Elbow

Here we have collated the most common conditions related to the elbow joint. We have also included a few case vignettes to help aid your clinical understanding of these conditions.

After you have worked through these we have included a brief quiz which upon completion will provide you with a nice certificate!

The Elbow

The Elbow is a synovial hinge joint that comprises of the humerus (upper arm) and the radius and ulna (forearm). It's prominent landmark include the Lateral and medial epicondyles, and the olecranon.

Image of the Distal Humerus

CASE 1:

A 45-year-old man presents to his GP with symptoms in his fingers. On questioning he describes his little finger and part of his ring finger on his right side often “falling asleep”, he also describes tingling in the same area. He states that these symptoms come on whilst he is working as a lorry driver or he also notices it if he happens to wake up in the middle of the night. He has had these symptoms for many years but just wanted to get it checked out.

PMHx: fracture of right elbow 20 years ago, hypertension and T2DM.

SHx: smokes 10/day, drinks few pints at the weekend. No relevant FHx.

What is your top differential diagnosis?

Cubital Tunnel Syndrome

Which test is used to confirm the diagnosis?

Nerve Conduction studies - measure how fast an electrical impulse moves through a nerve.

Cubital tunnel syndrome

Due to compression of the ulnar nerve at the medial epicondyle ie “funny bone”. Compression can be due to Osborne’s fascia (tight fascia over the roof of tunnel) or due to tightness at the intermuscular septum.

Symptoms

Numbness and tingling in the area of ulnar distribution ie the little finger and ½ of ring finger.

Over time, weakness can present in the muscles of hand innervated by the ulnar nerve:

1st dorsal interosseous (abduction index finger) and adductor pollicis.

Examination

Tinels test +ve (tapping over cubital tunnel will reproduce tingling)

Later in disease can have froment’s test +ve (asking the patient to grip onto a piece of paper with thumbs on top and due to weakness of adductor pollicis, patient will compensate by flexing flexor pollicis longus to hold onto paper)

Investigation

Nerve conduction studies

X-rays may be used to look for bony compression of the ulnar nerve

Management

General advice: avoid sleeping with bent elbows, avoid long periods of time with bent elbows

Non-surgical management: NSAIDs, bracing or splinting (nighttime to keep elbow straight)

Surgery

Risk Factors = Injury + disease to the elbow is a risk factor for developing cubital tunnel syndrome

CASE 2:

Luke O’Cyte is a 45 year old construction site worker who presented to his GP with gradually worsening pain on the medial side of his elbow which radiates down his forearm to his wrist. The pain is throbbing in nature and exacerbated by certain activities, including turning door handles and opening jars. He is worried it is starting to affect his job as the pain causes difficultly with gripping objects. He has not experienced any recent trauma to the region. He has smoked 30 cigarettes a day for the past 20 years. The GP suspects the patient has Golfer's Elbow.

What investigations should the GP consider?

The GP should physically examine the patient's elbow to determine the diagnosis.

An MRI may be considered which may reveal thickening of the common flexor tendon and evidence of oedema in the surrounding soft tissue.

How should this patient be managed?

Reassure that this is a self-limiting condition, although symptoms may take weeks to months to settle.

Avoid the activities which exacerbate his symptoms where possible.

A cold compress may be used 3-4 times a day, particularly following heavy bouts of activity.

Rest is useful for a few days during a flare up but exercises to maintain strength and mobility are equally important.

He is prescribed a short course of ibuprofen to manage the pain and advised regarding the importance of smoking cessation.

Golfer's Elbow

Also known as medial epicondylitis, is a tendinosis of the common flexor tendon which arises due to overuse or degeneration injury.

Symptoms

It typically presents with insidious onset medial elbow pain and is less common than tennis elbow (lateral epicondylitis).

Examination

Golfer's Elbow test - patient with a closed fist. Examiner grasps the wrist and palpates the medial epicondyle. The examiner then passively supinates the forearm and extends the elbow and wrist.

Investigation

MRI

Management

Rest, physiotherapy and NSAIDs.

Lifestyle changes can involve activity modification, smoking cessation and weight loss.

Why Smoking? =It’s thought that smoking impedes circulation to the tendon, predisposing to increased risk of injury and prolonging the process of healing. Tobacco also leads to vascular damage, increasing the risk of developing the condition in the first place.

Olecranon Bursitis

Inflammation of the bursa at the point of the elbow (olecranon). Bursa is a fluid filled cushion between the bone and soft tissues which allows the soft tissue to move freely over the bone. Bursitis is inflammation of the bursa. Causes include trauma to olecranon, prolonged pressure (e.g. elbow on desk), and infection (e.g. insect bite, penetrating injury)

Symptoms

Swelling, Pain on pressure and/or bending of elbow.

Signs of infection may include a warm and red olecranon.

Investigation

Examination of elbow

Repetitive instances of bursitis may require X-ray to rule out an ‘olecranon spur’

Fluid testing with a needle may be used to determine if there is an infection or gout

Management

NSAIDs to reduce swelling and relieve symptoms

If no symptom relief after 3-6 weeks consider corticosteroid injection.

Change in activity causing symptoms e.g. manual labourer may benefit from elbow pads.

An infection may require fluid aspiration and antibiotics.

Tennis Elbow

Inflammation of tendons which connect to the forearm muscles on the lateral side of the elbow. Also known as Lateral Epicondylitis.

Causes include: overuse lead to micro-tears and 'wear and tear' resulting in inflammation (e.g. athletes), occupational activities resulting in recurrent weight bearing motion (e.g. painters and cooks). Highest age of incidence is between 30-50.

Symptoms

Gradual worsening pain (weeks to months), pain or burning at lateral elbow, and weak grip strength.

Investigation

Examination of elbow

MRI

Management

Rest + NSAIDs + Ice

Physical Therapy – forearm strengthening exercises

Corticosteroid injection may be indicated for symptom relief

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