The document describes the anatomy and common injuries of the elbow joint. It discusses the bones and ligaments that make up the elbow, including the humerus, ulna, radius, and collateral ligaments. Common injuries mentioned include supracondylar fractures in children, lateral condyle fractures, pulled elbow, distal biceps ruptures, triceps tendonitis, triceps ruptures, olecranon impingement, olecranon stress fractures, and olecranon bursitis. Treatment options and potential complications are provided for some of the main injuries.

1. Elbow joint anatomy
BY DR/ KHALED ALSAYANI

2. Elbow Joint
• Articulation: occurs between the trochlea and capitulum of the
humerus and the trochlear notch of the ulna and the head of the
radius. The articular surfaces are covered with hyaline cartilage.
• Type: Synovial hinge joint
• Capsule: Anteriorly it is attached above to the humerus along the
upper margins of the coronoid and radial fossae and to the front of the
medial and lateral epicondyles and below to the margin of the coronoid
process of the ulna and to the anular ligament, which surrounds the
head of the radius.
• Posteriorly it is attached above to the margins of the olecranon fossa of
the humerus and below to the upper margin and sides of the olecranon
process of the ulna and to the anular ligament.
• Synovial membrane: This lines the capsule and covers fatty pads in the
floors of the coronoid, radial, and olecranon fossae; it is continuous
below with the synovial membrane of the proximal radioulnar joint.

5. Ligaments of the elbow joint
• Medial (ulnar) collateral
ligament
• Lateral (radial) collateral
ligament
• Nerve supply of the
elbow joint : Branches
from the median, ulnar,
musculocutaneous, and
radial nerves

6. Lateral collateral ligament
triangular and
• The lateral ligament is
is
attached by its apex to
the lateral epicondyle of
the humerus and by its
base
margin
to the upper
of the anular
ligament.

7. Medial collateral ligament
• The medial ligament is also triangular and consists of three strong bands: the anterior band,
which passes from the medial
the medial margin of
epicondyle of the humerus to
the
coronoid process; the posterior
band, which passes
medial epicondyle
from the
of the
humerus to the medial side of
the olecranon; and
transverse band, which
the
passes
between the ulnar attachments
of the two preceding bands.

8. Movements and relations of the elbow joint
• Movements: The elbow joint is capable of flexion and extension.
• Flexion is performed by the brachialis, biceps brachii, brachioradialis, and
pronator teres muscles and is limited by the anterior surfaces of the
forearm and arm coming into contact.
• Extension is performed by the triceps and anconeus muscles and is
checked by the tension of the anterior ligament and the brachialis
muscle..
• Carrying angle It should be noted that the long axis of the extended
forearm lies at an angle to the long axis of the arm. This angle, which
opens laterally, is called the carrying angle. The angle disappears when
the elbow joint is fully flexed.
• Important Relations
• Anteriorly: The brachialis, the tendon of the biceps, the median nerve,
and the brachial artery
• Posteriorly: The triceps muscle, a small bursa intervening
• Medially: The ulnar nerve passes behind the medial epicondyle and
crosses the medial ligament of the joint.
• Laterally: The common extensor tendon and the supinator.

11. Proximal Radioulnar Joint
• Type: Synovial pivot joint
• Articulation: Between the circumference of the head of the radius and the
anular ligament and the radial notch on the ulna
• Capsule: The capsule encloses the joint and is continuous with that of the
elbow joint.
• Ligament: The anular ligament is attached to the anterior and posterior
margins of the radial notch on the ulna and forms a collar around the head
of the radius. It is continuous above with the capsule of the elbow joint. It is
not attached to the radius.
• Synovial membrane: This is continuous above with that of the elbow joint.
Below it is attached to the inferior margin of the articular surface of the
radius and the lower margin of the radial notch of the ulna.
• Nerve supply: Branches of the median, ulnar, musculocutaneous, and radial
nerves

13. Distal Radioulnar Joint
• Type: Synovial pivot joint
• Articulation: Between the rounded head of the ulna and the ulnar notch
on the radius
• Capsule: The capsule encloses the joint but is deficient superiorly.
• Synovial membrane: This lines the capsule passing from the edge of one
articular surface to that of the other.
• Ligaments: Weak anterior and posterior ligaments strengthen the capsule.
• Articular disc: This is triangular fibrocartilage disc. It is attached by its apex
to the lateral side of the base of the styloid process of the ulna and by its
base to the lower border of the ulnar notch of the radius. It shuts off the
distal radioulnar joint from the wrist and strongly unites the radius to the
ulna.
• Nerve supply: Anterior interosseous nerve and the deep branch of the
radial nerve

