Elbow | Basics of Ortho

Biceps Tendon Tear (Distal)

Cause/Pathophysiology
- Failure of the distal biceps tendon
- Frequently results from forceful concentric flexion of the elbow (lifting) or excessive eccentric load
History and symptoms
- Mechanism of injury
- + pop or pull in front of elbow
- + antecubital pain
Exam Findings
- + biceps deformity in complete rupture, +/- with partial
- Palpable tendon defect
- Pain and decreased strength with elbow flexion and supination
Imaging/Diagnostic Studies
- MRI or ultrasound
Treatment
- Surgical repair is the standard
- Exceptions could include low demand and/or high risk patients
Common ICD-10 Codes
- S46.299A

Cubital Tunnel Syndrome

Cause/Pathophysiology
- Compressive/stretch injury to the ulnar nerve at the elbow
- Frequently results from repeated flexion of the elbow
History and symptoms
- +/- Pain, numbness, tingling in ring and small fingers
- +/- Pain posterior medial elbow in ulnar groove
Exam Findings
- +/- Tinel's over ulnar groove
- TTP over ulnar nerve in ulnar groove
- +/- altered sensation ring and/or small finger
- +/- intrinsic muscle wasting
- +/- grip, finger adduction strength
Imaging/Diagnostic Studies
- Imaging negative
- EMG/NCS diagnostic
- If concern that symptoms may be cervical, cervical X-Rays and MRI may play a role in work-up
Treatment
- First Line
  - NSAIDs or steroid
  - Elbow extension splint at night (towel or pillow wrapped around elbow, elbow pad turned backwards)
  - +/- PT for neural glide stretches
- Surgery - ulnar nerve transposition

Lateral Epicondylitis (Tennis Elbow)

Cause/Pathophysiology
- Repetitive use injury
- Acute inflammation or chronic micro-damage to extensor tendons at the lateral epicondyle
History and symptoms
- Pain with gripping, lifting, or turning
Exam Findings
- TTP over lateral epicondyle
- Pain with resisted wrist extension, especially with the elbow in extension
- Pain with gripping
- +/- pain with resisted supination
Imaging
- X-Rays - generally negative
- MRI may be helpful prior to surgery, if conservative treatment fails
Treatment
- Inflammation reduction: NSAIDs, steroids, cortisone injection, ice
- Physical therapy
- Cock-up wrist brace - in my opinion works better than tennis elbow strap
- Tennis elbow strap

Medial Epicondylitis (Golfer's Elbow)

Cause/Pathophysiology
- Repetitive use injury
- Acute inflammation or chronic micro-damage to flexor tendons at the medial epicondyle
History and symptoms
- Pain with gripping, lifting, or turning
Exam Findings
- TTP over medial epicondyle
- Pain with resisted wrist flexion, especially with the elbow in extension
- Pain with gripping
- +/- pain with resisted pronation
Imaging
- X-Rays - generally negative
- MRI may be helpful prior to surgery, if conservative treatment fails
Treatment
- Inflammation reduction: NSAIDs, steroids, cortisone injection, ice
- Physical therapy
- Cock-up wrist brace - in my opinion works better than tennis elbow strap
- Tennis elbow strap used backwards

Nursemaid's Elbow

Cause/Pathophysiology
- Pediatric dislocation/subluxation of the radial head from under the annular ligament
- Usually results from a traction and rotation
History and symptoms
- Usually under 4 years of age, but can happen in older kids
- MOI
- Pain/crying with manipulation of the arm
- May not be able to be consoled
- Observed splinting or disuse
Exam Findings
- Elbow usually held in slightly flexed position with the palm down in pronation
- TTP over radial head
- Pain with elbow motion and forearm rotation
Imaging
- X-Rays - usually negative, helpful in ruling out fracture
Treatment
- Manual reduction maneuver
- No other treatment necessary for single occurrence

Olecranon Bursitis

Cause/Pathophysiology
- Olecranon bursa inflamed, +/- fluid filled
- Repetitive pressure on olecranon
- Trauma
- Infectious
- Gouty
History and symptoms
- +/- trauma
- +/- frequent pressure on elbow (resting on armrest)
- +/- pain
- Usually focal painless swelling, unless septic which is usually painful
Exam Findings
- Focal well defined swelling over olecranon
- +/- erythema
- +/- TTP
- Gouty may be firm due to tofi
Imaging
- X-Rays negative
Treatment
- Aseptic
  - First Line
    - RICE
    - NSAIDs
    - Elbow pad/craddle
  - Second Line
    - Aspiration +/- cortisone injection
- Septic
  - Aspirate and send for Gram stain, cultures & sensitivities
  - Immobilization and antibiotics
  - If no quick improvement, may need formal irrigation and debridement

Osteoarthritis

Cause/Pathophysiology
- Degenerative wear of articular cartilage
- Post-traumatic
History and symptoms
- Gradually worsening pain and/or decrease in ROM
Exam Findings
- +/- effusion
- +/- TTP in joint space
- +/- loss of ROM
Imaging
- X-Ray - decreased joint space, osteophytosis
Treatment
- First Line
  - NSAIDs
  - PT - limited benefit
- Second Line
  - Intra-articular cortisone injection
- Surgery
  - Total Elbow Arthroplasty
  - Arthroscopy - limited to no benefit

FRACTURES

Olecranon fracture

Cause/Pathophysiology
- Fall on the point of the elbow
History and symptoms
- MOI
- Pain and inability to move
Exam Findings
- Swelling
- +/- ecchymosis
- TTP
- +/- palpable defect
- Inability to actively extend the elbow
Imaging
- X-Ray
- CT if evaluating complex intra-articular involvement
Treatment
- Vast majority ORIF
- Conservative treatment in cast for some completely non-displaced fractures

Common ICD-10 Codes
- S52.033A - intraarticular displaced
- S52.036A - intraarticular non-displaced
- S52.023A - extra-articular displaced
- S52.026A - extra-articular non-d

Radial Head/Neck

Cause/Pathophysiology
- FOOSH
- Usually an impaction type injury
History and symptoms
- MOI
- Patient may not present right away
- Pain increases with extension and supination activities
Exam Findings
- +/- swelling
- TTP over radial head
- Lack of full extension and supination in most cases
Imaging
- X-Ray - usually all that is necessary, look for bony injury, posterior fat pad, and anterior "sail sign"
- CT to evaluate any significant intra-articular deformity
Treatment
- Most conservative with sling/splint 1week
- Early ROM
- Possible surgery if significantly displaced intra-articular involvement or significant neck angulation
Common ICD-10 Codes
- S52.123A - head
- S52.133A - neck

Supracondylar Humerus

Cause/Pathophysiology
- Trauma
- Most frequently a pediatric injury resulting from a playground equipment fall
History and symptoms
- MOI
- Pain
- Parent may notice disuse
Exam Findings
- +/- swelling
- +/- deformity
- TTP over distal humerus and epicondyles
- +/- motion abnormality
Imaging
- X-Ray - May be subtle or occult
  - Look for bony injury, posterior fat pad, and anterior "sail sign"
- CT to evaluate any significant intra-articular deformity
Treatment
- Nondisplaced -
  - Posterior long arm splint for a few days to allow swelling to subside some
  - LA cast 3-4 weeks, some orthopedists prefer up to 6 weeks
- Displaced - Closed reduction and casting, CRPP, or ORIF
Common ICD-10 Codes
- S42.416A - non-displaced
- S42.413A - displaced