ELBOW AND FOREARM

Dr.Raad Al-Shaibany
 CONGENITAL DISLOCATION OF THE
RADIAL HEAD
• This may be anterior or posterior and is
usually bilateral
• palpable lump and can be felt to move when
the forearm is rotated.
• X-rays : the dislocated radial head is dome-
shaped .
• TREATMENT: Function is usually surprisingly
good and pain is unusual. Surgery is therefore
rarely required; however, if the lump limits
elbow flexion it can be excised
CONGENITAL DISLOCATION OF THE
RADIAL HEAD
 CONGENITAL SYNOSTOSIS
Proximal radio-ulnar synostosis causes loss
of rotation, but elbow flexion is retained
and the inconvenience is often only
moderate. Surgery to regain rotation rarely
succeeds. A rotational osteotomy can give
a more suitable angle of
pronation–supination tailored to the
individual patient’s needs.
CONGENITAL SYNOSTOSIS
 CUBITUS VALGUS
• The normal carrying angle of the elbow is 5–15
degrees of valgus.
• The commonest cause is longstanding non-union
of a fractured lateral condyle.
• The importance of cubitus valgus is the liability to
delayed ulnar palsy
• Years after the causal injury the patient notices
weakness of the handwith 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
CUBITUS VALGUS
 ’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.
CUBITUS VARUS
 UNREDUCED DISLOCATION OF THE
HEAD OF RADIUS
An unreduced Montegia fracture-
dislocation will leave the radial head
permanently dislocated. Open
reduction and realignment of the ulna,
together with soft-tissue
reconstruction, may improve function.
-unreduced Montegia fracture
dislocation
 PULLED ELBOW
Downward dislocation of the head of the radius from the
annular ligament is a fairly common injury in children under
the age of 6 years.
clinical features:
• There may be a history of the child being jerked by
the arm.
• 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.
Treatment:The radial head should be reduced by quick
supination and flexion of elbow(the radial head is
relocated with a snap)
 LOOSE BODIES
Loose bodies in the elbow may be due to:
(1) Acute trauma (an osteocartilaginous fracture).
(2) Osteochondritis dissecans;
(3) Synovial chondromatosis (a cluster of mainly
cartilaginous ‘pebbles’);
(4)Osteoarthritis (separation of osteophytes).

Clinical features:
• Sudden locking and unlocking of the joint.
• Symptoms of osteoarthritis may coexist.
• A loose body is rarely palpable.
IMAGING:
• X-rays may reveal the loose body or bodies
• CT arthrogram will define the size and the
number of loose bodies.

Treatment:
• If loose bodies are troublesome, they
should be removed by arthroscopic or open
mean
 STIFFNESS OF THE ELBOW
Stiffness of the elbow may be due to
• Congenital abnormalities (various
types of synostosis, or
arthrogryposis),
• Infection
• Inflammatory arthritis.
• Osteoarthritis .
• Late effects of trauma.
STIFFNESS OF THE ELBOW
 POST-TRAUMATIC STIFFNESS
Either extrinsic ,intrinsic or a combination of
these.
Clinical assessment
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
POST-TRAUMATIC STIFFNESS
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.
 OPERATIVE TREATMENT
Failure to regain a functional range of movement at 12
months after injury.
The objectives are determined by the type of
pathology.
• Heterotopic bone can be excised.
• Capsular release or capsulectomy (open or
arthroscopic).
• Intra-articular procedures include fixing of ununited
fractures or correction of malunited fractures.
• Post-traumatic radio-ulnar synostosis resection
when the synostosis has matured (this takes about
one year) followed by diligent physiotherapy.
 RECURRENT ELBOW INSTABILITY
Following a dislocation or severe sprain, the lateral
collateral ligament can be stretched or ruptured.
Clinical features:
• The patient may present with painful clunking and
locking.
• On examination: an apprehension response can be
elicited by supinating the forearm while applying a
valgus force to the elbow during flexion.
Treatment:
• The lateral collateral ligament can be directly
repaired or reconstructed with a tendon autograft
(e.g. palmaris longus).
 TENNIS ELBOW (LATERAL
Clinical features:
(EPICONDALGIA
• The patient is usually an active individual of 30 or 40
years.
• Pain comes on gradually, often after a period of
unaccustomed activity It is usually localized to the lateral
epicondyle,
On examination:
• 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.
TENNIS ELBOW
X-ray: occasionally shows calcification at the tendon
origin.
Treatment:
• 90 per cent of ‘tennis elbows’ will resolve
spontaneously within 6–12 months.
• The first step is restrict, the activities which cause
pain.
• Injection with corticosteroidand local anaesthetic
These measures failed surgery is indicated(The
origin of the common extensor muscle is detached
from the lateral epicondyle, division of the orbicular
ligament or removal of a ‘synovial fringe’).
• Surgery is successful in about 85 per cent of cases.
TENNIS ELBOW SURGERY
 GOLFER’S ELBOW (MEDIAL
(EPICONDYLITIS
• This is similar to tennis elbow but
about three times less common.
• In this case it is the pronator origin
that is affected.
• Treatment is the same as for lateral
epicondylitis but the outcome of
surgery seems less predictable.
 BASEBALL PITCHER’S ELBOW
• Repetitive, vigorous throwing
activities can cause damage to the
bones or soft-tissue attachments
around the elbow.
• Professional baseball players may
develop hypertrophy of the lower
humerus and incongruity of the joint,
or loose-body formation and
osteoarthritis.
 JAVELIN THROWER’S ELBOW
The over-arm action employed by javelin throwers
places huge strain on the medial collateral ligament
which can become either acutely injured or chronically
attenuated.

Clinical features:
• Pain.
• There may also be symptoms of ulnar nerve
impairment.
Treatment:
• .. rest and modification of activities.
• ..An attenuated medial collateral ligament may need
reconstruction with a tendon graft.
 BURSITIS
The olecranon bursa :causes;
1.continual pressure or friction; this used to be
called ‘student’s elbow’. If the enlargement is a
nuisance the fluid may be aspirated.
2.The commonest non-traumatic cause is gout.
3.In rheumatoid arthritis.(features of rheumatoid
arthritis).
A chronically enlarged bursa may prove a severe
nuisance and need to be excised. However,
wound healing can be a problem
OA. OF ELBOW
RHEUMATOID ELBOW
Tuberculosis of the elbow
SEE YOU NEXT WEEK INSHALLAH