15. Movements of the radioulnar joints
• The movements of pronation and supination of the forearm
involve a rotatory movement around a vertical axis at the
proximal and distal radioulnar joints.
• The movement of pronation results in the palm faces
posteriorly and the thumb lies on the medial side and is
performed by the pronator teres and the pronator
quadratus.
• The movement of supination results in the palm faces
anteriorly and is performed by the biceps brachii and the
supinator
• Supination is the more powerful of the two movements
because of the strength of the biceps muscle.

17. Supracondylar Fracture of the Humerus
Isa fracture, usuallyof the distal
humerus just above the
epicondyles, although it may occur
elsewhere. While relativelyrare in adults it is
one of the most common fractures tooccur
in children and is often associated with the
developmentof serious complications.

18. Flexion Type:20%
Classification:
Extension Type:80%

19. TYPES
Thereare three types based on thedegreeof separationof the fractured
fragments:
1-Type I: undisplaced or minimallydisplaced fractures.
2-Type II: partiallydisplaced.
3-Type III: fullydisplaced.

20. Epidemiology
1-This is the mostcommonelbow fracture inchildren.
2-About 60% of fractures inchildren.
3-It is mostcommon in children <10.
4- Peak incidence is between theagesof 5-8 yearsof age.
5-Primarily inchildren whoarearound age 7 years.

21. Presentation:
The child presents with history of a falling on an outstretched hand Followed by pain, swelling
and inability to move the affected elbow.
On examination: Unusual prominence of olecranon process but because it is a supracondylar
fracture, the three bony point relationship is maintained, as in a normal elbow.

22. Complications:
1. Brachial Artery Injury
2
. Nerve Injuries
3. Volkmann’s Ischaemic contracture
4. Myositisossificans
5. Mal-union(Cubitus Varus)

23. Cubitus Varus

24. Treatment

25. Treatment:
Closed Reduction& percutaneus Fixation

26. Lateral Humeral Condyle Fractures
Lateral condyle fractures are common and
their outcomes have historically been worse
than supracondylar fractures articular nature,
and often, missed diagnosis lead to an
unacceptably high incidence of malunion and
nonunion.

27. Epidemiology
6 Yearsold is the commonestage

28. Classification: According to
Displacement:
Classification based on fracture displacement:
Type 1: displacement <2mm, indicating intact
cartilaginous hinge
Type 2: displacement 2- 4mm, displaced joint
surface
Type 3: displacement >4mm, joint displaced
and rotated

29. Diagnosis:
Physical exam:
Exam may lack theobvious deformityoften seenwith supracondylarfractures.
Swelling and tendernessare usually limited to the lateral side.
Imaging:
Radiographs:
If the lateral condyle and capitellum have notossified then radiographic findingscan be
subtle.
Contra-lateral radiographsarevery important.
MRI and arthrogramscan be helpful as well

30. X-Rays

31. Treatment
Nonoperative
long arm casting:
Indications :
Only indicated if < 2 mm of displacement, which indicates the cartilaginous hinge is most likely intact.
Technique
follow patient very closely (every 4-5 days)

32. Operative
CRPP:
Indications:
closed reduction achieves adequate reduction with no evidence of intra-articular incongruity Technique.
Divergent pin configuration most stable
open reduction and percutaneous pinning
Indications:
if > 2mm of displacement any joint incongruity
Technique:
Kocher lateral approach used
avoid dissection of posterior aspect of lateral condyle (source of vascularization)
intraoperative arthrograms are valuable to delineate the fracture and ensure anatomic reduction

33. Complications
1-Lateral overgrowth bump
2-AVN
posteriordissectioncan result in lateral condyle osteonecrosis
3-Nonunion/malunion :
caused from delay indiagnosisand improper treatment mayresult incubitusvalgusand
tardyulnar nerve palsy

