THE ELBOW

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					                                      THE ELBOW                                             1
                              Gaetano P. Monteleone, Jr., M.D.
                          Dept. of Family and Community Medicine
                                 Division of Sports Medicine
                         West Virginia University School of Medicine
                                monteleoneg@rcbhsc.wvu.edu


I. The ELBOW- The Forgotten Child
              A. Anatomy
       • Tendons: common extensor tendon origin, flexor pronator muscle mass
       • Ligaments: medial collateral ligament, annular ligament, lateral collateral ligament
       • Bones: Humerus, radius, ulna
       • Growth Centers: capitellum, radial head, medial epicondyle, trochlea, olecranon and
          lateral epicondyle




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                                          THE ELBOW                                              2
                                 Gaetano P. Monteleone, Jr., M.D.
                             Dept. of Family and Community Medicine
                                    Division of Sports Medicine
                            West Virginia University School of Medicine
                                   monteleoneg@rcbhsc.wvu.edu

B. Specific Injuries

•        TENDON
                 1. Lateral Epicondylitis: 10 times more common than medial epicondylitis.
Hx- pain on the lateral aspect of the elbow. Pain may radiate to extensor tendon muscle bellies
proximally. Mech = repetitive microtrauma. Tennis, carpentry, painter.
PE- pain to palpation of lateral epicondyle. Pain with resisted supination and extension.
Neurovascularly intact.
Dx- easily by H&P. Xrays rarely needed for specific dx. May help r/o other disorders if dx in
doubt.
Rx- PRICES, NSAID's, stretch/strengthening exercises for the elbow and wrist. Use of
counterforce brace with activity may also help. Consider steroid injection if not responding to
Rx. REFER if pt not responding to this treatment after 6-12 months. If tennis is the culprit,
attention to proper technique and equipment is necessary:
                 •      Racket diameter = length from tip of ring finger to proximal palmar crease
                        (in inches)
                 •      Strings too tight increase risk
                 •      Hit ball off-center of racket increases risk
                 2. Medial Epicondylitis
Hx- pain on medial aspect of the elbow
PE- Tender to palpation of medial epicondyle. Pain with resisted flexion and pronation.
DDx- ulnar neuropathy, MCL sprain of the elbow, traction apophysitis of medial epicondyle
(little-league elbow).
Rx- as above for lateral epicondyle. Counterforce brace may not be as helpful here; sometimes
splinting wrist in slight flexion will help.

•         LIGAMENTS
               1. Medial (ulnar) collateral ligament sprain- repetitive microtrauma leads to
               stretch or tear of the medial collateral ligament. This may produce insidious onset
               of pain and instability at the elbow to valgus stress (vaLgus= distal part Lateral).
               Especially common in overhead throwing athletes (pitchers, quarterbacks) and
               wrestlers. Tenderness and instability with valgus stress test at the elbow, similar
               to the valgus stress test of the knee assessing the MCL. Compare to the unaffected
               side! Remember, dominant hand in throwing usually has more motion. Rx-
               PRICES, NSAID's, rehab (elbow stretch/strengthen exercises). If acute injury or
               severe pain, consider sling immobilization for comfort for a brief period in time.
               REFER for surgery if recurrent pain or instability if no response to above Rx.

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                 2. Subluxation of radial head (Nurse-maid's elbow)- Ave 1-3 years, rare after 6
                 yrs. Annular ligament tears or stretches.
                 Hx- episode of trauma: being swung, lifted or pulled by the arms.
                 PE- child in some distress, holding elbow in slight flexion, full pronation. Child
                 does not spontaneously bend elbow. Good pulses, neuro exam.
                 Dx- based on history, age, presentation. Xrays to r/o associated fractures, though
                 not helpful in specific dx of radial head subluxation.
                 Rx-
                 ·               Reduction: with wrist supination and forearm extension.
                        Examiner's thumb applying a posterior-directed force at radial head will
                        appreciate a reduction (clunk). Immediate pain relief and motion at elbow
                        is typical.
                 ·               Post-reduction treatment: immobilization not necessary for first
                        event. Some authors advocate posterior arm splint (elbow at 90° flexion
                        and full supination) for up to 10 days if prolonged time prior to reduction.
                        Ibuprofen 10 mg/kg/dose q 8 hrs as needed. Consider cast application if
                        recurrent (> 2 ) episodes.

•         BURSA
               1. Olecranon bursitis- inflammation of the bursa in posterior elbow. This may
               occur because of chronic repetitive pressure or acute blunt trauma.
               Hx- pain with decreased ROM.
               PE- significant swelling of the posterior elbow. May have overlying skin
               erythema, warmth. Must r/o septic bursitis! This will involve more swelling, pain
               and warmth than inflammatory bursitis (with or without fever).
               Dx- H&P, xrays usually negative. Aspirate fluid for analysis to help r/o infection,
                rheumatoid arthritis, gout, pseudogout.
               Rx- NSAID's, ice, compression wrap and avoidance of repetitive microtrauma.
               Tough cases of inflammatory bursitis may respond to intra-bursal steroids. Avoid
               steroids if septic bursitis! If septic bursitis, serial aspiration with antibiotics.

