Elbow dislocations
High among 10-30 year olds
MVA = most common cause
Can occur from sporting injuries and falls
Re-dislocation is uncommon
Chronic instability may be a problem post dislocation
MOI
- FOOSH
- Elbow hyperextension
- Combination of valgus, supination and ER of forearm during axial loading
Types
- Posterior or posterolateral (most common)
- Postero-medial less common
- Anterior is very rare
Patient presentation and signs/symptoms
- Severe pain and supporting arm
- Forearm shortened with olecranon and radial head protrusion
- Soft tissue swelling and deformity
- Potential damage to brachial artery, median and ulnar nerves
Diagnosis
- Physical examination
- X-ray
Treatment
- Early active management
- Early AROM started after 2 days, no passive ROM for 3 weeks, can immobilise in plaster cast for 3 weeks
- Static isometrics
- Shoulder abduction is avoided for 4 weeks
- Passive mobilisation techniques occur after healing period
- Stretches around 3 weeks
Associated injuries with elbow dislocations
Can lead to…
- Avulsion of either medial or lateral epicondyle
- Coronoid and radial head fractures
- Osteochondral lesions - particularly capitulum
- Injuries at other sites
- Ulnar styloid fractures
- Ligamentous injury to medial and lateral collateral ligaments
Terrible triad injury
Posterior elbow dislocation + radial head fracture + ulna coronoid process #
Always check neurovascular observation
Radial head fracture
Most common fracture site in elbow
MOI
- FOOSH in pronation
Damage to the collateral ligaments are commonly linked
Diagnosis
- Confirmed by x-ray
- Elbow extension test
Treatment
- Splinting
- Early ROM exercises
- 6 to 8 weeks healing
Radial head subluxations
Nursemaid’s elbow
More often sustained when the forearm is pronated
Dislocation head of the radius from the annular ligament that is often caused by an abrupt yanking of the arm
In small children, held by a stronger adult
Symptoms
- Pain in low forearm away from injury site
- Slight swelling
- Inability to supinate
- Wrist pain
Treatment
- Stop aggravating activities
- Minimal rehab due to younger age group
- Can put in brace for first 3 weeks
Medial epicondyle avulsion
Prior to epiphyseal closure rapid strong contraction of the forearm flexors is capable of avulsing the medial epicondyle in teenagers/young adult
Failure to detect it may lead to increasing valgus deformity
MOI
- Valgus strain of the joint, producing traction on the medial epicondyle through the flexor muscles. Fracture is usually extra-articular
Diagnosis
- Valgus stress test
- Xray
Treatment
- Stable: conservative (early AROM and AAROM)
- Unstable: ORIF followed by early AROM if deemed stable post-op
Olecranon bursitis
Presentation:
- Typically painless
- +/- history of injury
- Noticeable swelling
Causes
- Fall onto tip of elbow (direct blow)
- Resting elbow on hard surface
- Can be a systemic injury
Diagnosis
- Palpation
- X-ray/screening
Treatment
- Avoid provocative activity
- Rest
- Ice
- NSAID’s
- Compression
Posterior impingement
Impingement of the posterior medial corner of the olecranon tip on the olecranon fossa
Caused by 3 situations:
- Repetitive hyperextension/valgus stress overload syndrome
- Valgus instability (olecranon not fitting into fossa -> postero-medial pain)
- OA in the older patient of the radiocapitellar (RH) joint (with generalised osteophyte formation
Diagnosis and symptoms
- Valgus stress test
- Elbow extension with OP (pain)
- Pain with PAMS
- Flexion deformity
Treatment
- Rest from aggravating activities - may use ROM if compliance is poor
- Restriction of extension movements and throwing
- Return of pain free ROM
- Increase strength and stability at joint - supinators/pronators, flexion/extension strength
- Correction of throwing technique
Osteochondritis dissecans
Aetiology
- Impairment of blood supply - degeneration of articular cartilage
- Repetitive microtrauma via elbow motion (radio-capitular joint)
- Young athletes = throwing ++
Signs and symptoms
- Sudden pain, locking (loose bodies)
- Swelling, pain, crepitus, decreased ROM
- Full extension
Diagnosis
- X-ray
- MRI
Treatment
- Prevention!
