

32. Surgical Anatomy
• Posterior approach
- distal humerus fracture
- medial, lateral structures
- may require a drain; more risk for seroma

33. Surgical Anatomy
• Posterior approach
- distal humerus fracture
- medial, lateral structures
- may require a drain; more risk for seroma
- several different ways of handling triceps
- implications for therapy post-op!

34. Triceps Options

35. Triceps Options
• Olecranon osteotomy
• Triceps-reflecting
• Triceps-splitting
• Triceps-reflecting anconeus pedicle flap
• Paratricipital

36. Triceps Options

37. Triceps Options
• Olecranon osteotomy

38. Triceps Options
• Olecranon osteotomy
- pro: full visualization of articular surface

39. Triceps Options
• Olecranon osteotomy
- pro: full visualization of articular surface
- con: more adhesions, nonunion, painful
hardware

40. Triceps Options
• Olecranon osteotomy
- pro: full visualization of articular surface
- con: more adhesions, nonunion, painful
hardware
- several hardware options

41. Olecranon Osteotomy

42. Olecranon Osteotomy

43. Olecranon Nail

44. Triceps Options

45. Triceps Options
• Triceps-reflecting

46. Triceps Options
• Triceps-reflecting
- triceps repaired through drill holes in
olecranon

47. Triceps Options
• Triceps-reflecting
- triceps repaired through drill holes in
olecranon
- must protect the repair for six weeks
post-op

48. Triceps Options
• Triceps-reflecting
- triceps repaired through drill holes in
olecranon
- must protect the repair for six weeks
post-op
- no active extension against resistance for
six weeks

49. Triceps Options

50. Triceps Options
• Triceps-splitting, triceps-reflecting anconeus
pedicle, paratricipital approaches

51. Triceps Options
• Triceps-splitting, triceps-reflecting anconeus
pedicle, paratricipital approaches
- all may compromise active resisted
motion after surgery

52. Triceps Options
• Triceps-splitting, triceps-reflecting anconeus
pedicle, paratricipital approaches
- all may compromise active resisted
motion after surgery
- critical to know details of triceps repair/
approach to guide limitations after
surgery

53. Triceps-reflecting
Anconeus Pedicle

54. Surgical Anatomy

55. Surgical Anatomy
• Lateral approach (addressable injuries)

56. Surgical Anatomy
• Lateral approach (addressable injuries)
- radial head fracture

57. Surgical Anatomy
• Lateral approach (addressable injuries)
- radial head fracture
- capitellum fracture

58. Surgical Anatomy
• Lateral approach (addressable injuries)
- radial head fracture
- capitellum fracture
- some coronoid fractures

59. Surgical Anatomy
• Lateral approach (addressable injuries)
- radial head fracture
- capitellum fracture
- some coronoid fractures
- lateral collateral ligament complex injury

60. Surgical Anatomy

61. Surgical Anatomy
• Kocher interval/approach (lateral)

62. Surgical Anatomy
• Kocher interval/approach (lateral)
- between ECU and anconeus

63. Kocher interval

64. Surgical Anatomy

65. Surgical Anatomy
• Kocher interval/approach
(lateral)

66. Surgical Anatomy
• Kocher interval/approach
(lateral)
- designed to split the annular
ligament anterior to the LUCL

67. Surgical Anatomy
• Kocher interval/approach
(lateral)
- designed to split the annular
ligament anterior to the LUCL
- posterior interosseous nerve
(PIN - radial nerve motor
branch) at risk, especially if
radial neck/head plated

68. a) Kaplan’s interval (EDC split)
b) Kocher interval (ECU/anconeus)

69. PIN injury

70. PIN injury
• Creates a wrist drop or inability to extend
MCP joints and thumb IP joint

71. PIN injury
• Creates a wrist drop or inability to extend
MCP joints and thumb IP joint
• May not involve dorsal hand numbness

72. PIN injury
• Creates a wrist drop or inability to extend
MCP joints and thumb IP joint
• May not involve dorsal hand numbness
• You may be the first to recognize this!

