Elbow PainProfessor Hamdy Koryem;MD2012
PAINFULE ELBOW :Anatomy
Muscles around elbow: Posterior
Muscles around elbow: Anterior
Elbow pain may be due toGeneralized causesORLocalized causes
EP As a part of generalized causes: Arthritis RA. Septic. Hemophilic OA. Crystal induced.(gout or pseudo gout) Ente...
ORLocalized causes for EP
MEDIAL EPICONDYLITISSynonyms• Golfer’s elbow • Little leaguer’s elbow (children)Medial epicondylitis:Inflammation of the c...
MEDIAL EPICONDYLITISMechanismA repetitive valgus stress commonly seen inthe throwing motion.• The back and downward motion...
Treatment:• Conservative: Rest, ice, NSAIDs, immobilization.• Surgical pinning: Reserved for an unstable elbow joint.
•LATERAL EPICONDYLITISSynonyms :Tennis elbow Mechanism :Overuse and overload of the extensor andsupinator tendons seen in...
LATERAL EPICONDYLITISCLINICAL:1. Tenderness just distal to the lateral epicondyleat the common extensor origin.2. Pain and...
Cozens testPassive extension of the elbowwith forced flexion of the wristmay precipitate pain at thelateral epicondyle
Cozens testThe examiner stabilizesthe elbow with a thumbover the lateralepicondyle.Pain in the lateralepicondyle is seen w...
Cozens testThe test may be more sensitivewhen done in full extension at theelbow.
LATERAL EPICONDYLITISTreatmentConservative: Relative rest, ice, NSAIDs for 10–14 days Physical therapy (modalities) Spl...
OLECRANON BURSITISSynonyms:Student’s elbowMiner’s elbowDraftsman’s elbow
OLECRANON BURSITISMechanism Repetitive trauma, Inflammatory disorder (gout, pseudogout,RA)Pathology Inflammation of the...
Treatment• Conservative: Rest, NSAIDs,elbow padding.• Aspiration of fluid and send itfor culture if indicated
DISLOCATION OF THE ELBOWGeneral The most common type of dislocationin children and the second mostcommon type in adults f...
DISLOCATION OF THEELBOWMechanism:Fall on the Outstretched hand.
DISLOCATION OF THE ELBOWClinical Dislocation can be anterior or posterior withposterior being the most common, occurring9...
DISLOCATION OF THE ELBOWSymptoms Inability to bend the elbow. Pain in the shoulder and wristOn physical exam:The most im...
DISTAL BICEPS TENDONITISMechanismOverloading of the biceps tendon commonly due torepetitive elbow flexion and supination o...
DISTAL BICEPS TENDONITISComplication Biceps tendon avulsionClinical Insidious onset of pain in the ante-cubitalfossa usu...
DISTAL BICEPS TENDONITISTreatmentConservative Relative rest, ice, NSAIDs. Physical therapy: Modalities. Correct imprope...
TRICEPS TENDON AVULSIONMechanismTendonitis:Overuse syndrome secondary to repetitive tricepsextensionAvulsion:A deceleratin...
TRICEPS TENDONITIS/AVULSIONClinical Posterior elbow pain with tenderness at theinsertion of the triceps tendon Pain with...
TRICEPS TENDONITIS/AVULSIONTreatment Conservative Surgical:Reattachment.
VALGUS EXTENSION OVERLOADSYNDROME OF THE ELBOWSynonymsBoxer’s elbow
Boxer’s elbowMechanismAn overuse disorder caused by repetitive anduncontrolled valgus forces demonstratedduring the throwi...
Boxer’s elbowClinical Posterior elbow pain with lack of full extension Catching or locking during elbow extensionImaging...
ULNAR COLLATERAL LIGAMENTSPRAINMechanism A repetitive valgus stress occurring acrossthe elbow during the acceleration pha...
ULNAR COLLATERAL LIGAMENT SPRAINClinical Significant medial elbow pain occurring after thethrowing motion A pop or click...
Imaging Plain films may reveal calcification and spurring alongthe UCL Valgus stress radiographs demonstrating a 2 mmjoi...
RADIAL COLLATERAL LIGAMENT (RCL)SPRAINMechanism Elbow dislocation from a traumatic eventClinical Recurrent locking or cl...
Imaging Varus stress radiographs demonstrating a 2 mm jointspace suggestive of RCL injuryTreatmentConservative: Rest, ic...
PRONATOR SYNDROMEClinical1. Dull aching pain in the proximal forearm just distal to theelbow2. Numbness in the median nerv...
PRONATOR SYNDROMEMechanismMedian nerve compression at the elbow by thefollowing structures:1. Ligament .2. Supracondylar s...
PRONATOR SYNDROMEImagingPlain films: Rule out spurEMG/NCSTreatmentConservative Modification of activities Avoid aggravat...
ENTRAPMENT OF THE ULNARNERVESynonymsCubital tunnel syndrome
Cubital tunnel syndromeClinical An aching pain with paraesthesias, which may radiate distally tothe fourth and fifth digi...
Cubital tunnel syndromeEMG/NCSAbove and below the elbowTreatmentConservativeRelative rest, NSAIDs, elbow protection(splint...