34. Cubitus Valgus

35. Pulled Elbow(Nursemaid’s Elbow)
⚫ Age: 1 to 4 yrs
⚫ Elbow is pronated and flexed
⚫ Painful movements

36. Reduction

37. Distal Biceps Raptures
🠶 Traumatic avulsion of distal biceps tendon from bicipital tuberosity of the
proximal radius
🠶 Mechanism: Eccentric extension load applied to flexed, supinated forearm
🠶 Presentation: 97% of biceps raptures are proximal, only 3% are distal;
thought to be associated with pre-existing tendon injury/degeneration or
steroid use
🠶 Physical Exam: Tenderness in antecubital fossa, regional ecchymosis,
palpable tendon defect in complete tears, tendon retraction if lacertus
fibrosis torn; weakness with supination/elbow flexion

39. Differential Diagnosis: Biceps tendonitis, cubital bursitis, lateral antebrachial
cutaneous nerve entrapment
🠶Diagnostics: Mostly a clinical diagnosis, ultrasound or MRI to confirm
🠶Treatment: Acute injury surgically repair considered superior to non-operative
treatment
🠶Prognosis and return to play: Usually a season-ending injury; patients treated
early can be expected to have full return of power and function

40. Triceps Tendonitis
🠶Inflammation of the triceps tendon at its insertion at olecranon process of the ulna.
Mechanism: Overuse injury from repetitive extension/ hyperextension of the elbow.
🠶Presentation:
🠶Most commonly seen in baseball players and weightlifters
🠶Patients report pain focal to the triceps insertion on the olecranon.
🠶Physical Exam: Triceps tendon is tender to palpation at, or just proximal to, its
insertion site; focal pain with resisted elbow extension.

41. Differential diagnosis: Partial tendon tear; olecranon bursitis; olecranon stress fracture; fracture of olecranon osteophyte.
🠶Diagnostics: Plain x-ray can reveal traction osteophytes; MRI can be useful to distinguish between inflammation and
partial triceps tendon tear.
🠶Treatment:
🠶Almost all respond to rest, ice, NSAIDs, and/or rehabilitation with graduated stretching and strengthening
🠶steroid injection can also be considered in refractory cases
🠶Prognosis and return to play: Most athletes can continue to play with this disorder with initiation of rest and focused
rehabilitation in the off-season

42. Triceps Rupture/Olecranon Avulsion
Traumatic avulsion of the triceps tendon from its insertion on the olecranon process of
the ulna, or avulsion of the olecranon process from the ulna with triceps tendon
attached.
🠶Mechanism:
Most commonly occurs from fall on outstretched hand with deceleration load applied to an
actively contracting triceps
🠶also reported in weightlifters and in direct trauma.
🠶Presentation: Rare injury; can be associated with steroid use,
metabolic bone disorders, and renal osteodystrophy.

44. Physical Exam: Tenderness to palpation along olecranon and distal triceps; regional ecchymosis
and edema; palpable defect of triceps tendon or step-off at olecranon; weak elbow extension
🠶Differential diagnosis: Triceps tendonitis, olecranon bursitis olecranon stress fracture,
posterior elbow impingement.
🠶Diagnostics: Largely a clinical diagnosis; “flake sign” (small bony avulsion fragment from
olecranon process) noted in 80% of these injuries; can use MRI or ultrasound to aid in diagnosis
if unclear.

45. Triceps Rupture/Olecranon Avulsion
Treatment:
🠶Conservative treatment consists of splint immobilization with elbow in 30° of
flexion for 4 weeks is indicated only in the elderly or in partial tears
🠶Treatment of choice is surgical repair within 2 weeks of injury in young patients
and complete tear
🠶Prognosis and return to play: Usually a season-ending
injury with at least 6 months of recovery time expected

46. Olecranon Impingement Syndrome or
hyperextension valgus overload
syndrome or “boxer’s elbow
Mechanical abutment of olecranon process against posterior soft tissues or the olecranon fossa
that occurs with terminal extension of the elbow.
🠶Mechanism:
🠶Overuse syndrome caused by repetitive extension overloading
🠶Can seen in a stable elbow (football linemen, gymnasts, weightlifters)

