Snehal C. Dalal, MD Atlanta Trauma Symposium August 2021
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Snehal C. Dalal, MD
Atlanta Trauma Symposium
August 2021
Common Elbow Conditions
Differentiating Elbow Pain ê Lateral Elbow Pain ê Lateral epicondylitis ê Radial Tunnel Syndrome ê Posterior Lateral Rotatory Instability ê Medial Elbow Pain ê Medial Epicondylitis ê Cubital tunnel syndrome ê Medial Ulnar collateral ligament strain/tear ê Anterior Elbow Pain ê Brachioradialis strain ê Distal biceps tendonitis/tear ê Posterior Elbow Pain ê Triceps tendonitis ê Olecranon Bursitis ê Valgus Instablility/Posteromedial impingement
Elbow Anatomy
Elbow Anatomy
Case 1 ê 31 y/o racquetball player c/o lateral elbow pain ê Pain with hitting backhand, forearm rotation ê “..hurts to take a milk jug out of the fridge.” ê Painful with grip and resisted wrist extension
Exam
ê Lateral elbow pain with gripping
and resisted wrist extension
ê Pain to palpation just distal to the
lateral epicondyle
ê Pain with resisted wrist/long
finger extension
ê Worse with elbow extended
ê Chair lift/heavy book test
Ultrasound ê Hypoechoic area on ultrasound
Lateral Epicondylitis
ê Differential Diagnosis
ê Radiocapitellar osteochondral
lesion/degenerative arthritis (DJD)
ê May hurt more in flexion
ê Radial tunnel syndrome/Posterior
interosseus nerve syndrome
ê Ache with supination, weak wrist
extension
ê Tender 5-6 cm distal to lateral
epicondyle
ê Triceps tendonitis
Lateral Epicondylitis
¨ A.K.A. “Tennis Elbow”
¨ Most do not play
tennis
¨ Injury
¡ Repetitive use of wrist
extensors
¨ Pathology
¡ Tendinosis of ECRB
(extensor carpi radialis
brevis)Lateral Epicondylitis
¨ Treatment
¡ Activity Modification
¡ NSAI’s
¡ Stretching/strengthening
¡ Ice/Massage
¡ Counterforce brace
¡ Steroid Injection
¡ Surgery after at least 4-6 months of conservative
treatment
ú Arthroscopic ECRB release
ú Open debridement and repairLateral Epicondylitis ê Theraband Flexbar ê Eccentric stretching is important in the rehab for tendon injury
Arthroscopic Treatment
ê Arthroscopic ECRB release
ê Reproducible results:
ê Early return to work
ê Lower complications
ê Less immobilizationArthroscopic Treatment
ê Arthroscopic
visualizaton of ECRB
tendon (most medial
tendon)
ê Epicondylar
debridementCase 2
¨ 12 y/o boy, little league pitcher
c/o increasing medial elbow pain
with pitching
¨ Throws occasional curve balls
¨ Practices 30-40 pitches 3x/week
¨ Goes home and throws 30-40
more after practice
¨ Felt a pop/tearing sensation
¨ Pain and swelling over the
medial epicondyleExam
ê Medial epicondyle
tenderness/swelling
ê Loss of full extension
ê Pain with valgus stress
ê No gross instabilityMedial Apophysitis
¨ A.K.A. Little Leaguer’s Elbow
¨ Increasing valgus load
¨ Lateral compression, medial
distraction
¨ Injury: traction/avulsion at
the medial epicondyle physis
¨ X-ray: widening of physis to
complete avulsion of
epicondyle
¨ If not sure, get contralateral
films for comparisonMedial Apophysitis ¨ Treatment ¡ Stop pitching ¡ Normal x-ray: stretching / strengthening ¡ Fleck/slight physeal widening: period of rest/sling, gradual rehabilitation ¡ Avulsion/very wide physeal space: ortho referral for possible fixation ¨ Limit pitching ¡ 30-40 pitches/practice/day ¡ 6-10 innings gametime ¡ 60-100 pitches gametime ¡ No sidearm throwing: sliders or curve balls
Complete Avulsion
Surgical treatment if displacment
over 5 mm, ulnar symptoms, joint
entrapment, instability with gravity
