Msk injuries elbow injury injury of upper limb

1. Elbow Injuries
Dr.Muntaha Virk

6. Functional Anatomy
• Complex that allows for flexion, extension,
pronation and supination
– 145 degrees of flexion and 90 degrees of
supination and pronation
• Bony limitations, ligamentous support and
muscular stability at the elbow help to protect
it from overuse and traumatic injuries
• Elbow demonstrates a carrying angle due to
distal projection of humerus
– Normal in females is 10-15 degrees, males 5
degrees
• Critical link in kinetic chain of upper extremity

7. Elbow Disorders: Olecranon Bursitis
• Inflammation of the olecranon bursa is called olecranon bursitis. It is also
referred to as student’s elbow because the condition can be caused by
leaning excessively on the elbow. Chronic olecranon bursitis is seen in
people who throw repetitively, such as baseball pitchers; acute cases
usually occur after a direct fall onto a hard surface.
• Patients with bursitis are easily identified by the large amount of swelling
and masslike appearance of the elbow. In nontraumatic situations,
imaging may not be required if the bursa fluid can be aspirated. In
traumatic situations, however, the bursa can become inflamed because
of an olecranon fracture. Fluid aspiration sometimes leads to infection,
and continued pain should be investigated with further imaging studies.

8. Cubital Bursitis
• Cubital bursitis also is known as bicipitoradial bursitis, and
symptoms include antecubital fossa swelling and tenderness.

9. Tendonitis and Tendon Tears
• Tendonitis of the elbow is due to inflammation of the tendons.
Tendonitis of the biceps muscle can lead to rupture on either end. This
condition commonly occurs after lifting heavy objects and results in
tenderness near the biceps rupture site. On average, tendonitis of the
biceps occurs in men aged 45 to 60 years.
• When the distal end of the biceps muscle ruptures, symptoms include
proximal elbow pain and weakness, especially during supination. When
the rupture occurs, the patient can experience a snapping sensation
followed by the appearance of a bulbous deformity, or “Popeye sign,”
near the distal bicep.

10. Tendonitis and Tendon Tears
• Triceps tendonitis is common with repetitive elbow use in young
athletes. The individual often experiences a sensation on the
medial border of the elbow that patients describe as something
snapping into place.
• As with bicep tears, MR and ultrasonography images can help
physicians distinguish tears from other pathology.

11. Lateral Epicondylitis
• Lateral epicondylitis is the most common sports-related injury of
the elbow and a primary cause of elbow pain. The mechanism of
injury depends on repeated, forceful contraction of the wrist
extensor muscles; contraction occurs with frequent forearm
pronation and supination, along with wrist extension. The abuse of
the extensor muscles causes inflammation at the lateral
epicondyle.
• Lateral epicondylitis is frequently referred to as tennis elbow.
Although the condition is associated with tennis, many other
repetitive motions can cause epicondylitis. Estimates show that
90% of lateral epicondylitis patients develop the disorder from
activities other than tennis.

12. Lateral Epicondylitis
• The pain felt with lateral epicondylitis normally occurs at the lateral
epicondyle or slightly outside the elbow. Gripping items may
become difficult because of weakness and increased pain within
the forearm. This is known as the “coffee cup” sign.
• Radiographic evidence of lateral epicondylitis is rarely found. In any
case, radiographs differentiate lateral epicondylitis from other
disease processes of the elbow such as arthritis or loose bodies.
• In cases of chronic lateral epicondylitis, the capsule below the
extensor carpi radial brevis (ECRB) tendon should be examined for
tears.

13. Medial Epicondylitis
• Known to patients as golfer’s elbow, medial epicondylitis is
common in individuals who overuse their wrist flexors and forearm
pronator but is seen far less frequently than lateral epicondylitis.
• Medial epicondylitis primarily affects the insertion point of the
flexor carpi radialis. The patient presents with pain at the medial
aspect of the elbow.
• As with lateral epicondylitis, radiographic evidence of medial
epicondylitis can be difficult to find, but small calcifications or
spurs next to the medial epicondyle are common. MR imaging
most often is used for diagnosis.