•         BONE
                 1. Radial head fracture
                        a. Mech = fall on outstretched hand
                        b. Classification-
          •      Type I: undisplaced fractures
          •      Type II: displaced marginal and segmental fractures
          •      Type III: comminuted fractures of the head
          •      Type IV: Fracture/Dislocation radioulnar dissociation, elbow instability
                        c. PE = Significant edema, pain antecubital fossa, pain with
                        supination/pronation.

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                             d. Radiology- AP, lateral, ? radial head view: assess for anterior or
                             posterior fat pad sign. Visualization of an anterior fat pad on lateral xray
                             may be normal; pathologic anterior fat pad is thickened with characteristic
                             "sail sign." Posterior fat pat pad on lateral xray is always considered
                             pathologic. Therefore, if seen, must consider an occult fx. Consider
                             comparison view in pediatric population.
                             e. Treatment- Type I, and some types II and III (no mechanical block, less
                             displacement/angulation) sling or posterior splint for comfort 1-2 wks.
                             REFER Types II and III if moderate displacement of marginal and
                             segmental fractures. Another "rule" is the 3-3-3 rule: REFER for surgery
                             any fx depressed 3mm, angulated 30°, or if fx involves 30% of articular
                             surface. Many months may elapse before full extension is regained.
                             SURGERY especially if rotation block or ligamentous instability.



                       2. The Pediatric Elbow
a. In the pediatric population, remember the six ossification centers and sequence of fusion!
They can simulate a fx. In addition a fx may be overlooked as a "normal" ossification center.
They are easily remembered by the mnemonic CRITOE.


                          Ossification Center               Age at First Appearance (years)

           C: capitellum                                                  1

           R: radial head                                                 3

           I: internal (medial) epicondyle                                5

           T: trochlea                                                    7

           O: olecranon                                                   9

           E: external (lateral) epicondyle                               11


While exact adherence to the numbers is not helpful, remember the general timing of appearance
of each ossification center in relation to each other. The general appearance of ossification
centers at the elbow is 1,3,5,7,9,11.

Note: For example, visualization of a capitellum "ossification center" at the same time as
trochlear, olecranon and lateral epicondyle centers suggests a capitellum fracture.

b. On the lateral xray, a line drawn down the anterior shaft of the distal humerus will intersect

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the middle _ of the ossification center of the capitellum. If it does not, consider a capitellum fx.
In a true lateral xray, you can visualize the "hourglass." If an hourglass is not seen, then the
above rule does not apply.
                 3. Little-league elbow- traction apophysitis of the medial epicondyle. (The
                 lateral side sustains significant compression and is at risk for OCD at the radial
                 head).
        Hx- Overuse (high number of pitches per week in games and practices) may lead to
        repetitive microtrauma. Typically pain occurs at the medial epicondyle, especially with
        activity.
        PE demonstrates pain on palpation of the
        medial ossification center. +edema,
        ecchymosis
        Dx- xrays may demonstrate widened
        apophysis. Consider comparison views.
        Rx- nonsurgical treatment OK for no
        significant displacement (< 5mm) on xray.
        PRICES, NSAID's, rest from pitching for 6-
        12 weeks. If displacement of > 5mm, REFER
        to orthopedics.

                 4. Osteochondritis dessicans (OCD) of the capitellum and Panner's disease-
                 may also rarely occur on the radial head. Panner first described a process of cystic
                 degeneration in the capitellum in 1927. It is different from OCD in presentation
                 and prognosis. See table below for comparison. OCD most common in baseball
                 and gymnastics. Etiology include trauma, local ischemia and genetic factors
                 (Andrish, 1997).


                                    Panner’s disease                               OCD

 Age of presentation   5-10 years                             Preadolescent/adolescent

 Xray                  Defect involves entire capitellum      •        Localized (lateral) defect capitellum
                                                              •        Loose body formation
                                                              •        2o hypertrophy changes of the radius

 Prognosis             Resolves with growth and development   May lead to early arthritis


          Dx- xrays diagnostic with sclerosis and cyst formation. + loose bodies. If ?'s- CT vs
          MRI. Remember that finding of a cyst in this age group is not uncommon. Usually they
          are found in the metaphysis, not the epiphysis.
          Rx- PRICES, NSAID's, rehab. Surgery if failure of nonsurgical treatment, loose bodies,
          and locked elbow.

