Disorders of the elbow

Tennis elbow

Excluding traumatic conditions, this is the most common cause of pain around the elbow, and usually occurs in patients in their 30—50s. The exact cause is unknown but the condition commonly follows a period of overactivity, particularly an unaccustomed activity that involves active extension and suppination of the wrist. The tendon of extensor carpi radialis brevis is most commonly involved and, at exploration, a partial tear and chronic inflammatory tissue have been described.

History and examination

The patient complains of pain around the lateral epicondyle and in the back of the forearm. This is activity related and often a particular activity is implicated. There is not usually a history of trauma, but the patient may relate the onset to a period of unusual activity. On examination, the patient is locally tender, which is commonly just distal and anterior to the lateral epicondyle rather than the epicondyle itself. Forced palmar flexion and pronation against resistance reproduces the pain. The diagnosis is essentially a clinical one, although ultrasound and MRI may be indicated if there is any doubt.

Treatment

The prognosis is generally good. Many cases probably resolve without the need for any medical input, particularly if the precipitating activity can be avoided. Simple analgesia may be sufficient, but often a local injection of hydrocortisone is required. This can be repeated if there is some response, but repeated injections should be avoided. Physio­therapy, particularly local measures including ultrasound, can help, as can a tennis elbow splint, which is designed to alter the pull of the muscle. Surgery may be occasionally indicated and local excision of the abnormal tissue will produce good results in 70—80 per cent of patients.

GoIfer's elbow

This is less common and involves the flexor origin around the medial epicondyle. Ulnar nerve entrapment should be considered in the differential diagnosis and treatment is on similar lines. If medical treatment fails and surgery is being considered, further imaging such as ultrasound or MRI is appropriate to localise any abnormal tissue.

Arthritis of the elbow

Rheumatoid arthritis

The elbow is commonly involved in rheumatoid arthritis and can be a source of considerable discomfort and functional limitation. Medical management is initially tried but surgery is commonly required. If the elbow has good preservation of joint surfaces, then chemical synovectomy may be indicated, but again this is not commonly carried out in RA. If there is considerable pain and restriction of pronation and suppination, rather than flexion and extension, radial head excision and synovectomy is appropriate. This produces good short-term improvement but there is a high relapse rate.

With end-stage disease, particularly with gross joint des­truction, elbow arthroplasty is indicated. This is becoming more commonly performed and good results with 80—90 per cent of patients problem-free at 10 years (Fig. 22.16).

Osteoarthritis

Primary osteoarthritis of the elbow is rare and most cases of degenerative disease are due to previous trauma, osteochondritis dissecans or congenital problems such as epiphyseal dysplasia or radial head abnormalities. The patient is usually male, in their 40—60s and often works in a profession that requires heavy use of the upper limb. Pain is the chief complaint, although on examination there will usually be a 20-30degrees fixed flexion deformity and limited suppination. The history and examination should concentrate on differen­tiating the pain of a degenerate joint, which is activity related and predictable, from that of sudden unexpected pain and locking, which suggests loose bodies within the elbow (see below). In addition, ulnar nerve symptoms are more common in the arthritic elbow.

Treatment. Often no treatment is required other than reassurance about the nature of the condition. Osteoarthritic elbows seldom deteriorate rapidly and often the symptoms will improve after retirement. For the patient who is unable to carry out his normal activity, early retirement or a change of work is the best solution, as there is no satisfactory surgical procedure that will guarantee a return to a heavy manual job. Débridement is practised in the USA and will increase the range of motion; however, lack of movement is seldom a major complaint by the patient. Resurfacing arthroplasty using tendon or fascia has been tried but, in general, gives a less than satisfactory outcome. Joint replacement should not he carried out in a patient who wishes to return to heavy work but is indicated for severe pain and functional problems in a more sedentary patient. Arthrodesis of the elbow is rarely carried out.

In general, the results of elbow replacement for osteoarthritis are not as good as for RA. This may be related to the different lifestyles of the patients.

Loose bodies

After the knee, the elbow is the second most common site of symptomatic loose bodies. The most common cause is osteo­arthritis but in the younger patient osteochondritis dissecans is the usual cause. Most patients complain of sudden un­expected pain and locking of the elbow, and often they have to shake or manipulate the elbow to relieve it. Plain radiographs will confirm the diagnosis in 90 per cent of cases and further investigation is not necessary. Arthroscopic removal is indicated and, in the presence of mechanical symptoms, good results can be expected in most patients. In the absence of an appropriate history simple removal of loose bodies from a degenerate elbow will not result in any lasting benefit.

Osteochondritis dissecans

Osteochondritis dissecans is much less common in the elbow than the knee, and usually affects the capitellem. Teenage boys are usually affected and the condition is often related to sporting activities. The main symptoms are pain and swelling, and on examination there is a loss of full extension. Treatment is normally conservative with a rest from sport, hut arthroscopy may he required if the fragment detaches and the patient develops mechanical symptoms suggestive of a loose body.

Olecranon bursitis

Inflammation of the olecranon bursa is relatively common. The elbow is often very red, warm, swollen and painful, and a septic arthritis may initially be suspected. The signs and symptoms are, however, confined to the back of the elbow (Fig. 22.17) and movement within an arc of 30~1300 is usually possible. The bursitis is usually chemical rather than infective, and management consists of rest, ice, anti-inflammatories and a compression dressing. If there is any suspicion of a penetrating wound, antibiotics should be administered but formal drainage of the bursa should be avoided, unless purulent material is present.

Chronic bursitis can occur and may be associated with small calcific nodules. In general these should not be removed and surgical excision of the bursa should be avoided if possible.

Ulnar nerve compression

This is the second commonest nerve entrapment after carpal tunnel syndrome. The most common sites of compression are around the elbow and there is a number of possible sites:

the arcade of Struthers and the medial intermuscular septum — as the nerve passes into the posterior compartment of the distal humerus;

medial epicondyle — particularly if osteophytes are present;

cubital tunnel — as the nerve passes between the two heads of flexor carpi ulnaris (Fig. 22.18).

A nerve palsy may also be due to a flexion or a valgus deformity of the elbow.

History and examination

Unlike carpal tunnel syndrome, compression of the ulnar nerve may not be painful and the patient may present with weakness of the hand in association with paraesthesia. On examination a positive Tinnel’s sign is usually present, particularly at the site of compression, and wasting and weakness of the intrinsic muscles of the hand are evident. Nerve conduction studies are usually carried out, unless the site of compression is obvious. In addition, plain radiographs of the elbow should be obtained, particularly if any deformity is present.

Treatment

Despite the absence of pain, decompression of the nerve should be carried out. The nerve can be explored through a medial or posterior approach. Opinion is divided on whether simple decompression is sufficient or whether there is a need for formal anterior transposition of the nerve. Transposition is usually necessary in cases of deformity, or if the nerve is unstable after decompression. For most other situations decompression without transposition is sufficient, provided all sites of possible compression have been explored.

Any paraesthesia should resolve but the prognosis for the return of hand power should be guarded as the recovery is unpredictable.

  Compression of both the radial and median nerves at the elbow occurs but this is much less common than ulnar nerve compression (Fig. 22.19).