The aim is to understand the anatomy and physiology of the upper limb in relation to the problem that occur and their treatment and to explain the diagnosis and treatment of common problems the elbow with special fractures in children and also to appreciate the differences between adults and children in trauma involving the elbow joint

The elbow joint

It is consists of the humeroulnar joint a simple hinge with a radiohumeral and radioulnar joint beside it which work with the wrist joint to allow pronation and supination the ability of the elbow to flex allows the hand to work close to the upper body pronation and supination allow the orientation of the hand to be set appropriately


The principles of history and examination are laid out in section of clinical examination but revolve round pain , deformity and loss of function because the elbow joint also with shoulder joint serve the hand functional problems experienced by the patient may frequently by with the hand

Tennis elbow

Excluding traumatic conditions, this is the most common cause of pain around the elbow, and usually occurs in patients in their30-50s. The exact cause is unknown, but the condition commonly follows a period of over activity, particularly unaccustomed activity that involves active extension and supination of the wrist. The tendon of extensor carpi radialis brevis is most commonly involved and, at exploration, a partial tear and chronic inflammatory tissue have been described.

History and examinations

The patient complains of pain around the lateral epicondyle and in the back of the forearm. This is activity related and often a par­ticular activity is implicated. There is not usually a history of trauma, but the patient may relate the onset to a period of unusual activity. On examination, the patient is locally tender, which is commonly Just distal and anterior to the lateral epicondyle rather than at the epicondyle itself. Forced palmar
flexion and pronation against resistance reproduces the pain. The diagnosis is essentially a clinical one, although ultrasound and MRI may be indicated if there is any doubt.

Summary of Tennis elbow

• Usually follows a period of over activity

• Tenderness is distal and anterior to lateral epicondyle ,

• Forced palmar flexion and pronation against resistance reproduces the pain

• local injection may help

• Surgery gives good result in most cases


The prognosis is generally good. Many cases probably resolve Without the need for any medical input, particularly if the precip­itating activity can be avoided. Simple analgesia may be sufficient, but often a local injection of hydrocortisone is required. This can be repeated if there is some response. but repeated injections should be avoided. Physiotherapy, particularly local measures, including ultrasound, can help, as can a tennis elbow splint. which is designed to alter the pull of the muscle. Surgery may be occasionally indicated, and local excision of the abnormal tissue will produce good results in 70--80% of patients.

Golfer's elbow

This is less common and involves the flexor origin around the medial epicondyle. Ulnar nerve entrapment should be considered in the differential diagnosis, and treatment is on similar lines. If medical treatment fails and surgery is being considered, further imaging such as ultrasound or MRI is appropriate, to localise any abnormal tissue.

Arthritis of the elbow

Rheumatoid arthritis

The elbow is commonly involved in rheumatoid arthritis and can be a source of considerable discomfort and functional limitation. Medical management is initially tried, but surgery is commonly required. If the elbow has good preservation of joint surfaces, then chemical synovectomy may be indicated, but again this is not commonly carried out in rheumatoid arthritis. If there is consid­erable pain and restriction of pronation and supination, rather than flexion and extension, radial head excision and synovectomy is appropriate. This produces good short-term improvement but there is a high relapse rate.

With end-stage disease, particularly with gross joint destruction, elbow arthroplasty is indicated. This is becoming more com­monly performed and gives good results, with 80-90% of patients problem-free 10 years after surgery .

The elbow in rheumatoid arthritis

• Radial head excision helps if pain is mainly on pronation and supination

• Elbow replacement gives goad results in end-stage disease

Osteoarthritis of elbow

Primary osteoarthritis of the elbow is rare and most cases of degen­erative disease are due to previous trauma, osteochondritis disse­cans or congenital problems such as epiphyseal dysplasia or radial head abnormalities. The patient is usually male, aged 40 to 60 years, and often works in a profession that requires heavy use of the upper limb. Pain is the chief complaint, although on examina­tion there will usually be a 20-30 degree fixed flexion deformity and lim­ited supination. The history and examination should concentrate on differentiating the pain of a degenerate joint, which is activity related and predictable, from that of sudden unexpected pain and locking, which suggests loose bodies within the elbow (see below) In addition, ulnar nerve symptoms are more common in the arthritic elbow.


Often no treatment is required other than reassurance about the nature of the condition. Osteoarthritic elbows seldom deteriorate rapidly, and often the symptoms will improve after retirement. For the patient who is unable to carry out his normal activity. early retirement, or a change of work, is the best solution, as there is no satisfactory surgical procedure that will guarantee a return to a heavy manual job. Debridement is practised in the USA and will increase the range of motion; however, lack of movement is seldom a major complaint by the patient Resurfacing arthroplasty using tendon or fascia has been tried but, in general, gives a less than satisfactory outcome. Joint replacement should not be carried out in a patient who wishes to return to heavy work, but is indicated for severe pain and func­tional problems in a more sedentary patient. Arthrodesis of the elbow is rarely carried out.

In general, the results of elbow replacement for osteoarthritis
are not as good as for rheumatoid arthritis. This may be related to the different lifestyles of the patients
Summary of Osteoarthritis of the elbow

• Non-operative methods including change of job should be explored

• Joint replacement does not work well in patients doing heavy work

Loose bodies

After the knee, the elbow is the second most common site of symptomatic loose bodies. The most common cause is osteoarthritis, but in the younger patient osteochondritis dissecans is the usual cause . Most patients complain of sudden unexpected pain and locking of the elbow, and often they have to shake or manipulate the elbow to relieve it. Plain radiographs will confirm the diagnosis in 90% of cases, and further investigation is not necessary. Arthroscopic removal is indicated and, in the presence of mechanical symptoms, good results can be expected in most patients. In the absence of an appropriate his­tory, simple removal of loose bodies from a degenerate elbow will not result in any lasting benefit.

