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274
K. W. Zittel and M. W. Kessler
achieved through active work done by the patient,
rather than simple passive stretching by the therapist. Motion loss is usually in extension (inability to
completely straighten the elbow). A characteristic
of the elbow, like that of the hip, is its propensity to
develop heterotopic ossication (HO) bone formation within the soft tissues, after trauma or surgery.
This is particularly common anteriorly because of
the presence of the brachialis muscle belly immediately anterior to the elbow capsule. The risk of ossication is increased with passive stretching, and for
this reason, aggressive passive motion is often discouraged. Some specially designed splints which
exert a dynamic force across the elbow can be effective in restoring motion.
Injections
Generally, corticosteroid or protein rich plasma
(PRP) injections are reserved for specic diagnoses and conditions which fail initial activity modication, anti-inammatories, and therapy. The
exact timing and number of injections is controversial, but in general, no more than three injections should be given over a 6-month time frame.
The use of corticosteroids injections about the
elbow facilitates treatment of inammatory or
degenerative arthritis by decreasing pain and
potentiating motion. Because corticosteroid
injections can lead to cartilage and tendon damage, dermal depigmentation, and infection, they
should not be used arbitrarily or excessively.
PRP injections are now utilized more commonly for medial and lateral epicondylitis with
moderate results. For epicondylitis, corticosteroids
have fallen out of favor and are now infrequently
used since published outcomes versus saline placebo have been shown to be similar. In addition,
authors have argued against its use for epicondylitis, citing that the disease pathology does not
involve inammation, but rather histological
changes called angiobroblastic hyperplasia.
approaches or arthroscopic methods. Common
open elbow procedures include open reduction
internal xation (ORIF) for fracture xation, anatomical restoration of length, alignment, rotation,
bone healing, joint restoration, and allows for
early elbow ROM.In addition to ORIF, open dissections are used for ulnar nerve decompressions
and elbow instability requiring ligamentous
repair, augmentations, auto and allograft reconstructions. Common open approaches to the
elbow include lateral (Kaplan, Kocher, EDC
split), medial, posterior, and anterior.
Elbow arthroscopy has proven to be very
effective for specic elbow pathologies; however,
it should only be done by surgeons who are comfortable with the surrounding anatomy. Even
then, should be approached cautiously. Because
of the very tight concentration of nerves and
blood vessels in the area, the depth of the joint
capsule under the musculature, and tight articular
constraint, the procedure is technically difcult
and involves more risk than arthroscopy at most
other joints. Therapeutically, it has been used
effectively for the removal of inammation, synovectomy, debridement of the capsule and/or
extensor carpi radialis brevis (ECRB) origin for
lateral epicondylitis, radial head resections,
release of soft tissue contractures, excision of
painful or motion limiting osteophytes and/or
intra-articular loose bodies. Occasionally, it is
used in osteochondral reconstruction (osteochondritis dissecans). Interestingly, in other joints of
the body, arthroscopy is not generally indicated
or employed for the treatment of osteoarthritis.
The elbow’s ulnohumeral joint is an exception
and has shown to have mild/moderate results for
motion and pain. Relative contraindications to
arthroscopy include severe contracture, previous
ulnar nerve transposition or open elbow surgery,
signicant bone or joint distortion.
Operative Treatment
Surgery for the elbow is for patients in whom
nonoperative management has failed or inappropriate. Surgery can be performed via open
Evaluation andTreatment
ofCommon Elbow Problems
The following discussion highlights selected
examples of common chronic and acute traumatic elbow problems.
Common Extensor Tendon Origin Extensor Digiti Minimi (EDM)
11 The Elbow
275
Chronic: Atraumatic,
Post- Traumatic, Overuse Injuries
oftheElbow
Lateral andMedial Epicondylitis
Lateral Epicondylitis: “Tennis Elbow”
Lateral epicondylitis is popularly known as tennis elbow, even though only 5% of these patients
play tennis. Conversely, nearly 50% of tennis
players will develop some degree of the condition during their sports careers. It affects men and
women equally, most commonly between the age
of 30 and 50years of age, and those engaged in
backhanded sporting activity, repetitive gripping
or lifting tasks.
