Chapte

r9-
 
Injuries 
­Elbow

   

   
• Introduction

• Anatomy and biomechanics

• Ligamentous injuries and instability

○ Medial (ulnar) collateral ligament injuries

 Acute rupture of the MCL

○ Valgus extension overload

○ Posterolateral rotatory instability

• Tennis elbow

• Golfer’s elbow

• Osteochondritis dissecans

• Panners disease

• Little leaguer’s elbow

• Medial epicondylar fractures

• Olecranon bursitis

○ Acute

○ Chronic

○ Septic

• Tendinous ruptures

○ Tendon injuries around the elbow

○ Distal biceps rupture

○ Rupture of the triceps tendon

• Fractures and dislocations

○ Supracondylar fractures

○ Lateral condylar fractures

○ Fractures of the radial head

○ Fractures of the neck of radius

 ○ Elbow dislocations

• Nerve compression syndromes

○ Cubital tunnel syndrome

○ Radial nerve (radial tunnel)

○ Median nerve

○ Musculocutaneous nerve

• Intra-articular derangements

○ Loose bodies

○ Osteoarthritis of the elbow

1 D. Bokor, D Duckworth. The Elbow in E Sherry and D Bokor (eds), Manual of Sports Medicine. GMM London,

1997

Introduction

The elbow is a difficult joint to examine diagnose and treat (not a frequent site of trauma and
injury). Nevertheless the elbow is becoming better understood as more participate in throwing or
overhead sports resulting in an increasing number of elbow problems requiring treatment.
Overuse injuries in throwing or catching sports create most chronic elbow problems (may
involve the ligaments, capsule, muscles or articular surfaces of the joint to impair function).
Particular sports cause specific injuries around the elbow (Table 1).

  Table 1. Sports specific elbow problems  

  Sport Condition  
Golf Medial epicondylitis
Tennis Lateral epicondylitis
Baseball MCL injuries

Valgus extension overload

Little leaguers elbow

OCD Panner’s disease

Ulnar neuritis/cubital tunnel

Acute rupture MCL

Medial epicondylitis
Gymnastics OCD
 Javelin Acute rupture MCL

Partial rupture MCL

Epicondylitis

  Anatomy and biomechanics

The elbow is a highly constrained hinge joint, (its stability is maintained by ligamentous, osseous
and capsular structures) with a slight degree of varus/valgus and rotational laxity (3-5 degrees)
throughout the flexion - extension arc.
There are 3 articulations here (Fig. 1)
• Ulnohumeral - allows 0-150 degrees flexion.
• Radiocapitellar.
• Proximal Radio-ulnar joints (radiocapitellar allows 75 degrees pronation and 85 degrees
supination).

Note: Most daily activity is done through a 100 degree arc of flexion and extension (usually 30-
130 degrees) Forearm rotation occurs in an arc of 100 degrees, (usually 50 degrees supination
and 50 degrees pronation). Any loss of this arc of movement may limit one’s function.

Elbow Stability. Ligamentous stability is provided by the medial and lateral ligamentous complex.
(The relative importance of these ligaments depends on the position of the arm).

Medial Collateral Ligament: has 3 parts. The anterior oblique ligament is the most important of
these bands originating from the medial epicondyle and inserting onto the medial aspect of the
coronoid process; The anterior band is the primary constraint to VALGUS instability and the
radial head is of secondary importance (clinically, this is noted in throwing as the repetitive
valgus stress can result in microtrauma and attenuation of the anterior oblique ligament).

Lateral Collateral Ligament: has 3 parts and offers varus stability (rarely stressed in the athlete)
The lateral ulnar collateral, the most important of these ligaments plays an important role in
rotational instability, it originates from the lateral epicondyle and inserts onto the tubercle of the
supinator crest of the ulna; Its function is to prevent Varus and Posterolateral rotatory instability
of the elbow. The capsule serves as an important constraint to instability in full extension.

