Upper Extremity: Elbow

Cubital Tunnel Syndrome:

Pathoanatomy: the ulnar nerve is most commonly compressed on the medial side of the elbow at one or more of the following locations: 1. Between the two heads of the Flexor Carpi Ulnaris 2. Within the Arcade of Struthers 3. Between Osborne’s ligament and the Medial Collateral Ligament.  It is the second most common compression neuropathy of the upper extremity.

Presentation: numbness and tingling of the small finger and the ulnar half of the ring finger.  Things that seem to exacerbate the symptoms are cell phone use (secondary to the excessive flexion of the elbow) and occupations or hobbies that require repetitive elbow flexion.

Diagnosis: On physical examination, there can be atrophy of the interosseous and first web space.  Possible clawing of the ring and small fingers. Possible subluxation of the ulnar nerve over the medial epicondyle when the elbow moves from full extension into flexion.  Decreased sensation of the small finger and the ulnar border of the ring finger.  Weakened grasp and pinch.

Diagnostic Tests: EMG/NCS is a very helpful test in diagnosis this entity or in helping to quantify the degree of severity of the entrapment.

Treatment: 

• Non operative management is the first line of treatment with NSAIDs, nighttime extension splinting, and activity modification (such as switching hand for cell phone use).
• Operative management consists of either ulnar nerve decompression or ulnar nerve decompression and transposition.

Distal Biceps Tendon Rupture

Epidemiology: Most commonly occurs in males in their 30s, 40s, and 50s.  It generally involves the dominant arm.

Pathoanatomy: The most common mechanism is an eccentric overload of the elbow when it is flexed at 90 degrees.

Presentation:  The patient reports a “pop” with pain, swelling and bruising in the antecubital fossa.

Diagnosis: Physical examination shows a “Popeye” Muscle (the muscle belly is shorter and taller secondary to its lack of distal attachment similar to when Popeye ate a can of spinach and grew a short but tall muscle).  Palpable defect distally.  Increased distance from the elbow crease to the most distal aspect of the muscle belly. A Hook Test will be positive.  Loss of strength with supination and to a lesser extent elbow flexion.

Diagnostic Tests: X-rays will typically be normal.  A MRI will distinguish between a partial tear and a complete tear.  The MRI is useful in demonstrating if the tear is off the biceps tuberosity on the proximal radius or musculotendinous junction.

Treatment:

• Non Operative manage is considered for older, more sedentary patients with decreased functional demands.  Patients will typically lose forearm supination strength,  elbow flexion strength, and will experience early fatigueability with repetitive use of the arm.
• Operative management consists of reattaching the distally ruptured biceps tendon to the bicipital tuberosity of the radius.  Newer anterior one incision techniques with modern fixation seem to be promising.

Lateral Epicondylitis (Tennis Elbow)

Epidemiology:  Most common cause of elbow symptoms in patients with elbow pain.  Upwards of 50% of tennis players will develop Lateral Epicondylitis at some point in their life, but that means that 50% of people who do not play tennis can develop this as well.

Pathophysiology: Offending activities that involve repetitive pronation and supination of the forearm with the elbow in extension are the most common cause.  The tendon origin of the Extensor Carpi Radialis Brevis (ECRB) undergoes a degenerative process or in some cases can become torn.

Presentation: Patients complain of pain with resisted wrist extension, power grip,  shaking hands, opening a tight jar.  Patients will occasionally report pain at night or rest.  The pain can radiate up or down the arm.

Diagnosis: Pain with palpation of the tendon of the Extensor Carpi Radialis Brevis  just distal to its origin on the  Lateral Epicondyle of the elbow.  Pain with resisted wrist extension with the elbow extended.  Pain with resisted extension of the index and long fingers (2 finger extension test).

Diagnostic Studies: X-rays will typically be normal. MRI can show either a tear of the ECRB tendon origin or possibly tendinosis of the ECRB tendon.

Treatment:

• NonOperative treatment consists of two schools of thought.  The first is the historically taught Anti-Inflammatory Method.  This method consists of ice, stretches, Physical Therapy, NSAIDs, and steroid injection.  This method provides relief within 3-7 days.  The duration of relief is variable.  This method is more successful in patients who have not had symptoms for a long duration of time.  The second method is the Inflammatory Method.  Prolotherapy is used to cause micro trauma in the tendon of the ECRB and stimulate the body to repair the damage.  If the causative process is a degenerative, then it is logical that a regenerative process is necessary to restore the tendon.  In addition to the injection of dilute Dextrose and Marcaine, this method employs heat instead of ice and uses Tylenol for pain instead of NSAIDs.  A typical prolotherapy treatment involves injections into the ECRB tendon in 1 month intervals with a gradual resolution of symptoms.  In this case, gradual means over a period of 4 to 5 months.  The results are more predictable and seem to be more lasting than the Anti-Inflammatory methods.
• Operative management is considered if non operative management fails for 9-12 months.  The surgical procedure consists of resection of the ECRB tendon origin either open or in some cases arthroscopically and a marrow stimulating procedure in the lateral epicondyle.