In skeletally mature adults, strains to the
medial and lateral structures at the epicondyle
can result in epicondylitis and are the most common elbow pathologies seen in clinical practice.
These conditions can result from a single, particularly strenuous action, or with any repetitive
stress such as sports (especially racket sports,
golf, and baseball), labor intensive jobs, carrying
heavy bags, typing and cleaning activities. The
tendon origin is thought to undergo microtears,
degeneration, replacement with abnormal scar
and granulation tissue called angiobroblastic
hyperplasia (microscopic appearance). This
occurs within the extensor carpi radialis brevis
(ECRB) on the lateral side (Fig. 11.9) or the
exor carpi radialis (FCR) and pronator teres
(PT) muscle origins on the medial side
(Fig.11.10).
Patients complain of weakened grip strength,
pain over the lateral epicondyle with activity or at
night, often with some radiation into the forearm.
Symptoms develop gradually over a period of
weeks to months, typically without a specic
injury. The key physical exam nding is focal
tenderness over the lateral epicondyle or myotendinous attachment just anterior to it. Tenderness
more distal to the lateral condyle in the proximal
forearm, may instead suggest pain from posterior
interosseous nerve (PIN) entrapment.
Differential diagnosis for lateral elbow pain
includes radial tunnel syndrome/PIN entrapment
(which can coexist in 5% of patients), posterolateral plica (space occupying capsular involutions/
hypertrophy), posteromedial and posterolateral
rotatory instability, occult fracture (radial neck,
head, lateral column/distal humerus), cervical
radiculopathy, triceps tendinitis, capitellar osteochondritis dissecans, radiocapitellar arthritis, and
varicella-zoster (shingles).
XR imaging is non-diagnostic and usually normal, though it may reveal calcications in the
extensor muscle mass (up to 20%). MRI is not
necessary for diagnosis, though it may show
increased signal intensity, thickening, edema,
degeneration at the ECRB tendon origin.
Ultrasound is a useful diagnostic tool in experi-
Extensor Carpi Radialis Brevis (ECRB)
Extensor Digitorum Communis (EDC)
Lateral Epicondyle
Extensor Carpi Ulnaris (ECU)
Fig. 11.9 Lateral view of a right elbow illustrating the
common extensor origin, extensor muscle mass, site of
pain and point of maximal tenderness in lateral epicondy-
litis. Most commonly occurring within the extensor capri
radialis brevis. Other lateral muscle origins not imaged:
brachioradialis, extensor carpi radialis longus, anconeus
276
igin
Flexor Carpi Ulnaris (FCU)
K. W. Zittel and M. W. Kessler
Pronator Teres (PT)
Flexor Carpi Radialis (FCR)
Flexor Digitorum Superficialis (FDS)
Fig. 11.10 Medial view of a right elbow showing the
exor-pronator muscle mass and common exor tendon
origin. Point of maximal tenderness and site of pain in
enced operators and can reveal a thickened and
hypoechoic ECRB tendon or used to aid in placement of injections.
Treatment is almost always conservative and
based on pain modulation, emphasizing rest, ice,
avoidance of provocative activities. In addition,
identication and correction of sporting techniques is important; common tennis modications include slower playing surfaces, more
exible racquets, lower string tension, or larger
grips. Nonsteroidal anti-inammatory drugs
(NSAIDs) do not treat the pathology (not an
inammatory reaction) but are effective for pain
control. Wrist bracing during the night primarily,
and daytime with activity, is often utilized and
helpful by decreasing the need to re wrist extensor muscles. Structured physical therapy programs once pain levels have decreased, <2 out of
10 on visual analog scale (VAS), can be helpful
in treatment and prevention. PRP injections (up
to three/one every 2 weeks) are used in those
unresponsive to conservative management or
those presenting with severe symptoms. In clinical practice, even with proper use of nonoperative strategies, symptoms can persist for up to
12–18months before complete resolution.
