Elbow Injuires And Sport

Chapte r9Injuries 

 

­Elbow    

   

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Introduction

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Anatomy and biomechanics

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Ligamentous injuries and instability ○

Medial (ulnar) collateral ligament injuries 

Acute rupture of the MCL

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Valgus extension overload

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Posterolateral rotatory instability

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Tennis elbow

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Golfer’s elbow

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Osteochondritis dissecans

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Panners disease

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Little leaguer’s elbow

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Medial epicondylar fractures

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Olecranon bursitis

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Acute

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Chronic

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Septic

Tendinous ruptures ○

Tendon injuries around the elbow

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Distal biceps rupture

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Rupture of the triceps tendon

Fractures and dislocations

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Supracondylar fractures

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Lateral condylar fractures

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Fractures of the radial head

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Fractures of the neck of radius

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Elbow dislocations

Nerve compression syndromes ○

Cubital tunnel syndrome

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Radial nerve (radial tunnel)

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Median nerve

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Musculocutaneous nerve

Intra-articular derangements ○

Loose bodies

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Osteoarthritis of the elbow

1 D. Bokor, D Duckworth. The Elbow in E Sherry and D Bokor (eds), Manual of Sports Medicine. GMM London, 1997

Introduction The elbow is a difficult joint to examine diagnose and treat (not a frequent site of trauma and injury). Nevertheless the elbow is becoming better understood as more participate in throwing or overhead sports resulting in an increasing number of elbow problems requiring treatment. Overuse injuries in throwing or catching sports create most chronic elbow problems (may involve the ligaments, capsule, muscles or articular surfaces of the joint to impair function). Particular sports cause specific injuries around the elbow (Table 1).  

Table 1. Sports specific elbow problems

 

Sport Golf Tennis Baseball

 

Condition Medial epicondylitis Lateral epicondylitis MCL injuries Valgus extension overload Little leaguers elbow OCD Panner’s disease Ulnar neuritis/cubital tunnel Acute rupture MCL

Gymnastics

Medial epicondylitis OCD

 

Javelin

Acute rupture MCL Partial rupture MCL Epicondylitis

 

Anatomy and biomechanics The elbow is a highly constrained hinge joint, (its stability is maintained by ligamentous, osseous and capsular structures) with a slight degree of varus/valgus and rotational laxity (3-5 degrees) throughout the flexion - extension arc. There are 3 articulations here (Fig. 1) •

Ulnohumeral - allows 0-150 degrees flexion.

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Radiocapitellar.

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Proximal Radio-ulnar joints (radiocapitellar allows 75 degrees pronation and 85 degrees

supination). Note: Most daily activity is done through a 100 degree arc of flexion and extension (usually 30130 degrees) Forearm rotation occurs in an arc of 100 degrees, (usually 50 degrees supination and 50 degrees pronation). Any loss of this arc of movement may limit one’s function. Elbow Stability. Ligamentous stability is provided by the medial and lateral ligamentous complex. (The relative importance of these ligaments depends on the position of the arm). Medial Collateral Ligament: has 3 parts. The anterior oblique ligament is the most important of these bands originating from the medial epicondyle and inserting onto the medial aspect of the coronoid process; The anterior band is the primary constraint to VALGUS instability and the radial head is of secondary importance (clinically, this is noted in throwing as the repetitive valgus stress can result in microtrauma and attenuation of the anterior oblique ligament). Lateral Collateral Ligament: has 3 parts and offers varus stability (rarely stressed in the athlete) The lateral ulnar collateral, the most important of these ligaments plays an important role in rotational instability, it originates from the lateral epicondyle and inserts onto the tubercle of the supinator crest of the ulna; Its function is to prevent Varus and Posterolateral rotatory instability of the elbow. The capsule serves as an important constraint to instability in full extension. Neurological anatomy. Neurological compression syndromes are common here due to the closeness of the nerves. The ulnar nerve is vulnerable within the cubital tunnel, posterior to the medial epicondyle. The median nerve is anterior deep within the cubital fossa, the radial nerve is lateral and branches in the cubital fossa. Ligament injuries and instability