14. Arthritis
• Arthritis is a joint disorder that results in inflammation of the joints
within the body. There are varying kinds of arthritis, each
exhibiting different causes and symptoms. Regardless of the type
of elbow arthritis, the initial stages of pain management include
pain medication and physical therapy. Occasionally, corticosteroid
injections are used for pain management, but physicians must use
caution to ensure that the injections do not lead patients into a
false sense of treatment and overuse of the elbow joint, causing
further deterioration.

15. Rheumatoid Arthritis
• Rheumatoid arthritis is a severe form of arthritis that progressively
affects the body’s joint tissues. Joint erosion and destruction are
common because of the severity of rheumatoid arthritis.
• Rheumatoid arthritis commonly begins in the radiocapitellar joint.
The radial head may move out of its regular position and cause
problems with other elbow anatomy.
• Radiographs can monitor structural changes caused by rheumatoid
arthritis, but radiography is not the preferred method for early
disease assessment. Bone erosion from rheumatoid arthritis is
better displayed on CT images than on MR images or radiographs.
Ultrasonography can show inflammation related to rheumatoid
arthritis and document destructive changes.

16. Osteoarthritis
• Arthritic conditions of the elbow are not uncommon, but
osteoarthritis of the elbow is rare. Osteoarthritis is much more
prevalent in weight-bearing joints, such as knees and hips, and in
the interphalangeal joints of the hand.
• Patients with osteoarthritis affecting the elbow experience the
most pain during terminal flexion and extension of the joint.
• Radiographic evidence of osteoarthritis includes osteophyte
formation. These osteophytes usually are near the ulnohumeral
joint and occasionally impinge on the ulnar nerve. MR and CT
images of the elbow help show the joint surfaces and detect loose
bodies or spurs.

17. Gout
• Elevated uric acid levels can result in monosodium urate crystals to
infiltrate the synovial fluid of joint spaces and lead to gout. Gout
usually is found in the joint spaces of the toes but can appear at
the elbow.
• Evidence of gout is obvious in patients with advanced disease but
is not often apparent on images of early cases. MR images are
better for evaluating synovial involvement, and CT is better for
displaying intraosseous lesions. Ultrasonography also can highlight
thickening of the synovial fluid, along with inflammation.

18. Overuse Conditions in Children
• Children also can have elbow injuries and conditions related to
overuse of the elbow joint. Examples of these problems,
sometimes referred to as Little League elbow, include traction
apophysitis of the medial epicondyle, Panner disease, and
osteochondritis dissecans.

19. Traction Apophysitis of the Medial
Epicondyle
• Traction apophysitis of the medial epicondyle is inflammation of the
medial epicondyle due to an avulsion tear or trauma. Because of the
timing of ossification in children, traction apophysitis is the most
common elbow injury in young children.
• Approximately 97% of elbow problems in baseball pitchers are associated
with symptoms of the medial elbow. The main symptom of apophysitis of
the medial epicondyle is pain immediately after a repetitive motion such
as throwing.
• Radiographs of the elbow might show slight widening of the apophysis,
but this can be missed easily if the radiologist does not review
comparison radiographs of the opposite elbow. MR imaging can show
edema of the bone marrow around the medial epicondylar area.

20. Panner Disease
• Osteochondrosis affects the ossification centers of children when
the bone degenerates and then begins to regenerate, producing
excessive calcification in some areas. Panner disease is a form of
osteochondrosis that affects the capitulum of the elbow.
• Panner disease is most common in preadolescent boys and
children younger than 10. Panner disease is the most common
reason for lateral elbow pain in young children and routinely
affects the dominant arm.
• Radiographs can display sclerosis and areas of decreased density at
the capitulum. An MR series with T1-weighted images might show
fragmentation with decreased signal intensity at the capitulum
surface.