Medial Epicondylitis (Golfer’s Elbow)

Epidemiology: Far less common than lateral epicondylitis.  It affects men and women to the same degree.  The dominate hand is affected 75% of the time.

Pathoanatomy: Repetitive activities cause micro trauma to the insertion of the flexor-pronator mass.  Common sporting activities that cause this entity include: golfers, pitchers, and racquet sports.

Presentation: Pain with forearm and wrist motion.  Patients complain of pain over the medial elbow.

Diagnosis: Physical examination is specific for pain with palpation of the medial epicondyle and resisted forearm pronation and wrist flexion.  X-rays are typically negative.  MRI can show tendinosis of the pronator teres or the Flexor Carpi Radialis tendon origins.

Treatment: Similar to the Lateral Epicondylitis treatment regimen.

Olecranon Bursitis

Pathoanatomy: A bursae is a thin, slippery sac which decreases friction over areas of boney prominences.  The olecranon is the proximal most aspect of the ulna at the elbow.  The olecranon bursae lies between the skin of the elbow and the olecranon tip.  With trauma, pressure, infection, or conditions such as gout, the olecranon bursae can fill with fluid.

Presentation: Patients typically present to clinic with a large mass over the tip of the elbow.  It can look as though there is a golf ball below the surface of the skin.  If the patient has an infected olecranon bursitis, the skin can be red, hot, and painful to the touch.

Diagnosis: Physical examination will typically reveal a fluid filled sac over the olecranon process.  This is generally non painful to the touch but does interfere with Activities of Daily Living.  Xrays will typically be normal.  MRI is not generally ordered for this entity.

Treatment: If the olecranon bursae is not infected, patients can have the fluid from the bursae aspirated (sucked out with a needle and syringe).  Occasionally a small amount of steroid medication can be injected into the bursae.  A pressure dressing can be applied to help prevent the recurrence of the fluid in the bursae.  A roller blader elbow pad can be used to help prevent irritation to the bursae.  If the bursae is infected, antibiotics will be given to treat the cellulitis.  In non infected cases which do not respond to non operative management, the bursae can be surgically excised as an outpatient.  If there is an infected olecranon bursitis which is causing systemic illness, the bursae will be removed and the patient will be kept in the hospital for IV antibiotics and close follow-up.

Proximal Biceps Tendonitis (Tendinosis)

Epidemiology: Occurs in a bimodal age demographic.  This entity is acutely seen in younger, active males who lift weights and do repetitive overhead activities.   It is also seen in a more chronic setting in the older population who complain of anterior shoulder pain.

Pathoanatomy: the longhead of the biceps tendon originates off of the 12’oclock position of the glenoid (socket of the shoulder) and superior labrum.  It travels distally through the bicipital groove and passes under the transverse humeral ligament.

Presentation: Patients complain of anterior shoulder pain and pain which can be a background dull, achy pain or an exacerbation of sharp, stabbing pain.

Diagnosis: On physical examination, patients will generally have pain in the bicipital groove with palpation.  They can have a positive Speed Test (with the shoulder flexed to 90 degrees and the palm facing up, the examiner resists the patients ability to forward flex the shoulder).  A positive Yergason’s test ( with the patient’s elbow held at the side and flexed 90 degrees and the forearm pronated, the examiner resists the patients ability to supinate the palm) is occasionally present.  If there is a “Popeye” deformity, this indicates a proximal rupture.  Plain x-rays are generally negative.  Ultrasound may show a thickened tendon in the bicipital groove.  MRI can show tendinosis of the tendon or tenosynovitis in the groove.

Treatment: NonOperative management consists of NSAIDs, Physical Therapy, and a steroid injection in the bicipital groove.  If this fails to alleviate the symptoms in a lasting manner, a surgical procedure to address the biceps can be performed.  Biceps tenotomy is done by arthroscopically releasing the tendon from the attachment at the 12 o’clock position on the glenoid labrum.  The tendon then retracts into the bicipital groove where it scars into place.  This procedure is commonly performed in European Countries.  In the United States, a biceps tenodesis is more commonly performed.  The biceps tendon is released and then attached into a socket drilled into the proximal humerus and secured by a screw.  This procedure uncouples a pain generator in the shoulder and provides a secure attachment to the proximal humerus.

