Common Elbow Problems Duncan Ferguson FRACS Knee and Shoulder Specialist
Elbow Instability Common 10-25% of elbow injuries Median age 30 yrs Most simple dislocations are stable after reduction recurrence 1 3% Complex dislocations may be associated with recurrent instability Early ROM reduces stiffness Take care to identify any neurologic compromise
History Mechanism FOOSH/MVA/High velocity trauma Direction Posterior/posterolateral Anterior much less common Associated Symptoms Paraesthesia Wrist pain Chest/thoracic pain
Examination Soft tissue elbow swelling with deformity Pre-reduction neurologic/vascular state Ipsilateral wrist injury (10 15%)
Management Imaging AP/Lateral Views? Associated fracture - discuss acutely Reduction Adequate analgesia/relaxation Gentle inline traction with flexion thumb assisted reduction on tip of olecranon Immobilisation AE Backslab flexed 90 wrist free for ROM Imaging AP/Lateral? Congruent unsure refer/ reimage
Management Prolonged immobilisation > 3/52 = stiffness Follow up 10-14 days Removal of cast X-rays commence ROM with removal splint or sling for comfort Physio input
Surgical Indications Elbow instability post reduction in arc 40-60 Complex dislocation- Peri-articular fracture Late Posterolateral recurrent instabilty
Common Epicondylitis (Tennis/Golfers elbow) Lateral more than medial 4:1 NOT Inflammatory Tendinous microtearing followed by an incomplete healing response Numerous treatments with no universally accepted treatment protocol
History Burning rather than mechanical pain Pain with resisted wrist extension Pain with reaching out to lift Greater pain with elbow extended than flexed Reduced grip strength (50% of the strength of the healthy arm)
Examination Local tenderness over common extensor origin Pain with resisted wrist extension Elbow arc of motion preserved Normal sensation in superficial radial nerve distribution
Investigation Xray Ultrasound MRI Gold standard Oedema at common extensor origin Peritendon oedema
Management No treatment universally effective The majority of patients are asymptomatic at 1 year. Education Activity modification REST Non - surgical NSIAD s Physical therapy Counter force bracing Steroid injection
Cubital Tunnel Compression of the Ulnar at the elbow is the commonest cause of paresthesia on the ulnar border of the hand Second most common compressive neuropathy after carpal tunnel syndrome Present with ill defined pain around the medial aspect of the elbow in association with paraesthesia in the ulnar of the hand Reduced grip strength, wasting of the interossei
Examination Look Wasting forearm/interossei Scars Clawing if the ring and little finger Wartenburg s sign Feel Tinel s test at elbow, ulnar nerve distribution Subluxable ulnar nerve Move Elbow ROM(underlying OA) Hand power hypothenar eminence, 1 st dorsal interossei (cross finger test) Froment s test
Investigations X-rays AP/Lateral views elbow Cervical Spine Chest X-ray Wrist views Nerve Conduction studies To confirm clinical suspicion
Treatment Non- surgical For mild symptoms Night splintage extended or 45 flexed neutral forearm rotation NSAID s Occupational therapy input Surgical Indicated with failure of non surgical measures or late presentation with significant dysfunction Release/Transpose/Transpose and bury
Elbow Osteoarthritis Painfull stiffness, mechanical symptoms Typically affects middle aged men engaged in strenuous manual activity Primary OA Secondary OA Post traumatic Inflammatory
History Gradual onset painful reduced ROM Catching/jamming symptoms Associated neurologic symptoms Previous Trauma/surgery
Examination Look Feel Move Scars, deformity, wasting Bony prominence ROM mechanical block terminal flexion and extension, forearm pro/supination Special tests
Imaging X-Rays CT AP/Lateral views relative preservation of joint space, osteophytes
Management Imaging AP/Lateral views +/- CT Non Surgical Mainstay of treatment Surgical Debridement Open Arthroscopic Arthroplasty - Rarely reserved for elderly low demand
Distal Biceps Tendon Rupture Relatively uncommon Incidence 3 10% Often missed Best considered /referred to discuss surgical management early in appropriate patients History is the key Dominant arm males 30-60 manual workers
History Unexpected extension force on a flexed elbow followed by biceps activation and a tearing sensation in the antecubital fossa A popping sensation Acute pain settles, chronic pain Weakness - supination Awareness of assymmetry of distal biceps muscle bulk
Examination Look Assymmetry, haemtoma, compare to other side Feel Biceps tendon in antecubital fossa Distal biceps height Lacertus fibrosis Move Elbow ROM, compare resisted supination weakness and pain Special tests Hook test
Examination Hook test hook flexed index finger around the lateral edge of the biceps tendon with elbow flexed 90 - compare
Investigations X-rays AP/Lateral Elbow Fleck avulsion fracture Ultrasound - operator dependent MRI if clinical diagnosis uncertain