stress testPrevention Guidelines ê 75 for 8-10 year olds ê 100 for 11-12 year olds ê 125 for 13-14 year olds ê Includes both practice and competitive play ê Play three to four innings each game
Case 3 ê 32 y/o asthmatic with L anterior elbow pain ê Weight lifting Preacher Curls, felt sharp/burning pain ê Smokes 1 ppd ê Has recently taken predisone for asthma exacerbation
Exam ê Left antecubital fossa tender to palpation ê Weak elbow flexion and turning car key ê “Popeye muscle”
MRI
Attenuated biceps tendon Bare Radial TuberosityDistal Biceps Rupture ê Much less common than proximal avulsion ê Usually a complete avulsion injury ê May have h/o steroid, cigarettes, or quinolone antibiotic use ê Can occur after longstanding tendonosis/history of antecubital pain ê Diagnosed usually through H&P, although MRI helpful if incomplete rupture & surgical planning ê “Popeye deformity on exam” with weak supination
Distal Biceps Rupture
ê Can be a complete or partial tear
ê May have h/o steroid, cigarettes, or quinolone antibiotic use
ê Can occur after longstanding tendonosis/history of antecubital pain
ê Diagnosed usually through H&P, although MRI helpful if incomplete
ruptureDistal Biceps Rupture
ê Biceps is the most powerful supinator of the forearm
ê Treatment
ê Elderly
ê Nonoperative
ê 50% loss of supination power
ê 30-40% loss of flexion power
ê 35-40% complain of prolonged pain
ê Rehabilitation
ê Young/Active
ê Surgical repair
ê Long arm splint or sling initiallySurgical Repair: Endobutton
ê Insertion at biceps tuberosity bare
Distal
Biceps insertion
Biceps tendon
Biceps tuberositySurgical Repair: Endobutton
ê Main substance of tendon retracted proximal to
cubital fossaSurgical Repair: Endobutton
Surgical Repair: Endobutton
Surgical Repair
ê Start ROM after surgery, strengthening 6-8 wks
postoperativeCase 4 ê 36 y/o secretary c/o medial forearm achiness and paresthesias into the ring and small fingers ê Has numbness and tingling into the small finger at night ê Has to “shake it out” ê Occasional weakness in grip/clumsiness/dropping objects ê Dorsum of hand also tingling on the side of the small finger
Exam
ê Positive elbow hyperflexion
test
ê Hold for 2 minutes
ê Tinel’s at cubital tunnel
ê Tap lightlyExam
ê Weakness in small
finger flexion
ê Intrinsics weak/atrophy
ê Decreased Semmes-
Weinstein
monofilament exam/2
point discriminationExam ê When motor function affected: ê Wartenberg’s Sign ê loss of intrinsics ê Fromment’s Sign ê loss of adductor pollicis
Examination ê Differential diagnosis ê Ulnar tunnel syndrome ê Ulnodorsal hand is unaffected ê Snapping triceps ê Snapping posteromedially with elbow flex/extension ê Ulnohumeral arthritis ê Cervical radiculopathy ê C-spine XR ê Medial epicondylitis
Diagnostic Testing ê EMG/NCS shows slowing and decreased amplitude across elbow for ulnar nerve ê Can be normal ê Decrease 2-point discrimination ê Normal 4-5 mm ê Decreased monofilament exam most sensitive
Cubital Tunnel Syndrome ê Ulnar nerve compressive neuropathy at the elbow ê Injury: ê Direct trauma ê Traction injury ê Compression ê Subluxation
Pathoanatomy
Arcuate Ligament/Osborne’s
Ligament
Tightens with elbow flexion
Overlies MUCLCubital Tunnel Syndrome
ê Treatment
ê Rest, limit flexion
ê Brace at night
ê Stretching/nerve glides
ê Strengthen flexors/pronators
ê Ulnar nerve decompression/transposition
ê If any motor function affected clinically/on EMG
ê At least moderate compression on EMG
ê Failed treatment to mild compressionCase 5 ê 40 y/o executive developed R medial elbow pain ê Golfs 2-3x a week ê Pain with lifting with palm up
Ultrasound
Injury to the common flexor/pronator tendon
