Elbow

Elbow Contusion

Normal Elbow and Forearm Anatomy

The elbow and forearm form a functional unit whose primary role is to accurately position the hand in space. The elbow has a long lever arm and moves the forearm and hand 130 degrees covering much of the functional space used in our activities of daily living and in this sense the elbow is considered the most important single joint of the upper limb, second only to the thumb carpometacarpal joint. The functional space is defined as the space directly in front of a person’s body that lies below eye level and above the belly button. Because the elbow joint covers the entire functional space by virtue of its arc of motion, there has never been a satisfactory position to fuse an elbow joint if it were ever destroyed by injury or disease.


The elbow anatomy is best understood by thinking of it in three layers. The first layer is the bony layer, the second layer is the ligament layer and the third layer is the muscular layer within which the arteries and nerves travel.




Elbow & Forearm Elbow Joint Front View & Side View


The first layer is comprised of three bones that unite to form the elbow joint. The elbow joint islocated at the lower end of the arm bone (humerus), and the proximal end (towards the shoulder) of the radius and ulna which are the two forearm bones. These three bones allow the elbow to bend (Flex) and straighten (Extend) in a hinged type motion and the forearm to rotate the hand in a palm up (supination) and palm down position (pronation). The joint surfaces of the elbow are covered by hyaline cartilage which forms a cushioned layer that allows for smooth gliding and painless elbow motion.




Elbow & Forearm Ligament LayerElbow Joint Ligament Layer





Lateral Elbow Ligament View Medial Elbow Ligament View

The second layer in the elbow and forearm is the capsular ligament layer made up of collagen tissue. The ligament layer in the forearm is called the interosseous membrane. The collagen tissue forming the elbow joint capsule is normally very thin except on the inside (medial) and outside (Lateral) sides of the elbow where thickenings in the collagen substance form the ligaments of the elbow. These ligaments provide passive stability to the elbow joint keeping the humerus, radius and ulna together, allowing them to function as a unit.




Foerarm Flexor CompartmentForearm Flexor& Mobile Wad Compartments





Elbow Flexor Muscles Elbow Extensor Muscles


The third layer of the elbow and forearm is the muscle layer and is formed by the various muscle groups that pass through the elbow and forearm either originating (beginning) or ending in the elbow and forearm. The muscles of the arm that pass through the elbow includethe triceps muscle in the back of the arm and the brachialis and biceps muscles in the front of the arm. The forearm muscles that cross the elbowjoint are divided into three compartments with each compartment containing several muscles that work to move the elbow, forearm, wrist and hand in specific directions. The three compartments are: 1. the extensor compartment 2. the flexor compartment and 3.the mobile wad of Henry compartment. The median, ulnar, and radial nerves pass through the elbow and forearm within the muscle layers and innervate the muscles within these compartments as well as, the muscles of the hand.

Pathology

An elbow contusion results fromblunt direct trauma and produces muscle strains and ligament sprains. Symptoms include pain withmuscle use, bruising, muscle spasms and loss of elbow motion, particularly elbow extension. Loss of extension is more commonly affected because of two reasons:

1. the mobile wad and brachialis muscle that crosses the elbow joint when strained feels more comfortable when the length of the muscle is shortened making elbow flexion the preferred position.

2. The maximum amount of fluid the elbow joint capsule can hold is about 25 cc’s and this maximal capacity is allowed with the elbow in the flexed (bent position). Consequently, if active elbow extension is avoided, an elbow contracture will develop. Treatment of elbow contusions is symptomatic, similar to the treatment of contusions elsewhere in the body, with the application of RICE treatment, Anti-inflammatory medication, controlled early motion and therapy.

The acronym RICE stands for Rest, Ice, Compression and Elevation. A Strain is a muscle injury and a Sprain is a ligament stretch injury and both conditions are treated with the RICE technique. Rest is usually done for 24-48 hours, and can include the use of slings, splints or other types of immobilizers unless otherwise advised by a physician. Ice is used for no more than 20-30 minutes at a time, three to four times per day. Ice is best applied by using an ice slush which transmits the effects of the cold sensation best and can be made by crushing ice and mixing it with water and then placing it in a zip lock plastic bag. The ice bag should not be placed in direct contact with the skin but instead should have a layer between the skin and ice bag like a towel to prevent the skin from freezing. The ice should be applied for no more than 20-30 minutes at a time, to avoid skin freezing as can occur if you fall asleep with an ice pack on your limb. Ice functions by causing the arteries to narrow the size of their lumen which in turn decreases swelling and the pain from swelling.

Compression is the wrapping of a body part to further assist in minimizing swelling and is used in conjunction with elevation. The best way to do a compressive wrapping is by having the compression have multiple layers that provide a cushion effect. The compression is best applied by a qualified physician, performed by wrappingthe limb without causing the constriction of the blood supply which when present, is recognized by increasing pain to the wrapped body part. Other signs of a tight compressive dressing are the cold sensation of the wrapped limb, blue discoloration of the body part, or change in color from the natural skin color. Elevation of an injured body part is best done by elevating the limb to the level of the heart. If elevation is lower than heart level, the effects of gravity on the veins, will increase vein pressure and cause the blood in the veins to have difficulty traveling back to the heart resulting in limb swelling. When a compression dressing is initially applied, it can feel comfortable but if the arm is not elevated, the same compressive dressing can act as a tourniquet and so it is of paramount importance to elevate the limb as directed.
The use of anti-inflammatory medication helps treat pain, swelling, and inflammation thatoccur after an injury. Examples of anti-inflammatory medication includes aspirin products, Ibuprofen (Motrin, Advil,) Naprosyn, Mobic, Indocin, Arthrotec,and Celebrex to name a few. All of these medications have side effects and should be taken with this knowledge in mind. Prescriptions should be discussed with your pharmacist and physician.

Treatment

Controlled early motion and therapy to the involved limb decreases the effects of prolonged immobilization which includes stiffness, muscle atrophy, weakness and a longer return to the pre-injury state. The type of therapy recommended will depend on the tissue type injured and the severity of the injury. Consult your surgeon for the best advice.


When treating anelbow contusion, the use of ice, elevation of the hand, forearm or elbow to heart level and a compressive dressing may be needed. A sling will rest the arm until a physician is seen for further instructions if pain persists. Anti-inflammatories are helpful during the first 2-4 weeks depending on the severity. The home exercise program for the elbow focuses on avoiding an elbow contracture with the occasional use of splints called static progressive splints that assist in progressively regaining elbow motion.