Elbow articular conditions

Question 1

Describe the epidemiology of elbow arthritis?

Answer 1

• M 4:1 F
• Middel ages labourers
• assoc with dominant hand
• pathophysiology
  
  • RA
    
    • most prevalent form 50% pt affected
  • post-trauamtic arthritis
  • primary OA
    
    • rare
    • common middle aged labourers
  • HIstory of osteochondritis dissecans
  • MUCL or ligmanetous insuffuciency

Question 2

Name the stabilisers of the elbow?

Answer 2

Primary static

• anterior band of MCL
• Coronoid
• Lateral ulna collateral lig

Secondary stabilisers

• Radial head- valgus stability
• Capsule- full extension
• LCL, aconeus, lateral capsule- varus force
• Aconeus- varus force

Question 3

What is the presentaiton of elbow arthritis?

Answer 3

• Porgressive pain
• loss of terminal extension
• painful lock of elbow

O/E

• Loss of elbow rom
• ligamentous incompetence seen -esp RA
• Ulna neuropathy

Question 4

What is seen on imaging of elbow arthritis?

Answer 4

• Xray
  
  • elbow joint space narrowing
  • osteophytes found at
    
    • coronoid porcess and fossa
    • olecranon tip and posteromedial olecranon fossa
    • loose bodies
• Ct scan
  
  • can help better define osteophytes/ loose bodies

Question 5

How is elbow arthritis treated

Answer 5

Non operative

• Nsaids, cortisone injections, resting splints, activity modificiation
  
  • mild -mod symptoms

Operative

• Arthroscopic debridement & capsular release
  
  • mild disease with bone spurs
• Ulnohumeral distraction interposition arhropplasty
  
  • pt v limited rom 60-100 should unergo ulnar n decompression
• Olecranon fossa debridment-Outerbridge- Kashiwagi procedure
  
  • ​young pt with reduced rom
  • blurr hole thru olecranon fossa
  • remove osteophytes/arthritic bone
  • increased rom
• Total elbow arthoplasty
  
  • older pt >65 yrs w severe arthritis
  • unconstrained TEA
    
    • used with competent elbow ligaments w adequate bone stock
  • contrained TEA
    
    • ussed with incompetent elbow ligaments

Question 6

What is this?

Answer 6

• Unconstrained TEA
• unlinked
• e.g. Ewarld capitella
• requires competent collateral ligaments & bone quality
• instability is the most common complx

Question 7

What is this?

Answer 7

• A Constrained linked total elbow replacement
• e.g. Coonrad Moorey

Question 8

What are the indications for a TEA?

Answer 8

• RA
  
  • highest surviorship
  • for pain. loss of motion, instability
• Primary OA
  
  • pt >65 yrs
• posttraumatic OA ( advanced)
• Fx
  
  • complex intra-articular
• Chronic instability

Question 9

what are the contraindications for TEA?

Answer 9

• Absolute
  
  • infection
  • Charcot joint
• Relative
  
  • poor neurological control of affected limb
  • active pt <65 yrs

Question 10

Describe the technique for TEA?

Answer 10

• Triceps splitting approach or posterior sparing approach
• usually preform ulnar transposition
• radial head resection common
• http://www.orthobullets.com/video/view?id=781

post op

• life long weight lifting restriction of 10 lbs

Question 11

What are the outcomes of TEA in RA and post-traumatic arthritis?

Answer 11

• RA
  
  • 10 yr surviorship 92.4%
  • v high complx rate
    
    • triceps avulsion
    • deep infection
    • periprsothetic fx
    • aseptic loosening
• Post traumatic
  
  • 5 yr surviorship
    
    • most achieve funational rom adn pt satisfaction
    • High compx rate 27-43%
    • High reop rate 25%

Question 12

Discuss the complx of TEA?

