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the annular ligament.
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157
Part of the debate is because the complete lateral ligament complex, together with the lateral joint
capsule, are both torn away from the humeral epicondyle as 1
157
layer of tissue during the injurious event.
e diagnosis of
PLRI is much more elusive than other ligament injuries about
the elbow, so the dierential diagnosis must include varus posteromedial rotatory instability, cervical pain referral, LET, radial
158
tunnel syndrome, and valgus instability.
e reported symptoms, manifesting as either lateral elbow pain or mechanical
(clicking, etc) complaints, are due to a recurrent posterior radial
head subluxation when a load is applied while the elbow is in
158
exion and supination.
e diagnostic maneuvers to assess
PLRI include the lateral pivot-shift test, the posterolateral rotatory drawer test, chair sign, push-up test, and the table-top
relocation test.
•
Lateral pivot-shift test: is test, performed with the patient
in supine, involves the clinician elevating the patient’s arm
over the patient’s head with the shoulder placed in full external rotation and the forearm supinated. A valgus, supinating,
and axial force is applied as the elbow is slowly exed. At 40°
of exion, the rotatory displacement is maximized, and a skin
dimple proximal to the radial head can be seen owing to a
151
radial head dislocation.
With increased exion, the dimple
disappears as the radial head reduces. In an awake patient, the
159
only symptom may be apprehension.
In anesthetized patients, the lateral pivot-shift test is 100% sensitive for PLRI;
however, in awake patients, it is 38% sensitive.
43
• Posterolateral rotatory drawer test: Similar to the lateral piv-
and their forearm positioned in full supination. e elbow
is then placed in 40° of exion, and an anteroposterior force
is applied to the radius and ulna. e test elicits radial head
subluxation in a sedated patient or apprehension in an awake
158
patient.
• Chair sign (Table 1).
• Push-up test (Table 1).
• Table-top relocation test (Table 1): is test is theoretical-
ly more specic than the chair sign and push-up and prone
push-up tests because the relief from apprehension makes
intra-articular pathology less likely to be provoking symp-
44
toms.
Although nonoperative management is often ineective for
chronic PLRI, mildly symptomatic patients may benet from
a trial of not using instability provoking positions or motions
and strengthening of the muscles that act as secondary restraints
157
to PLRI (brachialis, biceps, and triceps).
It is worth noting
that the nonoperative management is often ineective because
so many ADLs require the motion combinations of elbow extension and forearm supination or gravity-varus positions with
157
the shoulder abducted.
Although restricting supination and
valgus movements through elbow bracing can be used for 4 to 6
weeks, most patients do not tolerate wearing a brace for such a
157
protracted period.
us, the majority of patients with chronic
PLRI will opt for operative treatment. ose with acute injuries and/or good-quality ligamentous tissue are best treated by
157
the repair of the LUCL (Appendix D).
Chronic cases do not
usually have adequate tissue to repair and require an open ligamentous reconstruction using autograft or allograft tissues.
153
e postoperative rehabilitation protocol, although varying among surgeons, usually involves the use of an immobilization device set at 45° to 90° of elbow exion with neutral
or slight pronation that is worn with an extension block for
approximately 8 weeks (60° at week 2, 45° at week 4, and 30°
at week 6). After the second week, forearm pronation exercises
with extension movements are initiated, and active supination
beyond 90° of elbow exion is permitted. Also, shoulder exercises are allowed while wearing the elbow brace. Normal ROM
is expected at approximately 8 weeks and strengthening is typically also initiated. For throwers, an interval throwing program
can be initiated at around 8 weeks. However, there should be
no return to play until strength is 85% to 90% of the uninvolved limb. Proprioceptive neuromuscular facilitation, rhythmic stabilization, and plyometric exercises are used to improve
the joint’s functional stabilization. Functional 2-handed exercises are performed in the nonprovocative ranges, initially with
the elbow positioned close to the body, and then progressed
to 1-handed activities with the involved arm in functional or
sports-related positions.
Varus posteromedial rotatory instability
Varus posteromedial rotatory instability, which typically
occurs when a valgus and axial load is applied with the forearm
positioned in pronation, can cause a fracture to the anteromedial facet of the coronoid and a rupture of the RCL complex.
160
Due to the absence of the RCL complex and the coronoid’s
medial reinforcements, the varus stress causes mechanical symp-
161-163
toms by loading the medial humeroulnar joint.
Physical
examination maneuvers may not be possible immediately after
trauma; but, in the subacute setting, the gravity-assisted varus
stress test can be used to elicit instability or mechanical symptoms.
161
Gravity-assisted varus stress test
: is test is performed
with the patient’s arm abducted to 90° and the shoulder in
neutral rotation. e patient then exes and extends the elbow
across the body while the clinician palpates the joint. A positive test is pain reproduction or palpable gapping. One study
that assessed several simulated examination maneuvers for RCL
complex and anteromedial facet decient–elbows found the
gravity-assisted varus stress test to be the most sensitive and specic maneuver.
164
Nonoperative treatment is generally considered appropriate for patients with very small coronoid fractures, no humeroulnar subluxation evident on computed tomography (CT),
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29
and minimal opening of the humeroradial joint on varus stress
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radiographs.
165
To date, no nonoperative treatment protocols
have been reported to have had long-term success for larger
fractures,
161
and, if a varus posteromedial rotatory instability
remains untreated, post-traumatic osteoarthrosis tends to occur
fairly quickly due to the variety of varus forces put on the trochlea and the relative incongruence of the humeroulnar joint.
164
e exact surgical approach used to xate the fracture of the
coronoid process depends on the fracture subtype. In addition
to fracture xation, any coexisting radial ligamentous injuries
and damage to either the anterior or posterior bundle of the
UCL, or both bundles, are repaired simultaneously.
