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264
K. W. Zittel and M. W. Kessler
Fig. 11.1 Anterior and posterior views of a right elbow joint demonstrate the three articulations, including the
ulnotrochlear joint, the radiocapitellar joint, and the proximal radioulnar joint
The medial column develops a broad outcropping called the medial epicondyle and is bridged
laterally to the capitellum by the trochlea, a spoolshaped articular segment with a 300° arc of cartilage. The trochlea is cradled by the sigmoid notch
of the olecranon, creating the ulnar- humeral joint
(or ulnotrochlear joint). The sigmoid notch is a
deep, semilunar shaped recess, with anterior and
posterior prominences called the coronoid and
olecranon processes, respectively.
Proximal to the trochlea, medial and lateral
humeral columns converge centrally to create
two fossae on the volar and dorsal aspects of the
distal humerus. The volar coronoid and dorsal
olecranon fossae are depressions that allow the
tip of the coronoid and posterior olecranon processes to recess beyond the cortical width of the
humerus at terminal exion and extension.
The ulnar-humeral joint is considered the
most important static stabilizer in the elbow.
In the sagittal plane, the trochlea is exed
~30° anteriorly, and sits within the reciprocally
oriented (posterior angled) sigmoid notch;
framed and deepened by its coronoid and olecranon processes (Fig.11.2). The reciprocal alignment and complementary ulnar-humeral
relationship are why the elbow is often referred
to as “highly constrained” and “inherently stable,” all the while allowing a tremendous exion–
extension arc of motion.
Unlike the shoulder whose stability is dependent on surrounding soft tissues, the osseous
anatomy of the elbow renders its stability. Yet, the
elbow is capable of rapid changes in position and
at extreme ranges of motion, subjecting it to large
and repetitive static/dynamic forces. To maintain
its stability and articular congruence during exion/extension, rotatory motion, and varus/valgus
directed stress, the elbow is supplemented by two
important ligamentous structures. The medial
collateral ligament complex (MCL) and lateral
collateral ligament complex (LCL). Both of these
structures are considered to be primary static stabilizers of the elbow.
11 The Elbow
Fig. 11.2 Lateral X-ray of the elbow
The MCL has three segments; the most important for stability is the anterior bundle. It primarily resists against valgus directed stress. It
attaches the medial epicondyle to the medial ulna
at the sublime tubercle (Fig.11.3).
On the lateral side of the elbow, the LCL consists of the lateral ulnar collateral ligament
(LUCL), which attaches the lateral epicondyle to
the lateral ulna, at the tubercle of the supinator
crest. In addition to the LUCL, included in the
LCL is the annular ligament (surrounding the
radial head and helps to stabilize the ulnar and
humeral articulation), the radial collateral ligament, and the accessory lateral collateral ligament. Of its four components, the lateral ulnar
collateral ligament is the most important primary
static stabilizer of the elbow to varus and external
rotational stresses (Fig.11.4).
Anteriorly and posteriorly the elbow joint is
lined by a single-cell layer of synovium and covered by a relatively thick brous capsule. Beneath
the capsule, within the olecranon and coronoid
fossae, a fatty layer of tissue is present between the
synovium and the surrounding capsule (Fig.11.5).
This layer is of signicance in radiographic evaluation of elbows in which intra- articular (intracap-
265
sular) effusion (uid) or hemarthrosis (bleeding
into the joint) causes capsular distention.
Subsequently, the displacement of these fat pads is
either anterior or posterior to their usual position.
Muscles
The muscles surrounding or crossing the elbow
can be divided into separate groups based on
their location in the arm or forearm (anterior,
posterior) and function (exion, extension). They
originate in the upper arm, on the epicondyles, or
proximal forearm. They can be thought of as four
groups including the wrist/nger exor and
extensor compartments; and the elbow exor and
extensor compartments.
The extensor compartment of the elbow (posterior) consists of the triceps/triceps brachii
(Long, medial, lateral heads). It inserts as one triceps tendon on the olecranon process to provide
a powerful extension moment.
The elbow exor muscles specically can be
found at the anterior aspect of the distal humerus
and consists of the brachioradialis, brachialis,
and biceps/biceps brachii (long and short heads).
