Fix the patient's forearm to your side and clasp around the slightly flexed elbow, applying the web of your thumb to the medial aspect of the joint. Compress the elbow between your hands and circumduct through a small range to find the optimum point of tension. The tip of the index finger of either hand palpates for this tension and applies a local compression to the radio-humeral joint. The thrust is performed with an increase of compression between the hands, an increase of fixing of the arm to your side and a short, sharp rotation of your body away from the table.
Tips: Note the angle of the thrusting arm is not directly across the joint but is directed slightly anteriorly, as the radio-humeral joint is anterior to the humero-ulnar joint. This technique may require several priming forces of gradually increasing amplitude until the optimum tension accumulates.
26.12 and 26.13 Thrust to radio-humeral joint supine These operator viewpoint photographs show a complex technique for gapping the radio-humeral joint. Sit on the edge of the table and place the internally rotated arm across your lower thigh. Fix the medial epicondyle against your thigh and hold back on the distal end of the humerus. Your other hand grips the distal end of the radius and applies a force directly toward the floor. Vary the pronation and supination until tension is felt to accumulate. The thrust is performed by an accentuation of all three forces, the operator's thigh and upper and lower hand simultaneously.
Tips: Try placing the fifth finger in the palm of the patient's hand to allow better control of the pronation and supination. This also allows control of the flexion and extension of the wrist to help focus the forces in the elbow. If a stronger effect is needed, instead of using more force, try introducing ulnar deviation of the wrist with the distal hand. If an even stronger effect is needed, place the patient's thumb in the palm of their hand to place the extensor muscles on stretch, and then apply ulnar deviation. Note: The internal rotation of the arm is essential if this is not to become an extension thrust. It is often very difficult to maintain this internal rotation. Ensure that the medial and lateral epicondyles are vertical before performing the technique.
26.14 and 26.15 Thrust to radial head supine Place your thumb behind the radial head and hold the distal end of the forearm against your abdomen. Maintain slight flexion of the elbow throughout the whole technique. Sharply pronate the forearm, flex the wrist and extend the elbow to slap the forearm against your abdomen. This 'Mills procedure' is often performed with hyperextension, which is not only painful, but can be potentially dangerous as the proximal end of the ulna can be driven through the floor of the cubital fossa. Hyperextension also means that the force will be unlikely to reach the radial head so the technique will be ineffective for the purpose intended!
Tips: Try compressing the radial head between thumb and fingers of the proximal hand to help localize the levers.
26.16 • Thrust to humero-ulnar joint into adduction supine This operator viewpoint photograph shows the patient's forearm gripped firmly against the operator's abdomen. His hands are gripping around the elbow and the metacarpo-phalangeal joint of the index finger is applied to the medial aspect of the ulna. While gripping firmly against the barrier of joint resistance he rotates his body away from the table to apply the thrust. The direction of force is from medial to lateral to reach the humero-ulnar joint, not the radio-humeral joint which would require a more anterior force. A few degrees of flexion must be maintained throughout the technique.
Tips: This technique would be used where there is an increased carrying angle or a perception of an inability for the head of the ulna to locate in the fossa on full extension.
26.17 • Thrust to humero-ulnar joint into adduction supine Stand outside the slightly flexed arm and pull with your proximal hand on the medial aspect of the ulna. Push the distal end of the forearm in the opposite direction to produce a force designed to reduce the carrying angle.
Tips: Try adding varied amounts of wrist deviation to help focus the technique. This hold can be used to perform the opposite function of increasing the carrying angle where necessary, by reversing the hand directions.
26.18 • Thrust to humero-ulnar joint into adduction supine Fix the forearm against your side and grip firmly around the elbow with both hands. Apply the metacarpo-phalangeal joint of your index finger of the proximal hand to the lateral aspect of the upper end of the ulna. Maintain slight flexion in the elbow and apply the thrust with your proximal hand and a small rotation of your body.
26.19 • Thrust for 'pulled' radius supine Shake hands with the patient and fix behind the elbow with your other hand. Apply a small compression force between the hands and gently pronate and supinate the elbow until the radial head is felt to relocate within the annular ligament.
Tips: This technique should only be necessary in children and any suspicion of a 'pulled' radius in an adult should alert the operator to the possibility of a fracture or dislocation. Dislocations of the ulna must NEVER be reduced using pronation and supination as there is a danger of the coronoid process damaging the brachial artery!
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