Other problems in the elbow

• Osteochondritis dissecans - occurs in teenage boys. Detached fragment can be removed

Olecranon bursitis - usually chemical not septic

• Ulnar nerve compression - may present with numbness in the hand Needs to be decompressed

Osteochondritis dissecans
Osteochondritis dissecans is much less common in the elbow than and usually affects the capitellum. Teenage boys are usually affected, and the condition is often related to sporting activity .The main symptoms are pain and swelling. and on examination there is loss of full extension
Treatment is normally­ conservative, with a rest from sport, but arthroscopy may required the fragment detaches and the patient develops symptoms suggestive of a loose body.

Olecranon bursitis
Inflammation of the olecranon bursa is relatively common. The elbow is often very red. warm. swollen and painful, and a septic arthritis may initially be suspected. The signs and symptoms are, confined to the back of the elbow and movement within an arc of 30-130 degree is usually possible. The bursitis­ usually chemical rather than infective, and management consists of rest, Ice, anti-inflammatories and a compression dress­ing if there is any suspicion of a penetrating wound, antibiotics should be administered but formal drainage of the bursa should be avoided unless purulent material is present
chronic bursitis can occur and may be associated with small calcific nodules In general these should not be removed and surgical excision of the bursa should be avoided if possible

Ulnar nerve compression
This is the second most common nerve entrapment after carpal tunnel syndrome. The most common sites of compression are around the elbow and there is a number of possible sites
the arcade of Structers and the medial intermuscular septum as the nerve passes into the posterior compartment of the distal humerus
medial epicondyle - particularly if osteophytes are present; cubital tunnel- as the nerve passes between the two heads of flexor carpi ulnaris .

A nerve palsy may also be due to a flexion or a valgus deformity of the elbow.

History and examination

Unlike carpal tunnel syndrome. compression of the ulnar nerve may not be painful and the patient may present with weakness of the hand in association with paraesthesia. On examination a pos­itive Tinel's sign is usually present, particularly at the site of cormpression, and wasting and weakness of the intrinsic muscles of the hand are evident. Nerve conduction studies are usually carried out, unless the site of compression is obvious. In addition. plain radiographs of the elbow should be obtained. particularly If any deformity is present.


Despite the absence of pain, decompression of the nerve should be carried out. The nerve can be explored through a medial or posterior approach. Opinion is divided on whether simple decem­pression is sufficient or whether there is a need for formal anterior transposition of the nerve. Transposition is usually necessary in cases of deformity, or if the nerve is unstable after decompression. For most other situations decompression without transposition is sufficient. provided all sites of possible compression have been explored.

Any paraesthesia should resolve but the prognosis for the return of hand power should be guarded as the recovery is unpredictable.

Compression of both the radial and median nerves at the elbow occurs but this is much less common than ulnar nerve compression .


Osteomyelitis of the upper limb is very uncommon in adults, unless there are specific predisposing factors such as penetrating wounds. As with other sites, staphylococci and streptococci are commonly implicated, although in the immunocompromised patient other organisms may be encountered. The treatment of osteomyelitis of the upper limb does not differ from other sites.

In children, osteomyelitis of the proximal humeral metaphysis can occur but this is much less common than osteomyelitis of the proximal femur or around the knee.
 osteomyeltitis will be discuss in details later on

Septic arthritis

In both adults and children, septic arthritis of the shoulder or elbow is uncommon. Arthroscopy is preferred to formal arthrotomy for washing out the shoulder. The elbow may be washed out arthroscopically or via a lateral Kocher type approach.

The shoulder and elbow are relatively uncommon sites for tuber­culosis (TB) and treatment is along conventional lines. Secondary degeneration can occur and may be difficult to man­ age. A previously infected joint is one of the few indications for shoulder arthrodesis but the elbow presents a dilemma  . Arthrodesis of the elbow is not a good procedure and there is little information on the outcome of other methods of treatment after previous TB.

Summary of sepsis In the shoulder and elbow
• Rare unless other trauma
• Sepsis of a joint may require fusion
. Function is not not good after elbow fusion


Tumours are unusual around the elbow but the proximal humerus is a relatively common site . It is the third most common site for both osteosarcomas and fibrosarcomas,after the dis­tal femur and proximal tibia. Treatment is on conventional lines. The shoulder is the second most common peripheral site after the proximal femur for chondrosarcomas, and the scapula body is also a common site. The principal method of treatment for chon­drosarcomas is surgical excision and this may be technically diffi­cult around the shoulder. Subtotal excision of the scapula can be carried out with good preservation of function if the glenoid can be left. The humerus is also a relatively common site for lym­phomas and Ewing's tumour. Treatment is, again, along conven­tional lines

 Summary of tumours In the upper limb

• These are rare apart from metastases in the humerus

• The shoulder and upper humerus are a site for osteo-, fibro- and chondrosarcomas

Benign and intermediate tumours such as osteochondromas, giant cell tumours and aneurysmal bone cysts are also relatively common. The proximal humerus is the most common site for unicameral bone cysts, which are thought to represent an abnormality of cells of the growth plate. They commonly present as pathological fractures in children around the age of 10 years and affect boys more commonly than girls. The lesion may resolve after fracturing but local medical treatment is often required . The humeral shaft is a common site for secondary deposits and intramedullary nailing may be required for pathological fracture or impending fracture. In the majority of cases primary tumours are found in the breast or prostate, but secondary spread from the thyroid, lung, kidney and bowel can also occur


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