21. Osteochondritis Dissecans
• A more advanced form of osteochondrosis is osteochondritis
dissecans. These lesions result from death of the articular cartilage
or subchondral bone of the capitulum due to a lack of blood
supply. Subchondral bone provides cartilage support at articulation
sites. If the subchondral bone or cartilage is slightly fractured, it is
known as osteochondritis dissecans.
• Patients with these osteochondritis dissecans lesions often have
plica, an inflamed lining of the radiocapitellar joint. Because the
pain is located on the lateral side of the elbow, radiocapitellar plica
commonly is misdiagnosed as lateral epicondylitis.

22. Osteochondritis Dissecans
• Osteochondritis dissecans typically affects adolescent athletes
aged 11 to 21 years.
• Osteochondritis dissecans is characterized by a dull ache with no
centralized location. The pain may disappear when the child is
resting then reappear during strenuous activities. If fragments are
loose in the area, the joint may routinely catch or cause a popping
sensation.

23. Osteochondritis Dissecans
• Radiographs typically are not very sensitive for identifying loose bodies,
and less than 30% of positive loose bodies are found using radiography.
• CT of the elbow joint can help physicians locate and count loose bodies
found throughout the elbow compartments before the patient
undergoes arthroscopic procedures to remove the fragments.
• On MR images, osteochondral lesions can be confused with normal
osseous variants of the elbow.
• Ultrasonographic imaging of osteochondritis dissecans is rare.
Arthroscopy is used most often because it remains a safe and effective
way to diagnose and evaluate osteochondritis dissecans or lesions of the
elbow. The benefit of arthroscopy is the ability to immediately remove
any loose bodies or deliver other treatments.

24. Nerve Damage
• The most common nerve condition in the elbow is ulnar neuritis.
This inflammation of the nerve can cause radiating pain from the
posterior medial elbow to the hand and fingers. Compression of
the elbow nerves is attributed to a wide range of abnormalities.
• An ulnar nerve injury typically is associated with supracondylar
fractures when the arm is in hyperflexion, but most ulnar nerve
injuries occur because of direct blows to the nerve. Damage to the
ulnar nerve can lead to numbness and tingling of the hand.
• In severe cases of ulnar nerve injury, symptoms can last for years
after the trauma. This is commonly known as tardy ulnar palsy.
• MR imaging is the best modality to show nerve damage and
edema.

25. Elbow Injuries: Ligament or Tendon Injury
• About 50% of the medial and lateral plane of the elbow is
stabilized by ligaments. If the anterior bundle of the elbow’s MCL is
injured, the elbow becomes extremely unstable except when fully
extended.
• Radiography can assess ligament tears and joint stability,
particularly with valgus or varus stress applied during a
fluoroscopic examination.

26. Dislocations
• The elbow is the joint that is dislocated most often among pediatric
patients. It is the second most dislocated joint in adult patients, with 50%
of cases resulting from sports activities.
• Elbow dislocations can occur as a result of many situations but most
often arise from a fall on an outstretched hand. The most common
dislocation involves displacement of both the ulna and radius.
• Elbow dislocations often present with other injuries. The MCL is routinely
compromised in elbow dislocation. With MCL damage, the elbow joint
might remain unstable unless the ligament heals or is surgically repaired.
• A patient with an elbow dislocation most often experiences extreme pain
and swelling. A deformity may or may not be clearly seen.

27. Dislocations
• An AP and lateral radiograph elbow series is sufficient to diagnose an
elbow dislocation.
• Elbow Reduction
• An elbow reduction most often is completed by having the patient’s
upper arm held in place while applying a steady pull on the forearm and
hand. Once the dislocation is reduced, the elbow should be tested for
mobility and examined with radiography to ensure satisfactory reduction
of the joint and exclude any further bone injury.
• A neurovascular examination should be performed and results noted
before and after reducing the elbow joint dislocation. Following an elbow
dislocation, extension may become compromised and the elbow may be
unstable. Over time, some patients might develop arthritis or ectopic
bone.