Therefore, surgery for lateral epicondylitis is
only indicated in patients who fail an appropriate
conservative trial (considered 2 years of duration), and in those compliant with the recommended nonsurgical treatment. Surgery is
Palmaris Longus
medial epicondylitis, most commonly occurring within
the pronator teres and exor carpi radialis
Common Flexor Tendon Or
necessary for less than 10% of patients. Open or
arthroscopic procedures involve identication
and debridement of the pathologic tissue, usually
located within the substance of the extensor carpi
radialis brevis. Advocates of arthroscopic technique report advantages in visualization and ability to address intra-articular pathology and faster
return to work following surgery. Albeit is associated with risk of neurovascular injury that accompanies arthroscopy.
Complications of surgical management include
excessive resection of the LUCL leading to posterolateral rotatory instability (PLRI), iatrogenic
radial nerve injury, heterotopic ossication, infection, and missed concomitant pathology.
Medial Epicondylitis: “Golfer’s Elbow”
Medial epicondylitis is often called golfer’s
elbow because of its association with forehanded
sporting activities like golf, bowling, throwing,
racquet sports, that require repetitive wrist
exion, forearm pronation, and valgus force on
the elbow. It is seen in patients with jobs requiring forceful gripping, lifting, or exposure to constant vibration at the elbow (plumbers, carpenters,
construction workers). It affects men and women
equally, commonly between the ages of 30 and
60, and involves the dominant extremity in 75%
of cases. It is 5–10 times less common than lateral epicondylitis.
11 The Elbow
277
Patients typically complain of pain over the
medial epicondyle (Fig.11.10), with or without
numbness and/or tingling in the ulnar digits.
Pain is generally an insidious onset but may be
associated with history of an acute traumatic
blow to the elbow. Pain may also be worse in
overhead throwers during late cocking/early
acceleration phases. Physical exam is positive
for point tenderness to the medial epicondyle or
just anterior to it. When more distal, it may be
due to medial ulnar collateral ligament (MCL)
insufciency or tears. Soft tissue swelling and
warmth may be present. Occasionally, in more
chronic cases, a exion contracture may be
observed. It is important to examine the patient
for associated conditions such as valgus instability and MCL insufciency/injury or ulnar neuritis/neuropathy looking for hypothenar bulk and
positive Tinel signs.
The differential diagnosis for medial sided
elbow pain includes MCL injury, cubital tunnel
syndrome, ulnar-humeral arthritis, fracture, cervical radiculopathy, triceps tendonitis, and
shingles.
X-rays are not needed for diagnosis and usually unremarkable, but can identify posterior
medial osteophytes or degenerative changes, and
25% of patients may have calcication of the
common exor tendon or ulnar collateral ligament. Stress XRs are useful to evaluate for valgus
instability if it is a concern. MRI is standard of
care to evaluate for concomitant pathology (UCL
injury/trochlear osteochondral lesions in overhead thrower), evaluate for loose bodies, rule out
rupture of exor-pronator origin, or if there is an
unclear source of medial elbow pain. Ultrasound
is effective to evaluate hypoechoic/anechoic
areas of focal degeneration and allows for
dynamic examinations or direct visualization of
injections. EMG/NCS may be used to evaluate
for ulnar nerve compression if symptoms are
identied on history or physical exam.
Like lateral epicondylitis, treatment for medial
epicondylitis is almost always conservative,
emphasizing rest, ice, avoidance of provocative
activities, and NSAIDs/Acetaminophen. It is
important to emphasize strict activity modication and a stop to all throwing for 6–12weeks
(about 3months) in overhead athletes. Use of a
wrist brace (day and/or night), and structured
therapy with passive wrist extension stretching
(once pain <2/10 on VAS), can be helpful. PRP
injections into peritendinous tissue may be benecial, however, must be performed carefully to
avoid ulnar nerve injury.