73. Surgical Anatomy

74. Surgical Anatomy
• Medial approach (addressable injuries)

75. Surgical Anatomy
• Medial approach (addressable injuries)
- coronoid fracture

76. Surgical Anatomy
• Medial approach (addressable injuries)
- coronoid fracture
- medial collateral ligament injury

77. Surgical Anatomy
• Medial approach (addressable injuries)
- coronoid fracture
- medial collateral ligament injury
- an uncommon, but sometimes necessary
approach

78. Surgical Anatomy
• Medial approach (addressable injuries)
- coronoid fracture
- medial collateral ligament injury
- an uncommon, but sometimes necessary
approach
- several ways of splitting/elevating muscles

79. Medial Approach

80. Medial Approach

81. Specific Injuries

82. Distal Humerus
Fractures

83. Distal Humerus Fractures

84. Distal Humerus Fractures
• 90-90 plating concept

85. Distal Humerus Fractures
• 90-90 plating concept
- historically recommended technique

86. Distal Humerus Fractures
• 90-90 plating concept
- historically recommended technique
- some problems with distal nonunions

88. Distal Humerus Fractures

89. Distal Humerus Fractures
• near-parallel plating technique

90. Distal Humerus Fractures
• near-parallel plating technique
- offers improved stiffness/
stability

91. Distal Humerus Fractures
• near-parallel plating technique
- offers improved stiffness/
stability
- better stability with varus/
shoulder abduction stress

92. Distal Humerus Fractures
• near-parallel plating technique
- offers improved stiffness/
stability
- better stability with varus/
shoulder abduction stress
- allows earlier motion

93. Distal Humerus Fractures

94. Distal Humerus Fractures
• Rehabilitation

95. Distal Humerus Fractures
• Rehabilitation
- splinted x 2-3 days (usually extended)

96. Distal Humerus Fractures
• Rehabilitation
- splinted x 2-3 days (usually extended)
- A/AAROM

97. Distal Humerus Fractures
• Rehabilitation
- splinted x 2-3 days (usually extended)
- A/AAROM
- PROM may promote ectopic ossification
(EO) - debated!

98. Distal Humerus Fractures
• Rehabilitation
- splinted x 2-3 days (usually extended)
- A/AAROM
- PROM may promote ectopic ossification
(EO) - debated!
- functional arc: 30°/130°, 50°/50°

99. Distal Humerus Fractures

100. Distal Humerus Fractures
• Rehabilitation

101. Distal Humerus Fractures
• Rehabilitation
- flexion returns first (within 2 months)

102. Distal Humerus Fractures
• Rehabilitation
- flexion returns first (within 2 months)
- extension maximized at 4-6 months

103. Distal Humerus Fractures
• Rehabilitation
- flexion returns first (within 2 months)
- extension maximized at 4-6 months
- supination/pronation minimally affected

104. Distal Humerus Fractures
• Rehabilitation
- flexion returns first (within 2 months)
- extension maximized at 4-6 months
- supination/pronation minimally affected
- 25% of patients may have exertional pain

105. Cubital Tunnel

106. Cubital Tunnel

107. Cubital Tunnel
• Conservative management

108. Cubital Tunnel
• Conservative management
- splinting

109. Cubital Tunnel
• Conservative management
- splinting
- padding

110. Cubital Tunnel
• Conservative management
- splinting
- padding
- activity/ergonomic
modification, education

111. Cubital Tunnel
• Conservative management
- splinting
- padding
- activity/ergonomic
modification, education
- 89% of patients with mild/
moderate symptoms will
improve (studies)

112. Cubital Tunnel

113. Cubital Tunnel
• Patient education

114. Cubital Tunnel
• Patient education
- motions and positions that
contribute to stretching,
compression of the nerve

115. Cubital Tunnel
• Patient education
- motions and positions that
contribute to stretching,
compression of the nerve
- analyze daily tasks for these
aggravating factors

116. Cubital Tunnel

117. Cubital Tunnel
• Splinting

118. Cubital Tunnel
• Splinting
- usually in 40-70° flexion, neutral rotation,
neutral wrist position

119. Cubital Tunnel
• Splinting
- usually in 40-70° flexion, neutral rotation,
neutral wrist position
- may need to allow room for an elbow
pad or at least build a “bulge” in the
medial elbow portion

120. Cubital Tunnel

121. Cubital Tunnel
• Splinting
- elbow pad during the day; reverse it at
night

122. Cubital Tunnel

123. Cubital Tunnel
• Nerve gliding exercises

124. Cubital Tunnel
• Nerve gliding exercises
- nerves may not respond to being
stretched, especially if already irritated

125. Cubital Tunnel
• Nerve gliding exercises
- nerves may not respond to being
stretched, especially if already irritated
- effectiveness is debated

126. Cubital Tunnel
• Nerve gliding exercises
- nerves may not respond to being
stretched, especially if already irritated
- effectiveness is debated
- as always - listen to the patient!

