Essentials of Orthopedic Surgery, third edition / 09-The Elbow

HISTORY PHYSICAL EXAM

X-ray exam

Anterior interosseous

+

–

nerve syndrome (AINS)

Activity

Osteochondritis

Fragmentation,

Normal

modification

No

Ulnar

dissecans

lucency

neurologic

vs.

neuritis

capitellum

capitellum

exam

surgery

Consider

No

Yes

Posterior interosseous

nerve syndrome (PINS)

surgery

Consider

Ossific density(ies)

Nonspecific

Loose

Yes

arthroscopic

Olecranon fossa

Empiric trial of

No

surgical

bodies

tenderness

or anterior

NSAI’s and +/–

Improvement

excision/

compartment

No

physiotherapy

debridement

with

nonop tx

No

Specific

Medial

Medial

Yes

tenderness

epicondyle

epicondylitis

Joint space

Lateral

Lateral

Nonop trial

narrowing

Continue tx

Elbow

+/– osteophyte

epicondyle

epicondylitis

until symptoms

NSAI’s

arthritis

formation,

tolerable/

Physiotherapy

sclerosis,

Lateral

resolved

cysts

radiocapitellar

Nonop tx

No

joint

No

Trial NSAI’s

NSAI’s

Calcification(s)

Restricted ROM

Modified activity

Activity modification

Medial/lateral

Medial/lateral

Counterforce brace

epicondylitis

Yes

epicondyle

Physiotherapy

MRI

Corticosteroid injection(s)

r/o OCD

Yes

Discontinue tx

Improvement

after 6 mos,

Non-op or op tx

3 injections

No

Consider surgery

		Nonop tx vs. surgery
EMG		based on symptom severity,
		physical findings,
NCV
		electrodiagnostic results,
		response to treatment

		Nonop tx
		NSAI’s					Improvement
	Activity modification
	Counterforce brace						after 6 mos,
	Physiotherapy						3 injections
Corticosteroid injection(s)							Yes		No
			Discontinue					Consider
					tx			surgery
	Improved		Yes		Continue tx until
					symptoms resolved
		No

Haque .A.M 374

FIGURE 9-4. Algorithmic approach to the diagnosis and treatment of atraumatic elbow pain.

Displaced or unstable

No
Cast or splint	Yes
immobilization
early ROM
if possible

No

Open surgical treatment

Dislocation

Attempt closed reduction

Acceptable

reduction

and Stable

Yes

Cast or splint immobilization early ROM

if possible

FIGURE 9-5. Algorithmic approach to the diagnosis and treatment of traumatic elbow pain.

Elbow The .9

375

376 M.A. Haque

Inflammation and pain are treated acutely with rest, ice, compression, and elevation (RICE). Later treatment includes activity modification, analgesics, nonsteroidal antiinflammatories, and local modalities, including ice, heat, electrical stimulation, and ultrasound. Occasionally, corticosteroid injection or systemic therapy is warranted.

Restoration of motion is done through careful stretching exercises. Elbow stiffness is best treated by prevention. Do not immobilize or use a sling any longer than absolutely necessary. Motion loss is usually in extension (inability to completely straighten the elbow) and takes much longer to regain than to lose. Once lost, motion return is best achieved through active exercise by the patient rather than passive stretching by the therapist. A unique characteristic of the elbow is its propensity to develop heterotopic ossification (HO), bone formation within the soft tissues. This problem is particularly common anteriorly because of the presence of the brachialis muscle immediately anterior to the elbow capsule. The risk of ossification is increased with passive stretching, and for this reason aggressive passive motion is discouraged. Specially designed splints that exert a dynamic force across the elbow are sometimes effective in restoring motion.

Corticosteroid Injections

The use of corticosteroids about the elbow facilitates treatment of a number of conditions, including medial and lateral epicondylitis, olecranon bursitis, and, less commonly, inflammatory or degenerative arthritis.

Because corticosteroid injections can lead to tendon damage, dermal depigmentation, and infection, they should not be used arbitrarily or excessively. Generally, their use is reserved for conditions that fail initial activity modification, antiinflammatories, and therapy. The exact timing and number of injections is controversial, but in general no more than three injections should be given over a 6-month time period.