28. Heterotopic Bone Formation
• Formation of bone or calcification that is not in the normal bone
growth area is called heterotopic bone formation. Heterotopic
bone growth at the elbow can be associated with traumatic injury
of the elbow, but heterotopic bone formation of the elbow also
can be caused by central nervous system trauma or excessive
burns.
• The formation of juxta-articular bone at the elbow joint can cause
problems because of decreased full range of motion. Once elbow
motion has been compromised by heterotopic bone formation, the
only treatment for restoring motion is surgical resection of the
bone.

29. Fractures
• The proximity of nerves, arteries, tendons, muscle, and bones in the elbow
contributes to the elbow being considered one of the most complex fracture
sites. Clinical examination begins by observing the patient’s arm. When both
arms hang normally at the patient’s sides, there should be a 5° to
15°separation of the forearms and hands from the body. This arm-to-body
separation is known as “the carrying angle.” If the patient’s arms and hands
are not observed within the acceptable ranges, it could indicate an elbow
fracture. Any variation of the angle that is more than 15°is known as
cubitus valgus. Angles less than 5°are called cubitus varus.
• All fractures are serious and should be treated as such, although open
fractures are at higher risk for adverse complications.
• There are three distinct phases in the healing process of bones and
complete fracture healing can last for months or years.

30. Distal Humerus Fractures
• Distal humerus fractures represent only 2% of adult fractures.
These fractures can appear in both condyles and often continue
into the joint space.
• Location determines the classification of distal humerus fractures.
• Patients with distal humerus fractures experience extensive
swelling, deformities, and pain. These fractures also can produce
bruising of the skin. Flexion of the arm may produce crackling or
popping sounds from bone fragments.

31. Distal Humerus Fractures
• A 2-projection radiographic examination usually is sufficient to evaluate
distal humerus fractures. A lateral oblique projection is helpful for
diagnosing lateral condyle fractures or displacement. An oblique radiograph
of the elbow might help identify nondisplaced fractures of the condyle in
children.
• Posterior displacement of the humerus, often seen in fractures, affects the
orientation of the anterior humeral line seen on the lateral image. If the
anterior humeral line passes through the anterior portion of the capitulum
or does not meet the capitulum at all, a fracture is possible.
• Displaced fractures are generally stabilized with surgery. Splinting is
sufficient in nondisplaced fractures. It is important to retake radiographs of
the elbow after several days of splinting to ensure adequate positioning.

32. Olecranon Process Fracture
• The olecranon process is at high risk for fracture because of its
prominent position directly under the surface of the skin.
Olecranon process fractures generally occur when an individual
falls directly onto the flexed elbow, resulting in a comminuted
fracture. Other fractures of the olecranon process include avulsion,
nondisplaced transverse and nondisplaced oblique fractures, and
fracture-dislocations. Swelling and extensive bruising often are
noted following an olecranon process fracture.
• AP and lateral radiographs can usually demontrate olecranon
process fractures, with a lateral projection providing the best view
of the fracture.

33. Olecranon Process Fracture
• If an olecranon process fracture is nondisplaced, a posterior splint
to flex the elbow 90°usually is the first step in treatment. Follow-
up for this treatment includes radiography to ensure that the
fracture remains nondisplaced. Displaced fractures require internal
fixation with plates, screws, pins, or wires to align the bone
properly.
• Even after healing, an olecranon process fracture can produce loss
of motion regardless of treatment. If fixating hardware is used, the
hardware can irritate the tissues around the fracture site, causing
more pain.

34. Coronoid Process Fracture
• Fractures of the coronoid process typically occur in conjunction
with posterior elbow dislocations. An avulsion fracture of the
coronoid is possible if the brachialis muscle is subjected to forceful
contraction. Antecubital fossa tenderness and swelling are
common symptoms of coronoid fracture.
• The radial head or oblique projection of the elbow highlights
possible fractures of the coronoid. The lateral projection best
demonstrates coronoid fractures, however, and also highlights
avulsion fractures.