163
As with
any surgical procedure, the subsequent rehabilitation is governed by the extent of the surgical repair. e length of the postoperative splinting time varies but a critical goal is to protect
stability and alignment by avoiding shoulder abduction (often
facilitated with the use of a locked hinged brace), which creates
varus stress at the elbow. It is also important to keep the forearm
in full pronation and elbow exion at greater than 60° during
ROM exercises and ADLs for approximately 6 weeks postoper-
163
atively.
e introduction of AROM to the hand and ngers,
submaximal isometrics of the triceps, biceps, and shoulder musculature occurs almost immediately, but AROM exercises of the
elbow with the forearm in pronation (and in the hinged brace
if prescribed) is not typically introduced until 4 weeks postoperatively. For the rst 8 weeks, the patient is typically instructed
to avoid PROM into elbow extension or supination. Normal
ROM is expected at approximately 12 weeks postoperatively,
although functional activities involving supination, varus, and
extension are still avoided.
e typical patient has a history of repetitive throwing or
other repetitive overhead activity, with reports of limited elbow
extension and locking or catching. ere is usually crepitus
and tenderness over the posteromedial olecranon and a loss of
passive extension with a bony end-feel. e extension impingement test, where the elbow is snapped into terminal extension,
usually elicits pain in the posterior compartment. One study
reported that, overall, the test had sensitivity and specicity (95% condence interval) for detecting elbow fracture of
96.8% (95.0, 98.2) and 48.5% (45.6, 51.4), respectively.
162
e
study also found that the test had a NPV for fracture of 98.4%
(96.3, 99.5) in adults and 95.8% (92.6, 97.8) in children, while
the LR- were 0.03 (0.01, 0.08) in adults and 0.11 (0.06, 0.19)
166
in children.
ere also may be evidence of valgus instability
during the stress tests. For example, the most sensitive test for
3
posterior elbow impingement is the moving valgus stress test.
e dierential diagnosis should include LET, cubital tunnel
syndrome, elbow instability, and radiocapitellar synovial plica.
Imaging is used to help conrm the diagnosis.
Nonoperative interventions include modication of physical activity and rest from throwing or overhead activities, combined with NSAIDs or intra-articular corticosteroid injections
of the elbow. is is followed by a progressive throwing program while assessing pitching mechanics to correct technique
3
errors and address any muscular imbalances.
When nonoperative measures are not successful, surgical
options include arthroscopic or limited incision posteromedial
decompression, with soft-tissue and bony debridement, loose
167
body removal, and osteophyte resection.
Postoperatively, mo-
Posterior Elbow Impingement
Posterior elbow impingement (also referred to as valgus extension overload, or pitcher’s elbow) is a common elbow injury
for throwers due to the high amount of valgus torque and rapid extension that occurs during pitching, which creates tensile,
shearing, and compressive forces at the elbow joint. ese forces
can eventually compromise the integrity of the UCL, producing
a radiocapitellar overload syndrome and valgus extension over-
3
load.
Posterior elbow impingement is most common in baseball pitchers, but it can also occur in other sports such as tennis,
football, gymnastics, lacrosse, and javelin throwing.
3
Of the 6 phases of throwing (wind-up, early cocking, late
cocking, acceleration, deceleration, and follow-through) the
fourth phase, acceleration, generates the most valgus force at
the elbow as the upper extremity rapidly accelerates from the
forwardly directed force generated by the shoulder muscles. e
AUCL bears the majority of the force, aided by the exor-pronator mass. During the deceleration phase, the dissipation of
forces creates pathologic forces in the posterior elbow, generating reactive bone formation on the olecranon’s posteromedial
tip. e reactive bone formation eventually leads to osteophyte
development or the occurrence of loose bodies that may result
in posteromedial impingement.
may be as early as 12 weeks post-surgery, depending upon the
extent of involvement.
167
Little League Elbow
Little League elbow deserves a special mention because of
its high incidence rate: as many as 30% to 40% of 7- to 18-yearold baseball players experience elbow and shoulder pain during
168,169
the baseball season.
described in 1960 by Brogden and Crow
is condition, which was originally
170
as an avulsion of the
humeral medial apophysis in adolescents, has since included a
variety of pathoanatomic lesions in the immature athlete, all
of which relate to the frequency and mechanics of throwing.
ese lesions at the medial epicondyle can range from simple
irritation of the origin of the exor-pronator mass, to MET, or
a UCL injury due to fragmentation and avulsion of the medial
epicondyle. is spectrum of injuries can result from a combination of repetitive throwing, weak physeal cartilage at growth
centers, muscle length changes associated with rapid long bone
growth, increased laxity of soft tissue structures, and decreased
171
development of neuromuscular movement patterns.
Of particular importance is that in the skeletally immature athlete, the
physis at the medial epicondyle is weaker than the UCL and
other restraints of the elbow.
30
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Overuse, exacerbated by high pitch counts, poor technique,
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and pitch type, have all been cited as contributing factors. Additional factors that appear to inuence its development include
age, weight, height, individual susceptibility, competitive level,
172
and geographic location.
It is also likely that a conuence of
factors, including an intrinsic desire for success, participation in
multiple leagues, and external pressure from parents and coach-
169
es contribute to overuse.
As previously mentioned, the repetitive motions involved
in the various phases of throwing place colossal strains on the elbow (a distraction force on the medial side, a compressive force
on the lateral side, and a translatory force across the olecranon),
particularly during the late-cocking and acceleration phases.
ese strains can result in inammation, scar formation, loose
bodies, ligamentous sprains or ruptures, and the most serious
conditions of osteochondritis dissecans (see later) or an avulsion
fracture.
173
Clinical ndings depend on the severity. With apophysitis, the patient usually reports a sudden increase in volume or
intensity of training, a steady increase in discomfort during
the throwing motion, and subsequent aching. If the condition
remains untreated, complaints of decreased throwing velocity
and problems with accuracy due to diminished grip strength,
171
are common.
Physical ndings at this stage usually include a
medial epicondyle that is tender to palpation and which may be
enlarged, and the ROM examination often reveals acute motion
loss and pain with extremes of elbow motion. e denitive
diagnosis of medial epicondylar apophysitis can be made only
by a combination of careful subjective and objective clinical examination and conrming radiologic studies that can highlight
the presence of any fragmentation at the condyle or avulsion
near the apophysis.
Management in the early stages of the condition is nonoperative, involving rest and eliminating the oending activity,
as well as any other aggravating activities such as repetitive motions, for approximately 2 to 3 weeks. Total-body conditioning,
including hip, back, and lower extremity strengthening, can
help optimize a player’s biomechanics by reducing strain on the
169
upper extremity.