Some authors have argued against using corticosteroids for conditions such as epicondylitis, contending that the disease does not involve inflammation. Despite this, most orthopedic surgeons believe they are a useful treatment adjunct at this time.

Operative Treatment

Surgery for the elbow is reserved for patients in whom nonoperative management has failed or is inappropriate, such as trauma requiring rigid fixation and early mobilization. Surgery can be performed via open or arthroscopic methods. Elbow arthroscopy should only be done by surgeons who are very comfortable with the surrounding anatomy and even then should be approached cautiously. Therapeutically it has been used effectively for removal of loose bodies, synovectomy, debridement of the capsule and extensor carpi radialis brevis (ECRB) origin for lateral epicondylitis,

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radial head resection, release of contracture, excision of osteophytes, and osteochondral debridement (osteochondritis dissecans, arthritis). Relative contraindications include severe contracture, previous nerve transposition, significant bone or joint distortion, and prior open elbow surgery.

Evaluation and Treatment of Common Elbow Problems

The following discussion highlights selected examples of common elbow problems.

Trauma

Fractures

Fractures around the elbow at the distal humerus, radial head and neck, and proximal ulna are fairly common. They occur through a wide variety of mechanisms, and one must be vigilant for associated soft tissue injuries. The treatment goals are complete healing of the fracture with painfree motion and good function. Treatment options include casting, traction, percutaneous pin fixation, rigid internal fixation, resection, and replacement arthroplasty. Stable, nondisplaced injuries such as simple radial head fractures can be treated with a brief period (1–2 weeks) of splinting followed by gentle range of motion. Most other fractures require operative management with rigid internal fixation and early motion to avoid stiffness, nonunion, and other complications. Severely comminuted, intraarticular fractures in elderly or rheumatoid patients are sometimes best treated with a total elbow arthroplasty.

Dislocations

Elbow dislocations are second only to those of the shoulder in frequency for major joints; they usually occur after a fall on an outstretched hand. By far the most common type is posterior, in which the olecranon dislocates posteriorly relative to the humerus. Associated injuries are common, such as radial head and neck fractures (5%–10%), avulsion fractures from the medial or lateral epicondyle (12%), and fractures of the coronoid process (10%).

On physical examination, there is visible deformity, with loss of the normal bony equilateral triangle, significant swelling, and loss of motion. A careful neurologic exam is mandated, the ulnar nerve is the most commonly injured nerve. Significant swelling anteriorly can lead to compartment syndrome of the forearm.

An AP and lateral X-ray are sufficient to make the diagnosis. The radial head should line up with the capitellum on both views. Failure to do so suggests residual subluxation. Special tests are rarely necessary. In the

378 M.A. Haque

patient with median nerve injuries, think of arterial injury because of the proximity of the median nerve to the brachial artery. If there is any question, arteriography is appropriate.

Initial neurovascular and radiographic assessment is followed by prompt reduction. Reduction is effected through manual forearm traction and brachial countertraction. The elbow is assessed for stability following reduction. If it is stable throughout the range of motion, application of a splint and sling, followed by early range-of-motion exercises, is indicated.

If the elbow starts to sublux or dislocate, immobilization at 90 degrees is appropriate for a longer period, but usually no more than 3 weeks to minimize the risk of permanent stiffness.

Ligamentous Injuries

Ligamentous injuries causing chronic elbow instability can be difficult to diagnose and treat. Anterior or posterior instabilities are usually caused by displaced olecranon or coronoid fractures or, more rarely, anterior capsule and brachialis disruptions. Addressing the source of pathology usually leads to a stable elbow. Other types include varus, valgus, and posterolateral rotatory instabilities. These conditions can all result from a single traumatic event such as a dislocation, but they can also come from repetitive stresses or iatrogenic injuries from excessive removal of epicondyles for ulnar nerve decompression or treatment of epicondylitis.