47. Olecranon Impingement Syndrome
Presentation: Posterior elbow pain, crepitus, and locking or catching; overhead
throwers often complain of premature fatigue, loss of velocity, or loss of control.
🠶Physical exam: Some loss of terminal extension; posterior elbow pain with
valgus stress in terminal extension; possible laxity of UCL with valgus stress.
🠶Differential Diagnosis: Olecranon bursitis, olecranon stress fracture, triceps
tendonitis.
🠶Diagnostics: Plain x-rays can reveal loose bodies, hypertrophic bone formation,
calcification of the UCL; MRI can help to further assess the status of the articular
cartilage

48. Treatment:
🠶PRICE and a physical therapy regimen aimed at improving flexibility and elbow
strength focused on wrist flexor and extensor strengthening;
🠶Athletes that fail to respond are candidates for arthroscopic debridement of the
posterior fossa with or without concomitant UCL reconstruction.

49. Olecranon Stress Fracture
Microfracture of the proximal portion of the ulna.
🠶Mechanism: Overuse injury that results from repeated tension on the proximal
ulna with throwing
🠶Presentation:
🠶Common seen in adolescents and children throwers
🠶Patients usually report gradual onset of pain in the
posterior or lateral elbow that occurs during the acceleration phase
of throwing.
🠶Physical Exam: Focal point tenderness at olecranon process

51. 🠶Differential Diagnosis: Triceps tendonitis, olecranon bursitis, posterior impingement
syndrome.
Diagnostics: CT scan or MRI or bone scan to confirm the diagnosis
🠶Treatment:
🠶Immediate cessation of throwing with non–weight bearing status in the affected arm till
tenderness subsided with gradual rehabilitation thereafter;
If patients become symptomatic again with rehab, percutaneous, cannulated screw fixation of
the fracture can be considered.

52. Olecranon Bursitis or miner’s elbow,”
or “student’s elbow”;
Inflammation of the bursa overlying the olecranon process
🠶Can be acute or chronic, septic or aseptic
🠶Mechanism: Typically occurs because of mild direct trauma to the posterior elbow;
may be secondary to a single direct blow, or to repetitive trauma to the superficial
tissues
🠶Presentation:
🠶Acute or gradual onset of swelling; acute/septic cases can be painful, whereas
chronic cases are often painless;
🠶
Most common in football and hockey players; high association
with play on artificial turf.

53. Physical Exam: Focal posterior elbow swelling; mobile, fluctuant mass that can wax and wane
in size
Differential Diagnosis: Gouty tophus, calcium pyrophosphate deposition.
Diagnostics: X-rays occasionally will show calcification of the bursa or olecranon spur;
aspiration can be performed in acute and chronic cases; fluid should be sent for cell count and
differential, Gram stain/culture, and crystal analysis

55. Treatment:
🠶Acute cases PRICE and NSAIDs
🠶Chronic cases can be treated with aspiration and injection of corticosteroid
Septic bursitis should be drained/excised with administration of intravenous and
or oral antibiotics
🠶Chronic aseptic cases can also be treated with excision of the bursal sac

56. TENNIS ELBOW

57. Introduction
Tennis elbow is a misnomer, because most people get this disease who don’t play
tennis & lateral epicondylitis a misnomer because of its pathophysiology different from
an inflammatory condition.
It is a tendinosis [ i.e., chronic symptomatic degeneration of the tendon ] that affects the
common attachement of the tendons of the extensor muscles of forearm ( ECRB,
Extensor digitorum, Extensor digiti minimi & Extensor carpi ulnaris ) to the lateral
epicondyle of humerus.
This disease is idiopathic , benign & self-limiting

58. COMMON EXTENSOR ORIGIN
 1:Extensor carpi radialis longus
 2:Extensor digitorum
 3:Extensor carpi ulnaris
 4:Supinator
 5: Extensor carpi radialis brevis
 6:Extensor digiti minimi

62. HISTORY
Lateral epicondylitis was first described in medical literature by RUNGE in 1873.
Term “tennis elbow” was attributed to description of the disorders as “ lawn tennis
elbow” first in 1883 by Major.
Cyriax postulated that microscopic / macroscopic tears in common extensor origin.
Goldie described granulation tissue found at the origin of the ECRB.

63. ETIOLOGY
• No obvious underlying cause can be identified.
• Mc incriminated activities like overuse of extensor / supinator muscle.
• These activies include but not restricted to typing , household work in females like
rinsing cloth & various types of industrial manual work in labourers.

