Download Elbow joint

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
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 then 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.