The brachioradialis is the most supercial lateral
elbow muscle, arising from the anterior lateral
aspect of the distal humerus, crosses the elbow
joint and helps elbow exion via its insertion on
the radial styloid (lateral distal radius at the
wrist). The brachialis, deep to the biceps, is the
elbow’s primary exor. It originates broadly
along the anterior humeral shaft and inserts distal
to the coronoid of the proximal ulna on the ulnar
tuberosity. The biceps, with two heads (longlateral, short-medial), crosses the elbow and has
two insertions that blend on the proximal radius.
1. The short head of the biceps (medial side of
arm) inserts on to the distal and apex of the
radial tuberosity, providing exion strength
(20% compared to brachialis giving 80% of
elbows exion strength).
2. The long head of the biceps (lateral side of
arm) inserts on to the oval footprint of the
radial tuberosity more medial and is a strong
forearm supinator.
266
Medial Epicondyle
Sublime Tubercle
ab
P
Lateral ulnar collateral ligament
Supinator Crest
ab
K. W. Zittel and M. W. Kessler
Anterior Bundle
Posterior Bundle
Transverse Ligament
Fig. 11.3 (a) A schematic view of a right elbow demon-
strating the three bundles or bands of the Medial Collateral
Ligament complex. The anterior bundle is most important
Anterior capsule
Radial collateral ligament
Annular ligament
osterior capsule
Capsule
in elbow stability and attaches at the sublime tubercle of
the ulna. (b) Grossly, these ligaments are seen as thickenings, blending with the joint capsule as depicted in b
Lateral epicondyle
Capsule
Fig. 11.4 (a) A lateral view of a right elbow demonstrat-
ing the lateral collateral ligament complex (LCL) consisting of the annular ligament, radial collateral ligament, and
Just distal to the elbow crease as the two
heads become tendinous, the short head of
the biceps tendon gives off a bicipital aponeurosis (fascia) called the lacertus brosus.
This structure travels obliquely, medially,
and distally to envelop the forearm exor
muscle bellies (wrist exors) and helps to
protect the underlying brachial artery and
median nerve.
lateral ulnar collateral ligament (LUCL). The LUCL is the
most important in stability and attaches at the supinator
crest of the ulna (b)
The wrist/nger exor and extensor muscle
groups originating around the elbow include the
extensor mass and the exor-pronator mass. The
extensor mass muscles arise from the lateral epicondyle and include the extensor carpi radialis
longus and brevis, which insert on the 2nd and 3rd
metacarpal, respectively (extends the wrist); and
extensor carpi ulnaris, inserting on the 5th metacarpal (extends the wrist); the extensor digitorum
C
Olecranon Bursa
in
11 The Elbow
Tr iceps Brachii
267
Brachialis
Biceps Brachii
Humerus
Posterior Fat Pad
Posterior Elbow
apsule and Synovium
Subtendinous
Olecranon Bursa
Trochlea
Articular
Surface/Cartilage
Tr iceps Tendon
Olecranon
Epiphyseal Plate
Fig. 11.5 Sagittal illustration of the elbow joint demonstrates the normal skeletal and soft tissue anatomy. Note
the presence of fat pads both anteriorly and posteriorly,
directly outside the joint capsule. Intra-articular swelling
can lead to displacement out of the olecranon (posterior)
Biceps Tendon
(Myotendinous)
Pronator Teres
Median Nerve
Brachial Artery and Ve
Flexor Digitorum
Superficialis
Anterior Fat Pad
Anterior Elbow
Capsule and Synovium
Coronoid Process
Semilunar Notch
(Trochlear Notch)
Flexor Digitorum
Profundus
Ulna
Anconeus
or coronoid (anterior) fossae, leading to the appearance of
“positive fat pad sign(s)” on lateral X-rays. An anterior fat
pad can be normal; a posterior fat pad if seen is always
abnormal and indicates elbow effusion
communis and extensor digiti mini (extend the
ngers). Deep to these posterior muscles lies the
supinator muscle which originates on the proximal ulna and inserts on the proximal radius. It
assists the biceps with supination of the forearm.