Neurological anatomy. Neurological compression syndromes are common here due to the
closeness of the nerves. The ulnar nerve is vulnerable within the cubital tunnel, posterior to the
medial epicondyle. The median nerve is anterior deep within the cubital fossa, the radial nerve is
lateral and branches in the cubital fossa.

Ligament injuries and instability

Medial (ulnar) collateral ligament injuries (MCL)

From throwing sports where repetitive valgus stress results in small tears in the anterior band of
the MCL and subsequent rupture. Occurs in javelin throwers and baseball pitchers (in throwing
there is an enormous valgus stress on the elbow during the late-cocking phase so overloading
the ligament leading to attenuation and rupture). Occasionally there is a single acute painful
throw or a fall onto the outstretched hand.

Examination reveals swelling and pain (localized to the medial side) and occasionally
paraesthesia in the ulnar nerve distribution. Valgus deformity and elbow contracture may follow.
Valgus stress testing with the elbow at 30 degrees of flexion displays increased laxity and pain.
Incongruity develops between the olecranon process and its fossa with loose body formation at
the medial side of the olecranon. X-ray’s may show osseous bodies in the MCL or fluffy
calcification at the tip of the olecranon.

Treatment is rest, activity modification, NSAIDs and physiotherapy. If posteromedial pain

continues then arthroscopy is necessary to debride the osteophytes. If there is chronic MCL
laxity or instability then surgical reconstruction (primary repair or use palmaris longus is
necessary.

Acute rupture of the MCL

Isolated tears of the anterior oblique ligament may occur in javelin throwers. The mechanism is
almost pure valgus stress with the elbow flexed at 60-90 degrees. There is severe pain and a
pop on the medial side of the elbow. Ulnar nerve symptoms may occur with ecchymosis about
the elbow (48 hours later). If the diagnosis is in doubt stress tests or stress x-rays are useful .
Acute repair of the ligament is necessary.

Valgus extension overload

Seen in pitchers during the acceleration phase. (In the early phase of acceleration excessive
valgus stress is applied to the elbow causing impingement). There results osteophyte formation
posteriorly and posteromedially which can cause chondromalacia with loose body formation.

The pitcher presents with pain on pitching (early in the game) and are not able to let go of the
ball. Pain over the olecranon fossa occurs in valgus and extension. X-rays show a posterior
osteophyte at the tip of the olecranon (on lateral views).

Treatment (should be started early) is increasing functional strength, heat and ultrasound. An
osteophyte needs surgical excision).

Posterolateral rotatory instability1

Differentiate from a frank elbow dislocation. Caused by a laxity or disruption of the ulnar part of
the lateral collateral ligament which then allows a transient rotatory subluxation of the ulno-
humeral joint (and secondary dislocation of the radio-humeral joint).

There maybe preceding trauma (dislocation or sprain from a fall on an outstretched hand).
Previous surgery, radial head excision or lateral release for a tennis elbow, maybe the cause of
instability.

There is a history of a recurring click, snap, clunking, locking of the elbow and a sense of
instability that ones elbow is about to dislocate. Such stability episodes occur with a loaded
extended elbow and supinated forearm. Examination, often unremarkable, should include the
‘Lateral Pivot Shift’ (Posterolateral rotatory apprehension test)(Fig 2- Performed with patient
supine, preferably under general anaesthesia; The elbow is extended overhead and the forearm
fully supinated; A valgus and supination force is then slowly applied to the elbow going from the
extended to flexed position; This results in subluxation of the ulno-humeral joint and radio-
humeral joint ).

On X-ray the joint will look normal (unless taken with the joint subluxed) so the diagnosis is
made from history and after above test. When symptomatic surgery is required (re-attach the
avulsed lateral ulnar collateral ligament or reconstructing it (with a tendon graft).