Additionally, playing in various sports to
augment athletic diversity, rather than engaging in early sports
specialization, may protect players while still enhancing athleti-
169
To prevent recurrence, young athletes should adhere to
cism.
the guidelines suggested by the USA Baseball and Little League
Baseball organizations, which limit the number of pitches per
game, per week, and per season and advise on the number of
days of rest between pitching. e pitch count is the most important of these statistics.
175,176
If nonoperative treatment fails, referral to an orthopedic
surgeon is essential. Depending on the severity, surgery may
involve removing loose bone fragments, screw-xation of the
growth plate and loose fragments, bone grafting, and/or reattaching the UCL (“Tommy John”).
Osteochondritis Dissecans
Osteochondritis dissecans (OCD) of the capitulum, a disorder of articular cartilage and subchondral bone, is a rare but
potentially debilitating condition related to excessive repetitive
valgus compression across the elbow joint in the presence of
177
immature articular cartilage.
through 3 stages
•
Stage 1. Characterized by hyperemic bone, edematous periar-
177
:
e condition usually evolves
ticular soft tissues are also found.
Stage 2. e epiphysis deforms, sometimes with fragmenta-
•
tion.
•
Stage 3. e necrotic bone is replaced by granulation tissue.
Elbow OCD should be distinguished from Panner’s disease
or osteochondrosis of the capitulum.
e key to successful treatment is early detection; any teenager presenting with lateral elbow pain should be suspected of
having an OCD lesion.
177
Radiographs (plain anteroposterior
and lateral) remain the screening test of choice but can be misleading because they are notoriously insensitive in identifying
OCD of the capitulum.
bow in 45° of exion may be better to highlight the lesion.
178
An anteroposterior view with the el-
179
Computed tomography and MRI are often required to diagnose an OCD.
e intervention for OCD remains controversial, which
is, in part, explained by a diculty in classifying the condition.
Treatment choice depends on several aspects, including the severity of symptoms and the lesion’s size, location, and stabili-
177
ty.
It would appear that smaller lesions without cyst-like features are more likely to heal with nonoperative treatment,
180
but
that more substantial and unstable lesions fare better with osteochondral autologous transplantation surgery (OATS).
181
e
nonoperative approach, which can last between 3 to 4 months,
focuses on pain control and non-abusive activity with biceps
and triceps exercises, to minimize the strength loss during the
rest period. On occasion, a motion-limiting brace can be used
to reduce stress.
Heterotopic Ossication
Heterotopic ossication (HO), also called ectopic ossication or myositis ossicans, refers to bone formation at an atypical site (eg, skeletal muscle, fascia, etc).
182
Heterotopic bone can
occur in any place about the elbow, but it is typically posterior, deep to the triceps extending from either epicondyle to the
olecranon, or anterior, associated with the brachialis. Although
direct elbow trauma or surgery are the most common causes,
HO can also result from neural trauma, burns, and genetic disorders. e spectrum of HO lesions runs the gamut from small
and clinically insignicant ones to more serious lesions.
182
Heterotopic ossication is thought to be initiated by a tissue insult
that provokes an erroneous osteogenic or osteochondrogenic
reaction.
182
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31
e clinical presentation of HO depends on the temporal
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stage of its development. e most common characteristics at
the elbow are limited active and passive elbow exion and extension, although, in some patients, these motions may remain
normal, especially in the early phase. Strength testing typically
reveals weak and painful elbow exion and extension, and the
end-feels of elbow ROM become rigid or abrupt. Plain radiographs, which can show HO as early as 2 weeks after injury,
establish the diagnosis by dening its location and showing its
maturity.
ere appear to be 2 common approaches to the management of HO: (1) preventative strategies to avert or lessen the extent of the condition, and (2) interventions to tackle the symptoms and address functional limitations once HO is present.
182
e prophylactic strategies include low‐dose radiation and
NSAIDs. e treatment strategies include active and passive
ROM exercises, continuous passive motion, dynamic splinting,
and static splinting, although some authors suggest that overly
aggressive passive elbow exercises enhance elbow HO formation
and exacerbate elbow stiness, there is little evidence to support
this belief. However, it is generally agreed to apply any passive
force slowly and progressively to prevent further damage to the
soft tissues and provoke an exacerbation.
Patients with persistent symptoms have few management
options other than operative intervention using surgical resection. Complete excision is not always practical or possible, while
incomplete resection of the HO is associated with recurrence.
182
Elbow Dislocations and Fractures
hand through the wrist and forearm, initiating a sequence of
soft tissue failures that may require preemptive approaches to
minimize stiness, and prevent more signicant complications
187
such as nerve damage.
In most instances, the greatest force
transfer is to the joint’s lateral side, where the radial ligament
is stripped superiorly. e posterior lateral capsule also tears,
allowing the radial head to rotate posteriorly from the capitulum surface. In addition, the capsule and anterior ligament are
185
damaged on the medial aspect if the force is severe enough.
Radial head dislocation
A complete radial head dislocation is most commonly associated with a high force injury, such as a motor vehicle accident or a fall onto an outstretched arm, and therefore is usually
188
associated with a forearm fracture.
Radial head fractures associated with a radial head dislocation may be isolated just to
the radial head (and neck) and the lateral elbow (and proximal
forearm), or they may be part of a combined complex fracture
pattern, involving other structures of the elbow, and even the
distal humerus, or forearm and wrist. For example, the most
common radial head dislocation is posterior and can be associated with tearing of the brachialis muscle, avulsion of the coronoid process, radial head fracture, capitulum fracture, perilunar
dislocation, and involvement of 1 or more of the major nerves
of the forearm.
Monteggia lesions, although relatively rare, are a combination of injuries involving dislocation of the proximal end of
the radius and a fracture of the ulna, often resulting in poor
functional outcomes.
189
e Bado classication
190
is used to
the upper extremity, and more than one-quarter of dislocations
are associated with elbow fractures.
183-185
Elbow dislocations
e elbow is the most common large joint dislocated in
183
children
adults.
and the second most common joint dislocated in
184,185
e displacement of bone can involve the radial
head, the olecranon from the humerus, or a combination of the
two. Simple dislocations are soft tissue injuries and are more
common than complex dislocations. Complex dislocations
involve both ligament injuries and associated fractures of the
185,186
articular surfaces.
