The elbow

1. The elbow Adonia haddad objectives : 1)Anatomy 2)Movements 3) Clinical Assessment ( history & physical examination) 4)Fractures 5) Dislocation & pulled elbow 6) Deformities 7) Tennis elbow’ & golfer’s elbow 8)Loose bodies 9) Osteoarthritis /Olecranon bursitis/Tuberculosis/Rheumatoid arthritis

2. Anatomy : • The elbow is the joint connecting the upper arm to the forearm. It is classed as a hinge-type synovial joint • It consists of two separate articulations: Trochlear notch of the ulna and the trochlea of the humerus Head of the radius and the capitulum of the humerus • Note: The proximal radioulnarjoint is found within same joint capsule of the elbow, but most resources consider it as a separate articulation.

5. Joint Capsule and Bursae • Like all synovial joints, the elbow joint has a capsule enclosing the joint. This in itself is strong and fibrous, strengthening the joint. The joint capsule is thickened medially and laterally to form collateral ligaments, which stabilise the flexing and extending motion of the arm. • A bursa is a membranous sac filled with synovial fluid. It acts as a cushion to reduce friction between the moving parts of a joint, limiting degenerative damage. There are many bursae in the elbow, but only a few have clinical importance:

6. Intratendinous – located within the tendon of the triceps brachii. • Subtendinous– between the olecranon and the tendon of the triceps brachii, reducing friction between the two structures during extension and flexion of the arm. • Subcutaneous (olecranon) bursa – between the olecranon and the overlying connective tissue (implicated in olecranon bursitis).

8. Ligaments • The joint capsule of the elbow is strengthened by ligaments medially and laterally. • The radial collateral ligament is found on the lateral side of the joint, extending from the lateral epicondyle, and blending with the annular ligament of the radius (a ligament from the proximal radioulnarjoint). • The ulnar collateral ligament originates from the medial epicondyle, and attaches to the coronoid process and olecranon of the ulna.

10. Neurovasculature • The arterial supply to the elbow joint is from the cubital anastomosis, which includes recurrent and collateral branches from the brachial and deep brachial arteries. • Its nerve supply is provided by the median, musculocutaneous and radial nerves anteriorly, and the ulnar nerve posteriorly.

12. Movements : • The orientation of the bones forming the elbow joint produces a hinge type synovial joint, which allows for extension and flexion of the forearm: • Extension – triceps brachii and anconeus • Flexion – brachialis, biceps brachii, brachioradialis

14. Clinical Assessment • HistorY : Pain may be felt diffusely on : • the medial side of the joint (ulnohumeral), • the posterolateral side (radiohumeral) • acutely localized to one of the humeral epicondyles (‘tennis elbow’ on the lateral side and ‘golfer’s elbow’ on the medial side). • over the back of the elbow is often due to an olecranon bursitis.

15. Stiffness, if severe, can be very disabling : • The patient may be unable to reach to the mouth (loss of flexion) or the perineum (loss of extension); • limited supination makes it difficult to hold something in the palm or to carry large objects

16. Swelling may be due to injury or inflammation; • a soft lump on the back of the elbow suggests an olecranon bursitis Deformity is usually the result of previous trauma : • cubitusvarusdue to a malunited supracondylar fracture • cubitusvalgus due to an old displaced and malunited fracture of the lateral condyle.

17. Instability is not uncommonin the late stage of rheumatoid arthritis . Ulnar nerve symptoms may occur in elbow disorders because the nerve is so near the joint. • tingling and numbness in the little and ring fingers • weakness of the hand Loss of function is noticed in : • grooming activities, • carrying and hand work.

18. Examination • Both upper limbs must be completely exposed • it is essential to look at the back as well as the front. The neck, shoulders and hands should also be examined.

19. Look • Looking at the patient from the front, with his or her arms outstretched alongside the body and the palms facing forwards, • the elbows are seen to be held in 5–15 degrees of valgus; this is the normal ‘carrying angle’. Anything more, especially if unilateral, is regarded as a valgus deformity. • Varus deformity is less obvious, but if the patient raises the arms to shoulder height, it is easily seen. • The most common swelling is in the olecranon bursa at the back of the elbow

21. Feel Important bony landmarks are : • the medial and lateral condyles • the tip of the olecranon. These are palpated to determine whether the joint is correctly positioned. Superficial structures are examined for • warmth • subcutaneous nodule.

22. The joint line (including the radioulnar joint depression) is located and palpated for synovial thickening. • Tenderness can usually be localized to a particular structure. • The ulnar nerve is fairly superficial behind the medial condyle and here it can be rolled under the fingers to feel if it is thickened or tapped to find if it is hypersensitive.

23. Move • Flexion and extension are compared on the two sides. • with the elbows tucked into the sides and flexed to a right angle, the radioulnarjoints are tested for pronation (palms downwards 0–90 degrees) and supination (palms upwards 0–90 degrees).

25. General examination If the symptoms and signs do not point clearly to a local disorder, other parts are examined: • the neck (for cervical disc lesions) • the shoulder (for cuff lesions) • the hand (for nerve lesions).

26. X-rays • The position of each bone is noted, then the joint line and space • the individual bones are inspected for evidence of old injury or bone destruction. • loose bodies are sought.