Radial Head Fracture

Epidemiology: This is a common fracture accounting for up to 20% of elbow injuries.  It occurs more commonly in the adult population.

Pathophysiology: The mechanism of injury is generally a fall onto an outstretched hand with the forearm in a pronated position.  This positioning allows the axial load to traverse the elbow and specifically the radial head and neck.  Some associated injuries include: Injury to the Distal Radial Ulnar Joint (DRUJ), injury to the interosseous membrane, ligament tears in the elbow, possible coronoid fracture.

Presentation: Patients present with a painful, swollen elbow with decreased range of motion (particularly pronation and supination).  The pain may be localized laterally or may radiate down the radius.  A thorough examination of the forearm and wrist is very important to rule out concomitant injuries.

Diagnosis: 4 views of elbow Xrays are a great way to diagnose this injury.   If further evaluation of the fracture is needed, a CT scan can give detailed information of the fracture pattern.  Newer CT scans can also be reformatted to reveal a 3D image of the injury which is very helpful in the surgical planning.

Treatment: Non operative management consists of a short period of immobilization then early, gently active range of motion.  The immobilization is generally performed in the Emergency Room where patients will be put in a splint and placed in a sling.  When patients present to the Orthopaedic Clinic and have a minimally to non displaced radial head/neck fracture, they will be taken out of the splint and evaluated for range of motion.  The sling is used as a “beacon” to people to stay away from the injured elbow as much as to alleviate pain.  I do encourage patients to remove the sling multiple times a day and participate in a gentle range of motion program of flexion and extension of the elbow and pronation/supination of the forearm.  The only motion to avoid is pronation of the forearm followed by flexion of the elbow.  This motion will lead to excessive forces across the radial head fracture and could displace the fracture.  Surgical options include excision of the fragment, excision of the entire radial head, or radial head replacement.  Depending on the severity of the fracture, the surgeon will discuss the risks and benefits of each option.

Supracondylar Humerus Fracture

Epidemiology: More than half of all pediatric elbow fractures are supracondylar humerus fractures.  Over 90% of these fractures are the extension type.  Males are more commonly affected than females and the age group is generally 5-7 years old.

Pathophysiology: Fall onto an outstretched hand with the forearm in a supinated position.  Associated injuries can include injury to the Anterior Interosseous nerve, Radial Nerve, and Ulnar Nerve.  The vast majority of the nerve injuries will spontaneously resolve.  There can be a transient asymmetry of radial pulse or even an absence of radial pulse which resolves with reduction of the fracture.

Presentation: Patients complain of elbow pain and do not want to range the elbow.

Diagnosis: On physical examination, patients will gave bruising, swelling, and possible gross deformity of the elbow.  Motion is limited.  If a nerve injury is present, there can be motor or sensory deficits in that particular nerve distribution.  A pulse may be weak or absent, but this generally resolves with reduction of the fracture.  X-ray examination of the elbow will differentiate between Type I, Type II, and Type III supracondylar fractures.

Treatment: A Type I supracondylar humerus fracture is a nondisplaced fracture and can be treated in a Long Arm Cast for 3 weeks.  After 3 weeks, the cast is removed and patients can begin the rehab process to regain motion. Type II fractures is a displaced fracture with the posterior cortex intact.  It is possible to reduce this fracture and place the patient in a Long Arm Cast with weekly follow-up to ensure that the fracture does not “settle” into an unacceptable position.  Type II fractures can also be treated in the operating room with a closed reduction and placement of percutaneous pins.  The patient is then placed in a Long Arm Cast and followed for 3 weeks.  After 3 weeks in a cast, the patient is removed from the cast and the pins are removed in the office.  The rehabilitation process is then initiated.  Patients are generally tearful and fearful to begin moving their elbow.  They tend to have become accustomed to having the cast in place and feel safe with the cast.  Type III fractures are completely displaced.  These fractures have a higher rate of nerve injury and 5-17% have an associated vascular insult.  If the vascular insult does not respond to the operative reduction and stabilization, then a vascular surgeon will need to be involved.  The fracture will need to be reduced in the AP plane and the Lateral Plane.  It is important to get an anatomic reduction to regain full post operative range of motion.  The fracture will at times require an open reduction followed by a percutaneous pinning.  The patient is then placed in a Long Arm Cast for 3 weeks.  After 3 weeks in the Long Arm Cast, the elbow is removed from the cast and the pins are removed in the clinic.  Of all pediatric fractures, the pediatric elbow supracondylar humerus fracture is one of the very few that can result in permanent loss of range of motion.