Surgery should be considered only after a prolonged trial of appropriate conservative management (2years in duration). As symptom resolution
can take up to 12–18months and due to less predictable success, operative treatment is often
avoided. Only 80% of patients report good to
excellent outcomes (less than lateral epicondylitis). Worse outcomes tend to occur when ulnar
nerve symptoms are present preoperatively. A
clear diagnosis, appropriate conservative management, and severe symptoms affecting quality
of life are an indication for surgical management
of medial epicondylitis. It involves an open
medial approach to the elbow to excise or debride
pathological tissue near the exor-pronator mass.
This is done in conjunction with repair or reattachment, if the proximal tendon origin is
involved. Cubital tunnel release and ulnar nerve
transposition can also be performed if nerve
symptoms are present.
Complications after surgical management
include medial collateral ligament complex
injury (posterior medial rotatory or valgus instability), medial antebrachial cutaneous nerve neuropathy, ulnar nerve injury, and infection.
Elbow Arthritis
Arthritis (degenerative joint disease) is much less
commonly seen in the elbow than encountered in
the hip or knee, generally, because it is a
nonweight bearing joint. The three major types
are primary osteoarthritis (OA), post-traumatic
arthritis, and inammatory arthritis (rheumatoid,
psoriatic, systemic lupus erythematosus, pigmented villonodular synovitis).
Clinically symptomatic primary osteoarthritis of the elbow is rare (2%). It is characterized
by widespread osteophyte and loose body formation, capsular contraction, with relative pres-
278
K. W. Zittel and M. W. Kessler
ervation of articular cartilage in some areas. It
typically occurs in middle aged males with a
history of manual labor, from 20 to 70years of
age (avg. 50). Post-traumatic elbow arthritis is
more common in younger patients, seen after
nonoperatively treated radial head fractures,
simple elbow dislocations with instability,
elbow fracture dislocations, and other general
trauma. In either circumstance, primary OA or
post- traumatic OA, patients typically present
with progressive elbow pain at end ranges of
motion secondary to osteophytes and impingement, associated with painful locking and clicking, worsened with activity. Midrange motion
pain and night pain are less common complaints.
Loss of terminal extension is common with pronation/supination motion preserved early. Ulnar
neuropathy is commonly observed in up to 50%
of patients.
In patients with inammatory (especially
rheumatoid) arthritis, 20–50% have elbow
involvement. Elbow inammatory arthritis
may present with hand and wrist involvement
preceding the elbow. In some cases, rheumatoid disease rst presents in the elbow and
should be considered in patients with an atypical history on presentation. They will complain
of elbow pain and loss of range of motion often
without an inciting incident or without a manual labor history. On physical exam, a xed
exion contracture, ligamentous incompetence, and ulnar nerve symptoms may be seen.
It is important to include cervical spine evaluation in all RA patients. If undiagnosed or in
rst time presenters with suspected elbow pain
secondary to RA, patients require appropriate
lab tests for evaluation of systemic arthritis
including erythrocyte sedimentation rate
(ESR), C-reactive protein (CRP), antinuclear
antibody (ANA) test, rheumatoid factor (RF)
test, and complete blood count (CBC).
Additional rheumatologic tests should be
determined in consultation and referral to a
rheumatologist. Prevention is key as treatment
with disease modifying anti-rheumatic drugs
(DMARDs) has signicantly decreased the
incidence of inammatory arthritis and need
for operative treatment.
The differential diagnosis includes infection/
septic arthritis, gout (uric acid crystallization),
chondrocalcinosis or pseudogout (calcium pyrophosphate deposition) crystalline arthropathy,
osteoarthritis versus inammatory arthritis. To
aid in the diagnosis and treatment planning, aspiration of the elbow joint synovial uid, and analysis of cell count, differential, gram stain, and
crystals, can often be performed.
AP and lateral X-rays of the elbow can conrm the presence of osteoarthritis. XR ndings
include joint space narrowing (<2mm), with the
ulnohumeral joint space relatively preserved.
Osteophytes at the coronoid process and fossa,
radial head and fossa, olecranon tip and posteromedial olecranon fossa are common (Fig.11.11).