In addition, the anconeus is a small triangular
muscle that originates on the lateral epicondyle
and inserts on the lateral aspect of the olecranon,
it is thought to assist with elbow extension and
lateral stability of the elbow (Fig.11.6).
The exor-pronator mass takes its origin from
the medial epicondyle, the medial ulna, and the
interosseous membrane. From proximal to distal
absent in ~30% of population); exor digitorum
supercialis, inserting on middle phalanges 2–5
(nger exion at PIP and MCP joints); and the
exor carpi ulnaris, inserting on the pisiform, hook
of hamate, 5th metacarpal (wrist exion).
Occasionally, there is an accessory muscle present
supercially at the medial elbow called the anconeus epitrochlearis. It is present in approximately
15% of the population and can be a source of compression of the ulnar nerve at the cubital tunnel.
Neurovascular
on the medial epicondyle, it consists of the pronator teres, inserting on mid lateral radius (forearm
pronation); exor carpi radialis, inserting on 2nd
metacarpal (wrist exion); palmaris longus, inserting on exor retinaculum (weak wrist exor/
In contrast to deeper-seated neurovascular structures of other extremities, those about the elbow
are both tightly concentrated and supercial,
making them uniquely vulnerable to both direct
268
K. W. Zittel and M. W. Kessler
Fig. 11.6 Medial view of forearm demonstrating the
exor-pronator muscle mass and lateral view showing
extensor mass. Note the common tendon origins on the
and indirect injury. Injuries or symptoms due to
nerve involvement around the elbow make familiarization with normal neurovascular anatomy
crucial.
Brachial Artery
The brachial artery lies anterior to the medial
aspect of the brachialis muscle, entering the antecubital space medial to the biceps tendon and lateral to the median nerve. At the level of the radial
head, it divides into its terminal branches, the
ulnar and radial arteries.
Musculocutaneous Nerve
Continuing from the lateral cord of the brachial
plexus and composed of bers from the C5–C8
nerve roots, this nerve travels through (and innervates) the biceps and brachialis. Injury to the
musculocutaneous nerve results in inability to
ex the elbow and loss of sensation to the lateral
forearm from its terminal sensory branch, the lateral antebrachial cutaneous nerve (LABCN). The
LABCN is vulnerable to injury during anterior
approaches to the elbow, especially during distal
biceps repair.
Median Nerve
Arising from C5–T1 nerve roots, combined from
the upper and lower cords, the median nerve travels along anterior to the brachialis muscle, enters
the antecubital fossa, then passes medial to the
biceps tendon and the brachial artery. It then
passes through the pronator teres and gives off
the anterior interosseous nerve (AIN), a branch
which supplies motor innervation to the exor
pollicis longus, the index and middle exor digi-
medial and lateral columns of the distal humerus over lie
the elbow capsule, medial and lateral ligamentous
complexes
torum profundus, and the pronator quadratus.
Injury to the AIN results in the inability to ex
the thumb at the IP joint. The remainder continues distally in the forearm under the exor digitorum supercialis. The median nerve provides
sensory innervation to the volar radial aspect of
the hand, including the thumb, index, middle, and
radial half of ring nger; dorsally its sensory contribution is isolated, present only distal to the IP
joint of the thumb and the PIP joints of the index,
middle, and radial half of the ring nger. Sensory
testing is commonly performed at the volar index
or middle nger.
Radial Nerve
Originating from C6–8 nerve roots, the radial
nerve is a continuation of the posterior cord and
travels in the spiral (radial) groove of the proximal humerus until its encountered laterally at the
distal 1/3 of the humerus, entering the anterior
compartment between the brachialis and brachioradialis. It innervates the triceps, brachioradialis,
and extensor carpi radialis longus and brevis
muscles. In the antecubital fossa, anterior to the
lateral epicondyle, the nerve divides into a deep
motor branch, or posterior interosseous nerve
(PIN); and a supercial sensory branch continues
underneath the brachioradialis to provide sensation to the dorsal radial aspect of the wrist and
hand to the level of the IP joint of the thumb, and
PIP joints of the index, middle, and radial half of
the ring nger. Check radial sensory function
over the dorsal thumb–index web space. The PIN
is found on the posterolateral surface of the radius
after it pierces the supinator muscle entering the
posterior compartment. The PIN innervates the
11 The Elbow
269
supinator, extensor carpi radialis brevis, extensor
digitorum communis, extensor carpi ulnaris,
extensor pollicis longus and brevis, extensor
indicis, and abductor pollicis longus. Injury to
PIN results in inability to extend the wrist or
ngers.