1 S W O’Driscoll, D F Bell, B F Morrey 1991. Posterolateral rotatory instability of the elbow JBJS 73A 440

Tennis elbow (lateral epicondylitis)

A lateral tendinitis which involves the origin of Extensor Carpi Radialis Brevis. It is related to
activities that increase tension and stress on the wrist extensors and supinator muscles (not all
activities include tennis.

It occurs between the ages of 35-55 years with pain localized to the lateral epicondyle especially
after a period of unaccustomed activity (such as tennis 3-4 times a week). The pain is worsened
by movements such as turning a door handle or shaking hands Examination reveals pain
localized to the lateral epicondyle and distally. Typically aggravated by passive stretching the
wrist extensors or actively extending the wrist with the elbow straight (Fig.3 ).

X-rays are often normal (to exclude OA, LB or tumour). A bone scan will show increased uptake
about the lateral epicondyle. An ultrasound or MRI will show degeneration within the belly of
ECRB. The differential diagnosis includes: posterior interosseus nerve entrapment ( has a more
distal localization of the pain and associated weakness); radial tunnel syndrome (pain distal and
exacerbated by resisted extension of long digit, i.e. ECRB); OA/LB/Tumour.

It will resolve over a 10-12 month period but there is a 30% recurrence therefore treat
comprehensively1 with rest, activity modification, NSAIDs, heat, ultrasound, phonophoresis with
10% hydrocortisone cream, brace (counterforce effect), eccentric muscle strengthening, modify
tennis handle (usually too large) or tennis stroke (occurs in back hand stroke). injection of
cortico-steroid (no more than 3, just below ECRB, anterior and distal to the epicondyle), and
then surgery (symptoms >12 months, release and excise ECRB, note Nirschl scratch effect).
Return to sport when strength 80% back or after 4 to 6 months.

1 C C Teitz et al 1997. Tendon Problems in Athletic Individuals JBJS 79A p 138-152.

Golfers elbow (medial epicondylitis)

An inflammation of the flexor tendinous origin from the medial epicondyle. From repetitive
activity of wrist flexion and active pronation such (in baseball pitching or occasionally golf and
tennis). The pathology is at the interface of pronator teres and FCR.

Presents with tenderness over the medial epicondyle radiating down the forearm, exacerbated
by resisted palmer flexion and pronation. Ulnar nerve symptoms are present in 60% of cases.

Treatment is very similar to lateral epicondylitis. Exclude other ulnar neuropraxia, joint stability or
cervical pathology. Treatment is rest, activity modification, NSAIDs and physiotherapy. Avoid
repeated steroid injections (so close to ulnar nerve). Only rarely is surgical release needed,
(release the common flexor origin with occasionally a medial epicondylectomy).

Osteochondritis dissecan’s (OCD)

This is a spontaneous necrosis and fragmentation of the capitellar ossific nucleus (thought to be
from compression forces at the Radio-Capitellar joint producing focal arterial injury and bone
death). Occurs in gymnastics and throwing sports (baseball pitchers).

There is lateral elbow pain post activity, occurs in the 10-15 year old group, and involves the
dominant arm. Examination shows an inability to fully extend the elbow and pain on forced
extension. Panner’s is a similar condition; the major difference being the x-ray appearance
(fragmentation of entire capitellar ossific nucleus versus island of subchondral bone in OCD)
and age of onset (<10 years). Early on the X-rays may be normal and if clinically suspected a
bone scan or CT Scan is needed. Treatment is rest for 6 weeks, however if pain and contracture
persist fragmentation may have occurred. Arthroscopy is then performed and if the fragment is
separately removed (occasionally reattached if large).

Panner’s disease

An ‘Osteochondrosis’ which affects the growth centres in children resulting in necrosis followed
by regeneration. Here it involves the capitellum resulting in fragmentation and then
regeneration. Commonly confused with OCD due to similar presentation dull aching elbow pain
aggravated by use, loss of full elbow extension and lateral swelling. X-rays show fragmentation,
irregularity and a smaller capitellum (compared to OCD) (as growth progresses the capitellum
returns to normal) A self limiting condition, no specific treatment is necessary apart from rest
during the acute period.

