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Elbow Disorders

DISLOCATIONS

Elbow Dislocations

  • Usually posterior
  • Neuropraxia in 20% (ulnar & median nerves - usually AIN)
  • Usually stable once reduced, since bony stability is good.
  • If instability occurs in 30 deg of flexion, then place forearm in maximum pronation (which tensions lateral soft tissues crossing the elbow).
  • Main problem is stiffness, thus go for early ROM
  • Complex injury = with associated fractures:
    1. Radial head fracture causing instability then replace radial head (silastic or titanium implant)
    2. MCL is always damaged to variable degrees. May be fracture of Medial epicondyle = ORIF
    3. Coronoid fractures:
      • due to avulsion by brachialis when elbow is hyperextened
      • Type I: avulsion of the tip of the coronoid process  - closed reduction and early motion
      • Type II: involving less than 50% of the process - closed reduction and early motion
      • Type III: involving > 50% of process - = high redislocation rate & requires ORIF - there may be an associated valgus instability since MCL inserts onto the fracture fragment. 
    4. Terrible Triad = radial head + coronoid + MCL 

 

Radial Head Dislocation

Congenital:

  • Posterior
  • Often have little functional deficit
  • Capitellum is dysplastic
  • Therefore relocation is not successful
  • Develop OA of ulnohumeral joint in adulthood

Traumatic

  • Reduce
  • Look very carefully for Monteggia fracture of ulna
  • If unstable - reconstruct annular ligament (may need triceps sling)

CONTRACTURES

  1. Trauma
  2. Arthritis
  3. Miscellaneous - infection, burns, haemophilia
  4. Arthrogryposis

LATERAL EPICONDYLITIS (Tennis Elbow)

= tendinosis of the lateral epicondyle

Clinical

  • Pain over lat epicondyle exacerbated by gripping and forearm rotation
  • Tenderness
  • Pain reproduction on resisted wrist dorsiflexion (Mills' Test)
  • middle finger test = pain on resisted extension of MCPJ of middle finger (because ECRB inserts into the base of the 3rd MC) 

Aetiology

  1. Trauma:
    • usually in throwing athletes & can follow direct trauma
  2. Constitutional factors:
    • Same patients develop other tendonoses - e.g. impingement syndrome of the shoulder, carpal tunnel syndrome, deQuervain's tenosynovitis, trigger finger, Achilles tendinitis.
    • = 'Mesenchymal syndrome'

PathologyAnatomy of Extensors - from McGrouther, Primal Pictures CD

  • Degenerative changes in the origin of ECRB 
  • Hyaline degeneration, fibroblasts & vascular granulation tissue - 'angiofibroblastic tendonosis'

Treatment

Always Non-operative initially, since most settle down:

= rest; activity modification; NSAIDs; physiotherapy; clasp; steroid injections.

Surgery is reserved for those that fail to respond to the above.

Options:

  1. Extensor origin release
  2. Release of portion of the annular ligament
  3. ECRB lengthening in the distal forearm [Picture] [Powerpoint Presentation]
  4. Localised denervation of the lateral epicondyle
  5. PIN decompression

Results of surgery = 85% complete relief, 5% no benefit & 10% some improvement

No one form is significantly better than the others.



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