Medial (ulnar) collateral ligament injuries (MCL) From throwing sports where repetitive valgus stress results in small tears in the anterior band of the MCL and subsequent rupture. Occurs in javelin throwers and baseball pitchers (in throwing there is an enormous valgus stress on the elbow during the late-cocking phase so overloading the ligament leading to attenuation and rupture). Occasionally there is a single acute painful throw or a fall onto the outstretched hand. Examination reveals swelling and pain (localized to the medial side) and occasionally paraesthesia in the ulnar nerve distribution. Valgus deformity and elbow contracture may follow. Valgus stress testing with the elbow at 30 degrees of flexion displays increased laxity and pain. Incongruity develops between the olecranon process and its fossa with loose body formation at the medial side of the olecranon. X-ray’s may show osseous bodies in the MCL or fluffy calcification at the tip of the olecranon. Treatment is rest, activity modification, NSAIDs and physiotherapy. If posteromedial pain continues then arthroscopy is necessary to debride the osteophytes. If there is chronic MCL laxity or instability then surgical reconstruction (primary repair or use palmaris longus is necessary.

Acute rupture of the MCL Isolated tears of the anterior oblique ligament may occur in javelin throwers. The mechanism is almost pure valgus stress with the elbow flexed at 60-90 degrees. There is severe pain and a pop on the medial side of the elbow. Ulnar nerve symptoms may occur with ecchymosis about the elbow (48 hours later). If the diagnosis is in doubt stress tests or stress x-rays are useful . Acute repair of the ligament is necessary.

Valgus extension overload Seen in pitchers during the acceleration phase. (In the early phase of acceleration excessive valgus stress is applied to the elbow causing impingement). There results osteophyte formation posteriorly and posteromedially which can cause chondromalacia with loose body formation. The pitcher presents with pain on pitching (early in the game) and are not able to let go of the ball. Pain over the olecranon fossa occurs in valgus and extension. X-rays show a posterior osteophyte at the tip of the olecranon (on lateral views). Treatment (should be started early) is increasing functional strength, heat and ultrasound. An osteophyte needs surgical excision). Posterolateral rotatory instability1

Differentiate from a frank elbow dislocation. Caused by a laxity or disruption of the ulnar part of the lateral collateral ligament which then allows a transient rotatory subluxation of the ulnohumeral joint (and secondary dislocation of the radio-humeral joint). There maybe preceding trauma (dislocation or sprain from a fall on an outstretched hand). Previous surgery, radial head excision or lateral release for a tennis elbow, maybe the cause of instability. There is a history of a recurring click, snap, clunking, locking of the elbow and a sense of instability that ones elbow is about to dislocate. Such stability episodes occur with a loaded extended elbow and supinated forearm. Examination, often unremarkable, should include the ‘Lateral Pivot Shift’ (Posterolateral rotatory apprehension test)(Fig 2- Performed with patient supine, preferably under general anaesthesia; The elbow is extended overhead and the forearm fully supinated; A valgus and supination force is then slowly applied to the elbow going from the extended to flexed position; This results in subluxation of the ulno-humeral joint and radiohumeral joint ). On X-ray the joint will look normal (unless taken with the joint subluxed) so the diagnosis is made from history and after above test. When symptomatic surgery is required (re-attach the avulsed lateral ulnar collateral ligament or reconstructing it (with a tendon graft).

1 S W O’Driscoll, D F Bell, B F Morrey 1991. Posterolateral rotatory instability of the elbow JBJS 73A 440

Tennis elbow (lateral epicondylitis) A lateral tendinitis which involves the origin of Extensor Carpi Radialis Brevis. It is related to activities that increase tension and stress on the wrist extensors and supinator muscles (not all activities include tennis. It occurs between the ages of 35-55 years with pain localized to the lateral epicondyle especially after a period of unaccustomed activity (such as tennis 3-4 times a week). The pain is worsened by movements such as turning a door handle or shaking hands Examination reveals pain localized to the lateral epicondyle and distally. Typically aggravated by passive stretching the wrist extensors or actively extending the wrist with the elbow straight (Fig.3 ). X-rays are often normal (to exclude OA, LB or tumour). A bone scan will show increased uptake about the lateral epicondyle. An ultrasound or MRI will show degeneration within the belly of ECRB. The differential diagnosis includes: posterior interosseus nerve entrapment ( has a more distal localization of the pain and associated weakness); radial tunnel syndrome (pain distal and exacerbated by resisted extension of long digit, i.e. ECRB); OA/LB/Tumour. It will resolve over a 10-12 month period but there is a 30% recurrence therefore treat

comprehensively1 with rest, activity modification, NSAIDs, heat, ultrasound, phonophoresis with 10% hydrocortisone cream, brace (counterforce effect), eccentric muscle strengthening, modify tennis handle (usually too large) or tennis stroke (occurs in back hand stroke). injection of cortico-steroid (no more than 3, just below ECRB, anterior and distal to the epicondyle), and then surgery (symptoms >12 months, release and excise ECRB, note Nirschl scratch effect). Return to sport when strength 80% back or after 4 to 6 months.

