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
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
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
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
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.