In RA, XR ndings are more diffuse and range
from periarticular osteopenia in early disease to
subchondral erosions, destructive appearing joint
collapse, and ultimately bony ankylosis (fusion)
as untreated disease progresses. Including a cervical spine XR in patients with RA is necessary
prior to surgery because of the risks of cervical
manipulation while under anesthesia. CT scan,
although not often necessary, can be used for surgical planning and useful to dene osteophytes
and loose bodies.
First line treatment of primary and posttraumatic elbow osteoarthritis is nonoperative
with NSAIDS, cortisone injections, resting
splints, and activity modication. Treatment of
the rheumatoid elbow varies with the stage of
presentation. Early in the course, antiinammatory and anti-rheumatoid medication,
analgesics, and activity modication may be sufcient treatment and slow the progression. Initial
goals are to decrease pain and inammation,
maintain motion, and avoid further destructive
changes.
Late stage efforts to relieve pain and improve
function may rely on surgical treatment such as
arthroscopic or open debridement, synovectomy
with or without radial head resection. In endstage disease, a total elbow replacement (TEA)
may be the only viable or functional option. Total
elbow replacement is indicated in low demand
patients, generally older than 65 years of age,
with severe osteoarthritis or post-traumatic
11 The Elbow
Fig. 11.11 Elbow Arthritis
279
arthritis, and OA secondary to distal humerus
nonunion/malunions in the elderly. The procedure involves a hinged type metal prosthesis that
replaces the distal humerus and proximal ulna at
the ulnar-humeral joint and spares the radial head
articulation. After TEA, patients are restricted to
a 5-pound weight restriction to the operative
extremity for life. TEA is contraindicated in
another variant of OA called Charcot joint
arthropathy, and in active patients with high
demand because overuse is known to lead to
failure.
Cubital Tunnel Syndrome (Ulnar Nerve Compression)
Cubital tunnel syndrome is a compressive neuropathy of the ulnar nerve caused by entrapment
amongst the structures of the medial elbow. The
position of the ulnar nerve at the medial elbow
renders it susceptible to compression, traction,
and direct trauma. There are ve major sites of
compression of the ulnar nerve in the region of
the medial elbow: the arcade of Struthers (a fascial band of the triceps 5–10cm proximal to the
medial epicondyle), the medial intermuscular
septum, the medial epicondyle groove, the ligament of Osborne (between the medial epicondyle
and olecranon) and the humeral and ulnar heads
of the exor carpi ulnaris muscle (FCU). Up to
16% of patients are further predisposed to symptoms by having “instability,” with either subluxation or frank dislocation out of the groove.
Cubital tunnel syndrome can occur in isolation or
be associated with chronic elbow deformity such
as cubitus varus or valgus, medial epicondylitis,
burns, or elbow contractures.
Patients with cubital tunnel syndrome present
with complaints of numbness and tingling in the
distribution of the ulnar nerve in the hand (ring,
little nger, ulnar dorsal hand). They often have
isolated elbow pain with or without radiation;
usually worse during long periods of elbow exion such as in sleep or repetitive exion activities.
The patient may feel clumsy or weak in grasping
or throwing (ulnar nerve—hand intrinsic muscles). He or she may note actual “snapping” in
cases in which the ulnar nerve is unstable and
contributory.
In early disease, there is usually no sensory or
motor decit, although a Tinel sign over the cubital tunnel may be positive. Check for nerve instability by exing and extending the elbow while
280
Olecranon
K. W. Zittel and M. W. Kessler
feeling the ulnar nerve at its recess below the
medial epicondyle. As compression progresses,
patients can lose sensation over the ulnar border
of the ring nger and all of the small nger.
Weakness to nger abduction and eventually
intrinsic atrophy of the interosseous muscles and
rst webspace (adductor pollicis) can develop.
Moreover, in advanced cases with chronic ulnar
denervation, 4th and 5th digit claw deformities
can occur.
The differential for Cubital tunnel syndrome
includes Guyon canal syndrome (ulnar nerve
compression at wrist), C8 radiculopathy (commonly compression in cervical spine), concomitant medial elbow pathology associated with
ulnar neuropathy such as arthritis, MCL injury,
epicondylitis.