Classication of elbow dislocation is according to the severity and the direction of displacement of the
radius and ulna in relationship to the humerus. us, acute elbow dislocations are classied as posterior (the most common),
anterior, or divergent. Divergent dislocations involve displacement of the radius and ulna from each other, and both are dislocated from the humerus. Anterior and divergent dislocations
are rare.
183
Dislocations of the various components of the elbow
complex typically are traumatic injuries, usually from a falling
event, that create a combination of supination with valgus and
posterolateral and axial forces that are transmitted up from the
displacement:
•
Type I: anterior dislocation of the radial head accompanied by
a fracture of the proximal or middle third of the ulna (most
common in children/young adults).
Type II: posterior dislocation of the radial head accompa-
•
nied by a fracture of the proximal or middle third of the ulna
(most common in adults).
• Type III: lateral dislocation of the radial head with fracture of
the ulnar metaphysis.
• Type IV: dislocation of the radial head in any direction accompanied by a fracture of the proximal or middle third of
the ulna and radius.
In children, these injuries are managed with closed reduction, but in adults, surgical intervention is required, including
open reduction of the radial head and internal xation of the
ulna, internal xation of the ulna, or internal xation of the
ulna with excision of the radial head. It is not within this monograph’s scope to cover the postoperative management of these
various lesion types.
e examination of a suspected simple dislocation should
include a thorough history and description of events and a
32
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thorough examination of the entire involved arm. If the history
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involved trauma, the clinician should be alert to deformities,
swelling, neurovascular compromise, and length discrepancies
when compared to the other limb. For example, a child with a
partial displacement of the annular ligament (nursemaid elbow)
will often have a protuberant radial head and will protectively
hold their arm, commonly in an extended and pronated fash-
188
ion.
e most common treatment approach for a simple dislocation involves a reduction of the dislocation. Closed methods
are usually successful in reducing uncomplicated elbow dislocations when treated early.
186
Following the reduction, no immobilization is required if the elbow is stable throughout the
range, and unprotected extension and exion exercises can be
initiated. If the subluxation occurred in extension, a splint or
brace with an extension block is used to prevent dislocation for
3 to 10 days (or until stability is apparent).
Following the removal of the splint or brace, the best outcomes are achieved by early mobilization to the patient’s tolerance to prevent stiness, with isometric strengthening introduced when appropriate (usually at around 3 weeks). Indeed,
joint mobilizations have demonstrated eectiveness in restoring
AROM of the elbow following immobilization.
191
Olecranon fracture
An olecranon fracture is relatively common due to its subcutaneous location (10% of all upper limb fractures involve the
olecranon
192
), especially in the elderly, and is usually caused by
a fall backward onto the elbow. Olecranon fractures, which are
usually intra-articular, can be classied according to:
• Anatomical location: metaphyseal (most common), physeal
(growth plate), or epiphyseal.
Fracture pattern: longitudinal, transverse, or oblique.
•
•
Displacement: undisplaced/minimally displaced but stable or
displaced and unstable (approximately 85% of all olecranon
fractures).
Associated injuries of the elbow complex: can include radial
•
head dislocation, radial neck fracture, lateral condyle fracture,
or supracondylar fracture.
e classic examination ndings with an undisplaced fracture include pain, tenderness, and swelling at the fracture site,
and decreased overall ROM of the elbow. If the injury included
an avulsion of the triceps, there is a loss of active elbow extension, a palpable gap, and a large hematoma. If the injury included a radial head dislocation, some deformity might be evident.
e intervention focus for undisplaced or minimally displaced fractures is to allow triceps function while initiating early
ROM. However, the ROM exercises should avoid extremes of
elbow exion for up to 2 months, while resistance exercises are
avoided for up to 3 months.
Displaced fractures may result in humeroulnar instability and incongruity of the articular surface. Also, the proximal
portion of the triceps that inserts on the proximal olecranon
tends to displace the fracture and prevent healing. us, displaced fractures are usually managed with open reduction either by tension band wiring or plate xation.
193
No dierences
have been found in clinical- or patient-rated outcome measures
192,193
between xation methods.
Rehabilitation following operative procedure is dependent on the extent of the surgery and
the duration of the immobilization, although the emphasis on
regaining early motion, especially extension, remains the same.
Coronoid fracture
As the coronoid forms a signicant portion of the proximal
ulna’s articular surface and serves as an essential attachment site
for muscles and ligaments about the elbow, it is essential for
elbow stability. An isolated coronoid fracture, which is typically
seen following a high-energy injury, is uncommon; it is more
likely to be seen as part of the terrible triad injury of the elbow
(the coronoid and olecranon processes of the ulna are fractured,
and the head of the radius is dislocated posterolaterally).
194
Regan and Morrey
initially classied coronoid fractures
according to the size of the fragment type with type I fractures
involving the tip of the coronoid, type II fractures involving
more than the tip but less than 50% of the coronoid, and type
III fractures involving greater than 50% of the coronoid. Also,
they included A and B designations for each type, with the B in-
194
dicating an associated dislocation.
195
described a classication system designating type 1 as a
et al
More recently, O’Driscoll
tip fracture, type 2 as an anteromedial facet fracture, and type 3
as a fracture through the base of the coronoid process.
Most patients with coronoid fractures present with a histo-
ry of hyperextension or twisting, or hyperexion with a sense of
2
dislocation followed by a spontaneous reduction.
If the elbow
is deformed, the clinician should defer ROM testing, but otherwise, the ndings will reveal limited elbow exion, extension,
and forearm rotation. Neurovascular testing distal to the elbow
is critical and should include light touch and 2-point discrimination, and an examination for any abnormal or diminished
2
pulses.
Optimal operative approaches for an isolated coronoid
fracture have yet to be determined, whether lateral, medial,
posterior, or anteromedial. While it is recommended to x all
large coronoid fracture fragments and small fracture fragments
associated with instability, there is little data regarding the
196
management of small coronoid fracture fragments.