Patients with varus instability or posterolateral rotatory instability have a spectrum of injury starting with disruption of the lateral ulnar collateral ligament and progressing to posterior capsule and even medial collateral ligament injury. They usually present with lateral elbow pain and often a mild flexion contracture. They have clicking and recurrent symptoms of popping or subluxation of the elbow. Varus stress test and elbow pivot shift test help make the respective diagnoses. X-rays are usually negative. Treatment involves reconstruction of the lateral ligamentous structures; this often requires a tendon graft.

Injuries to the medial ulnar collateral ligament (MCL) cause valgus instability. It ranges from the grade I sprains with microscopic hemorrhage causing chronic pain to complete grade III disruption and true instability to valgus stress. The problem is particularly common in throwing athletes. Patients have a sense of “giving way” of the medial elbow. They have medial elbow pain and tenderness, especially with throwing. Pain typically occurs when the arm is in the “cocking position” of throwing, that is, with the shoulder abducted and externally rotated. Occasionally the patient has sudden onset of symptoms with one particular event such as in javelin throwing, but more commonly, prodromal symptoms precede the “final event” when the ligament completely tears.

Physical examination shows focal tenderness over the MCL or its coronoid insertion. On valgus stress there may be pain, tenderness, or the subtle

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sensation of medial joint opening. Look for signs of ulnar nerve irritability, which commonly accompanies MCL pathology. X-rays may show ossification or the spur sign at the ulnar insertion of the ligament.

The most difficult differential diagnosis is that of medial epicondylitis. Valgus stress may cause pain in this condition as well because of stress on the medial epicondylar tendinous origin. However, in the isolated MCL sprain, forearm pronation or wrist flexion against resistance (common in epicondylitis) should not cause pain.

Special stress X-rays may be helpful to document this subtle instability. By flexing the elbow 30 degrees, thereby unlocking the olecranon from its fossa, either gravity or manual force can apply a valgus stress. Probably any opening is of some significance, although it is appropriate to compare with the other side. When positive, these stress views are confirmatory. When negative, however, they do not exclude MCL insufficiency.

In almost all grade I and II injuries, symptomatic treatment, including rest, ice, compression, and strengthening, allow return to activity. Grade III tears often require surgical reconstruction, in which a palmaris longus tendon graft is used to reconstruct the MCL.

Tendon Ruptures

Ruptures of the distal biceps tendon, which are uncommon, nearly always occur in muscular men aged 30 to 50 years. They can occur as partial tears at the insertion or the musculotendinous junction, but they are most commonly complete insertional detachments from the biceps tuberosity of the radius. They almost always occur from a very heavy eccentric load to the biceps, and patients usually feel a “pop” and sharp pain in the antecubital space at the time. Patients are tender anteriorly and have weakness to elbow flexion and supination. If the diagnosis is unclear, an MRI can be helpful, but it is rarely needed.

Complete ruptures should be surgically reattached as soon as possible. In chronic presentations, patients can be treated with graft reconstructions or just observed if their functional losses are tolerated.

Triceps tendon ruptures are even more uncommon. Patients again present after an eccentric load. A defect in the triceps is often palpable, and elbow extension is weak. These injuries should be treated with surgical reattachment of the tendon to the olecranon process.

Atraumatic and Overuse Injuries of the Elbow

Lateral and Medial Epicondylitis

In skeletally mature adults, strains to the medial and lateral epicondyle can result in epicondylitis. These conditions can also result from a single,

380 M.A. Haque

particularly strenuous action, or with any repetitive stress such as sports (especially racket sports, golf, and baseball), carrying heavy bags, or even typing or cleaning activities. The tendon origin is thought to undergo microtears, degeneration, and replacement with abnormal scar and granulation tissue (called angiofibroblastic hyperplasia because of its microscopic appearance) within the extensor carpi radialis brevis (ECRB) on the lateral side or the flexor carpi radialis (FCR) and pronator teres (PT) muscles on the medial side.

Lateral epicondylitis is popularly known as tennis elbow, despite the fact that only 5% of patients play tennis. Conversely, nearly 50% of tennis players will develop the condition during their sports careers. Medial epicondylitis is often called golfer’s elbow.