Differentiation between ulnar nerve compression at Guyon canal (wrist) vs. the cubital tunnel
(elbow) can be done by testing the strength of
intrinsic (hand) vs. extrinsic (forearm) muscles
supplied by the ulnar nerve, respectively.
Weakness in both intrinsic and extrinsic groups
points toward Cubital tunnel syndrome (compression proximal to muscle innervation loss).
Spared extrinsic strength (FCU/4–5th FDP) in
the presence of weak intrinsics, and/or spared
light touch of the dorsal surface of ulnar dermatome (dorsal medial hand and 4th and 5th ngers), points to more Guyon canal syndrome and
distal nerve compression. The anatomy of Guyon
canal and its three common sites of ulnar nerve
compression (via cysts, lipomas, hamate fracture), are out of the scope of this chapter. Signs
and symptoms can be purely motor, purely sensory, or mixed depending on the zone.
X-rays are almost always negative although
they may reveal deformity or structural compression. Electrodiagnostic tests, nerve conduction
study/electromyography (NCS/EMG), are helpful to establish diagnosis and prognosis. Often
negative in early disease, a conduction velocity
<50m/s across the elbow is diagnostic for cubital
tunnel syndrome.
Treatment is initially nonoperative, with rest,
ice, NSAIDs, night-time arm position education
and modication versus extension splinting with
the elbow in 45° extension and forearm in neutral
rotation. The goal of treatment is to halt the progression and resolution of symptoms. For patients
with continued symptoms or signicant denervation on NCS/EMG, surgery involves in situ nerve
decompression and anterior transposition of the
ulnar nerve via an open medial elbow approach.
The most common post-operative complications include recurrence of symptoms, neuroma,
or hematoma formation.
Olecranon Bursitis
Olecranon bursitis (OB) is inammation around
and uid collection within the bursa of the olecranon and is the most common supercial bursitis
(Fig. 11.12). It is caused by aseptic, inammatory, and infectious processes (occurring in 20%
of acute cases). The olecranon bursa is anatomically present after 7 years of age, covering the
dorsal aspect of the olecranon to the distal insertion of the triceps and proximal subcutaneous
border of the ulna. Pressure from the bony olecranon and shearing forces applied to the skin contributing to uid lled bursa formation.
Patients with olecranon bursitis present with
unilateral swelling over the proximal olecranon
(acutely up to 7 cm long × 3 cm wide), commonly with a history of repetitive micro trauma
(desk jobs/chronic elbow positioning/pressure).
Aseptic OB is characterized as a compressible,
uctuant mass, with or without tenderness. In
sterile bursitis up to 45% of these patients report
Bursitis
Fig. 11.12 Olecranon Bursitis
11 The Elbow
281
tenderness depending on the level of acute
inammation and may have hyperemia of the
skin (increased blood ow, warmth, color
change), with edema extending into the forearm.
Septic olecranon bursitis is associated with
greater tenderness and may also have a visible
cellulitis component. Elbow effusions can be
seen in severe cases with elbow ROM limited by
the degree of swelling and pain. These factors
make olecranon bursitis often indistinguishable
on initial exam.
The differential includes idiopathic, infection,
and inammatory when associated with systemic
conditions such as rheumatoid arthritis, gout,
chondrocalcinosis (pseudo gout), and pigmented
villonodular synovitis.
Imaging including XR is generally not indicated unless there is concern for concomitant
pathology, ruling out inoculating or foreign bodies, or history of acute trauma. Instead, aspiration of the uid collection can be performed with
analysis of gram stain, culture, white blood cell
(WBC) count, and glucose level, to aid in the
diagnosis and treatment. A positive Gram stain
and culture, most commonly gram-positive
staphylococcus species, denitively diagnoses a
septic process. However, gram stains are positive
in only 50% to 60% of cases, and it may take
several days to obtain the results of culture. A
WBC count <1000/mm3, is consistent with aseptic bursitis, and a WBC count >10,000/mm3 is
generally consistent with septic bursitis. With
counts between these levels, the predominant
cell type may be used to distinguish septic from
aseptic bursitis. A preponderance of polynuclear
cells is indicative of septic bursitis, whereas predominance of mononuclear leukocytes is indicative of aseptic bursitis. Bursal uid glucose
levels indicate infection when values are <50%
of serum levels.