Ulnar Nerve
Derived from roots C8 and T1, the ulnar nerve
continues from the medial cord of the brachial
plexus until passing posteriorly through the intermuscular septum at the level of the mid-humerus.
It then travels through the cubital tunnel of the
medial elbow, where pathologic compression,
traction, or irritation commonly can occur. In the
forearm, the ulnar nerve innervates the exor
carpi ulnaris and the ulnar half of the exor digitorum profundus. Distally, it continues to provide
motor function to many of the intrinsic hand
muscles and sensation to the skin of the ulnar
wrist/hand (palmar cutaneous branch), little nger and ulnar half of ring nger both volarly
(supercial cutaneous branch), and dorsally (dorsal cutaneous branch). Sensory testing commonly
occurs at the ulnar border of the little nger.
Injury to the ulnar nerve can result in a loss of
nger abduction; test by crossing the index and
middle nger.
Extrinsic muscles (located in the forearm)
innervated by the ulnar nerve include exor carpi
ulnaris, medial half of exor digitorum profundus (4th and 5th digit). Intrinsic muscles (located
in the hand) innervated by the ulnar nerve include:
1 thenar muscle (adductor pollicis—oblique and
transverse heads), 3 hypothenar muscles (exor
digiti minimi, abductor digiti minimi, opponens
digiti minimi), the 3rd and 4th (ulnar/medial two)
lumbricals, all 7 interossei muscles (three volar
interossei and four dorsal interossei), and palmaris brevis.
“FOAL” Mnemonic for the four intrinsic hand
muscles, not innervated by the ulnar nerve.
Instead, are innervated by the median nerve:
F: exor pollicis brevis
O: opponens pollicis
A: abductor pollicis brevis
L: lateral/radial two (1st and 2nd) lumbricals
Evaluation ofElbow Problems
The evaluation of elbow problems relies on a
thorough history, physical, and radiographic
examination, supplemented by other pertinent
clinical or diagnostic tests when indicated.
History
Elbow problems can be divided into two major
categories: (1) acute traumatic injuries and (2)
chronic elbow problems which tend to be more
atraumatic in nature, though can present as posttraumatic sequelae. In the situation of acute
trauma, a detailed history of the event must be
obtained. The mechanism of injury including the
position of the arm, initial treatment, and subsequent symptoms are all very important in guiding
further evaluation and management. For chronic
elbow conditions, the most common complaint is
pain. Stiffness or other mechanical symptoms
such as locking, catching, or instability may
accompany pain or become the primary problem.
Determine what treatments the patient has had
including specics of previous surgery, and if
anything has been effective.
The nature of the pain and any zone to which
they radiate is important. For example, is it burning or radiating (nerve) or is it an aching related
only to activity (tendinitis)? Does it hurt at rest or
at night (tumor, infection)? Establish the exact
location of the symptoms and if there is a relationship to the patient’s activity. In a throwing
athlete, when during the pitch or throw does the
pain occur? Medial elbow pain when the arm is in
the cocking position suggests medial collateral
ligament pathology, whereas medial pain during
follow-through suggests involvement of the
exor-pronator group or impingement in the posterior ulnar-humeral joint.
Is it associated with any other symptoms, such
as neck pain (cervical radiculopathy) or wrist
pain (distal radioulnar joint problem)? Numbness,
tingling, and weakness may be obvious clues to
neurologic involvement, but sometimes nerve
entrapment syndromes in the arm or neck present
with pain only. In addition to inquiring about
270
K. W. Zittel and M. W. Kessler
tingling or numbness, ask about weakness or loss
of dexterity.