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More about growth plates and ossification centers:
          II. Apophysis (apophysitis or avulsion fx)- growth plate at site of tendon insertion

          Generally occurs with acute forceful contraction of muscle; usually without trauma.
          Mostly treated nonsurgically; excellent outcomes, no functional limitations.
          The ability of the apophysis to resist tension is weakest at time of its appearance.
          Rx initially with rest and anti-inflammatories, then gradual increase in ROM,
          strengthening. Return to work/play when sx tolerance.
          Note REFER if wide displacement of fx fragment or if continued sxs after reasonable
          attempt at nonsurgical Rx.
Apophysis                               Muscle attachments                   Age at 1st appearance

Iliac crest                             •       Tensor fascia lata                12-15 years
                                        •       Gluteus medius
                                        •       Transverse abdominis
                                        •       Internal/external obliques

Anterior superior iliac spine (ASIS)    •       Sartorius                         13-15 years

Ischial tuberosity                      •       Hamstrings                        14-16 years

Lesser trochanter                       •       Iliopsoas                         8-12 years


Greater trochanter                      •       Gluteus medius, minimis             4 years
                                        •       Obturator


III. Other apophyses
               1. Tibial tubercle = Osgood-Schlatter disease
       Hx- insidious onset anterior knee pain, especially with overuse (jumping, running, etc.).
       Common in the patient undergoing a growth spurt (ie: 11-15 yrs old).
       PE- point tender on tendon or tibial tubercle (Osgood-Schlatter Disease). Also, may see
       deformity or bony irregularity with Osgood-Schlatter disease (tibial tubercle) and
       Sinding-Larsen-Johansson syndrome (inferior pole of the patella). Tightness of the
       hamstring, quadriceps and heel cord musculature.
       Xrays- most often, normal. May see calcification at one of the poles of the patella. May
       also see fragmentation or avulsion fracture at the tibial tubercle. Some authors advocate
       xray to rule out tumor.
       Rx- A Chopat strap may be used to provide comfort. This may also be accomplished
       with taping or other braces.
       Paramount in treatment of patellofemoral disorders is the strengthening of the VMO and
       the improved flexibility of the hamstrings:

•         PRICES
•         NSAID's or analgesics
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•         Bracing- include lateral support (donut or "U") with patellar cutout
•         VMO strengthening
•         Hamstring flexibility
•         Correct leg length inequality (heel lift- not pad or cushion)
•         ? McConnell patellar taping

                   2. Calcaneus = Sever's disease
          Hx- pain in the posterior heel. Common during growth spurt (early adolescence).
          PE- tender to palpation posterior heel and positive heel compression test (pain with
          lateral compression).
          Dx- H&P; xrays may demonstrate sclerosis and fragmentation of the calcaneus. Most
          often, xrays are normal.
          Rx- supportive care. Exercises emphasizing stretching of the achilles and plantar fascia.

IV. General physeal (growth plate) injuries

                 a. Salter-Harris physeal injury classification- note that the physis (growth
plate) is the weak link in the system. For example, this means that an ankle inversion injury in a
child is less likely to cause a ligament sprain, and more likely to result in bony fracture at the
physis. High clinical suspicion is necessary in this population in Salter I injuries since an
obvious fracture may not be easily identified on xray.



•         I      Through the growth plate
•         II     Through the physis and metaphysis
•         III    Through the physis and epiphysis
•         IV     Through the epiphysis and metaphysis
•         V      Compression injury through physis

N.B. Types I and II fibular fractures are the most
common ankle fractures in children. Mechanism is
inversion. Prognosis with these fractures is very good,
with less concern for growth abnormalities as child
ages.



This system of classification has prognostic significance. Rarely do Salter I and II injuries result
in delayed or abnormal growth patterns as the child grows. On the other hand, Salter III-V do
result in risk for growth delays and abnormal growth patterns as the child grows.



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REFERENCES

Andrish JT. Osteochondritis dessicans in a young pitcher- why early recognition matters. Phys
Sports Med. 25(3):85-90, 1997.

Caldwell GL, Safran MR. Elbow problems in the athlete. Ortho Clinics North Am. 26(3): 465-
85, 1995.

Fick DS, Lyons TA. Interpreting elbow radiology in children. Am Fam Phys. 55(4):1278-81,
1997.

Gutierrez G. Management of radial head fractures. Am Fam Phys. 55(6):2213-8, 1997.

Hall TL, Galia AM. Osteochondritis of the elbow. Phys Sports Med. 27(2): 85-94, 1999.

Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J AM Acad Orthop Surg.
2(1)-1-8, 1994.

Mellion MB, Walsh WM, Shelton GL. The team physician's handbook. 2nd edition.Mosby,
Phila, PA, 1996.

Nirschl RP, Kraushaar BS. The assessment and treatment of elbow injuries. Phys Sports Med.
24(5):321-6, 1996.

Pien FD, Ching D, Kim E. Septic bursitis: experience in a community practice. Orthopedics.
14:981-1991.

Salzman KL, Lillegard WA, Butcher JD. Upper extremity bursitis. 56(7):1987-93, 1997.




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