35. Radial Head Fracture
• The radial head is believed to be the secondary stabilizing source
for the elbow during valgus stress. As a result, radial head fractures
tend to occur when patients fall with a forearm turned inward and
land on an outstretched hand. These are the most common elbow
fracture among adults.
• Patients who have radial head fractures experience pain on the
outer surface of the elbow and may not be able to pronate or
supinate the forearm. The elbow can show signs of swelling,
limiting the amount of flexion and extension.
• Standard 2-projection radiographs of the elbow are routine for
suspected radial head fractures because these fractures usually
produce a positive posterior fat pad sign on radiographs.

36. Capitulum Fractures
• Fractures of the capitulum are not very common, but when they occur, they
share a similar mechanism of fracture as radial head fractures because of
the axial alignment of the capitulum. In fact, nearly 50% of capitulum
fractures are accompanied by a radial head fracture.
• Results of routine radiography often are misleading in cases of capitulum
fracture. The AP projection can hide a fracture fragment behind the
humerus, and any rotation or a slight oblique lateral positioning often
obscures a capitulum fracture. Radiographs of the elbow consistently show a
positive fat pad sign on the lateral projection, but radiographers should
acquire a radiocapitellar projection to better demonstrate any fracture
fragments. Determining the degree of displacement in capitulum fractures is
difficult with radiographs. CT images can show precise details of the fracture.

37. Avulsion Fracture
• Stress to the elbow joint can cause avulsion fractures. Avulsion
fractures often are found in adolescents aged 9 to 12 years, and
they are the most common type of elbow fracture in adolescent
athletes who participate in throwing as part of their sport.
• Avulsion fractures most often are found before the secondary
ossification centers fuse. A common symptom of avulsion fractures
is an acute popping sensation in the elbow followed by pain. The
pain often is felt immediately after making a hard pitch or throw.
• Images obtained following the injury might show a disconnection
of the medial epicondyle apophysis or subtle displaced fractures.
Occasionally, a gravity stress test or manual stress projections of
the elbow also are ordered.

38. Combined Fractures and Dislocations
• Monteggia fracture-dislocations involve a fracture of the ulnar
shaft and displacement of the radial head. If the alignment of the
radiocapitellar line does not point to the capitulum on all
radiographic projections, a Monteggia fracture or lateral condyle
fracture is likely.
• Galeazzi fracture-dislocations combine a distal radial head
disruption with a distal radial fracture. Essex-Lopresti fracture-
dislocation consists of a radial head fracture that is comminuted
and a distal subluxation or dislocation of the radioulnar joint.
• The “terrible triad” is a devastating elbow injury that includes a
radial head fracture, an MCL injury, and a coronoid process
fracture.

39. Arterial Injuries
• Specific trauma, such as supracondylar fractures, carry such a high
risk for arterial injury that arterial injury should be suspected in
most cases. Arterial injuries are very serious and can lead to
contracture or loss of the affected limb.
• If the brachial artery is damaged, the patient may have a decreased
pulse, radiating pain, decreased skin temperature, and the skin of
the affected arm may appear pale. A pulse should be detectable
distal to the fracture. If the skin appears pale or the pulse is
noticeably low or absent, arterial injury is likely. A CT examination
with IV contrast can display any occlusions or hematomas.

40. Fractures in Children
• Fractures of the elbow are not uncommon in children, given their typical
behavior. Supracondylar fractures are the most common elbow fracture
in the pediatric population, however, constituting up to 60% of cases.
After the reduction of a supracondylar fracture, a radiographic image
using the Jones method image can confirm adequate reduction.
• Roughly 35% of pediatric skeletal injuries involve a growth plate. During
the growth process, the long bones of pediatric patients contain a physis
or growth plate that allows the bone to grow longitudinally. The bone in
the growth plate grows rapidly. This can benefit fracture healing, but care
must be taken when managing any fracture that extends into the growth
plate because the bone can heal unevenly, leading to deformities.