Typically,
Type I fractures generally are stable and can be treated as simple
dislocations with early motion; Type II fractures are unstable
and require open reduction and internal xation (ORIF); and
Type III fractures involve the insertion of the AUCL and are
inherently unstable, so often require ORIF or a hinged external
xator. For types II and III, disrupted ligaments are also xed or
reconstructed as necessary.
Postoperatively, early mobilization is required to help
prevent persistent stiness, pain, and loss of function due to
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33
prolonged immobilization (beyond 3–4 weeks).2 e elbow is
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protected from varus and valgus stress with hinged bracing, and
the last 30° of elbow extension is usually blocked during early
197,198
rehabilitation for both open and closed procedures.
e
rehabilitation involves striking a balance between maintaining
stability and regaining motion such that patients who are slow
to recover motion may require either serial progressive splints
or dynamic splints.
Medial epicondyle fracture
Medial humeral epicondyle fractures, which involve an
avulsion injury of the attachment of the forearm’s common
exors, are relatively common in adolescents and older children
and are associated with elbow dislocation in 30% to 50% of
199
is type of fracture is uncommon in adults.
cases.
Undisplaced or minimally displaced fractures are treated
with simple immobilization, but operative intervention is considered when valgus instability or ulnar nerve entrapment is suspected, when the fracture fragment is displaced into the elbow
joint, or when the fracture fragment is displaced greater than 5
200
e operative approaches include ORIF with K-wires
mm.
or screws or excision of the fracture fragment, with sutured reattachment of the tendons and the UCL. e ORIF has been
found to reduce the nonunion frequency and prevent valgus
instability; however, elbow stiness, ulnar nerve symptoms,
and radiologic abnormalities such as hyperplasia, hypoplasia, or
199,201
pseudarthrosis have been reported.
Interestingly, nonoperative management of elbow dislocations and severely displaced
medial epicondyle fractures have been reported to yield results
similar to those of surgery.
202
e rehabilitation following a medial epicondylar ORIF
should progress relatively slowly for the rst 6 weeks to allow
bone healing. e outline that follows should serve only as a
guideline. e elbow is usually splinted or braced in 90° of
exion for the rst 7 to 10 days, and the following are NOT
allowed for approximately 4 to 6 weeks:
Elbow joint mobilizations
•
•
Wrist exors or pronators strengthening exercises
• Wrist exors or pronators stretching exercises
Valgus stress to the medial elbow
•
• Lifting greater than 5 pounds
Initially, cold therapy is used to relieve pain and reduce
inammation. Once the splint or brace has been discontinued,
the patient is instructed on AROM exercises into wrist exion
and extension. It is worth noting that because most of these
patients will be children, the typical exercise prescriptions will
often need to be built around fun activities if patient compliance is to be successful. Also, isometric exercises are initiated for
the shoulder (except external rotation) and biceps. Depending
on the surgeon, ROM exercises in the brace are initiated at week
2, starting at 25° to 100°, and increased by 5° extension and
10° exion per week. Also, by the second week, the patient is
permitted to initiate elbow extension isometrics, and by week 3,
is introduced to AROM of the elbow. By week 4, depending on
the protocol, there should be a gradual increase to full ROM of
elbow exion and extension within the brace. Once permission
is received from the physician, light resistance exercises for the
shoulder, elbow, and forearm can be introduced, but shoulder
external rotation exercises are typically delayed until at least 6
weeks post-surgery.
Lateral epicondyle fracture
Lateral epicondyle fractures account for up to 15% of all
elbow fractures in children but are rare in adults, with an in-
203
cidence of 5.7/100 000.
Management of these fractures is
based on the Jakob classication:
• Stage 1: the fracture line goes through the capitellar ossication center, but there is minimal displacement (< 2 mm).
is type of fracture is equivalent to a Salter-Harris Type IV
fracture.
• Stage 2: the fracture line runs medial to the capitellar ossication center. is type of fracture, which usually has a 2
mm to 4 mm displacement but an intact articular surface, is
equivalent to a Salter-Harris type II fracture.
•
Stage 3: the fracture is completely displaced and rotated, leading to disruption of the articular surface.
e recommended treatment is based on the above classi-
cation:
Stage 1 fractures are treated with cast immobilization in 90°
•
exion with the forearm pronated for 3 to 4 weeks. Although
these fractures have minimal displacement, they require close
monitoring, because approximately 15% can displace over
204
e patient is usually tted with a backslab (half cast)
time.
and sling.
• Stage 2 fractures are managed with immobilization or treated
with closed reduction percutaneous pinning if there is questionable stability.
• Stage 3 fractures can be treated with either closed reduction
percutaneous pinning or ORIF.
e main complication of these fractures is nonunion,
which may lead to a valgus deformity.
e typical rehabilitation protocol is based on the severity
of the initial injury and the subsequent surgery. General guidelines include methods to reduce swelling and pain, and then
techniques, based on the current stage of healing, to enhance
mobility (gentle joint mobilizations), restore ROM (AAROM
then AROM exercises of wrist and elbow exion and extension; forearm supination and pronation), before progressing to
strength, endurance, and joint stability exercises. As with medial epicondylar fractures, the clinician will need to be creative in
34
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designing prescriptive exercises to enhance patient compliance
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with the younger population.
Compartment Syndromes
Compartment syndromes, which can occur in several locations throughout the body, result from increased tissue uid
pressure within an osseofascial compartment causing capillary
blood perfusion to fall below the level necessary for tissue vi-
205
ability.
us, compartment syndrome can occur secondary
to either a decrease in compartment size or an increase in the
compartment contents. Causes of a decrease in compartment
size include limb placement during surgery and the use of tight
dressings and plaster casts. An increase in the compartment
contents can occur due to bleeding, increased capillary permeability, trauma, burns, intensive use of muscles, and some miscellaneous causes, including snakebites, infection, and inltrated
205
infusions.
Compartment syndromes can occur rapidly (acute)
or over an extended period (chronic or exertional). e acute
variety is the more severe because, unless the pressure is relieved
swiftly, irreversible damage can occur to muscle tissue leading
to disability because sustained avascular compromise can lead
to muscle necrosis, brosis, contracture (Volkmann ischemic
205,206
contracture), and associated nerve injury.
