Elbow and Forearm Pathologies Mark R. Davies, MD Center for Shoulder and Sports Disorders Kaiser Permanente Medical Group Santa Teresa Medical Center San Jose, CA

Dr. James Andrews Birmingham, Alabama Over 900 “ Tommy John” surgeries American Sports Medicine Institute Birmingham, AL

Elbow and Forearm Pathologies Elbow ligamentous sprains Epicondylitis Disorders of the capitellum Rupture of distal biceps tendon Olecranon bursitis Neurologic injury Elbow dislocations Fractures

Elbow ligamentous sprains

Epicondylitis

Disorders of the capitellum

Rupture of distal biceps tendon

Olecranon bursitis

Neurologic injury

Elbow dislocations

Fractures

Elbow Ligamentous Sprains Medial (ulnar) collateral ligament injury Lateral (radial) collateral ligament injury

Medial (ulnar) collateral ligament injury

Lateral (radial) collateral ligament injury

Ulnar Collateral Ligament (UCL) UCL is the main medial stabilizer of the elbow Anterior bundle is the primary structure involved in throwing

UCL is the main medial stabilizer of the elbow

Anterior bundle is the primary structure involved in throwing

UCL History Pain or instability with throwing What phase of throwing? 85% of throwers with medial elbow instability complain of pain in the acceleration phase of throwing

Pain or instability with throwing

What phase of throwing?

85% of throwers with medial elbow instability complain of pain in the acceleration phase of throwing

UCL Injury History: - Acute medial pain - Onset during throwing, inadequate warmup - “Pop” heard or felt - Can be one pitch or can be insidious

History:

- Acute medial pain

- Onset during throwing, inadequate warmup

- “Pop” heard or felt

- Can be one pitch or can be insidious

UCL Injury Physical exam: - Medial elbow ecchymosis - Ulnar nerve symptoms - Tender at anterior bundle - Difficult exam: +/- instability

Physical exam:

- Medial elbow ecchymosis

- Ulnar nerve symptoms

- Tender at anterior bundle

- Difficult exam:

+/- instability

Milking Maneuver

Palpation of UCL Palpate in flexion to move flexor-pronator mass anteriorly

Complete UCL tear on MRI

Complete UCL tear on MRI

Normal UCL

Bone tunnels are drilled “ Tommy John” Surgery

Bone tunnels are drilled

Graft is harvested – Palmaris longus Operative Technique

Graft is harvested –

Palmaris

longus

Graft is passed and crossed in a figure eight pattern Operative Technique

Graft is passed and crossed in a figure eight pattern

Results Return to Sport 85 % of major league professional baseball players were able to return

85 % of major league

professional baseball players

were able to return

Lateral Epicondylitis “ Tennis elbow”

Lateral Epicondylitis More common by 9:1 ratio than medial epicondylitis Degenerative process: “tendinosis” Extensor Carpi Radialis Brevis (ECRB) most commonly involved

More common by 9:1 ratio than medial epicondylitis

Degenerative process: “tendinosis”

Extensor Carpi Radialis Brevis (ECRB) most commonly involved

Lateral Epicondylitis Palpate mobile wad while resisting active wrist extension Pain at lateral epicondyle or over muscle mass usually present No neurologic symptoms Normal sensation

Palpate mobile wad while resisting active wrist extension

Pain at lateral epicondyle or over muscle mass usually present

No neurologic symptoms

Normal sensation

Lateral Epicondylitis Conservative Treatment Up to 90% of epicondylitis resolves spontaneously Rehab focus on stretching wrist extensors, eccentric wrist extensors Activity modification Anti-inflammatory medications Counterforce bracing Steroids Injected Topical –Iontophoresis / 24 Hr. patch Surgery

Up to 90% of epicondylitis resolves spontaneously

Rehab focus on stretching wrist extensors, eccentric wrist extensors

Activity modification

Anti-inflammatory medications

Counterforce bracing

Steroids

Injected

Topical –Iontophoresis / 24 Hr. patch

Surgery

Medial Epicondylitis “Golfer’s Elbow”

Pain with resisted wrist flexion Pain with resisted pronation Tender either within muscle belly or directly over medial epicondyle Medial Epicondylitis Diagnosis