The elbow is commonly involved (and sometimes one of the rst joints affected) in inammatory arthritides, so it is important to elicit a history
of other joint complaints, known arthritis, and
family history. Is there a history of skin problems
(lupus, dermatitis, psoriasis) or gastrointestinal
problems (colitis)? Have there been any systemic
symptoms of illness (malaise, fevers), suggesting
septic arthritis?
Perhaps the most important part of the history is determining how the symptoms interfere
with function and is the patient's dominant
extremity affected. This can direct treatment
strategies more than any other factors. For
example, a functional arc of motion, 30–130°
exion/extension, 50° pronation, 50° supination, is typically relied upon for most activities
of daily living. The inability to ex the elbow
completely is generally well tolerated by most
patients. However, considering a patient with
rheumatoid arthritis, shoulder motion may
already be compromised, thus, a seemingly mild
degree of elbow restriction actually may interfere with independence, and/or their ability to
feed or clean themselves.
Physical Examination
The examination of the elbow begins with inspection, palpation, passive/active range of motion
assessments, evaluation for strength, and neurovascular integrity. These maneuvers are then followed by special tests, designed to evaluate
specic conditions based on the examiner’s differential diagnosis. A thorough physical exam
should also include a directed evaluation of the
shoulder, wrist and hand, including the cervical
spine when relevant.
Inspection begins with careful observation of
elbow, forearm, and hand use as soon as one
begins interaction with the patient. Does the
patient extend the elbow to shake hands with the
examiner? Are there obvious adaptive maneuvers
that the patient uses to avoid pain or compensate
for functional loss?
A more formal visual exam is then performed.
One should evaluate the elbow alignment (neutral, varus, and valgus) in exion/extension, and
the “valgus carrying angle.” The carrying angle is
formed between the longitudinal axis of the
humerus/forearm with the elbow in extension
(normally 10–15° valgus). With the elbow exed
90°, note that the normal bony prominences
(medial/lateral epicondyles/olecranon) form an
equilateral triangle. In dislocations, this normal
relationship is often distorted. Look for evidence
of joint swelling laterally by inspection of the
soft tissue triangle bordered by the radial head,
olecranon tip, and lateral epicondyle.
Palpate the anterior, medial, lateral, and posterior elbow in a systematic fashion, noting its anatomic structures: the medial epicondyle, lateral
epicondyle, olecranon, radio capitellar joint,
biceps, triceps, forearm muscle masses and their
respective origins. Be specic in trying to identify the exact area of tenderness.
Note the location and timing of pain during
motion. Check both active and passive motion,
noting any difference between them. Comparing
the ROM to the unaffected side can serve as a
reference. Normal exion values are on average
between 130 and 154° and extension between −6
and 11°; pronation from 75 to 85° and supination
from 80 to 104°. If passive motion is greater than
active motion, consider pain, muscle, or nerve
injury as possible causes.
Check for sensation to light touch and motor
function in the distribution of the ulnar, median,
radial nerves, and specic branches (AIN, PIN,
cutaneous). A positive Tinel sign is useful in the
assessment of peripheral entrapment problems.
Gently tapping in the vicinity of suspected
pathology reproduces the symptoms, causing
numbness, tingling, or pain in the nerves distribution indicating a positive test.
Vascular assessment is mandatory after any
acute elbow trauma or suspected vascular compromise from pathology at the elbow. It includes palpation of the radial and ulnar arteries at the wrist,
and the brachial artery in the antecubital fossa. If
an extremity appears warm, pink, and well perfused, but there is delayed capillary rell (>2s), a
nonpalpable, “thready” or weak pulse, compared
11 The Elbow
271
to the unaffected side, a portable ultrasoundDoppler should be used to conrm the presence or
absence of an arterial pulse. Doppler is commonly
used for objective exam trending or clinical conrmation when examination is limited by factors
such as patients body habitus, acute traumatic/
post-operative swelling, overlying wounds, overlying splint/bandages, vascular disease. Specic
physical examination tests and signs are useful
depending on the condition suspected.