- Limit number of throws
- Non-displaced lesion: rest, gentle ROM exercises, no throwing until symptoms subside and fully ROM has returned
- Displaced lesion: rest, arthroscopic debridement (removal of loose bodies), poorer prognosis
Medial elbow pain: valgus instability
MCL of the elbow - main supporting ligament to valgus stress
Causes:
- Sprain can lead to valgus instability of the elbow and pain during flexion
- Acute trauma: associated with dislocation
- Overuse injury: repetitive overload causing microtrauma
Complications:
- Bony impingement of the olecranon in superomedial aspect of the fossa
- Osteochondral lesions, bony spurs and loose bodies in the olecranon fossa
- Possible ulnar nerve injury at elbow cubital tunnel
Diagnose:
- Valgus stress test
- Moving valgus stress test
- Milk test
Treatment:
- Activity modification
- Throwing retraining
- Medial strapping
- Forearm flexor and pronator muscle strengthening
Pitcher’s elbow
UCL undergoes repetitive stress deformation
Elbow extension + valgus strain - olecranon impinges against medial trochlear groove on olecranon fossa = posteromedial osteophytes
Signs and symptoms
- Pain over medial elbow during flexion and throwing
- POP over MCL
- Unable to throw at full speed
- May eventually rupture (acute on chronic)
- Possible swelling (often absent in chronic conditions)
Diagnosis
- Loss of extension ROM
- Laxity on valgus stress test
- Hyperalgesia on palpation over ulnar nerve/posteromedial tenderness (near MCL)
- Radiographic examination
Little league elbow
Same injury as pitchers elbow but in adolescents
Medial epicondylar apophysitis or traction apophysitis and epicondylitis
Can lead to medial epicondyle avulsion fracture which requires surgery
Treatment
- Stop throwing/aggravating activities
- Restore motion and when appropriate begin strengthening of dynamic stabilisers of medial elbow
Medial epicondylalgia
Golfer’s Elbow
Overuse of the common flexor tendons of the wrist
Management/treatment is dependent on symptoms
Diagnosis
- Resisted wrist flexion
- TOP over medial epicondyle
- Could have pain during wrist extension
Treatment
- Isometrics wrist flexion, ulnar deviation, pronation (build to isotonics starting with slow eccentric then progressing to concentric: 3 sets 15 reps)
- Gentle ROM of elbow and wrist extension in supination
- Kinetic chain
- Functional rehab
Ulnar nerve injury
Causes
- Traction with throwing activities
- Anatomy/congenital variations
- Perineural adhesion
- Joint disease/osteophytes
- Prolonged bed rest
- Leaning on elbow (repetitive)
Signs and symptoms
- Posteromedial elbow pain
- Pins/needles/numbness/weakness
- TOP
- History - traction versus compression (secondary to valgus instability)
- May report snapping (subluxations over medial epicondyle
Diagnosis
- Ulnar neurodynamic test
- Tinel’s sign
Treatment:
- Splint may help
- Improve forearm/wrist flexor and pronator flexibility
- Vitamin B6
- Avoid aggravating factors; sustained and/or repetitive elbow flexion and supination
Radial tunnel syndrome
Repeated use of extensor/supinator muscle mass
Compression of posterior interosseous nerve entering the supinator muscle through Arcade of Frohse
Symptoms
- Pain over lateral elbow
- Pain with grip
- TOP over extensors
- Neural symptoms
Diagnosis
- Neurodynamic radial test
- Grip strength test
- Weakness of thumb abduction/extension
- Weakness on resisted wrist extension (ED and ECU)
Treatment
- Soft tissue manipulation over supinator
- Strengthen impairment
- Slider exercises for radial nerve
Lateral epicondylalgia
Tennis Elbow
Signs and symptoms
- Pain over lateral epicondyle +/- into forearm
- Not radiating into shoulder or to fingers
- Pain when gripping, twisting or lifting
- Often associated with repetitive use
Diagnosis
- Resisted wrist extension
- TOP over lateral epicondyle
- Grip strength test
- No Cx joint signs at C5-6
- Negative neurodynamic test
- 2nd/3rd finger isometric extension (ERCB; ECRL)
Treatment
- lateral gliding taping
- MWMs with radial head PA/AP with grip strength
- POLICE, NSAIDS
- Build up to wrist ROM and strengthening exercises
