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hinge joint formed between the distal end of the humerus in the upper arm and the proximal ends of the ulna and radius in the forearm The elbow allows for the

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Slide1

Elbow joint

The elbow joint is a complex hinge joint formed between the distal end of the humerus in the upper arm and the proximal ends of the ulna and radius in the forearm. The elbow allows for the flexion and extension of the forearm relative to the upper arm, as well as rotation of the forearm and wrist.

Slide2

TENNIS ELBOW (LATERAL EPICONDALGIA)

Pain and tenderness over the lateral epicondyle of the elbow (or, more accurately, the bony insertion of the common extensor tendon) is a common complaintamong

tennis players

– but even more common in non-players who perform similar activities involving forceful repetitive wrist extension. It is the extensor

carpi

radialis

tendon (which automatically extends the wrist when gripping) which is pathological in tennis elbow.

Slide3

Like

supraspinatus tendinitis, it may result in small tears, fibrocartilaginous

metaplasia

, microscopic

calcification

and a painful

vascular reaction in the tendon fibres close to the lateral epicondyle.

Slide4

Clinical features

The patient is usually an active individual of 30 or 40 years. Pain comes on gradually, often after a period of unaccustomed activity involving forceful gripping and wrist extension. It is usually localized to the lateral epicondyle, but in severe cases it may radiate widely.

It is aggravated by movements such as pouring out tea, turning a stiff

doorhandle

, shaking hands or lifting with the forearm

pronated

.

Slide5

On examination The elbow looks

normal, and flexion and extension are full and painless. Characteristically there is localized tenderness at or just below the lateral epicondyle; pain can be reproduced by passively stretching the wrist extensors (by the examiner acutely flexing the patient’s wrist with the forearm pronated

) or actively by having the patient extend the wrist with the elbow straight.

Slide6

X-ray is usually normal, but occasionally shows calcificationat the tendon origin.

Slide7

Treatment

Many methods of treatment are available but the benefits of most are unclear; it is well to remember that 90 per cent of ‘tennis elbows’ will resolve spontaneously within 6–12 months.The first step is to identify, and then restrict, those activities which cause pain. Modification of sporting style may solve the problem.

The role of

physiotherapy

and manipulation is

uncertain

.

Slide8

Injection of the tender area with

corticosteroid and local anaesthetic relieves pain but is not curative.

Slide9

OPERATIVE TREATMENT

Some cases are sufficiently persistent or recurrent for operation to be indicated. The origin of the common extensor muscle is detached from the lateral epicondyle. Surgery is successful in about 85 per cent of cases.

Slide10

 

OLECRANON

BURSITIS

There

are two types :

1-Traumatic

bursitis

:-as a result

ofpressure

or friction.

2-non

traumatic bursitis

:- its painful and due to

infection,gout

or rheumatoid arthritis.

Gout

is suspected if there is a history of previous

attacks,bilateral

with tophi or if the x-ray shows calcification in the bursa which mimic acute infection unless pus is aspirated.

Rheumatoid

arthritis

causes both swelling and nodularity over the olecranon with typical symmetrical poly arthritis, in late

stages,erosion

of elbow may cause marked in stability .

 

Slide11

OLECRANON BURSITIS

Slide12

Treatment

we

must treat the underling

causes.septic

bursitis may need local

drainage,occasionally

achronic enlarged bursa need to be excised.

Other causes of

painfull

elbow are osteoarthritis, rheumatoid

arthritis,gout

and

and

infection like TB.

 

 

Slide13

CUBITUS VALGUS

The normal carrying angle of the elbow is 5–15 degrees of valgus; anything more than this is regarded as a

valgus

deformity, which is usually quite

obvious when the patient stands with arms to the sides and palms facing forwards.

The

commonest cause is longstanding non-union of a fractured lateral condyle; the deformity may be associated

with marked prominence of the medial condylar outline. The importance of cubitus

valgus

is the

liability to delayed

ulnar

palsy

; years after

the causal

injury the patient notices weakness of the

hand, with

numbness and tingling of the

ulnar

fingers.

TREATMENT

:The

deformity

itself needs no treatment, but for

delayed

ulnar

palsy the nerve should be transposed to

the front

of the elbow.

Slide14

CUBITUS VALGUS

Slide15

CUBITUS VARUS (‘GUN-STOCK’ DEFORMITY

The deformity is most obvious when the elbow is extended and the arms are elevated. The most common cause is malunion of a

supracondylar

fracture.

The deformity can be corrected by a

wedge

osteotomy of the lower humerus but this is best left until

skeletal maturity.

Slide16

CUBITUS VARUS

Slide17

‘PULLED ELBOW’

the annular ligament is a fairly common injury in children under the age of 6 years. There may be a history of the child being jerked by the arm and subsequently complaining of pain and inability to use the arm. The limb

is held more or less immobile with the

elbow fully

extended and the forearm

pronated

; any attempt to supinate the forearm is resisted. The diagnosis is essentially clinical, though x-rays are usually obtained in order to exclude a

fracture. The radial head can be forcibly pulled out of the noose of the annular ligament only when the forearm is pronated; even then the distal attachment of the

ligament is

sometimes

torn.

TREATMENT:

If

the history and clinical picture are suggestive,

an attempt

should be made to reduce the

subluxation

or dislocation

. While the child’s attention is diverted,

the elbow

is quickly

supinated

and then slightly

flexed; the

radial head is relocated with a snap. (This

sometimes happens

‘spontaneously’ while the

radiographer is

positioning the arm!)

Slide18

Pulled elbow

Slide19

STIFFNESS OF THE ELBOW

Stiffness of the elbow may be due to 1-congenital abnormalities (various types of synostosis, or arthrogryposis).2-Aquired abnormalities

like infection, inflammatory arthritis, osteoarthritis or

the late effects of

trauma.

Slide20

Slide21

POST-TRAUMATIC STIFFNESS

the elbow is particularly prone to post-traumatic stiffness. The more obvious causes (as with other joints) are either:1-extrinsic (e.g. soft-tissue contracture or heterotopic bone formation).2- intrinsic (e.g. intra-

articular

adhesions

and

articular

incongruity), or a combination ofthese.

Slide22

Clinical features

Clinical assessment should include examinationof all the joints of the upper limb as well as an evaluation of the functional needs of the particular patient. Most of the activities of daily living can be managed with a restricted range of elbow motion

: flexion from

30 to 130 degrees and

pronation

and

supination of 50 degrees each.

Any greater loss is likely to be disabling.

Slide23

NON-OPERATIVE TREATMENT

The most effective treatment is prevention, by early active movement through a functional range. If movement is restricted and fails to improve with exercise, serial splintage

may help; aggressive passive manipulation may aggravate more than help.

Slide24

OPERATIVE TREATMENT

The indication for operative treatment is failure to regain a functional range of movement at 12 months after injury.If there is heterotopic ossification

, it is important to wait until the bone is ‘mature’, i.e. showing clear cortical margins and

trabecular

markings on x-ray. There is no point in a soft tissue

release if the x-ray or CT shows that bone incongruity is blocking movement.

Slide25

The objectives are determined by the type of

Pathology:1-Heterotopic bone can be excised,2-Capsularrelease or capsulectomy (open or arthroscopic) may restore a satisfactory range of movement. 3-Intra-articular procedures include fixing of ununited fractures or correction of

malunited

fractures.

Slide26

Post-traumatic radio-

ulnar synostosis sometimes follows internal fixation of fractures of the radius and ulna. It is treated by resection when the synostosis has matured (this takes about one year) followed by diligent physiotherapy.

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