Radiographic Evaluation
Anteroposterior (AP) and lateral X-rays are the
minimum views necessary to evaluate the elbow
joint. Following trauma, additional views are
often necessary, including oblique elbow and
radiocapitellar joint / radial head views (Figs.11.7
and 11.8). Obtain full forearm/wrist and humerus/
shoulder series if concomitant injury is suspected
or for preoperative planning. After any fracture
manipulation or reduction maneuvers with application of an immobilizing split, it is prudent to
obtain repeat “post-reduction” X-rays to assure
adequate osseous alignment, soft tissue integrity,
and splint mold or position as it relates.
Alignment: On a lateral XR of the elbow, alignment should be assessed by the anterior humeral
line (AHL) and radiocapitellar line (RCL). The
AHL is drawn down the anterior cortex of the
humerus and should intersect the middle 1/3rd of
the capitellum. If it does not, consider a distal
humerus fracture. On AP and lateral XR, the RCL
is drawn along the radial neck and should always
intersect the capitellum. If it does not, consider
radial head dislocation or subluxation, and check
for accompanying fracture, especially at the proximal ulna (Monteggia fracture).
Bones: Trace the cortex of each bone, the distal humerus, radial head-neck-shaft, olecranon,
coronoid process, and ulnar shaft. Evaluate the
joint surfaces and space. Look for lucency, erosions, osteophytes, cortical irregularity, and common fractures: radial head and neck, capitellum,
coronoid, olecranon, epicondyles, distal humerus.
Effusion: On a lateral elbow X-ray, the presence of a posterior fat pad (usually deeply contained in olecranon fossa) indicates an elbow
effusion. Think occult intra-articular fracture not
well visualized on XR; commonly radial head/
a b
Fig. 11.7 (a) Lateral X-ray view demonstrating a posterior
elbow fracture dislocation with an osseous fragment anteriorly and irregular radial head contour with cortical step off
at the articular surface. Findings indicate a displaced intraarticular radial head fracture and possible coronoid process
fracture. (b) Attempted AP view redemonstrates a posterolateral dislocation and radial head fracture. In addition to
the above elbow X-ray series, two views (AP and Lateral)
of the wrist, forearm, and humerus is recommended, three
views if concern for concomitant injury or fracture
272
ab
K. W. Zittel and M. W. Kessler
c
Fig. 11.8 Elbow fracture dislocation status postreduction and splinting. After reduction, the next step in
management of this injury is to obtain a CT scan of the
elbow to further evaluate the fracture patterns and for preoperative planning. The presence of a coronoid fracture,
known dislocation (LUCL injury), and radial head fracture is often referred to as the “Terrible Triad” because of
its frequency of persistent instability if not surgically
treated. (a) Lateral view of left elbow demonstrating a
concentrically reduced ulnotrochlear joint; a well reduced
radiocapitellar joint with alignment conrmed by the
neck in an adult or supracondylar fracture in a
child. A small anterior fat pad can be seen in
patients and considered normal, though it may be
signicant with a history of trauma or if massively raised.
Beyond X-rays, the following special radio-
graphic tests can be helpful.
Stress X-Rays
Stress views may be helpful in evaluating the
patient with a suspected tear of the medial or lateral collateral ligament complexes. This is
achieved through manual stress, during which the
clinician applies a valgus or varus stress to the
elbow to open the contralateral side, with 2mm
of gapping usually indicating pathology.
straight radiocapitellar line intersecting the radial head
and capitellum. Re-demonstrated is the radial head fracture and small coronoid process fracture. Note the presence of a posterior slab plaster splint with cotton (webril)
padded soft tissue protection. Elbow reduction held by the
splint in 70–80° of exion to diminished risk of compartment syndrome from an increase in antebrachial soft tissue pressure seen with excessive elbow exion past 90°.
(b) Anterior–Posterior view and (c) External Oblique
X-ray views demonstrating appropriate reduction
can help to discern seemingly unidentiable
elbow anatomy sometimes encountered on initial
injury XRs.
Computed Tomography
Computed tomography (CT) scans without contrast enhancement are effective in preoperative
planning of complex elbow trauma, assessment
of bone fracture morphology and joint deformity,
and occasionally for the evaluation of loose bodies of the elbow. A CT with intravenous contrast
can be obtained to evaluate the presence of infection/abscesses within the surrounding soft tissue.