127. Cubital Tunnel

128. Cubital Tunnel
• Conservative management - problems

129. Cubital Tunnel
• Conservative management - problems
- splints poorly tolerated

130. Cubital Tunnel
• Conservative management - problems
- splints poorly tolerated
- elbow pad reversal may not be effective
(too soft)

131. Cubital Tunnel
• Conservative management - problems
- splints poorly tolerated
- elbow pad reversal may not be effective
(too soft)
- anecdotally poor results

132. Cubital Tunnel

133. Cubital Tunnel
• Surgery - current trends

134. Cubital Tunnel
• Surgery - current trends
- move toward less extensive surgery

135. Cubital Tunnel
• Surgery - current trends
- move toward less extensive surgery
- in situ decompression, simpler
transpositions

136. Cubital Tunnel
• Surgery - current trends
- move toward less extensive surgery
- in situ decompression, simpler
transpositions
- earlier ROM, return of function

137. Cubital Tunnel

138. Cubital Tunnel
• Surgery - what I do

139. Cubital Tunnel
• Surgery - what I do
- in situ decompression

140. Cubital Tunnel
• Surgery - what I do
- in situ decompression
- subcutaneous anterior transposition

141. Cubital Tunnel

142. Cubital Tunnel
• Post-op rehabilitation

143. Cubital Tunnel
• Post-op rehabilitation
- remove dressing in five days

144. Cubital Tunnel
• Post-op rehabilitation
- remove dressing in five days
- unlimited ROM

145. Cubital Tunnel
• Post-op rehabilitation
- remove dressing in five days
- unlimited ROM
- progressive resumption of activity

146. Cubital Tunnel
• Post-op rehabilitation
- remove dressing in five days
- unlimited ROM
- progressive resumption of activity
- unusual to need formal outpatient visits

147. Tennis Elbow

148. Tennis Elbow

149. Tennis Elbow
• What is it?

150. Tennis Elbow
• What is it?
- a tendinosis/tendinopathy = “failed
reparative process”

151. Tennis Elbow
• What is it?
- a tendinosis/tendinopathy = “failed
reparative process”
- no inflammatory cells in biopsy
specimens

152. Tennis Elbow
• What is it?
- a tendinosis/tendinopathy = “failed
reparative process”
- no inflammatory cells in biopsy
specimens
- involves ECRB origin

153. Tennis Elbow

154. Tennis Elbow

155. Tennis Elbow

156. Tennis Elbow
• Treatment

157. Tennis Elbow
• Treatment
- nonoperative

158. Tennis Elbow
• Treatment
- nonoperative
• therapy

159. Tennis Elbow
• Treatment
- nonoperative
• therapy
• splinting

160. Tennis Elbow
• Treatment
- nonoperative
• therapy
• splinting
• injection

161. Tennis Elbow
• Treatment
- nonoperative
• therapy
• splinting
• injection
• most studies show some short-term
benefit but no difference between
treatments long-term

162. Counterforce Bracing

163. Counterforce Bracing

164. Counterforce Bracing
• How does it work?

165. Counterforce Bracing
• How does it work?
- ECRB compression transfers contraction
force away from origin

166. Counterforce Bracing
• How does it work?
- ECRB compression transfers contraction
force away from origin
- creates a “second origin” for the ECRB
further distal

167. Counterforce Bracing
• How does it work?
- ECRB compression transfers contraction
force away from origin
- creates a “second origin” for the ECRB
further distal
- limits full expansion; may limit force of
contraction on the origin

168. Counterforce Bracing

169. Counterforce Bracing
• Effectiveness data is mixed

170. Counterforce Bracing
• Effectiveness data is mixed
- some studies show improvement

171. Counterforce Bracing
• Effectiveness data is mixed
- some studies show improvement
- others show no significant advantage
over therapy alone