41. Fractures in Children
• If a posterior fat pad is seen on a lateral radiograph and no other
abnormality is seen, it is likely that the patient has a nondisplaced
intracapsular fracture. About 76% of follow-up radiographs of pediatric
patients show healing fractures in the elbow area. These findings support
the decision to manage these situations as though a fracture existed in the
original radiograph. If a hairline or small fracture is suspected after a
negative radiographic examination, pediatric patients can return sooner than
adult patients for repeat images because children have faster callus
formation.
• Radiologic technologists and care providers should be aware of specific
elbow fractures that might indicate child abuse. A transphyseal fracture of
the humerus, common in children younger than 6 years, often indicates child
abuse. This fracture normally presents as pain in the elbow, limited range of
motion, and swelling over the fracture site.

42. Fractures in Children
• The routine 3-projection radiograph of the elbow is not always
helpful to diagnose a transphyseal fracture because of a lack of
ossification in pediatric patients. Comparison radiographs of the
opposite elbow can assist the radiologist in diagnosing
transphyseal fractures. If radiographs of the elbow are not
definitive, MR imaging, ultrasonography, or arthrography may be
required to confirm a diagnosis.
• If a transphyseal fracture is found and child abuse is suspected, the
provider might want to order additional radiographs. Child abuse
victims often have fractures in multiple areas of their bodies. The
types of child abuse fractures that might be seen in addition to the
transphyseal fracture are diaphyseal or long-bone shaft fractures.

43. Congenital Radial-Ulnar Synostosis
• Bones sometimes can fail to form as they should in children. In
congenital radial-ulnar synostosis, the radius and ulna fail to grow
apart at their proximal locations. This condition can be bilateral or
unilateral. When the proximal radius and ulna are not freely
mobile, supination and pronation of the forearm is limited.
• Radiographs of the forearm confirm cross-synostosis of the
proximal radius and ulna. This appearance of the bony union is
easily seen by the increased bony formation.

44. Radial Head Subluxation
• Children who have loose ligaments are at risk for subluxation of the radial
head. Radial head subluxation sometimes is called nursemaid’s elbow and is
the most common elbow injury in younger children. Most often, radial head
subluxation affects the left arm of children who are between the ages of 2
and 3 years.
• Problems with the radial head develop when a young child’s arm is pulled
with forearm extension and pronation. This injury often occurs when a child
is pulled up by the arm or suddenly drops to the floor to tug away from
being held.
• Diagnosis of radial head subluxation is complicated by young children’s
inability to describe their symptoms in detail. Radiographs of the elbow do
not always show a subluxation of the radial head. Occasionally, a
displacement of the radiocapitellar line is evident, but the lack of this
displacement on images should not alter treatment plans.

45. – Management
• Cold and pressure immediately w/ sling
• Refer for reduction
• Neurological and vascular fxn must be assessed prior to
and following reduction
• Physician should reduce - immediately
• Immobilization following reduction in flexion for 3 weeks
• Hand grip and shoulder exercises should be used while
immobilized
• Following initial healing, heat and passive exercise can be
used to regain full ROM
• Massage and joint movement that are too strenuous
should be avoided before complete healing due to high
probability of myositis ossificans
• ROM and strengthening should be performed and
initiated by athlete (forced stretching should be avoided

46. Rehabilitation of the Elbow
• General Body Conditioning
– Must maintain pre-injury fitness levels - cardiovascular
and strength (lower body)
• Flexibility
– Restoring ROM is critical in elbow rehab
– Variety of approaches can be used as long as they
don’t force the joint
• Joint Mobilizations
– Loss of proper arthrokinematics following
immobilization is expected
– Joint mobilization and traction can be very useful to
increase mobility and decrease pain through
restoration of accessory motions

47. • Strengthening
– Achieved through low-resistance, high-repetition
exercises - must be pain free
– Shoulder and grip exercises should also be performed
– Continuous passive motion units followed by dynamic
splinting is ideal following surgery
– Isometrics can be used while elbow is immobilized
– PNF and isokinetics are useful in early and
intermediate active stages of rehab
– A graded PRE program w/ tubing, weights or manual
resistance should be included
– Closed kinetic chain activities should also be
incorporated - assist in both static and dynamic
stability to the elbow
– Proprioceptive training should also incorporated