Proper recognition and medical management
of inammatory systemic conditions, in addition
to nonoperative principles (RICE), generally provides adequate treatment and prevents recurrence
of inammatory olecranon bursitis,
Treatment of acute atraumatic or idiopathic
olecranon bursitis is also generally nonoperative
with ice, compression, avoidance of aggravating
activity. In patients with bothersome aseptic
atraumatic bursitis or failed conservative management, aspiration has shown patient recovery
of 90% at 6months. Patients should be aware of
the risk of infection via direct inoculation when
utilizing aspiration injection as a form of treatment for aseptic bursitis. Septic bursitis is managed with aspiration sent for culture/analysis,
RICE, and oral or intravenous systemic antibiotics. Surgical management with open bursectomy
is rarely necessary and reserved for failed nonoperative management, advanced or uncontrolled
infection.
Postoperative complications can include
infection, recurrence, and hematoma formation.
Osteochondritis Dissecans
andPanner’s Disease
Osteochondritis dissecans (OCD) of the elbow
and Panner’s disease are considered two separate
disease processes with different etiologies.
Despite having nearly identical pathology and
characteristics, it should be recognized that alternative treatment strategies for each are employed.
Panner’s disease is the presence of a subchondral defect or lesion in the capitellum of preadolescent aged children. Commonly occurring
before the age of 10, it is diagnosed with the
absence of overhead throwing or a history of
repetitive elbow stress. Thought to be caused by
an interference in blood supply to the growing
epiphysis, the natural history of this process is
most commonly a period of symptomatic subchondral resorption with eventual self-limited
repair and resolution of pain if properly treated.
Osteochondritis dissecans of the elbow occurs
in adolescent aged patients and is an osteochondral injury that can persist or worsen if not
addressed. It has been described as the leading
cause of permanent disability in the young throwing athlete. It is characterized by localized stress
to the immature capitellum, resulting in subsequent separation of articular cartilage and subchondral bone, possibly as a result of avascular
necrosis (AVN) of the capitellum. OCD is particularly common among adolescent throwing
282
K. W. Zittel and M. W. Kessler
athletes and gymnasts (particularly vaulting, balance beam, uneven parallel bars, oor exercises).
Patients predictably present with a history of
these activities, overuse, and mild to moderate
associated pain. In throwing, enormous valgus
stresses are imparted to the elbow joint, absorbed
primarily by the medial collateral ligament. The
second line of defense is the radiocapitellar buttress, which in turn is subjected to signicant
repetitive compression and shear stress, even
with an intact or normally functioning MCL.
The most common presenting symptom is that
of activity-related lateral elbow pain with insidious onset in the dominant or throwing arm. On
physical exam, there is often pain and a restriction
in motion, loss of extension up 20–30° in more
advanced cases and/or crepitus on supination/pronation. There may be associated tenderness over
the radiocapitellar joint and presence of swelling
or effusion. Catching, locking, or grinding episodes with mechanical blocks to motion can occur
later in the disease process if loose bodies are
present.
AP and lateral X-rays are recommended and
are initially often normal, although there may be
early signs of lucency or irregular ossication of
the capitellum upon presentation. This is often a
subtle and easily missed nding on XR, thus a
high level of suspicion should be present when
the history and physical exam is positive. In
Panner’s disease, XRs exhibit an irregular epiphysis, while in OCD, a well-dened subchondral
lesion is visible. In later stages, there may be a
crescent sign, fragmentation, or loose body formation. MRI is often obtained and is the best
method of establishing the diagnosis and assessing the degree of articular involvement. It is also
useful in assessing subchondral involvement,
loose bodies, and extent of disease. MRI is often
repeated after treatment is undertaken to view
the status and healing of the lesion.