172. Tennis Elbow

173. Tennis Elbow
• operative treatment

174. Tennis Elbow
• operative treatment
- many options (open, arthroscopic,
percutaneous)

175. Tennis Elbow
• operative treatment
- many options (open, arthroscopic,
percutaneous)
- all focus on ECRB

176. Tennis Elbow
• operative treatment
- many options (open, arthroscopic,
percutaneous)
- all focus on ECRB
- depending on post-op pain relief, more
therapy may be necessary

177. The Stiff Elbow

178. The Stiff Elbow

179. The Stiff Elbow
• Etiologic factors (post-op stiffness)

180. The Stiff Elbow
• Etiologic factors (post-op stiffness)
- immobilization

181. The Stiff Elbow
• Etiologic factors (post-op stiffness)
- immobilization
• leads to capsular contracture

182. The Stiff Elbow
• Etiologic factors (post-op stiffness)
- immobilization
• leads to capsular contracture
- forced passive manipulation (increased
risk for HO)

183. The Stiff Elbow
• Etiologic factors (post-op stiffness)
- immobilization
• leads to capsular contracture
- forced passive manipulation (increased
risk for HO)
• gentle progressive PROM may be
needed

184. The Stiff Elbow

185. The Stiff Elbow
• Etiologic factors (post-op stiffness)

186. The Stiff Elbow
• Etiologic factors (post-op stiffness)
- multiple procedures early on in
treatment course

187. The Stiff Elbow
• Etiologic factors (post-op stiffness)
- multiple procedures early on in
treatment course
- burns

188. The Stiff Elbow
• Etiologic factors (post-op stiffness)
- multiple procedures early on in
treatment course
- burns
- head trauma (as high as 90% risk)

189. The Stiff Elbow

190. The Stiff Elbow
• Nonoperative treatment

191. The Stiff Elbow
• Nonoperative treatment
- gradual AAROM, modalities in therapy

192. The Stiff Elbow
• Nonoperative treatment
- gradual AAROM, modalities in therapy
- splinting

193. The Stiff Elbow
• Nonoperative treatment
- gradual AAROM, modalities in therapy
- splinting
• dynamic spring/rubber band devices

194. The Stiff Elbow
• Nonoperative treatment
- gradual AAROM, modalities in therapy
- splinting
• dynamic spring/rubber band devices
• static progressive splint (patient-
adjustable)

195. The Stiff Elbow
• Nonoperative treatment
- gradual AAROM, modalities in therapy
- splinting
• dynamic spring/rubber band devices
• static progressive splint (patient-
adjustable)
- better compliance

196. The Stiff Elbow

197. The Stiff Elbow
• Nonoperative treatment

198. The Stiff Elbow
• Nonoperative treatment
• splinting (adjustable static type)

199. The Stiff Elbow
• Nonoperative treatment
• splinting (adjustable static type)
- goal: plastic deformation of
soft tissue through stress
relaxation

200. The Stiff Elbow
• Nonoperative treatment
• splinting (adjustable static type)
- goal: plastic deformation of
soft tissue through stress
relaxation
- 21 hour program (morning,
noon, night breaks)

202. The Stiff Elbow

203. The Stiff Elbow
• Heterotopic bone (ectopic
bone)

204. The Stiff Elbow
• Heterotopic bone (ectopic
bone)
- inappropriate formation
of mature lamellar bone
in soft tissue

205. The Stiff Elbow
• Heterotopic bone (ectopic
bone)
- inappropriate formation
of mature lamellar bone
in soft tissue
- may be prevented by
radiation or NSAID
administration -
controversial

206. The Stiff Elbow

207. The Stiff Elbow
• Signs of HO

208. The Stiff Elbow
• Signs of HO
- swelling, warmth, tenderness

209. The Stiff Elbow
• Signs of HO
- swelling, warmth, tenderness
- endpoints of ROM abrupt, solid

210. The Stiff Elbow
• Signs of HO
- swelling, warmth, tenderness
- endpoints of ROM abrupt, solid
• May appear 2-12 weeks after initial event
(trauma, surgery, burn, etc.)