1 C C Teitz et al 1997. Tendon Problems in Athletic Individuals JBJS 79A p 138-152.

Golfers elbow (medial epicondylitis) An inflammation of the flexor tendinous origin from the medial epicondyle. From repetitive activity of wrist flexion and active pronation such (in baseball pitching or occasionally golf and tennis). The pathology is at the interface of pronator teres and FCR. Presents with tenderness over the medial epicondyle radiating down the forearm, exacerbated by resisted palmer flexion and pronation. Ulnar nerve symptoms are present in 60% of cases. Treatment is very similar to lateral epicondylitis. Exclude other ulnar neuropraxia, joint stability or cervical pathology. Treatment is rest, activity modification, NSAIDs and physiotherapy. Avoid repeated steroid injections (so close to ulnar nerve). Only rarely is surgical release needed, (release the common flexor origin with occasionally a medial epicondylectomy). Osteochondritis dissecan’s (OCD) This is a spontaneous necrosis and fragmentation of the capitellar ossific nucleus (thought to be from compression forces at the Radio-Capitellar joint producing focal arterial injury and bone death). Occurs in gymnastics and throwing sports (baseball pitchers). There is lateral elbow pain post activity, occurs in the 10-15 year old group, and involves the dominant arm. Examination shows an inability to fully extend the elbow and pain on forced extension. Panner’s is a similar condition; the major difference being the x-ray appearance (fragmentation of entire capitellar ossific nucleus versus island of subchondral bone in OCD) and age of onset (<10 years). Early on the X-rays may be normal and if clinically suspected a bone scan or CT Scan is needed. Treatment is rest for 6 weeks, however if pain and contracture persist fragmentation may have occurred. Arthroscopy is then performed and if the fragment is separately removed (occasionally reattached if large). Panner’s disease An ‘Osteochondrosis’ which affects the growth centres in children resulting in necrosis followed by regeneration. Here it involves the capitellum resulting in fragmentation and then

regeneration. Commonly confused with OCD due to similar presentation dull aching elbow pain aggravated by use, loss of full elbow extension and lateral swelling. X-rays show fragmentation, irregularity and a smaller capitellum (compared to OCD) (as growth progresses the capitellum returns to normal) A self limiting condition, no specific treatment is necessary apart from rest during the acute period. Little leaguer’s elbow A medial epicondylar stress lesion or acute valgus stress syndrome which occurs in children. Results from repetitive valgus stress in a young throwing athlete which causes a flexor forearm muscle pull on the medial epicondyle epiphysis(Fig 4). Present with medial sided elbow pain with decreased throwing effectiveness and throwing distance. Examination reveals medial epicondylar tenderness and pain on loading the flexor muscles. An elbow flexion contracture may be present. X-ray show separation and fragmentation of the epiphyseal lines. A benign injury which responds to rest and activity modification. Return to throwing after 6 weeks, and only occasionally (if a large fragment separated) surgical fixation. Medial epicondylar fractures A substantial acute valgus stress (fall or violent muscle contracture whilst throwing) can produce a fracture through the epiphyseal plate seen in adolescents and throwers. There is pain and localized tenderness over the medial epicondyle. A 15 degrees flexion contracture is present. X-ray’s may show a minimal to markedly displacement (with the fragment sometimes caught in the joint). Treatment depends upon the degree of displacement. If the fragment is undisplaced or displaced less than 1 cm, then immobilize for 3-4 weeks; If grossly displaced or caught in the joint or if ulnar nerve symptoms are present then open reduction is necessary. Olecranon bursitis Acute An inflammation of the superficial olecranon bursa, (from direct trauma or repetitive stress about the elbow). Non traumatic causes are gout or rheumatoid arthritis. There is an enlarged, non tender bursa with normal ROM. Exclude a septic bursitis (the bursa is inflamed and tender; the patient septic with fever and malaise).