Patients complain of pain on activity over the medial or lateral epicondyles of the elbow, often with some radiation into the forearm. The key physical exam finding is focal tenderness over the epicondyle or the muscles just anterior to it. Resisted wrist extension and grip reproduce symptoms in lateral epicondylitis, and wrist flexion and forearm pronation against resistance reproduce the symptoms in medial epicondylitis. X-rays are usually normal.

On the lateral side, the differential diagnosis includes radial tunnel syndrome (which coexists in 5% of patients), varus or posterolateral rotatory instability, or radiocapitellar arthrosis. On the medial side, the main diagnoses to also consider are ulnar nerve compression (which frequently coexists) and medial collateral ligament injury.

Treatment is almost always conservative, emphasizing rest, ice, avoidance of provocative activities, and nonsteroidal antiinflammatory drugs (NSAIDs). In addition, modalities such as ice, heat, or contrast therapy are helpful. Identification and correction of faulty technique, use of a counterforce brace, and a structured physical therapy program can be helpful. Cortisone injections are used in those unresponsive to early conservative management or those presenting with severe symptoms.

Surgery is required for less than 10% of patients who develop epicondylitis. It may be indicated in patients who fail an appropriate conservative trial, usually considered at least 6 months duration, and up to three injections of cortisone. Successful surgery involves identification and debridement of the pathologic tissue, usually located within the substance of the flexor carpi radialis and pronator teres on the medial side or the extensor carpi radialis brevis on the lateral side. Most surgeons also drill or osteotomize the epicondyle itself to promote new vascularity to the overlying soft tissues. For lateral epicondylitis, some surgeons are now advocating an arthroscopic technique in which the lateral joint capsule and the ECRB origin are debrided from the joint surface outward, without opening the superficial skin or musculature.

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Ulnar Nerve Compression (Cubital Tunnel Syndrome)

Patients with cubital tunnel syndrome present with complaints of numbness and tingling in the distribution of the ulnar nerve. They often have elbow pain with or without radiation; it is usually worse with sleep or long periods of elbow flexion. The patient may feel clumsy or weak in grasping or throwing; he or she may note actual “snapping” in cases in which the ulnar nerve is unstable.

The position of the ulnar nerve at the elbow renders it susceptible to both compression and direct trauma. There are five major sites of compression of the ulnar nerve in the region: the arcade of Struthers (a fascial band 5–10 cm proximal to the medial epicondyle), the medial intermuscular septum, the groove behind the medial epicondyle, the ligament of Osborne [a fascial band between the humeral and ulnar heads of the flexor carpi ulnaris (FCU) muscle], and the exit of the nerve from the FCU. Extremes of elbow flexion can cause tethering of the ulnar nerve around the medial epicondyle and compression. Up to 16% of patients are further predisposed to symptoms by having “instability,” with either subluxation or frank dislocation out of the groove.

In early disease, there is usually no sensory or motor deficit, although Tinel’s sign over the cubital tunnel may be positive. Check for nerve instability by flexing and extending elbow while feeling the ulnar nerve. As the compression progresses, patients can lose sensation over the ulnar border of the ring finger and all of the small finger. Weakness to finger abduction and eventually intrinsic atrophy can develop. A positive Froment’s test, in which the thumb collapses into interphalangeal (IP) joint flexion and is weak with key pinch is an important diagnostic sign. X-rays are almost always negative. Electrodiagnostic tests are often negative in early disease but can show slowing of conduction velocity specifically at the elbow in later disease. It is important to rule out other similarly presenting compressive neuropathies such as thoracic outlet or ulnar tunnel syndrome, as well as medial epicondylitis.

Treatment is usually nonoperative, with rest, ice, NSAIDs, nighttime extension splinting, or occasional cast immobilization for 2 to 3 weeks. In some patients, conservative management fails and surgery is necessary. Surgery usually involves decompression and anterior transposition of the ulnar nerve (Fig. 9-6).

Little Leaguer’s Elbow

In the skeletally immature athlete, injury to the medial epicondylar apophyseal structures is known as little leaguer’s elbow because of its high incidence in young baseball players. Repetitive stresses to the vulnerable epicondylar origin of the flexor-pronator group and MCL, during both

382 M.A. Haque

Median n.