64. • Over training & prolonged duration of play that give inadequate time to heal.
• Frequency of play.
• Choose optimal size of racquet handle. Too large/ too small effect the lever arm of force
applied though forearm & racquet weight shouldn’t be more

65. RISK FACTORS
• Obesity
• Repetitive movements
• Forceful activities
• Manual labour

66. ASSOCIATIONS
• Found to be associated with “mesenchymal syndrome”.
• These pts have multiple problems
- Rotator cuff pathology
- Epicondylopathy
- Carpal tunnel syndrome
- Trigger finger
- De quervain’s disease.

67. • Pts with tennis elbow tend to gave a high incidence of Rheumatoid factor – positive
HLA B 27 – positive.
• It may suggest auto-immune disorder of low severity.

68. PATHOGENESIS
• LE was previously considered to be tendinitis, arising as inflammation of the
tendon [inflammatory mediators atleast partially present in pathogenesis]
• Histopathologically to have a paucity of inflammatory cells such as
macrophages & neutrophils
• The condition, is therefore now considered as Tendinosis.

69. TENDINOSIS- “OSIS –
ABNORMAL/ DISEASED
• Don’t involve inflammation, it can be
painful.
No redness / warmth of surrounding soft
tissue.
Under microscope, micro tears of tendon
seen & no evidence of inflammatory cells.
3 – 6 months to heal.
TENDINITIS- “IT IS – Inflammation”
• Results in inflammation.
• Swelling, redness & warmth, pain
present.
Inflammatory cells present.
Tears & damage would typically be
more pronuounced.
Fast recovery upto 6 weeks

70. • Stage – 1 : An acute inflammatory response
commonly resolves in initial episodes completely while with recurrence if
persists & pts are inclined to seek medical help.
• Stage – 2 : Sustained stage 1 / recurrent cases
histological appearance of “angiofibroblastic hyperplasia” with pathological
tissue comprising of high concentration of fibroblasts, vascular hyperplasia &
disorganised collagen bundles in the region.
pts commonly present at this stage for treatment.

71. • Stage – 3 : Partial / complete tendon exposure.
• Stage – 4 : along with features of stage 2/3, also other associated changes fibrosis,
soft tissue calcification.
the collagen is grossly disorganised & loose in hard osseous calcification.

72. CLINICAL FEATURES
• Affects approx ~ 1 – 2 % population.
Signs & Symptoms :
• Disease is affecting males & females equally in 4th& 5thdecade.
• Usually affects pts below 35 & 55yrs of age.
• Pain over lateral epicondyle region localized in stage – 1 & later
get diffused.
• Gripping movements with wrist extension & lifting of heavy
weights is painful.

73. • Point tenderness first anterior & distal to the
lateral epicondyle & then proximal region of
ECRB & EDC muscles.
• Inability to extend the elbow completely after
long sleep / rest [ morning stiffness ].
• Non specific symptoms :
Radiating pain to forearm & wrist
Forearm weakness
Pain during uncountered extension of
wrist [ pain on shacking hands ]

74. PROVACATIVE TESTS
• COZENS / THOMPSON TEST :
restricted wrist extension with radial
deviation & full pronation causes pain in
antero-lateral elbow.
• MILLS TEST :
Pronating the pt forearm & fully flexing
the wrist , the elbow is extended to stretch
the tendon.

75. • MAUDSLEY’S TEST :
resisted 3rddigit extension.
• CHAIR LIFT TEST :
lifting the back of the chair with 3 finger
pinch ( first 3) & elbow fully extended.
• Injecting local anaesthesia in pathological
region partially / completely abolishes the
pain.

80. DIFFERENTIAL DIAGNOSIS
• Stenosis of annular ligament.
• Cervical spondylosis &/ C6 /C7 root compression.
• Inflammation of synovium adjacent to radial head..
• Radiocapitellar overload syd, early OA of radial head/
capitellum.
• Bursitis.
• Radial nerve entrapment.
• Elbow overuse as a compensatory mechanism for I/L
frozen shoulder.
• Osteochondritis dissecans (OCD) of capitellum.
• Lateral collateral ligament laxity

81. INVESTIGATIONS
• Plain elbow radiographs – to rule out any bony
pathologies & patchy calcification.
• Doppler ultra sound.
• Thermography.
• MRI.
• Nerve conduction studies & EMG can be used to
exclude PIN entrapment.
• High resolution real- time ultrasound imaging
identify thickening / thinnig hypiechogenic
foci indicating intra substance degenerative
areas, tendon tears & calcification.