OSTEOCHONDROSIS DISSECANSOF THE ELBOWSynonymsPanner’s disease.(involving epiphysial aseptic necrosis of thecapitellum)
OSTEOCHONDROSISDISSECANS OF THE ELBOW
FRACTURES FRACTURE OF THE HUMERAL SHAFT FRACTURE OF THE DISTALHUMERUS RADIAL HEAD FRACTURE FRACTURE OF THE OLECRANON
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Presentation elbow

  1. 1. Elbow PainProfessor Hamdy Koryem;MD2012
  2. 2. PAINFULE ELBOW :Anatomy
  3. 3. Muscles around elbow: Posterior
  4. 4. Muscles around elbow: Anterior
  5. 5. Elbow pain may be due toGeneralized causesORLocalized causes
  6. 6. EP As a part of generalized causes: Arthritis RA. Septic. Hemophilic OA. Crystal induced.(gout or pseudo gout) Enteropathic arthropathy. Traumatic. Neoplasm. Bones. Muscles. Synovial membrane.etc
  7. 7. ORLocalized causes for EP
  8. 8. MEDIAL EPICONDYLITISSynonyms• Golfer’s elbow • Little leaguer’s elbow (children)Medial epicondylitis:Inflammation of the common flexor tendon.Little leaguer’s elbow: (children)Hypertrophy of the medial epicondyle withmicro tearing and fragmentation of the medialepicondylar apophysis.
  9. 9. MEDIAL EPICONDYLITISMechanismA repetitive valgus stress commonly seen inthe throwing motion.• The back and downward motion of a golfswing just prior to the impact of the ball.Clinical presentation:Tenderness over the medial epicondyle.• Pain may be reproduced with wrist flexionand pronation.
  10. 10. Treatment:• Conservative: Rest, ice, NSAIDs, immobilization.• Surgical pinning: Reserved for an unstable elbow joint.
  11. 11. •LATERAL EPICONDYLITISSynonyms :Tennis elbow Mechanism :Overuse and overload of the extensor andsupinator tendons seen in Sports or Workthat require repetitive extension elbowmovements.Pathology:Micro-tearing of the extensor carpi radialis brevismuscle.
  12. 12. LATERAL EPICONDYLITISCLINICAL:1. Tenderness just distal to the lateral epicondyleat the common extensor origin.2. Pain and weakness in hand grip strength.3. Pain can be produced by Cozens test.
  13. 13. Cozens testPassive extension of the elbowwith forced flexion of the wristmay precipitate pain at thelateral epicondyle
  14. 14. Cozens testThe examiner stabilizesthe elbow with a thumbover the lateralepicondyle.Pain in the lateralepicondyle is seen withpatient making afist, pronating theforearm, radiallydeviating andextending the wristagainst resistanceby the examiner.
  15. 15. Cozens testThe test may be more sensitivewhen done in full extension at theelbow.
  16. 16. LATERAL EPICONDYLITISTreatmentConservative: Relative rest, ice, NSAIDs for 10–14 days Physical therapy (modalities) Splinting, bands Local Corticosteroid injection Correct improper techniqueOperative: ECRB debridement
  17. 17. OLECRANON BURSITISSynonyms:Student’s elbowMiner’s elbowDraftsman’s elbow
  18. 18. OLECRANON BURSITISMechanism Repetitive trauma, Inflammatory disorder (gout, pseudogout,RA)Pathology Inflammation of the bursa located between theolecranon and skinClinical Swelling, pain, and a decreased range of motion in theposterior aspect of the elbow A hot, erythematous elbow may indicate infection
  19. 19. Treatment• Conservative: Rest, NSAIDs,elbow padding.• Aspiration of fluid and send itfor culture if indicated
  20. 20. DISLOCATION OF THE ELBOWGeneral The most common type of dislocationin children and the second mostcommon type in adults followingshoulder dislocation. Sports activities account for almost50% of these injuries
  21. 21. DISLOCATION OF THEELBOWMechanism:Fall on the Outstretched hand.
  22. 22. DISLOCATION OF THE ELBOWClinical Dislocation can be anterior or posterior withposterior being the most common, occurring98% of the time . Associated injuries include fracture of the radialhead, injury to the brachial artery and mediannerve.
  23. 23. DISLOCATION OF THE ELBOWSymptoms Inability to bend the elbow. Pain in the shoulder and wristOn physical exam:The most important part of the exam is theneurovascular evaluation of the radial artery, andmedian, ulnar and radial nerves Plain AP and lateral radiographs
  24. 24. DISTAL BICEPS TENDONITISMechanismOverloading of the biceps tendon commonly due torepetitive elbow flexion and supination or resistedelbow extension.PathologyMicro tearing of the biceps tendon distally.
  25. 25. DISTAL BICEPS TENDONITISComplication Biceps tendon avulsionClinical Insidious onset of pain in the ante-cubitalfossa usually after an eccentric overload Audible snap with an obvious deformity,swelling, and ecchymosis if an avulsion issuspected
  26. 26. DISTAL BICEPS TENDONITISTreatmentConservative Relative rest, ice, NSAIDs. Physical therapy: Modalities. Correct improper technique.Surgical: Reattachment.