If worried about sepsis then aspirate under aseptic conditions. For recurrent bursitis X-ray to look for an olecranon spur or calcification as seen in gout. If the bursitis is associated with an inflammatory condition then control of the underlying condition. On first presentation use NSAID, and treat cause. Rest, activity modification and NSAIDs will usually relieve the bursitis (over a few months). Chronic Severe persistent olecranon bursitis will require operative intervention (a posterior incision with excision of the burial sac). Septic Note: Infection of the bursa does not mean elbow joint infection (as it does not communicate with joint) 1/3 give a history of a previous non infected bursitis. Symptoms are either acute onset of cellulitis to a low grade process of 2 or more weeks. The bursa is erythematous and tender and there are signs of generalized sepsis. Diagnosis is confirmed by aspiration (look for organisms) and an increased white cell count (consistent with infection). The presence of crystals in the aspirate indicates gout or pseudogout. Treatment is aspiration and antibiotics however if this fails surgical drainage is required. Tendinous ruptures Tendon injuries around the elbow1 Apart from epicondylitis, injuries to the tendons around the elbow are uncommon. The tendons that can rupture are the distal biceps (from the radial tuberosity) or the distal triceps (from its insertion into the olecranon).

1 R P Nirschl 1993. Sports and overuse injuries to the elbow. In Morrey BF (ed). The Elbow and its Disorders 2nd ed. Philadelphia. Saunders. p 537-552.

Distal biceps rupture 3-10% of all biceps ruptures occurs in the dominant arm of a well developed male (in his 40’s50’s). The result of a single traumatic event, (sudden extension force whilst flexing (contracting) the biceps). There is sudden sharp pain and discomfort in the antecubital fossa. Note weakness the elbow flexion and supination (with the elbow flexed). The muscle contracts proximally and a defect is noticeable.

Surgical treatment is (difficult, suggest anterior approach with anchor suture to bicipital tuberosity) almost always recommended (conservative management leads to moderate weakness especially in manual workers). Complications of surgery include cross union between the radius and ulna or a posterior interosseous nerve palsy. Rupture of the triceps tendon May occur spontaneously or after injury (from a decelerating force on the arm in extension during a fall). It can also result from sudden forced flexion whilst the elbow is being extended. Sudden pain and local swelling with a corresponding defect in the triceps tendon. X-ray may show a small bony fragment (avulsion of the tendon from the olecranon). Some loss of extension power is present. Fractures and dislocations Supracondylar fractures The worrisome fracture. These occur in children with 97% being posteriorly displaced or angulated (from an extension injury due to a fall on an outstretched hand, causing the distal lower humerus to be pushed backwards). There is a painful, swollen elbow and S-deformity. Check the pulse (and circulation) which may be compromised from swelling and fracture configuration. Check the nerves as (10-15% have a neuropraxia of radial, anterior interosseous, median nerve, ulnar -in that order). Treat undisplaced fractures in a collar n cuff for 3 weeks (Monitor the position with serial X-rays). Displaced fractures require at least a closed reduction and (occasionally) percutaneous K-Wires if unstable. Complications include cubitus varus (gun-stock deformity, cosmetic) or neurological. Vascular insufficiency resulting in Volkmann’s ischaemia and later myositis ossifications can occur (a disaster). Adult supracondylar and intercondylar fractures are not nearly as common (generally require open reduction and internal fixation). Lateral condylar fractures The lateral condyle epiphysis begins to ossify by one and fuses to the shaft by 12 to 14 years of age. During these years (from 4 to 10) fracture separations may occur. It is important to pick up such a fracture as it may lead to growth plate damage and as involves the joint accurate reduction is critical. Later problems include cubitus valgus with tardy ulnar nerve palsy. If undisplaced splint the arm in a backslab at 90 degrees; if displaced requires accurate reduction and fixation with K wires.

Fractures of the radial head More common in adults than children, result from a fall on the outstretched hand pushing the elbow into valgus and compressing the radial head. If undisplaced treat in a backslab; if displaced require open reduction (if possible) excision (if grossly comminuted). Fractures of the neck of radius Same mechanism as radial head fractures. (In adult fracture the radial head; children, due to the cartilaginous epiphysis, fracture through the radial neck). Up to 20 degrees of radial tilt is ok, beyond 20 degrees closed reduction and occasionally open reduction (if difficult) Monteggia Fractures result from a fall on an outstretched hand resulting in a fracture of the ulna with dislocation of the radial (often missed). This fracture requires a closed reduction and immobilisation closely monitoring the position of the radial head (on x-ray line down the middle of the radial shaft should bisect radial head in all views). Elbow dislocations More common in adults. Without fracture are called simple and classified according to the direction of the displacement of the olecranon (79% are posterior or posterolaterally). Result from a fall on the outstretched hand (with the elbow in extension); The anterior capsule brachialis. The surrounding ligaments may stretch or rupture depending on the direction of the dislocation. There may be a fracture. There is obvious deformity, pain and swelling. There may be vessel and neurological damage. (Neuropraxia seen in 20% of cases , involves the ulnar or median nerves, and transient). X-ray’s necessary . Closed reduction is performed (Apply longitudinal traction, with the free hand move the olecranon back onto the trochlea, ideally under general anaesthetic so as to assess the elbow stability post reduction). If stable can return to protected motion as soon as possible although (may loose the last few degrees of extension and supination). Associate injuries and complications (do note) include fractures (or avulsion of the medial of epicondyle), head of radius, or olecranon process; heterotopic ossification, recurrent dislocations and vascular or neural injury. Nerve compression syndromes Numerous nerves maybe compressed around the elbow. These include:

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ulnar nerve - cubital tunnel, Guyons canal.

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radial nerve - radial tunnel/ arcade of Frohse (post. interosseous nerve) / Wartenburg

syndrome

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median nerve - pronator syndrome / ant. interosseous syndrome / carpal tunnel.

Compression may occur from fracture or gradual onset (no injury) from degenerative changes about the joint, a space occupying lesion (ganglion or bursa) or musculotendinous anomalies. Clinically localized sensory and motor changes specific for a particular nerve are seen. Cubital tunnel syndrome This is an irritation or compression of the ulnar nerve within the cubital tunnel at the elbow (in the athlete a response to chronic activity). Chronic valgus strain may cause traction neuritis, scar formation, spurs, calcification in the MCL or osteophytes (all can compress ulnar nerve). Pain along the medial side of the forearm which may be proximally or distally. Paraesthesia in the little and ring ringers is seen early and precedes any detectable motor weakness of the hand. Ulnar paradox present (claw deformity of hand is less than if ulnar compressed in hand as FDP to little not working). There is a positive percussion test over the ulnar nerve at the elbow, abnormal mobility of the nerve over the medial epicondyle and a positive provocative test(Fig 5hyperflex elbow; dorsiflex wrist pain/symptoms reproduced). Clumsiness of the hand especially after pitching may be noted. Diagnosis may require nerve conduction studies. Differential diagnosis includes cervical spine pathology, thoracic outlet or pathology involving the ulnar nerve at the wrist. Treatment is initially an elbow splint and correction of the underlying pathology. If this fails then surgical decompression with transposition of the ulnar nerve (or medial epicondylectomy). Radial nerve (radial tunnel) The radial nerve may be compressed along its path from the lateral head of triceps to mid forearm (where branches into the posterior interosseous nerve) from trauma. There is lateral elbow pain (similar to lateral epicondylitis pain). Neurological symptoms and signs including weakness of wrist and finger extension and paraesthesia dorsally over the base of the thumb (exacerbated by resisted extension of long digit: which differentiates from tennis elbow). Surgical decompression is often required. Median nerve The median nerve is vulnerable to compression from: supracondyloid process (lig. struthers), fibrosus lacertus, pronator teres or flexor superficialis arch. Such compression may produce the: Pronator syndrome- not uncommon in athlete, symptoms are vague (discomfort in the forearm) with numbness of the hand in the median nerve distribution secondary. Repetitive activities such as industrial activities, weight training or driving will provoke symptoms. Signs include

tenderness over pronator muscle, proximal forearm pain on resisted pronation, elbow flexion and wrist flexion. Test: Resisted flexion of the middle or ring finger PIP will reproduce symptoms. Anterior interosseous syndrome. Where the anterior interosseous branch of the median is compressed between the two heads of the pronator muscle. Pain in proximal forearm, weakness of end pinch with FPL, and index finger FDP (difficulty forming OK sign with flexion of DIP index and IP of thumb). Treatment requires surgical release. Musculocutaneous nerve May be compressed between biceps and brachialis by lateral epicondyle Surgical release sometimes necessary. Intra-articular derangements Loose bodies In the elbow from old trauma, OA, osteochondritis dissecans and synovial chondromatosis. Extension is reduced and there is pain and locking (intermittent) or grating. X-ray’s are useful. If troublesome then remove surgically (arthroscopically or if multiple loose bodies then via an arthrotomy). Synovectomy may be necessary for synovial chondromatosis. Osteoarthritis of the elbow OA of the elbow joint from trauma, OCD or synovial disease (chondrometaplasia). Pain with loss of range of motion, locking, localized tenderness, joint thickening, crepitus and flexion contracture often with associated ulnar nerve irritation. Treatment: Rest, physiotherapy and NSAIDs with modification of activity. Later arthroscopic debridement, radial head excision or arthroplasty may be required.