48. • Functional Progressions
– Will enhance healing and performance
• PNF, swimming, pulley machines and rubber tubing
• to simulate sports activities
– Should include steps
• Warm-up
• Gradual build up to activity, becoming increasingly more
difficult
• Return to Activity
– Can re-engage in activity when criteria has
successfully been completed
– ROM w/in normal limits, strength should be equal w/
no complaint of pain
– Return should progress with use of restrictions in an
effort to objectively measure activity progression

49. • Protective Taping and Bracing
– Should be continued until full strength and
flexibility have been restored
– Chronic conditions usually cause gradual
debilitation of surrounding soft tissue
• Must restore maximum state of conditioning w/out
encouraging post-injury aggravation

50. Precautions Following Traumatic
Injury to the Elbow
• If the brachialis muscle is injured, ossification of the
injured tissue is a potential complication, and
stretching is contraindicated.
• After healing of fractures in the forearm, malunion is
not unusual, preventing full range of pronation or
supination. A bony block end-feel or an abnormal
appearance of the forearm should alert the therapist to
the cause of this impairment. X-ray films are helpful in
verifying the problem. No amount of stretching or
mobilizing changes the patient’s range. Indiscriminate
stretching may lead to hypermobility of related joints,
which could cause additional trauma and pain.

51. Surgical Options for Displaced
Fractures of the Radial Head
Open Reduction and Internal Fixation
• Advantages: Achieves stabilization and fixation of multiple fracture
fragments with normal or near-normal alignment; ability to repair
significant ligamentous damage; early postoperative motion
permissible unless reconstruction of ligaments required
• Disadvantages: Extensive soft tissue disruption and arthrotomy
required; not amenable to nonreconstructible fractures and less
practical than radial head excision for severely comminuted
fractures
Arthroscopic or Arthroscopically Assisted Reduction and Internal
Fixation
• Advantages: Allows arthroscopic evaluation of the joint and
débridement of fracture debris; if fully arthroscopic, no
arthrotomy, less soft tissue disturbance, less postoperative pain,
better cosmetic outcome

52. • Disadvantages: Limited to reduction and fixation of no
more than two-part displaced fractures; not
appropriate for radial neck fractures; if fully
arthroscopic, fixation techniques more technically
difficult (e.g., use of percutaneous screw fixation) than
open procedure
Excision of the Radial Head
• Advantages: Only option for severely comminuted,
nonreconstructible fractures; no potential for
mechanical blockage of joint motion from
malalignment of fracture fragments or internal fixation;
early ROM permissible
• Disadvantages: Requires arthrotomy; may compromise
joint stability if a prosthetic implant is not used.

53. Severity of Elbow Joint Disease and
Selection of Surgical Procedure
Severity of Joint Disease
• Mild synovitis: joint surfaces
normal or minimally eteriorated;
osteoporosis
• Moderate synovitis; some loss of
articular cartilage; narrowing of
joint space but joint contour
maintained
• Moderate to severe synovitis; loss
of articular cartilage; loss of joint
space; intact collateral ligaments
• Severe synovitis; destruction of
articular cartilage; complete loss
of joint space (bone-to-bone
articulation); significant joint
instability; bone loss; ankylosis
Selection of Surgical Procedure
• Nonoperative/medical
management
• Arthroscopic synovectomy or
resection of the radial head
with synovectomy
• Resurfacing total elbow
arthroplasty or, possibly in a
growing child, an
interpositional arthroplasty
• Semiconstrained total elbow
arthroplasty

54. Contraindications to Total Elbow
Arthroplasty
Absolute
• The presence of active (acute or subacute) infection
• Inadequate control (paralysis) of elbow musculature,
particularly the elbow flexors
Relative
• Irreparable supporting ligaments
• Inadequate control of elbow extensors
• Heterotopic ossification or pain-free ankylosis
• Insufficient bone stock
• A young patient, particularly one who needs to lift
heavy loads

55. Analysis of Three Potential Complications
after Total Elbow Arthroplasty
• Joint Instability
• Triceps Insufficiency
• Implant Loosening