A CT angiogram (CTA), using arterial contrast,
can help identify locations of vascular injury,
occlusion, or compression.
Traction X-Rays
In the case of a severely shortened or comminuted distal humerus or proximal ulna/radius
fractures, traction X-rays can be performed, utilizing a principle called ligamentotaxis. The is
dened as the molding fracture fragments into
alignment because of tension applied across a
fracture by the surrounding intact soft tissues and
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) without contrast provides superior soft tissue imaging and
allows visualization of cartilage, marrow and
vascularity changes in bone. Its current use about
the elbow includes imaging occult fractures,
tumors, infections, synovitis or other causes of
joint effusion, and osteochondritis dissecans. It
11 The Elbow
273
also can be repeated after time to compare and
evaluate stages of osteochondral healing. It is
occasionally useful in evaluating ligament disruptions, but it is usually unnecessary in diagnosing medial or lateral epicondylitis and rarely
helpful in nerve entrapment syndromes. MRI
with contrast enhancement is generally reserved
for infectious or oncologic pathology.
Electrodiagnostic Tests
Electromyography (EMG) and nerve conduction
velocity (NCV) testing have denite indications
in the patient with suspected nerve entrapment or
injury. Such testing may indicate the site of the
compression or injury. However, failure to demonstrate specic neurologic ndings by electrodiagnostic testing does not rule out their presence.
Treatment ofElbow Problems:
Introduction toNonoperative
andOperative Principles
Treatment of elbow problems is algorithmic,
dividing conditions into either traumatic or atraumatic causes. One general principle of treatment
in the elbow is to minimize the length of immobilization. The adult elbow has a high propensity
for developing stiffness with prolonged immobilization (>2 weeks), especially after fracture or
dislocation. The resultant loss of motion can be
disabling, and treatment for it can be prolonged
and difcult. Because of this, in the adult population, casting with circumferentially wrapped
berglass for the treatment of upper arm/elbow
injuries or fractures is uncommon. Occasionally,
after initial management/immobilization, casting
for denitive management is indicated in adults if
they are nonsurgical candidates or in specic circumstances such as cognitive impairment or
compliance concerns. This is a different treatment strategy than in adolescent or pediatric
elbow/arm injuries which often are casted. The
developing elbow in children can tolerate longer
periods of immobilization. Therefore, circumferential berglass casting, with or without bi-
valving (splitting/cutting the berglass with a
cast saw and loose overwrap), commonly is used
as a primary means of treatment.
In adults, when immobilization is indicated
acutely, noncircumferential berglass or plaster
splints or a brace is often placed with the elbow
positioned in 90° of exion and neutral pronation/
supination. This allows for maintenance of the
most useful arc of function and a position of maximal capsular volume (less pain/intracapsular
pressure/stretch from effusion). After an initial
treatment such as closed reduction, casting, splinting, external xation, internal xation, one should
carefully assess and sometimes trend the patient’s
neurovascular exam. Swelling commonly
increases up to 24h after an acute injury and the
multiple conned fascial compartments of the
forearm leave patients vulnerable to compartment
syndrome or other severe compromise. Avoidable
iatrogenic causes (caused by treatment), include
circumferential casting or excessively tight wrapping of an acutely swollen extremity, and elbow
immobilization in exaggerated exion (>90–100°)
increasing anterior antecubital pressure. Occasionally, splinting of the arm in varying degrees of
extension, pronation, supination is necessary for
elbow stability after reduction, unstable fractures,
anatomic considerations, or comfort.
Nonoperative Treatment
Rehabilitation andPain Management
Rehabilitation through either a patient selfguided program or formal occupational/physical
therapy plays an important role in the treatment
of elbow problems. The goals should include (1)
reduction of pain and inammation, (2) restoration of motion, (3) rebuilding strength, and (4)
return to normal function and activity. These
goals, often accomplished with help of hand/
elbow therapists, should be carefully monitored
by the treating physician until the patient is discharged or alternative management is instituted.
Elbow stiffness is best treated by prevention.
Restoration of motion lost is done through careful
stretching exercises and takes much longer to regain
than to lose. Once lost, motion return is best