211. The Stiff Elbow

212. The Stiff Elbow
• Treatment of HO

213. The Stiff Elbow
• Treatment of HO
- usually wait six months before resecting

214. The Stiff Elbow
• Treatment of HO
- usually wait six months before resecting
• Start with therapy, splinting

215. The Stiff Elbow
• Treatment of HO
- usually wait six months before resecting
• Start with therapy, splinting
• Surgical excision, capsule release/excision

216. The Stiff Elbow
• Treatment of HO
- usually wait six months before resecting
• Start with therapy, splinting
• Surgical excision, capsule release/excision
- CPM, early and frequent therapy

217. The Stiff Elbow

218. The Stiff Elbow
• Stages of stiffness after surgery/injury

219. The Stiff Elbow
• Stages of stiffness after surgery/injury
- bleeding

220. The Stiff Elbow
• Stages of stiffness after surgery/injury
- bleeding
• in minutes to hours

221. The Stiff Elbow
• Stages of stiffness after surgery/injury
- bleeding
• in minutes to hours
• joint capsule distension

222. The Stiff Elbow
• Stages of stiffness after surgery/injury
- bleeding
• in minutes to hours
• joint capsule distension
• swelling of tissues

223. The Stiff Elbow
• Stages of stiffness after surgery/injury
- bleeding
• in minutes to hours
• joint capsule distension
• swelling of tissues
• pain, resistance to ROM

224. The Stiff Elbow

225. The Stiff Elbow
• Stages of stiffness after surgery/injury

226. The Stiff Elbow
• Stages of stiffness after surgery/injury
- edema

227. The Stiff Elbow
• Stages of stiffness after surgery/injury
- edema
• over hours, days

228. The Stiff Elbow
• Stages of stiffness after surgery/injury
- edema
• over hours, days
• inflammation vasodilation

229. The Stiff Elbow
• Stages of stiffness after surgery/injury
- edema
• over hours, days
• inflammation vasodilation
• swelling, decreased compliance of soft
tissues

230. The Stiff Elbow

231. The Stiff Elbow
• Stages of stiffness after surgery/injury

232. The Stiff Elbow
• Stages of stiffness after surgery/injury
- granulation tissue

233. The Stiff Elbow
• Stages of stiffness after surgery/injury
- granulation tissue
• over days to weeks

234. The Stiff Elbow
• Stages of stiffness after surgery/injury
- granulation tissue
• over days to weeks
• tissue is loose initially, then becomes
solidified

235. The Stiff Elbow

236. The Stiff Elbow
• Stages of stiffness after surgery/injury

237. The Stiff Elbow
• Stages of stiffness after surgery/injury
- fibrosis

238. The Stiff Elbow
• Stages of stiffness after surgery/injury
- fibrosis
• granulation tissue matures

239. The Stiff Elbow
• Stages of stiffness after surgery/injury
- fibrosis
• granulation tissue matures
• forms rigid scar tissue

240. The Stiff Elbow

241. The Stiff Elbow
• Stiffness prevention after surgery

242. The Stiff Elbow
• Stiffness prevention after surgery
- CPM started on day one

243. The Stiff Elbow
• Stiffness prevention after surgery
- CPM started on day one
• creates a “pumping effect” on edema
fluid in soft tissues

244. The Stiff Elbow
• Stiffness prevention after surgery
- CPM started on day one
• creates a “pumping effect” on edema
fluid in soft tissues
• 24 hours/day is ideal

245. The Stiff Elbow
• Stiffness prevention after surgery
- CPM started on day one
• creates a “pumping effect” on edema
fluid in soft tissues
• 24 hours/day is ideal
• lasts for 3-4 weeks

246. Case Example - HO

247. Case Example - HO
• 37yo university professor

248. Case Example - HO
• 37yo university professor
• Sustained comminuted olecranon fracture

249. Case Example - HO
• 37yo university professor
• Sustained comminuted olecranon fracture
• ORIF

251. Case Example - HO

252. Case Example - HO
• Healed the fracture, started therapy

253. Case Example - HO

254. Case Example - HO
• Began having wrist pain in therapy, limited
forearm motion

255. Case Example - HO
• Began having wrist pain in therapy, limited
forearm motion
• CT scan confirms forearm synostosis

256. Case Example - HO

257. Case Example - HO

258. Case Example - HO

259. Case Example - HO

260. Case Example - HO
• Eventually chose surgery

261. Case Example - HO

262. Case Example - HO