Normal Tendon Thickened TendonMedial Epicondylitis
• A.K.A Golfer’s elbow
• Overuse syndrome of flexor-pronator mass origin
• Less common than tennis elbow
• Caused by micro-trauma to insertion of flexor-
pronator mass caused by repetitive activities
Symptoms:
• Symptoms insidious onset pain over medial
epicondyle
• worse with wrist and forearm motion
• worse with gripping
• during late cocking/early accelerationMedial Epicondylitis
ê aka “Golfer’s Elbow”
ê Pain over medial
epicondyle and common
flexor tendon
ê Pain with resisted flexion
and pronation
ê Much less common the
lateral tendonitisMedial Epicondylitis
Physical Exam:
• Tenderness 5-10 mm distal and anterior to medial epicondyle
• Soft tissue swelling and warmth if inflammation present
• Pain with resisted forearm pronation and wrist flexion
• Examine for associated conditions
• valgus instability in overhead athlete (milking maneuver, valgus stress, moving valgus
stress test)
• ulnar neuritis (Tinel's along length of nerve, ulnar subluxation)
Imaging:
• XR: usually WNL, sometimes will show a calcification or degenerative changes
• MRI:
-Standard of care for diagnosis
-Will show tendinosis / tendon disruption of common flexor tendonMedial Epicondylitis Differential Diagnosis: • MCL injury • Cubital tunnel syndrome • Fracture • Cervical radiculopathy • Triceps tendinitis • Herpes zoster (shingles)
Medial Epicondylitis
ê Treatment
ê Activity Modification
ê NSAI’s
ê Stretching/strengthening
ê Ice/Massage
ê Counterforce brace
ê Steroid Injection
ê Surgery after at least 4-6 months of conservative treatment
ê Open debridement and repair
ê Some patients will have concomittant ulnar nerve symptoms: perform
transposition/decompressionMedial Epicondylitis
Treatment:
• rest, ice, activity modification (stop throwing x 6-
12wks), PT (passive stretching), counter-force
bracing, NSAIDS
• Cortisone injection (caution for ulnar nerve injury)
• Surgery if failed conservative treatment (open medial
epicondyle release)Case 6 ê 19 y/o freshman college baseball pitcher ê Increasing pain in medial elbow after pitching several innings in a game ê Progressive loss of distance and speed over the last few days ê Pain with early phase of throwing
Examination
ê Point tenderness over MUCL
ê Pain with late cocking/early
acceleration phase of
throwing
ê Valgus instability with elbow
flexion 20-30 degrees
ê Positive Milking Maneuver
ê Moving Valgus stress test
ê Most sensitive and specificUlnar Collateral Ligament Injury
MRI arthrogram to evaluate the MUCL is the study of choice
Ultrasound can also be useful as a dynamic studyTreatment ê Repetitive Injury: Surgical intervention usually reserved for throwing athletes ê Intervention for either partial or complete tears ê Nonoperative treatment with brace for traumatic injuries
Case 7 ê 55 y/o truck driver with R posterior elbow pain with swelling ê Progressive burning, tightness, and redness ê No trauma ê h/o of gout
Olecranon Bursitis
• The olecranon bursa is located posteriorly over the olecranon
process of the ulna
• It may become swollen in relation to:
− Trauma
− Hemorrhage
− Sepsis
− inflammatory arthritis
− It is also a common site for the development of rheumatoid
nodules or gouty tophiOlecranon Bursitis
XR: Will show soft tissue swelling at posterior
elbow, occasionally there is an olecranon spur
Exam:
• Check for erythema, warmth, abrasion or cellulitis symptoms to r/o
septic bursitis
• Can distinguish between an elbow effusion if patient is able to fully
extend elbow joint without accentuating pain