Ulnar n.

Pronator-flexor

mass

A

B

FIGURE 9-6. (A) A medial incision is made over the elbow, allowing exposure of the ulnar nerve proximal, through and distal to the cubital tunnel through which it travels. (B) The ulnar nerve is transposed submuscularly underneath the flexorpronator muscle mass, after which the muscle origin is reattached to the medial epicondyle. (From Morrey BF (ed) The Elbow and Its Disorders, 2nd ed. Philadelphia: Saunders, 1993. Reprinted by permission of Mayo Foundation for Medical Education and Research. All rights reserved.)

acceleration and follow-through phases of throwing, result in abnormalities in secondary ossification and physeal plate structures. These children present with medial elbow pain, diminished throwing effectiveness, and decreased throwing distance.

On examination, there is focal tenderness over the medial epicondyle and pain on attempting active wrist flexion or forearm pronation, especially against resistance. X-ray findings vary, and include apophyseal fragmentation, irregularity or enlargement, abnormality of the physis, or avulsion of the medial epicondyle. Stress views are useful; even an inno- cent-appearing minimally displaced fracture may be unstable.

Fortunately, treatment is rarely operative, and includes rest, ice, and gradual return to activity as pain resolves. Restricting the number of innings pitched in Little League has led to a reduction in the incidence of elbow complaints. Surgery is reserved for those with displaced or unstable avulsion injuries or symptomatic nonunions.

Osteochondritis Dissecans (Panners’ Disease)

This condition is particularly common among adolescent throwing and gymnastic athletes. It has been described as the leading cause of permanent disability in the young throwing athlete. The most common symptom

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is that of lateral elbow pain, related to activity. There may be associated swelling, limitation of motion, or catching or locking episodes.

In throwing, enormous valgus stresses are imparted to the elbow joint. Absorbed primarily by the medial collateral ligament, the second line of defense is the radiocapitellar buttress, which is subjected to significant compression and shear. This stress also occurs in gymnastics, particularly during vaulting, balance beam, uneven parallel bars, and floor exercises. In skeletally immature individuals, such repetitive stresses are thought to compromise the vascularity to the vulnerable epiphysis, with consequent avascular necrosis (AVN) of the capitellum.

There is a classification system based on articular involvement. Type I lesions have no articular involvement. In types II and III, there is articular involvement; in type II, there is no fragment separation, and in III there is separation with loose body formation.

On physical examination, there may be restriction in motion, crepitus on supination/pronation, and tenderness over the radiocapitellar joint. X- rays are initially often normal, although there may be lucency or irregular ossification of the capitellum. In later stages, there may be a crescent sign, fragmentation, or loose-body formation. MRI or CT with arthrogram is probably the best method of establishing the diagnosis and assessing the degree of articular involvement. MRI is also useful in assessing subchondral involvement and the extent and status of healing of the lesion.

Treatment depends on clinical and radiographic findings. Nonoperative treatment for type I includes rest, ice, NSAIDs, and physical therapy with modalities. Resumption of activities is usually contraindicated because of the time required for healing. Because the healing process is slow, the area must be protected against overzealous activity (i.e., hard throwing or weight-bearing) for a long time.

Treatment of type II and III (articular involvement) lesions is usually operative, arthroscopically removing loose bodies, curetting, and/or drilling the base of the lesion.

Arthritis

Arthritis of the elbow is much less common than that of the hip or knee. The three major types are primary osteoarthritis, posttraumatic arthritis, and inflammatory. In patients with inflammatory (especially rheumatoid) arthritis, 20% to 50% have elbow involvement. It can lead to severe loss of arm function because of pain, instability, or loss of motion, especially when there is concomitant shoulder and hand involvement. In some cases, rheumatoid disease first presents in the elbow. These patients require appropriate laboratory tests for evaluation of systemic arthritis including erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA) test, rheumatoid factor (RF) test, and complete blood count (CBC). Additional rheumatologic tests should be determined in consultation with a rheuma-