Acute compartment syndrome
Although relatively rare, an acute compartment syndrome
(ACS) can result in severe complications, either limb-threatening or life-threatening. Consequently, early recognition is crucial.
ere are 3 compartments in the upper arm: the exor (anterior) and extensor (posterior) compartments, and the
deltoid compartment. ere are 4 compartments in the lower
arm (forearm), which is the most common location for an ACS:
the deep exor and supercial exor anterior compartments,
the posterior compartment, and the lateral compartment. Both
anterior compartments are at the highest risk for developing
196,197
ACS following trauma.
e deep anterior compartment
is aected more often than the supercial one and usually develops the highest interstitial pressures, negatively impacting
the contained exor digitorum profundus and exor pollicis
longus muscles (the FDS and pronator teres of the supercial
207,208
compartment are involved less often).
e most frequent
injuries associated with an ACS in the forearm are supracondylar humerus fractures in children and distal radius fractures
207
in adults.
Important indicators of the development of ACS
include a rapid progression of signs and symptoms over a few
hours and the presence of the following ndings in a patient at
risk and conrmation by measurement of intra-compartmental
205,209
pressure
:
• Pain with palpation of a swollen and tense compartment with
overlying skin that is often pink or red;
•
Severe pain that may seem out of proportion to the injury and
which is exacerbated by passive stretching of the muscles of
the involved compartment (this is an important and reliable
clinical sign);
• Sensory decits or paresthesia, which usually occurs within
30 minutes to 2 hours of the initial development of ACS;
• Muscle weakness, the onset of which typically occurs within
2 to 4 hours of an ACS;
• Possible absence of radial and ulnar pulses at the wrist, although systolic arterial pressure (approximately 120 mmHg)
usually exceeds the pressure within the involved compartment.
It is important to note that the presence of the above
symptoms can be unreliable for diagnostic purposes in some
circumstances, which often makes compartment pressure measurements critical for diagnosis. For example, the presence of
neurologic symptoms such as paresthesia or muscle weakness
may have resulted from the initial trauma and not because of
an ACS.
e intra-compartmental tissue uid pressure is measured
using various techniques, including infusion, slit catheter, and
continuous infusion and monitoring. A tissue compartment’s
normal pressure should be between 0 mmHg and 8 mmHg.
210
Capillary blood ow becomes compromised when tissue pressure increases to within 25 mmHg to 30 mmHg of mean arte-
211
rial pressure.
Accordingly, although these values are approximations, pain may develop as tissue pressures reach between
20 mmHg and 30 mmHg and ischemia occurs when tissue
212,213
pressures approach diastolic pressure.
Generally speaking,
frequent serial examinations are used to conrm a diagnosis.
Immediate management involves relieving all external pressure on the compartment (eg, removal of the dressing, splint,
cast, or other restrictive covering), and placing the limb level
with the heart. If the cause is an increase in the compartment
content or the symptoms do not resolve swiftly, the denitive
treatment is a fasciotomy from the elbow to the wrist, including
division of the lacertus brosus and the transverse carpal ligament to fully decompress all involved compartments. Complete
debridement may require several trips to the operating room,
in which case the wounds are left open and covered with rayon,
with delayed closure, which usually requires split-thickness skin
212,213
grafts performed at 7 to 10 days postoperatively.
Chronic (exertional) compartment syndrome
is type, which is much less common, especially in the
female athlete, is usually self-limiting. It usually arises in sports
requiring repetitive gripping (eg, gymnastics, climbing) but also
in non-recreational pursuits (eg, carpentry).
214
Clinical suspicion of chronic compartment syndrome is
aroused by combined ndings of the physical examination: pain
on palpation of the muscles involved, pain with passive stretching of the muscle of the suspected compartment, and rmness
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35
of the involved compartment. e patient should be exam-
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ined after completing the exercise or activity that reproduces
the symptoms - the symptoms should occur with the exercise/
activity but completely resolve between periods of exercise/activity. Conrmation of the diagnosis is made using intra-compartmental pressure monitoring in the suspected compartments
before, during, and after exercise.
214
e denitive treatment for chronic compartment syndrome is fasciotomy, realizing that nonoperative approaches (ceasing exercising or decreasing the intensity of training,
215
stretching, therapeutic ultrasound, and NSAIDs)
have been
tried with limited success.
Complex Regional Pain Syndrome
Complex regional pain syndrome (CRPS), previously referred to as reex sympathetic dystrophy, Sudeck atrophy, shoul-
der-hand syndrome, or causalgia, is a condition of intense burning pain, stiness, swelling, and discoloration that most often
aects the hand but can also aect the arms, legs, and feet. is
condition is categorized as a neuropathic pain disorder due to
its distinctive clinical characteristics, which include amplied
pain responses, alterations in perspiration, vasomotor anomalies, and trophic changes. e symptoms experienced are inconsistent with the tissue injury severity and continue beyond the
216
usual tissue healing time.
Chronic regional pain syndrome
appears to be triggered by a malfunction in the autonomic nervous system and the immune system but has also been attributed to other factors, including genetic markers and psychological
216
inuences.
ere are 2 subtypes of CRPS, although, clinical-
• Type I, which was formerly known as reex sympathetic dys-
trophy, occurs in the absence of nerve trauma, following a
minor injury such as a strain or sprain or several other causes,
including fracture, surgery, stroke, or spinal cord injury.
Type II, which was formerly known as causalgia, occurs in the
•
setting of known nerve trauma.
Chronic regional pain syndrome can be further subdivided
into warm, in which inammatory characteristics dominate, or
cold, in which autonomic features dominate, and sympathetically-maintained or sympathetically-independent types, which
216
may aect prognosis and treatment options.
Multiple peripheral and central mechanisms seem to be involved, the relative
contributions of which may dier among individuals and over
217
ere were considered to be 3 overlapping stages with
time.
CRPS: acute inammation, dystrophy, and atrophy, but because most patients do not necessarily go through all 3 stages
sequentially or demonstrate the signs and symptoms of each
stage, these delineations have been questioned.
216,218,219
ere is no gold standard diagnostic conrmatory test for
CRPS, so the diagnosis is often delayed because most patients
present with many symptoms. Patients with CRPS often adopt
a protective posture of the involved extremity to prevent mechanical or thermal stimulation. ere may be signs and symptoms of allodynia, hyperalgesia, vasomotor dysfunction, and
sudomotor dysfunction. e vasomotor and sudomotor dysfunctions manifest as alterations in sweating, skin color, and
temperature and trophic changes in the skin, hair, or nails.