  27. 27. TRICEPS TENDON AVULSIONMechanismTendonitis:Overuse syndrome secondary to repetitive tricepsextensionAvulsion:A decelerating counterforce during active elbowextension
  28. 28. TRICEPS TENDONITIS/AVULSIONClinical Posterior elbow pain with tenderness at theinsertion of the triceps tendon Pain with resistive elbow extension orsudden loss of extension with a palpabledefect in the triceps tendon (avulsion)Imaging Plain films to rule out other causes, ifindicated
  29. 29. TRICEPS TENDONITIS/AVULSIONTreatment Conservative Surgical:Reattachment.
  30. 30. VALGUS EXTENSION OVERLOADSYNDROME OF THE ELBOWSynonymsBoxer’s elbow
  31. 31. Boxer’s elbowMechanismAn overuse disorder caused by repetitive anduncontrolled valgus forces demonstratedduring the throwing motion, especially in lateacceleration and deceleration.Also may be seen in boxers.PathologyOsteophyte and loose body formation occurssecondary to a repetitive friction of theolecranon against the fossa.
  32. 32. Boxer’s elbowClinical Posterior elbow pain with lack of full extension Catching or locking during elbow extensionImaging Plain films: AP/lateral may show a loose body orosteophyte formation at the olecranonTreatment Conservative Surgical: Removal of the loose body
  33. 33. ULNAR COLLATERAL LIGAMENTSPRAINMechanism A repetitive valgus stress occurring acrossthe elbow during the acceleration phase ofthrowing.Pathology Inflammation to the anterior band of theulnar collateral ligament.
  34. 34. ULNAR COLLATERAL LIGAMENT SPRAINClinical Significant medial elbow pain occurring after thethrowing motion A pop or click may be heard precipitating the pain Medial pain or instability on valgus stress with theelbow, flexed 20–30 if the UCL is torn.Provocative Test Valgus stress test:Tenderness over the medial aspect of the elbow whichmay be increased with a valgus stress.
  35. 35. Imaging Plain films may reveal calcification and spurring alongthe UCL Valgus stress radiographs demonstrating a 2 mmjoint space suggestive of UCL injuryTreatmentConservative1. Rest, ice,2. NSAIDs3. Rehabilitation program for strengthening and stretchingSurgical reconstruction if needed
  36. 36. RADIAL COLLATERAL LIGAMENT (RCL)SPRAINMechanism Elbow dislocation from a traumatic eventClinical Recurrent locking or clicking of the elbow withextension and supination Lateral pain or instability on varus stress with the elbowflexed 20–30 if the RCL is tornProvocative test Varus stress testTenderness over the lateral aspect of the elbow, whichmay be increased with a varus stress.
  37. 37. Imaging Varus stress radiographs demonstrating a 2 mm jointspace suggestive of RCL injuryTreatmentConservative: Rest, ice, NSAIDs Rehabilitation program for strengthening and stretching Establishing return to play criteriaSurgical reconstruction if needed.
  38. 38. PRONATOR SYNDROMEClinical1. Dull aching pain in the proximal forearm just distal to theelbow2. Numbness in the median nerve distribution of the hand3. Symptoms exacerbated by pronation
  39. 39. PRONATOR SYNDROMEMechanismMedian nerve compression at the elbow by thefollowing structures:1. Ligament .2. Supracondylar spur.3. Fibrosis.4. Pronator teres muscle.5. Between the two heads of the flexordigitorum superficialis (FDS).
  40. 40. PRONATOR SYNDROMEImagingPlain films: Rule out spurEMG/NCSTreatmentConservative Modification of activities Avoid aggravating factors Stretching and strengthening programSurgical:Release of the median nerve at the location of thecompression
  41. 41. ENTRAPMENT OF THE ULNARNERVESynonymsCubital tunnel syndrome
  42. 42. Cubital tunnel syndromeClinical An aching pain with paraesthesias, which may radiate distally tothe fourth and fifth digits Positive Tinel’s sign at the elbow Weakness in the ulnar musculature of the hand, demonstratedby a weak grip strength and atrophy and poor hand coordination.Mechanism A hyper mobility of the ulnar nerve, excessive valgus force orloose body/osteophyte formation, which aggravates the integrityof the ulnar nerve at the elbow.Pathology Hyperirritability of the ulnar nerve
  43. 43. Cubital tunnel syndromeEMG/NCSAbove and below the elbowTreatmentConservativeRelative rest, NSAIDs, elbow protection(splinting) and technique modification
  44. 44. OSTEOCHONDROSIS DISSECANSOF THE ELBOWSynonymsPanner’s disease.(involving epiphysial aseptic necrosis of thecapitellum)
  45. 45. OSTEOCHONDROSISDISSECANS OF THE ELBOW
  46. 46. FRACTURES FRACTURE OF THE HUMERAL SHAFT FRACTURE OF THE DISTALHUMERUS RADIAL HEAD FRACTURE FRACTURE OF THE OLECRANON
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