Elbow joint The elbow joint is a complex

Elbow joint • The elbow joint is a complex hinge joint formed between the distal end of the humerus in the upper arm and the proximal ends of the ulna and radius in the forearm. The elbow allows for the flexion and extension of the forearm relative to the upper arm, as well as rotation of the forearm and wrist.

TENNIS ELBOW (LATERAL EPICONDALGIA) • Pain and tenderness over the lateral epicondyle of the elbow (or, more accurately, the bony insertion of the common extensor tendon) is a common complaintamong tennis players – but even more common in non-players who perform similar activities involving forceful repetitive wrist extension. It is the extensor carpi radialis tendon (which automatically extends the wrist when gripping) which is pathological in tennis elbow.

• Like supraspinatus tendinitis, it may result in small tears, fibrocartilaginous metaplasia, microscopic calcification and a painful vascular reaction in the tendon fibres close to the lateral epicondyle.

Clinical features • The patient is usually an active individual of 30 or 40 years. Pain comes on gradually, often after a period of unaccustomed activity involving forceful gripping and wrist extension. It is usually localized to the lateral epicondyle, but in severe cases it may radiate widely. It is aggravated by movements such as pouring out tea, turning a stiff doorhandle, shaking hands or lifting with the forearm pronated.

• On examination The elbow looks normal, and flexion and extension are full and painless. Characteristically there is localized tenderness at or just below the lateral epicondyle; pain can be reproduced by passively stretching the wrist extensors (by the examiner acutely flexing the patient’s wrist with the forearm pronated) or actively by having the patient extend the wrist with the elbow straight.

X-ray is usually normal, but occasionally shows calcification at the tendon origin.

Treatment • Many methods of treatment are available but the benefits of most are unclear; it is well to remember that 90 per cent of ‘tennis elbows’ will resolve spontaneously within 6– 12 months. • The first step is to identify, and then restrict, those activities which cause pain. Modification of sporting style may solve the problem. • The role of physiotherapy and manipulation is uncertain.

• Injection of the tender area with corticosteroid and local anaesthetic relieves pain but is not curative.

OPERATIVE TREATMENT • Some cases are sufficiently persistent or recurrent for operation to be indicated. The origin of the common extensor muscle is detached from the lateral epicondyle. Surgery is successful in about 85 per cent of cases.

OLECRANON BURSITIS There are two types : 1 -Traumatic bursitis: -as a result ofpressure or friction. 2 -non traumatic bursitis: - its painful and due to infection, gout or rheumatoid arthritis. Gout is suspected if there is a history of previous attacks, bilateral with tophi or if the x-ray shows calcification in the bursa which mimic acute infection unless pus is aspirated. Rheumatoid arthritis causes both swelling and nodularity over the olecranon with typical symmetrical poly arthritis, in late stages, erosion of elbow may cause marked in stability.

OLECRANON BURSITIS

Treatment we must treat the underling causes. septic bursitis may need local drainage, occasionally achronic enlarged bursa need to be excised. Other causes of painfull elbow are osteoarthritis, rheumatoid arthritis, gout and infection like TB.

CUBITUS VALGUS • The normal carrying angle of the elbow is 5– 15 degrees of valgus; anything more than this is regarded as a valgus deformity, which is usually quite obvious when the patient stands with arms to the sides and palms facing forwards. • The commonest cause is longstanding non-union of a fractured lateral condyle; the deformity may be associated with marked prominence of the medial condylar outline. The importance of cubitus valgus is the liability to delayed ulnar palsy; years after the causal injury the patient notices weakness of the hand, with numbness and tingling of the ulnar fingers. • TREATMENT: The deformity itself needs no treatment, but for delayed ulnar palsy the nerve should be transposed to the front of the elbow.

CUBITUS VALGUS

CUBITUS VARUS (‘GUN-STOCK’ DEFORMITY • The deformity is most obvious when the elbow is extended and the arms are elevated. The most common cause is malunion of a supracondylar fracture. • The deformity can be corrected by a wedge osteotomy of the lower humerus but this is best left until skeletal maturity.

CUBITUS VARUS

‘PULLED ELBOW’ • the annular ligament is a fairly common injury in children under the age of 6 years. There may be a history of the child being jerked by the arm and subsequently complaining of pain and inability to use the arm. • The limb is held more or less immobile with the elbow fully extended and the forearm pronated; any attempt to supinate the forearm is resisted. The diagnosis is essentially clinical, though xrays are usually obtained in order to exclude a fracture. The radial head can be forcibly pulled out of the noose of the annular ligament only when the forearm is pronated; even the distal attachment of the ligament is sometimes torn. TREATMENT: If the history and clinical picture are suggestive, an attempt should be made to reduce the subluxation or dislocation. While the child’s attention is diverted, the elbow is quickly supinated and then slightly flexed; the radial head is relocated with a snap. (This sometimes happens ‘spontaneously’ while the radiographer is positioning the arm!)

Pulled elbow

STIFFNESS OF THE ELBOW • Stiffness of the elbow may be due to • 1 -congenital abnormalities (various types of synostosis, or arthrogryposis). • 2 -Aquired abnormalities like infection, inflammatory arthritis, osteoarthritis or the late effects of trauma.

POST-TRAUMATIC STIFFNESS • the elbow is particularly prone to posttraumatic stiffness. The more obvious causes (as with other joints) are either: 1 -extrinsic (e. g. soft-tissue contracture or heterotopic bone formation). 2 - intrinsic (e. g. intra-articular adhesions and articular incongruity), or a combination of these.

Clinical features • Clinical assessment should include examinationof all the joints of the upper limb as well as an evaluation of the functional needs of the particular patient. Most of the activities of daily living can be managed with a restricted range of elbow motion: flexion from 30 to 130 degrees and pronation and supination of 50 degrees each. Any greater loss is likely to be disabling.

NON-OPERATIVE TREATMENT • The most effective treatment is prevention, by early active movement through a functional range. If movement is restricted and fails to improve with exercise, serial splintage may help; aggressive passive manipulation may aggravate more than help.

OPERATIVE TREATMENT • The indication for operative treatment is failure to regain a functional range of movement at 12 months after injury. • If there is heterotopic ossification, it is important to wait until the bone is ‘mature’, i. e. showing clear cortical margins and trabecular markings on x-ray. There is no point in a soft tissue release if the x-ray or CT shows that bone incongruity is blocking movement.

• The objectives are determined by the type of Pathology: 1 -Heterotopic bone can be excised, 2 -Capsularrelease or capsulectomy (open or arthroscopic) may restore a satisfactory range of movement. 3 -Intra-articular procedures include fixing of ununited fractures or correction of malunited fractures.

• Post-traumatic radio-ulnar synostosis sometimes follows internal fixation of fractures of the radius and ulna. It is treated by resection when the synostosis has matured (this takes about one year) followed by diligent physiotherapy.