82. TREATMENT
• Non operative
• Operative

84. PROGNOSIS USING PAIN PHASE
• Phase 1-4 - Responds to rehabilitation.
• Phase 5 - watershed phase.
• Phase 6-7 – usually requires surgical
intervention.

85. NON OPERATIVE
• Approximately 80 – 95% of pts have success
though recurrence is common.
• Rest & NSAIDS.
• Stretching exercises - for wrist with elbow
extended.
• Physical therapy –
eccentric exercise of forearm extensor muscles.
low application of low intensity ultrasonic, ice
massage to improve muscle healing & healthy scar
formation.

86. • Brace ( counterforce brace ) – over centred over
back of forearm.
Mechanism :
inhibit maximum contraction of wrist & finger flexors
& extensors
restrict full muscle expansion
partially fix the muscle to underlying forearm bone &
soft tissue.

87. TENNIS ELBOW
BRACE

88. • Steroid injections :
- maximum of 3 triamcinolone acetonide
injections
- 20 – 40 mg diluted in 5ml 2% xylocaine
at an interval of 4 – 6 wks.
• Extracorporeal shock wave therapy.
• Autologous blood injection.
• Local injection of autologous concentrated
platelets.

89. STEROID INJECTION
SITE

90. OPERATIVE MANAGEMENT
Nirsch, modified
•

91. POST-OPERATIVE CARE
• Strenuous activity can be resumed with in the
limits of pain in 8 – 10 weeks.
• Full power return in approx 3 months.

92. • Arthroscopic management
obtain results equal to those of open
procedures with several advantages.
lesions can be treated without sacrifice
of common extensor origin.
arthroscopy allows intra-articular
examination for other pathologic process &
permits a shorter post-operative rehabilitation
period & early return to work.

93. GOLFERS
ELBOW

94. INTRODUCTION
• Also known as “ Medial Epicondylitis”
• Pathological changes to the musculotendinous
origin at the medial epicondyl.
• Golf swing is more common cause and other
repetitive activities that result into overuse of
forearm wrist and finger flexor muscles( pronator
teres & flexor carpi radialis ) can also lead to
golfers elbow.

96. PATHOPHYSIOLOGY
• Micro tearing of tendon origin at epicondyle that
progresses to a failed reparative response and
subsequent tendon regeneration.

97. CLINICAL FEATURES
• Pain at medial epicondyle and may spread down
the forearm.
• Bending of wrist , twisting the forearm down /
Grasping objects make pain worse.
• Feeling of weakness/ less strength while grasping
items.
• Ulnar nerve symptoms are associated in up to 50%
of athletes with golfers elbow.

98. PROVOCATIVE TEST
• Resisted forearm pronation and resisting wrist
flexion increases pain.
• Area of maximum tenderness-
Approx. 5mm distal and anteriorly
to midpoint of medial epicondyle.

100. DIFFERENTIAL DIAGNOSIS
. Cervical radiculopathy
. Elbow and forearm overuse injuries
. Little league elbow syndrome
. UCL injury

101. INVESTIGATIONS
• Plain radiographs – To rule out traumatic
injury , apophyseal fracture.
• Bone scanning – To evaluate stress fracture ,
Infection and tumours.
• CT scanning
• MRI
• Ultrasonography

102. TREATMENT
• Non operative
• Operative

103. NON OPERATIVE
• NSAIDS
• PRICE ( Protection , rest , Ice compression
& Elevation ) method.
• Modification of activities.
• Elbow braces.
• Local corticosteroids
• Platelet rich plasma injection

104. OPERATIVE
( NIRSCHL PROCEDURE )

105. POST OPERATIVE CARE
• Splint removed 1 wk after surgery and elbow
ROM initiated.
• Strengthening exercises started when full ROM
achieved, typically after 3 wks after surgery.
• Strenuous exercises can resume typically after 3
months after surgery.
• Longer period of immobilisation and slower
progression of rehabilitation are indicated in
patients who had ulnar nerve transposition.