Elbow Resources

Elbow arthritis (R) Elbow arthritis (R)


Primary osteoarthritis

Epidemiology
Seen almost exclusively in men, age 40-60. Seen in wheelchair athletes, heavy manual workers.
Primary OA is uncommon.
Tends to affect the dominant arm.

Pathology
Characterized by osteophytes with relative preservation of the joint spaces. Osteophytes are found at the coronoid tip, olecranon tip and sometimes the radial neck. Frequent loose bodies suggest that there may be some relation to osteochondritis dissecans. The ulnar nerve may be compressed by osteophytes, and ulnar nerve symptoms are found in up to 50%.

Clinical
Pain is present at the end range, but not typically at mid range because the cartilage is intact, and pain is caused by impingement of osteophytes. Men find it difficult to carry heavy suitcases (because elbow is held in extension). There is loss of flexion and extension, with a flexion contracture of around 30 degrees common. When assessing extension, apply a slight valgus force in an attempt to provoke postero-medial impingement. “Making a fist” increases the forces across the radiohumeral articulation, which can help localize symptoms to this compartment. There can be symptoms of ulnar nerve dysfunction.
If osteoarthritic changes are seen in the elbow, one should suspect calcium pyrophosphate arthropathy as a DDx.

Imaging
Osteophytes as described.
Loose bodies are frequently seen.

Treatment
Removal of the osteophytes can lead to substantial pain relief and increased mobility. This can be done arthroscopically or openly. One open procedure is the Outerbridge-Kashiwagi procedure (transhumeral ulno-humeral arthroplasty), where the posterior aspect of the humerus is reached via a triceps splitting approach; a Cloward drill hole is made into the olecranon fossa (Morrey describes using a 20mm trephine), removing the marginal osteophytes from the olecranon and coronoid fossae, and the coronoid is debrided through this hole using a 7mm curved osteotome.

Osteophytes are also removed from the olecranon tip. The anterior capsule can be released to some extent through the osteotomy; if a more extensive release is required the lateral epicondyle can be exposed via the posterior approach and ECRL and BR elevated to expose the capsule, which is released.
The ulnar nerve should be decompressed and or transposed if there are ulnar nerve symptoms preoperatively or if there is less than 100 degrees flexion arc preoperatively.

Results of Outerbridge-Kashiwagi procedure
At 7 years, around 75% of patients have no or little pain, and an improvement in their flexion arc of 30 degrees. At 12 years, around 55% have no or little pain. TER should not be performed in manual labourers (10 kg weight restriction). Elbow arthrodesis is not satisfactory, because there is no one acceptable position for fusion.

Post-traumatic arthritis
This usually damages cartilage, and may lead to mid range pain as well as stiffness.
If the radial head is damaged, late excision can provide good pain relief. If this leads to later valgus instability a radial head replacement can be considered.
If the ulnohumeral joint is affected, the choices are fascial interposition arthroplasty or TER if the patient is willing to limit activities.

Rheumatoid arthritis

Epidemiology
Involved in 50% of RA patients.
Majority have bilateral involvement.

Clinical
Ulnar bursitis and rheumatoid nodules are found on the back of the elbow. Pain and tenderness due to synovitis is particularly common laterally, over the radiohumeral joint. Movements are restricted; as bone is lost the joint may become unstable. Synovial swelling can lead to compression of the posterior interosseous nerve with dropped fingers.

Imaging
XR reveal bone erosion, with gradual destruction of the radial head and widening of the trochlear notch of the ulna.

Treatment
Synovitis can be treated with open or arthroscopic synovectomy if medical treatment is unsatisfactory. Open synovectomy is usually combined with excision of the radial head. Satisfactory pain relief is seen in around 70-90% of patients, but there is not as much improvement in range of motion. A stiff, painful or grossly unstable elbow can be treated with arthroplasty, with good long term results.

Distal nonunion of the humerus
In elderly patients with stiff, painful nonunions post intra-articular distal humeral fractures, TER is effective. OKU 7 advises antibiotic impregnated cement.

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