Little leaguer’s elbow

A medial epicondylar stress lesion or acute valgus stress syndrome which occurs in children.
Results from repetitive valgus stress in a young throwing athlete which causes a flexor forearm
muscle pull on the medial epicondyle epiphysis(Fig 4).

Present with medial sided elbow pain with decreased throwing effectiveness and throwing
distance. Examination reveals medial epicondylar tenderness and pain on loading the flexor
muscles. An elbow flexion contracture may be present.

X-ray show separation and fragmentation of the epiphyseal lines. A benign injury which
responds to rest and activity modification. Return to throwing after 6 weeks, and only
occasionally (if a large fragment separated) surgical fixation.

Medial epicondylar fractures

A substantial acute valgus stress (fall or violent muscle contracture whilst throwing) can produce
a fracture through the epiphyseal plate seen in adolescents and throwers.

There is pain and localized tenderness over the medial epicondyle. A 15 degrees flexion
contracture is present. X-ray’s may show a minimal to markedly displacement (with the fragment
sometimes caught in the joint).

Treatment depends upon the degree of displacement. If the fragment is undisplaced or

displaced less than 1 cm, then immobilize for 3-4 weeks; If grossly displaced or caught in the
joint or if ulnar nerve symptoms are present then open reduction is necessary.

Olecranon bursitis

Acute

An inflammation of the superficial olecranon bursa, (from direct trauma or repetitive stress about
the elbow). Non traumatic causes are gout or rheumatoid arthritis.

There is an enlarged, non tender bursa with normal ROM. Exclude a septic bursitis (the bursa is
inflamed and tender; the patient septic with fever and malaise).
If worried about sepsis then aspirate under aseptic conditions. For recurrent bursitis X-ray to
look for an olecranon spur or calcification as seen in gout. If the bursitis is associated with an
inflammatory condition then control of the underlying condition. On first presentation use NSAID,
and treat cause. Rest, activity modification and NSAIDs will usually relieve the bursitis (over a
few months).

Chronic

Severe persistent olecranon bursitis will require operative intervention (a posterior incision with
excision of the burial sac).

Septic

Note: Infection of the bursa does not mean elbow joint infection (as it does not communicate
with joint) 1/3 give a history of a previous non infected bursitis.

Symptoms are either acute onset of cellulitis to a low grade process of 2 or more weeks. The
bursa is erythematous and tender and there are signs of generalized sepsis. Diagnosis is
confirmed by aspiration (look for organisms) and an increased white cell count (consistent with
infection). The presence of crystals in the aspirate indicates gout or pseudogout. Treatment is
aspiration and antibiotics however if this fails surgical drainage is required.

Tendinous ruptures

Tendon injuries around the elbow1

Apart from epicondylitis, injuries to the tendons around the elbow are uncommon. The tendons
that can rupture are the distal biceps (from the radial tuberosity) or the distal triceps (from its
insertion into the olecranon).

1 R P Nirschl 1993. Sports and overuse injuries to the elbow. In Morrey BF (ed). The Elbow and its Disorders 2nd

ed. Philadelphia. Saunders. p 537-552.

Distal biceps rupture

3-10% of all biceps ruptures occurs in the dominant arm of a well developed male (in his 40’s-
50’s). The result of a single traumatic event, (sudden extension force whilst flexing (contracting)
the biceps).

There is sudden sharp pain and discomfort in the antecubital fossa. Note weakness the elbow
flexion and supination (with the elbow flexed). The muscle contracts proximally and a defect is
noticeable.
Surgical treatment is (difficult, suggest anterior approach with anchor suture to bicipital
tuberosity) almost always recommended (conservative management leads to moderate
weakness especially in manual workers). Complications of surgery include cross union between
the radius and ulna or a posterior interosseous nerve palsy.