216
Several other conditions need to be ruled out before establishing a diagnosis of CRPS, and these include rheumatoid and
septic arthritis, gout, cellulitis, vasculitis, peripheral neuropathy, peripheral nerve entrapment, Raynaud disease, and peripheral vascular disease.
Although there is a possibility that patients may spontaneously improve, an aggressive multidisciplinary approach, in
which the physical therapist plays a pivotal role, is recommended for eective management of CRPS because a delay in treatment may result in an unfavorable outcome.
220
Indeed, physical
therapy is often the rst line of intervention, whether it be the
sole intervention, or performed immediately following a nerve
219,221,222
block.
Despite having not been shown to provide significant long-term improvement, chemical or thermal neurolysis
or serial sympathetic ganglion blocks, either with a local anesthetic, continue to be prescribed.
216
Finally, cognitive behavioral
therapy is recommended as a necessary component in treating
CRPS, despite a lack of studies to support this method.
216
It is vital to minimize pain and not reinjure the region or
aggravate the problem while providing physical therapy interventions because when excessive pain is created the sympathetically mediated pain may worsen.
221
e typical physical therapy
protocol is initiated with gentle AAROM exercises followed by
sensory threshold techniques, including vibration desensitization, uidotherapy, light and heavy pressures with various textures, transcutaneous electrical nerve stimulation, and contrast
baths. As tolerated, the patient is progressed slowly and gently
with AROM and strengthening exercises. Weight-bearing and
active loading exercises (carrying, scrubbing, etc) should also be
gradually incorporated as tolerated.
Osteoarthritis of the Elbow
Osteoarthritis is a chronic disorder of synovial joints causing a progressive disintegration and softening of articular cartilage, cyst formation and sclerosis in the subchondral bone, mild
synovitis, and capsular brosis.
224
In general, primary osteoarthritis of the elbow is relatively uncommon when compared
with other joints, whereas rheumatoid arthritis and posttraumatic sequelae are more common causes of arthritis of the elbow. To date, the etiology of primary osteoarthritis of the elbow
has not been fully elucidated.
e presenting symptom is usually chronic musculoskeletal pain, but it can be accompanied by stiness, a reduction in
ROM, weakness, instability, and, most importantly, a decrease
in the quality of life of the patient. e physical examination
may reveal a capsular pattern of limitation with passive exion
more limited than extension, whereas the motions of pronation
and supination are typically unaected.
36
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e management is dictated by the severity of the symp-
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toms, the etiology, and the patient’s age, although the initial
intervention is typically nonoperative unless the pathology and
symptoms are severe. Nonoperative management of elbow osteoarthritis consists of NSAIDs, intra-articular corticosteroid
injections, and physical therapy. e focus of the physical therapy intervention is to help control pain, swelling, and stiness
using moist heat or cryotherapy depending on whether the
condition is chronic or acute; the use of an elastic or neoprene
sleeve to provide compression; ROM exercises to maintain motion; and patient education on joint protection methods (eg,
using the largest joint available for a task, avoiding sustained
positions, using adaptive equipment where necessary, and using
the least amount of force necessary to complete the task). Manual therapy techniques (distraction, grade I or II mobilizations)
can be used for pain relief and to aid in the relaxation of the
surrounding tissues, and scapulohumeral stabilization exercises
can be used to help unload the elbow joint during functional
activities.
e operative management can include arthroscopic
soft-tissue release, debridement, interposition arthroplasty, and
total elbow arthroplasty (TEA), with each having its advantages and disadvantages. For example, the open techniques provide good visualization and allow for most pathologies to be
addressed, but they produce more soft tissue damage, a higher risk of soft tissue contraction, and longer rehabilitation. In
contrast, arthroscopic techniques are minimally invasive, create
less soft tissue damage, and allow for quicker rehabilitation, but
cannot be used in advanced osteoarthritis cases due to nerve
adhesion.
224
e postoperative rehabilitation protocol will depend on
the surgical approach, the structures involved, and the surgeon’s
preferences.
Joint Arthroplasty
Arthroplasty techniques for the elbow continue to evolve
and are typically classied as linked semi-constrained (which link
the humeral and ulnar components) or unlinked (the prosthesis
congruency depends on adequate positioning of each component, ligamentous integrity, and the dynamic stabilizing eect
225
of the musculature).
Although the most common indications
for TEA are inammatory arthropathies such as rheumatoid arthritis, other conditions including posttraumatic osteoarthritis,
acute distal humerus fractures, distal humerus non-unions, and
reconstruction after tumor resection are also potential indica-
225
tions.
e problem with a TEA compared with an arthroplasty at the knee or hip joint is that the elbow is relatively
small, and its stability depends greatly on ligamentous integri-
225
While the linked semi-constrained type TEA ensures joint
ty.
stability, its lack of mobility tends to facilitate the polyethylene
component’s wear and loosening. In contrast, the unlinked implant type has a decreased risk of mechanical failure secondary
to wear and loosening.
Several studies have suggested that the most important
overall factor in determining the clinical success of TEA is the
226-229
patient’s baseline health status.
e most common complications of TEA include infection, fracture of the proximal ulna,
posterior elbow instability, triceps weakness, ulnar neuropathy,
and component loosening. Most of these lead to pain and eventual repeated operative intervention.
Postoperatively, the initial goal is to limit edema. Postoperative protocols vary according to several factors, including
the surgery’s extent and the surgeon’s preferences. e elbow
is typically immobilized in extension with an anterior plaster
splint and a bulky dressing, and the upper extremity is kept elevated. Following a linked semi-constrained arthroplasty, elbow
motion without protection may be initiated in the rst few days
postoperatively depending on the quality of the reconstruction,
whereas the elbow is typically immobilized for approximately 2
weeks following the use of an unlinked prosthesis to protect the
ligamentous structures.
225
Elbow Stiffness
Elbow stiness and pain can be attributed mainly to pathologic bone formation (eg, myositis ossicans and periarticular
calcication) or following trauma (eg, second and third-degree
230-233
burns and elbow fractures with dislocations).