Treatment:
• 24/7 compression wrap w/ cushioning
• NSAIDS
• Ice
• Avoid microtrauma
• Olecranon bursa excision can be indicated with chronic persistent bursitis
or septic bursitisOlecranon Bursitis Aspiration: ê The two main indications to aspirate the bursa are to r/o infection or gout ê Fluid aspiration can be used to decompress the bursal sac but it is typically not recommended due to: − Risk of introducing an infection − Very common for fluid to re-accumulate rapidly into the bursa after drainage ê Do not inject glucocorticoids in patients with olecranon bursitis
Examination
ê Fluid filled swelling
ê Mild warmth
ê Mild erythema
ê No lymphadenopathy
ê Pain with dependency and
elbow flexionOlecranon bursitis
ê Fluid filled sac over bony prominences can become inflammed
ê More common in RA and gout
OLECRANON SPUR
GOUTY CALCIFICATIONTreatment
ê Compression, ice, nsai
ê Antibiotic if surrounding cellulitis
ê Conservative treatment for 6 weeks
ê RESIST ASPIRATION, unless infected
bursa is suspected
ê Aspirate if persistent or recurrent
ê BEWARE STEROID INJECTIONS
ê Superimposed triceps tendonitis
may result in triceps rupture
ê May need surgical bursectomy
ê May drain and place packing in
clinic/ED if infectedSummary
Lateral Epicondylitis
ê Repetitive wrist extensor irritation
ê Tendinosis of the extensor carpi radialis brevis
ê Worse pain with the elbow extended rather
than flexed
ê Suspect radial tunnel syndrome if pain with
supination and pain more distal on forearm
ê Surgical consideration after MONTHS of
conservative treatmentSummary Medial Apophysitis ê Peak incidence occurs during fastest growth, 10- 12 y/o girls or 12-14 y/o boys ê Comparitive radiographs are helpful ê Prevent by limiting number of pitches/adding rest days ê No sliders/curve balls/side pitching ê Treat with rest from throwing 4-6 weeks, followed by gradual rehab program ê Surgery if apophysis displaced greater than 4- 5mm
Summary Distal Biceps Rupture ê Suspect if weak forearm supination ê Fluoroquinolone, steroid, and tobacco use are associated with decreased tendon healing and higher rupture rate ê MRI indicated in partial tear/question on exam ê Majority of patients would benefit from surgical repair
Summary Cubital Tunnel Syndrome ê Medial elbow pain ê Paresthesias in entire ulnar nerve distribution ê Ulnar Tunnel spares the dorsum of the hand ê Semmes-Weinstein is the most sensitive ê Surgical consult if moderate changes on EMG or atrophy/weakness present ê Postive Wartenberg’s and Fromment’s signs
Summary
Medial Epicondylitis
ê Repetitive wrist flexor irritation
ê Tendinosis of the common flexor tendon
ê Worse pain with the elbow extended rather
than flexed, and lifting with the palm up
ê Evaluate for cubital tunnel syndrome when
determining treatment
ê Surgical consideration after MONTHS of
conservative treatment
ê May need decompression of ulnar nerve as wellSummary Medial Ulnar Collateral Injury ê Consider patients athletic demands ê Conservative treatment includes bracing and rehab ê Surgery usually for those athletes who wish to continue throwing and go through extensive rehab ê Cubital tunnel syndrome is still the most common complaint among throwing athletes
Summary Olecranon Bursitis ê Swelling of fluid filled sac ê Usually resolves with compression, ice, nsai ê Aspirate only if infection suspected ê Olecranon spur, RA, gout are predisposing factors ê Cortisone injections may lead to triceps tendon rupture
Thank You
Snehal Dalal, MD
hand2shoulder@gmail.com
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