Rupture of the triceps tendon

May occur spontaneously or after injury (from a decelerating force on the arm in extension
during a fall). It can also result from sudden forced flexion whilst the elbow is being extended.
Sudden pain and local swelling with a corresponding defect in the triceps tendon. X-ray may
show a small bony fragment (avulsion of the tendon from the olecranon). Some loss of
extension power is present.

Fractures and dislocations

Supracondylar fractures

The worrisome fracture. These occur in children with 97% being posteriorly displaced or
angulated (from an extension injury due to a fall on an outstretched hand, causing the distal
lower humerus to be pushed backwards).

There is a painful, swollen elbow and S-deformity. Check the pulse (and circulation) which may
be compromised from swelling and fracture configuration. Check the nerves as (10-15% have a
neuropraxia of radial, anterior interosseous, median nerve, ulnar -in that order).

Treat undisplaced fractures in a collar n cuff for 3 weeks (Monitor the position with serial X-rays).
Displaced fractures require at least a closed reduction and (occasionally) percutaneous K-Wires
if unstable.

Complications include cubitus varus (gun-stock deformity, cosmetic) or neurological. Vascular

insufficiency resulting in Volkmann’s ischaemia and later myositis ossifications can occur (a
disaster). Adult supracondylar and intercondylar fractures are not nearly as common (generally
require open reduction and internal fixation).

Lateral condylar fractures

The lateral condyle epiphysis begins to ossify by one and fuses to the shaft by 12 to 14 years of
age. During these years (from 4 to 10) fracture separations may occur. It is important to pick up
such a fracture as it may lead to growth plate damage and as involves the joint accurate
reduction is critical. Later problems include cubitus valgus with tardy ulnar nerve palsy. If
undisplaced splint the arm in a backslab at 90 degrees; if displaced requires accurate reduction
and fixation with K wires.
Fractures of the radial head

More common in adults than children, result from a fall on the outstretched hand pushing the
elbow into valgus and compressing the radial head. If undisplaced treat in a backslab; if
displaced require open reduction (if possible) excision (if grossly comminuted).

Fractures of the neck of radius

Same mechanism as radial head fractures. (In adult fracture the radial head; children, due to the
cartilaginous epiphysis, fracture through the radial neck). Up to 20 degrees of radial tilt is ok,
beyond 20 degrees closed reduction and occasionally open reduction (if difficult) Monteggia
Fractures result from a fall on an outstretched hand resulting in a fracture of the ulna with
dislocation of the radial (often missed). This fracture requires a closed reduction and
immobilisation closely monitoring the position of the radial head (on x-ray line down the middle
of the radial shaft should bisect radial head in all views).

Elbow dislocations

More common in adults. Without fracture are called simple and classified according to the
direction of the displacement of the olecranon (79% are posterior or posterolaterally).

Result from a fall on the outstretched hand (with the elbow in extension); The anterior capsule
brachialis. The surrounding ligaments may stretch or rupture depending on the direction of the
dislocation. There may be a fracture.

There is obvious deformity, pain and swelling. There may be vessel and neurological damage.
(Neuropraxia seen in 20% of cases , involves the ulnar or median nerves, and transient). X-ray’s
necessary .

Closed reduction is performed (Apply longitudinal traction, with the free hand move the
olecranon back onto the trochlea, ideally under general anaesthetic so as to assess the elbow
stability post reduction). If stable can return to protected motion as soon as possible although
(may loose the last few degrees of extension and supination).

Associate injuries and complications (do note) include fractures (or avulsion of the medial of
epicondyle), head of radius, or olecranon process; heterotopic ossification, recurrent
dislocations and vascular or neural injury.

Nerve compression syndromes

Numerous nerves maybe compressed around the elbow. These include:

• ulnar nerve - cubital tunnel, Guyons canal.