Pain with resisted wrist flexion

Pain with resisted pronation

Tender either within muscle belly or directly over medial epicondyle

Medial Epicondyle Avulsion Fractures Result from extreme valgus loads or violent muscle contractions during the throwing motion Commonly occur in adolescents as the medial epicondyle begins to fuse May report a “pop” Tender at medial epicondyle, ecchymosis present medially

Result from extreme valgus loads or violent muscle contractions during the throwing motion

Commonly occur in adolescents as the medial epicondyle begins to fuse

May report a “pop”

Tender at medial epicondyle, ecchymosis present medially

Medial Epicondyle Avulsion Fractures

Medial Epicondyle Avulsion Fractures

Panner’s Disease Osteochondrosis of the capitellum Elbow’s version of Legg-Calve-Perthes Disease Presents with lateral elbow pain and perhaps stiffness in an active youngster

Osteochondrosis of the capitellum

Elbow’s version of Legg-Calve-Perthes Disease

Presents with lateral elbow pain and perhaps stiffness in an active youngster

Panner’s Disease Usually seen in children less than age 10 Fragmentation of the capitellum usually seen on xrays

Usually seen in children less than age 10

Fragmentation of the capitellum usually seen on xrays

Panner’s Disease

Panner’s Disease Treatment Orthopedic referral appropriate as is MRI Stop offending activities - typically throwing (baseball) or handsprings (gymnastics) Rest elbow – may consider splinting for a few weeks Typically symptoms will resolve in a few months and capitellum ossification will normalize within 2 years Long term prognosis excellent in most cases

Treatment

Orthopedic referral appropriate as is MRI

Stop offending activities - typically throwing (baseball) or handsprings (gymnastics)

Rest elbow – may consider splinting for a few weeks

Typically symptoms will resolve in a few months and capitellum ossification will normalize within 2 years

Long term prognosis excellent in most cases

Osteochondritis Dissecans (OCD) of the Capitellum OCD is a localized lesion in which a segment of subchondral bone and articular cartilage separates from the underlying bone Presents with lateral elbow pain and perhaps stiffness in an active youngster Usually seen in children older than age 12 Focal area of lucency in the subchondral bone in the anterior aspect of the capitellum Prognosis worse

OCD is a localized lesion in which a segment of subchondral bone and articular cartilage separates from the underlying bone

Presents with lateral elbow pain and perhaps stiffness in an active youngster

Usually seen in children older than age 12

Focal area of lucency in the subchondral bone in the anterior aspect of the capitellum

Prognosis worse

Osteochondritis Dissecans of the Capitellum

Osteochondritis Dissecans of the Capitellum Physical exam Lateral elbow pain with tenderness directly over the capitellum Small effusion may be noted. Limited range of motion is typically observed with approximately 20° of extension loss Crepitus may be present in the radiocapitellar joint with active or passive forearm rotation May also complain of locking & catching, which may indicate a loose body

Physical exam

Lateral elbow pain with tenderness directly over the capitellum

Small effusion may be noted.

Limited range of motion is typically observed with approximately 20° of extension loss

Crepitus may be present in the radiocapitellar joint with active or passive forearm rotation

May also complain of locking & catching, which may indicate a loose body

Osteochondritis Dissecans of the Capitellum Treatment Orthopedic referral appropriate as is MRI Stop offending activities - typically throwing (baseball) or handsprings (gymnastics) Rest elbow – consider splinting for a few weeks Treatment will depend on symptoms Long term prognosis more guarded – may require surgery

Treatment

Orthopedic referral appropriate as is MRI

Stop offending activities - typically throwing (baseball) or handsprings (gymnastics)

Rest elbow – consider splinting for a few weeks

Treatment will depend on symptoms

Long term prognosis more guarded – may require surgery

Osteochondritis Dissecans of the Capitellum Surgical indications Symptomatic loose bodies Articular cartilage fracture Displacement of the osteochondral lesion Surgical management of OCD lesions Excision of loose bodies or partially attached lesions Abrasion chondroplasty or subchondral drilling. Results of internal fixation of the loose fragment vary New techniques to harvest cartilage from the knee and transplant into the elbow promising

Surgical indications

Symptomatic loose bodies

Articular cartilage fracture

Displacement of the osteochondral lesion

Surgical management of OCD lesions

Excision of loose bodies or partially attached lesions

Abrasion chondroplasty or subchondral drilling.