In the treatment of Panner’s disease, without
the presence of the loose body, surgery is contraindicated. 3–4 weeks of long arm cast may be
necessary to reduce elbow activities until pain,
swelling, and tenderness subsides. Elbow immobilization in this pre-adolescent age group is
generally well tolerated with low concern for
persistent ROM decits. Repeat MRI is often
obtained to ensure healing and typically selfresolution of the lesion is seen without lasting
sequelae.
In OCD of the elbow, goals of treatment
include painless elbow function and return to
activity or prior level of sport. Articular involvement and lesion characterization as stable or
unstable is an important treatment consideration.
The characterization of lesions remains under
considerable debate. Generally, in stable lesions,
there is formation of an osteochondral fragment
without separation from its bed, in unstable
lesions, there is separation with loose body formation. In addition, lesions are described as with
or without articular involvement. Treatment
depends on lesion characteristics, clinical and
radiographic ndings. Nonoperative treatment for
extra articular and stable fragments includes rest,
ice, NSAIDs, extension splinting, and physical
therapy with modalities for 3–6 weeks (about 1
and a half months). Because the healing process is
slow, the area must be protected against overzealous activity (i.e., hard throwing or weight-bearing), with gradual return to activities over a period
of 6–12weeks (about 3months). This results in
about a 90% success rate. Treatment of articular,
stable or unstable lesions is generally nonoperative initially but operative treatment is frequently
required. Surgical treatment includes arthroscopic
micro-fracture or drilling of the capitellum, xation of the lesion, debridement, and loose body
excision, or osteochondral autograft or allograft
transplantation (OATS). In unstable extra-articular or stable intra-articular lesions, micro-fracture
or subchondral drilling of defects has shown success. In contrast, large unstable lesions that
require xation have highly variable outcomes. In
unstable articular lesions, arthroscopic debridement with loose body excision is indicated. If
large lesions engage the radial head, OATS can be
indicated. OATS commonly is performed with
autologous osteochondral graft harvest from the
ipsilateral knee.
Complications after surgery include elbow
stiffness, pain, and arthritis. Returning to sport at
the same level after surgery is highly variable
with a wide range of potential future disability.
11 The Elbow
283
Little Leaguer’s Elbow
In the skeletally immature athlete, injury to the
medial epicondylar apophyseal structures is
known as little leaguer’s elbow because of its
high incidence in young baseball players. It is
caused by repetitive stresses to the vulnerable
epicondylar origin of the exor-pronator group
and MCL, during both acceleration and followthrough phases of throwing (Fig. 11.13). This
results in abnormalities in secondary ossication
and physeal plate structures. Younger patients are
more likely to have apophysitis or avulsion injuries rather than UCL sprains or tears because the
cartilaginous growth plate is weaker than the
bone or ligament. These children present with
medial elbow pain, diminished throwing effectiveness, and distance. On examination, there is
focal tenderness over the medial epicondyle and
pain on attempting active wrist exion or forearm
pronation, especially against resistance.
X-ray ndings vary and include apophyseal
fragmentation, irregularity or widening of the
physis, or avulsion of the medial epicondyle. The
medial epicondyle physis typically is no longer
visible (fused) by the age of 15years in females
and up to 18years in males. Valgus stress views
are useful; even an innocent appearing minimally
displaced fracture may be unstable. MRI will
show edema of the medial epicondyle apophysis
and can rule out UCL insufciency.
Fortunately, treatment is rarely operative and
includes rest, ice, physical therapy, and gradual
return to activity as pain resolves. Immobilizing
the elbow is not usually recommended.
Educating coaches and parents is critical for
treatment, after recovery, and in prevention, as
restricting the number of innings pitched in
Little League has led to a reduction in the incidence of elbow complaints. Surgery is reserved
for those with displaced (>2 mm), unstable
avulsion injuries or symptomatic nonunions via
open reduction internal xation of the medial
epicondyle. Ulnar collateral reconstruction is
indicated for UCL disruption and insufciency,
instability.
Complications after surgery include ulnar
nerve neuropathy, continued pain/instability, loss
of motion, and inability to return to the same
level of play.