Other causes
include articular cartilage destruction, osteophytes, synovitis,
joint capsule tightness, ligamentous contracture, malunion, or
232
loose bodies.
Elbow stiness secondary to trauma is described
here.
Posttraumatic sti elbow, dened as less than 120° of ex-
234
ion and a loss of more than 30° of extension,
is a frequent and
disabling complication. Due to several confounding factors, the
precise prevalence of posttraumatic elbow stiness is dicult to
235
approximate,
although some credence has been given to the
theory that complex articular congruity, the brachialis muscle
covering the elbow (predisposing it to myositis ossicans), and
prolonged immobilization in the presence of an unstable xa-
236
tion can cause the elbow to be prone to stiness.
From a physical therapy point of view, it is important to
carefully document AROM and PROM of the elbow and determine whether the end feel is abrupt and painless, suggesting
a bony block, or soft, suggesting capsular/muscular contrac-
235
e presence of crepitus and/or pain can suggest syno-
tures.
vitis, loose bodies, or degeneration.
235
e nonoperative approach for elbow stiness runs the
gamut from serial casting, static splinting, dynamic splinting,
AROM/PROM exercises, continuous passive motion, manip-
235
ulation, and botulinum toxin A.
It was traditionally thought
that passive elbow exercises enhance ossication formation and
exacerbate elbow stiness, but there is little evidence to support
237
this belief.
As studies have shown that the process of inammation,
broblasts, and myobroblasts activation starts early after the
initiating trauma, it is important to introduce elbow motion
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using AROM as early as possible. If early motion is not possi-
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ble, the elbow should be splinted in extension to create enough
pressure within the tissues around the elbow to minimize the
234
bleeding and extravasation of uid.
and meta-analysis, Müller et al
238
In a systematic review
compared the eectiveness of
static, dynamic, and static–progressive splints on elbow stiness
of posttraumatic and postoperative origin and suggested that
static–progressive stretching 3 times for 30 minutes per day in
each direction should be the rst line of treatment.
e surgical option is very much need-based because different people tolerate elbow stiness to dierent extent, but as
a general guideline, it is usually recommended when there is
a lack of response to nonoperative treatment, a bony block to
movements, a exion contracture that is greater than 30°, or
235
when elbow exion is less than 130°.
e various surgical approaches include open contracture release, arthroscopic release,
a hinged external xator, interposition arthroplasty (insertion
of an articulated xator), or TEA. It is important to start motion soon after surgery (day 1-2) to have AAROM/AROM that
matches what was achieved on the operating table by the fourth
235
or fth postoperative day.
e speed of the subsequent rehabilitation, using the usual hierarchical ROM and strengthening
progressions, is a mix of patient tolerance and surgeon preference.
OUTCOME MEASURES AND SCALES
e assessment of change in a patient’s symptoms and
function over time is essential to both clinical practice and research and is integral to evaluating the eectiveness and eciency of interventions. e developers of numerous elbow scoring systems have selected dierent outcome criteria, assigned
various weights to each criterion, and given dissimilar ranges
of values to each categorical ranking, so the results should be
interpreted within the context of the individual rating scales.
239
Optimal outcome measures are designed to be reliable, valid,
and responsive to change, and relevant to a patient in the context of their injury. Two types of outcome-based questionnaires
are available: physician-rated, which uses clinical and functional
measurements, and self-reported, that are completed by the patient. ere are currently only a handful of outcome measures
specic to the elbow, including at least 1 explicitly devoted to
240
tennis elbow (Appendix G),
but only a few of these have been
validated, and many assess only some aspects of elbow func-
241
A summary of the more common outcome measures
tion.
used for the elbow, along with their clinical characteristics, is
provided in Appendix H.
230,240-258
CASE SCENARIOS
Case Scenario 1
A 44-year-old female presents with complaints of a constant burning sensation in her right forearm that extends into
the wrist and hand, which has worsened over the past 2 weeks.
e patient reports no specic injury mechanism but has now
had to reduce her right upper extremity use due to the symptoms. e patient’s medical and surgical history is unremarkable except for a bout of severe cellulitis in her right foot 4
months ago, after being stung by a stingray. e patient has
been through an extensive workup, including laboratory tests, a
treadmill stress test, and an MRI of the brain, neck, and entire
right upper extremity. While the treadmill stress test results were
normal, the patient has not yet received the lab or MRI results.
e physical examination reveals mild to moderate swelling in the right forearm and wrist and evidence of a moisture
lm that appears to cover the whole right hand as if it were
perspiring. Upon palpation, the patient cringes and pulls away,
even from a light touch. e ROM testing reveals signicant
limitations due to mild to moderate stiness and swelling of
the right elbow, wrist, and ngers. Muscle strength is not tested
secondary to pain and tenderness. Muscle stretch reexes are
normal at the triceps. Other muscle stretch reexes are deferred
because they would likely exacerbate the patient’s symptoms.
1.
Based on the current presentation, which of the following
conditions could initially be ruled out?
a. Systemic disease.
b.
Peripheral neuropathy.
Cardiac pain referral.
c.
d.
Peripheral vascular disease.
patient’s history and extensive workup, including a treadmill
stress test, it is highly unlikely that the patient’s symptoms are
emanating from the heart. However, a systemic, vascular, or
neurologic cause cannot yet be completely ruled out.
e initial examination has to be cut short because of the
2.
patient’s low pain threshold. e clinician calls the patient’s
primary care physician and learns that the MRI results for
the brain, cervical spine, and right upper extremity were
negative and that laboratory tests for scleroderma, rheuma-
toid arthritis, venous obstruction, and angioedema were also
negative. e physician also noties the clinician that the
patient has occasional anxiety attacks, something the patient
had failed to mention while in physical therapy. Given the
ndings thus far, which of the following diagnoses should be
the clinician’s provisional hypothesis?
a. Peripheral vascular disease.
b. Raynaud disease.
c. Complex regional pain syndrome (CRPS).
d. Peripheral neuropathy.
e correct answer is c. Complex regional pain syndrome
(CRPS). ere is no gold-standard test to diagnose CRPS, thus,
the diagnosis is often one of exclusion from the patient’s re-
38
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