27. In children, while the epiphyses are still incompletely ossified the anatomy has to be deduced from the shape and position of the emerging secondary ossificcentres-the average ages at which they appear can be remembered from the mnemonic CRITOE • Capitulum– 2 years • Radial head – 4 years • Internal epicondyle – 6 years • Trochlea – 8 years • Olecranon – 10 years • External epicondyle – 12 years.

28. NOTE : THE DOCTOR SAID HE DOESN’T WANT SPICIFIC FRACTURES SO I GUESS YOU CAN SKIP THIS PART 

29. Fractures : • Fractures of the distal humerus in adults: There are three types of distal humeral fracture: • extra-articular supracondylar fracture, • intra articular a) unicondylarfracture b)bicondylar fractures.

30. Supracondylar fractures rare in adults When they do occur, they are usually : • displaced and unstable • severely comminuted (high-energy injuries). .

32. Treatment • Closed reduction is unlikely to be stable and K-wire fixation is not strong enough to permit early mobilization. • Open reduction and internal fixation is therefore the treatment of choice. • The distal humerusis approached through a posterior exposure and reflection of the triceps tendon. • A transverse or oblique fracture can usually be reduced and fixed with a single contoured plate and screws. • Comminuted fractures may require double plates and transfixing screws

33. Condylar fractures • Except in osteoporotic individuals, intra-articular condylar fractures should be regarded as high energy injuries with soft-tissue damage. • A severe blow on the point of the elbow drives the olecranon process upwards, splitting the condyles apart. • Swelling is considerable and the bony landmarks are difficult to feel. • The patient should be carefully examined for evidence of vascular or nerve injury; • vascular insufficiency must be addressed as a matter of urgency.

35. X-rays • The fracture extends from the lower humerusinto the elbow joint; • it may be difficult to tell whether one or both condyles are involved, especially with an undisplaced condylar fracture. • Sometimes the fracture extends into the metaphysis as a T-shaped or Y-shaped break, and the bone between the condyles may be comminuted.

36. Treatment These are usually severe injuries associated with joint damage prolonged immobilization will certainly result in a stiff elbow. Early movement is therefore a prime objective. often the elbow ends up with marked loss of movement,eventhough the general anatomy has been restored. It can be : • Undisplacedfractures • Displaced condylar fractures

37. Undisplaced fractures • These can be treated by applying a posterior slab with the elbow flexed almost 90 degrees; • Gentle movements are commenced after 1 week, but only after obtaining another x-ray to exclude late displacement.

38. Displaced condylar fractures • Open reduction and internal fixation through a posterior approach is the treatment of choice. • The best exposure is obtained by performing an intraarticular olecranon osteotomy. The ulnar nerve should be identified and protected throughout. • The fragments are reduced and held temporarily with K-wires • . A unicondylar fracture without comminutioncan then be fixed with screws; if the fragment is large, a contoured plate is added to prevent re-displacement.

39. Bicondylar and comminuted fractures will require double plate and screw fixation, and sometimes also bone grafts in the gaps. Postoperatively, movement is encouraged but should never be forced. • The fracture heals in about 8 weeks • the elbow often does not regain full movement; in severe injuries, movement may be markedly restricted,however beautiful the postoperative x-ray. • In elderly osteoporotic patients, elbow replacement is often a more reliable option

41. Complications • Vascular injury Always check the circulation (repeatedly!). Vigilance is required to make the diagnosis institute treatment as early as possible

42. Nerve injury There may be damage to either the median or the ulnar nerve. It is important to examine the hand and record the findingsbefore treatment is commenced and again after treatment. The ulnar nervemay shut down following surgery but it usually recovers in time.

43. Stiffness Comminuted fractures of the elbow always result in some degree of stiffness. disabilitymay be reduced by encouraging an energetic exercise programme. Late operations to improve elbow movement are difficult but can be rewarding. • Heterotopic ossification Severe soft-tissue damage may lead to heterotopic ossification. Forced movement should be avoided.

44. Fractured capitulum • occurs only in adults. • The patient falls on the hand, usually with the elbow straight.The anterior part of the capitulumis sheared off and displaced. • Fullness in front of the elbow is the most notable feature. The lateral side of the elbow is tender and flexion is grossly restricted.

45. xray • In the lateral x-ray view the capitulum(or part of it) is, seen in front of the lower humerusand the radial head is not opposed to it. • The images can be difficult to interpret and a CT scan is invaluable in planning treatment.

47. Treatment • Undisplaced fractures can be treated by resting the arm in a sling for 4–5 days and then starting movement. • Displaced fractures should be treated by operative reduction and fixation with small buried screws. • If this proves too difficult, the fragment is best excised. Movements are commenced as soon as discomfort permits.

48. Fractures of the proximal end of the radius • Fractures of the proximal end of the radius are fairly common in young adults and children. • A fall on the outstretched hand with the elbow extended and the forearm pronated causes impaction of the radial head against the capitulum. • In adults this may fracture the head of the radius; • in children, it is more likely to fracture the neck of the radius(possibly because the head is largely cartilaginous). • In addition, the articular cartilage of the capitulum may be bruised or chipped; this cannot be seen on x-ray but is an important complication.

50. Special features • Following a fall on the oustretched arm, the patient complains of pain and local tenderness posterolaterallyover the proximal end of the radius. • A further clue is a marked increase in pain on pronation and supination of the forearm.