Answer 12

• Aseptc loosening
• infection 8%
  
  • acute- serial irrigation/debridment/antib
  • chronic- 2 stage reimplantation
• Instability
• Bushing wear- notice varus/valgus angle on AP >10 degree is a concern
• wound healing
• ulnar neuropathy
• triceps insufficiency

Question 13

What is osteochondritis dissicans of elbow?

Answer 13

• localised injury of articular cartilage and chondral bone of the capitellum
• usally occirs after 10 yrs
• typically in capitellum in dominant arm
• risk factors
  
  • repetitive overhead activities- gymnastics/throwers
• pathology
  
  • repeititve compression of imature capetillum

Question 14

Name any assoc condition with osteochondritis dissicans of elbow?

Answer 14

• Panner disease
  
  • pesent similar symptoms but in 1st decade of life
  • self limiting condition

Question 15

What is the presentation of osteochondritis dissicans of elbow?

Answer 15

• elbow pain
  
  • insidious
• locking/clicking
• tenderness over elbow
• loss of motion

Question 16

What is the tx of osteochondritis dissicans of elbow?

Answer 16

Non operative

• cesation of activity+/- immobilisation
  
  • type 1 lesions- bony stability present
  • 3-6 wks by slow pregression back to activities over next 6-12 wks
  • 90% success rate

Operative

• diagnostic arthroscopy and drilling of capitellium
  
  • for unstable type 1 or stable type 2
  • microfx of chondral lesion
  • protected early rom, strengthening at 2/12, gd outcome
• fixation of lesion
  
  • for large lesion
  • portective early rom, strengthening 2/12, variable outcome
• debridment and loose body excision
  
  • unstable type 2/type 3 lesions

Question 17

What is little league elbow?

Answer 17

• A adolescent term for medial elbow injury
• include
  
  • medial epicondyle stress fx
  • ulnar collateral ligament injurues
  • flexor-pronator mass strains
• Due to repitive calgus stress causing repititive microtrauma to immature skeleton
• tenderness medial epicondyle
• xary- widened physis, avulsion mediaal epicondyle
• Tx -
  
  • non op :rest, activity modification, physio
  • operative- orif medial epicondyle for avulsion fx
  • UCL reconstruciton for UCL disruption insufficiency

Question 18

What is an olecranon stress fx?

Answer 18

• A rare injury that effects throwing athletes
• predominantly involves eiphyseal plate
• fx line ay be transverse/oblique
• pathology
  
  • olecranon posteriomedial impingment
  • triceps tractio force
  • valgus extension overload
• assoc injuries: Ulnar collat lig tears, medial epicondyle avulsion fx
• PC: posteriomedial pain on throwing arm
• Tx- non op- nsaids, rest +temporary splinting 4-6 wks
• operative if delayed fx union- large compression screw

Question 19

What are the causes of elbow stiffness?

Answer 19

• Trauma
• Iatrogenic- surgery -> HO
• Arthritis - OA/RA
• Cerebral palsy
• Traumatic brain injury
• Burns
• congential
  
  • arthrogyrposis
  • congential radial head dislocation
• Pathology
  
  • jont incongruity
  • synovitis
  • loose bodies
  • intr-articular fx
  • osteochondirtis dissicans
  • post -traumatic arthritis
  • formation of eschar form a burn
  • HO
  • myositis ossifcans

Question 21

What is the prognosis of elbow stiffness?

Answer 21

• Pt can do ADL is rom 30-130

Question 22

What is the tx for elbow stiffness?

Answer 22

Non operative

• nsaids, physio with active and passive range of movement
  
  • first lien if contractions <40 degrees

Operative

• Osteophyte excision
• Distraction interpositional arthroplasty- intrinsic contractue in young pt with arthritis
• Total elbow replacment
  
  • low demand elderly pt w intrinsic contracture
• Capsular release
  
  • extrinsic contractures
• OK proceedure

Question 23

Describe the complciations of elbow surgery for stiffness?

Answer 23

• Post op Heterophic ossification
  
  • may tx with prophylatic radiatio therapy
• Transient ulnar neuroparaxia
• Ulnar nerve damage
• recurrent contracture