Results of internal fixation of the loose fragment vary

New techniques to harvest cartilage from the knee and transplant into the elbow promising

Distal Biceps Rupture Usually dominant extremity Male (often weight lifters) Steroids?!? Mean age of 50 (reported 18 to 72)

Usually dominant extremity

Male (often weight lifters) Steroids?!?

Mean age of 50 (reported 18 to 72)

Biceps Rupture - Mechanism Often a single traumatic event Unexpected eccentric extension force applied to an arm at 90 degrees of flexion

Often a single traumatic event

Unexpected eccentric extension force applied to an arm at 90 degrees of flexion

“ Popeye” muscle

Rupture of Distal Biceps Tendon AROM/PROM may be WNL but RROM limited due to pain with elbow flexion and forearm supination Almost always treated surgically followed by progressive ROM and strengthening program

AROM/PROM may be WNL but RROM limited due to pain with elbow flexion and forearm supination

Almost always treated surgically followed by progressive ROM and strengthening program

Olecranon Bursitis Typically due to direct trauma Usually easily treated with rest, modalities compression, and NSAIDs If persists, may be aspirated – risk of infection

Typically due to direct trauma

Usually easily treated with rest, modalities compression, and NSAIDs

If persists, may be aspirated – risk of infection

Neurologic Injury Ulnar nerve At elbow (cubital tunnel) or wrist Median nerve At elbow or wrist (carpal tunnel) Radial nerve Least involved with overuse

Ulnar nerve

At elbow (cubital tunnel) or wrist

Median nerve

At elbow or wrist (carpal tunnel)

Radial nerve

Least involved with overuse

Sensory Examination Radial First dorsal webspace of hand Ulnar Pad of pinky finger Median Pad of index finger

Radial

First dorsal webspace of hand

Ulnar

Pad of pinky finger

Median

Pad of index finger

Tinnel’s Test Gentle percussion of the ulnar nerve above or within the cubital tunnel should not elicit pain in the normal elbow Pain or paresthesias into the ring and small fingers with tapping over the ulnar nerve in the cubital tunnel is considered a positive test

Gentle percussion of the ulnar nerve above or within the cubital tunnel should not elicit pain in the normal elbow

Pain or paresthesias into the ring and small fingers with tapping over the ulnar nerve in the cubital tunnel is considered a positive test

Elbow Dislocations Typically results from hyperextension, trochlea levered over coronoid process Vast majority are posterior with most common direction being posterolateral Involve injury to most ligamentous structures, and potential for injury to neurovascular structures – if stable post-reduction, treat conservatively and if unstable, treat surgically

Typically results from hyperextension, trochlea levered over coronoid process

Vast majority are posterior with most common direction being posterolateral

Involve injury to most ligamentous structures, and potential for injury to neurovascular structures – if stable post-reduction, treat conservatively and if unstable, treat surgically

Posterior Elbow Dislocation

Fractures Humerus Radius Ulna

Humerus

Radius

Ulna

Humerus Fractures Supracondylar fracture Supracondylar fracture with posterior elbow dislocation

Supracondylar fracture

Supracondylar fracture with posterior elbow dislocation

Humerus Fractures Most common in children/adolescents from fall on flexed elbow or hyperextension mechanism Deformity present if displaced, often missed on initial evaluation if nondisplaced Often requires surgery if displaced

Most common in children/adolescents from fall on flexed elbow or hyperextension mechanism

Deformity present if displaced, often missed on initial evaluation if nondisplaced

Often requires surgery if displaced

Ulnar Fractures Olecranon process fractures If stable/nondisplaced, short immobiliazation period (45-90 degrees of flexion) If displaced, ORIF with longer immobilization period and early ROM if tolerated

Olecranon process fractures

If stable/nondisplaced, short immobiliazation period (45-90 degrees of flexion)

If displaced, ORIF with longer immobilization period and early ROM if tolerated

Radial Fractures Radial head fracture Radial neck fracture Most treated non operatively

Radial head fracture

Radial neck fracture

Most treated non operatively

Thank you!!!