• radial nerve - radial tunnel/ arcade of Frohse (post. interosseous nerve) / Wartenburg
 syndrome

• median nerve - pronator syndrome / ant. interosseous syndrome / carpal tunnel.

Compression may occur from fracture or gradual onset (no injury) from degenerative changes
about the joint, a space occupying lesion (ganglion or bursa) or musculotendinous anomalies.
Clinically localized sensory and motor changes specific for a particular nerve are seen.

Cubital tunnel syndrome

This is an irritation or compression of the ulnar nerve within the cubital tunnel at the elbow (in
the athlete a response to chronic activity). Chronic valgus strain may cause traction neuritis,
scar formation, spurs, calcification in the MCL or osteophytes (all can compress ulnar nerve).

Pain along the medial side of the forearm which may be proximally or distally. Paraesthesia in
the little and ring ringers is seen early and precedes any detectable motor weakness of the
hand. Ulnar paradox present (claw deformity of hand is less than if ulnar compressed in hand as
FDP to little not working). There is a positive percussion test over the ulnar nerve at the elbow,
abnormal mobility of the nerve over the medial epicondyle and a positive provocative test(Fig 5-
hyperflex elbow; dorsiflex wrist pain/symptoms reproduced). Clumsiness of the hand especially
after pitching may be noted.

Diagnosis may require nerve conduction studies. Differential diagnosis includes cervical spine
pathology, thoracic outlet or pathology involving the ulnar nerve at the wrist. Treatment is initially
an elbow splint and correction of the underlying pathology. If this fails then surgical
decompression with transposition of the ulnar nerve (or medial epicondylectomy).

Radial nerve (radial tunnel)

The radial nerve may be compressed along its path from the lateral head of triceps to mid
forearm (where branches into the posterior interosseous nerve) from trauma. There is lateral
elbow pain (similar to lateral epicondylitis pain). Neurological symptoms and signs including
weakness of wrist and finger extension and paraesthesia dorsally over the base of the thumb
(exacerbated by resisted extension of long digit: which differentiates from tennis elbow). Surgical
decompression is often required.

Median nerve

The median nerve is vulnerable to compression from: supracondyloid process (lig. struthers),
fibrosus lacertus, pronator teres or flexor superficialis arch. Such compression may produce the:

Pronator syndrome- not uncommon in athlete, symptoms are vague (discomfort in the forearm)
with numbness of the hand in the median nerve distribution secondary. Repetitive activities such
as industrial activities, weight training or driving will provoke symptoms. Signs include
tenderness over pronator muscle, proximal forearm pain on resisted pronation, elbow flexion
and wrist flexion. Test: Resisted flexion of the middle or ring finger PIP will reproduce symptoms.

Anterior interosseous syndrome. Where the anterior interosseous branch of the median is
compressed between the two heads of the pronator muscle. Pain in proximal forearm,
weakness of end pinch with FPL, and index finger FDP (difficulty forming OK sign with flexion of
DIP index and IP of thumb). Treatment requires surgical release.

Musculocutaneous nerve

May be compressed between biceps and brachialis by lateral epicondyle Surgical release
sometimes necessary.

Intra-articular derangements

Loose bodies

In the elbow from old trauma, OA, osteochondritis dissecans and synovial chondromatosis.
Extension is reduced and there is pain and locking (intermittent) or grating. X-ray’s are useful.

If troublesome then remove surgically (arthroscopically or if multiple loose bodies then via an
arthrotomy). Synovectomy may be necessary for synovial chondromatosis.

Osteoarthritis of the elbow

OA of the elbow joint from trauma, OCD or synovial disease (chondrometaplasia). Pain with loss
of range of motion, locking, localized tenderness, joint thickening, crepitus and flexion
contracture often with associated ulnar nerve irritation.

Treatment: Rest, physiotherapy and NSAIDs with modification of activity. Later arthroscopic
debridement, radial head excision or arthroplasty may be required.