1. Elbow PainProfessor Hamdy Koryem;MD2012

2. PAINFULE ELBOW :Anatomy

3. Muscles around elbow: Posterior

4. Muscles around elbow: Anterior

5. Elbow pain may be due toGeneralized causesORLocalized causes

6. EP As a part of generalized causes: Arthritis RA. Septic. Hemophilic OA. Crystal induced.(gout or pseudo gout) Enteropathic arthropathy. Traumatic. Neoplasm. Bones. Muscles. Synovial membrane.etc

7. ORLocalized causes for EP

8. MEDIAL EPICONDYLITISSynonyms Golfers elbow Little leaguers elbow (children)Medial epicondylitis:Inflammation of the common flexor tendon.Little leaguers elbow: (children)Hypertrophy of the medial epicondyle withmicro tearing and fragmentation of the medialepicondylar apophysis.

9. MEDIAL EPICONDYLITISMechanismA repetitive valgus stress commonly seen inthe throwing motion. The back and downward motion of a golfswing just prior to the impact of the ball.Clinical presentation:Tenderness over the medial epicondyle. Pain may be reproduced with wrist flexionand pronation.

10. Treatment: Conservative: Rest, ice, NSAIDs, immobilization. Surgical pinning: Reserved for an unstable elbow joint.

11. LATERAL EPICONDYLITISSynonyms :Tennis elbow Mechanism :Overuse and overload of the extensor andsupinator tendons seen in Sports or Workthat require repetitive extension elbowmovements.Pathology:Micro-tearing of the extensor carpi radialis brevismuscle.

12. LATERAL EPICONDYLITISCLINICAL:1. Tenderness just distal to the lateral epicondyleat the common extensor origin.2. Pain and weakness in hand grip strength.3. Pain can be produced by Cozens test.

13. Cozens testPassive extension of the elbowwith forced flexion of the wristmay precipitate pain at thelateral epicondyle

14. Cozens testThe examiner stabilizesthe elbow with a thumbover the lateralepicondyle.Pain in the lateralepicondyle is seen withpatient making afist, pronating theforearm, radiallydeviating andextending the wristagainst resistanceby the examiner.

15. Cozens testThe test may be more sensitivewhen done in full extension at theelbow.

16. LATERAL EPICONDYLITISTreatmentConservative: Relative rest, ice, NSAIDs for 1014 days Physical therapy (modalities) Splinting, bands Local Corticosteroid injection Correct improper techniqueOperative: ECRB debridement

17. OLECRANON BURSITISSynonyms:Students elbowMiners elbowDraftsmans elbow

18. OLECRANON BURSITISMechanism Repetitive trauma, Inflammatory disorder (gout, pseudogout,RA)Pathology Inflammation of the bursa located between theolecranon and skinClinical Swelling, pain, and a decreased range of motion in theposterior aspect of the elbow A hot, erythematous elbow may indicate infection

19. Treatment Conservative: Rest, NSAIDs,elbow padding. Aspiration of fluid and send itfor culture if indicated

20. DISLOCATION OF THE ELBOWGeneral The most common type of dislocationin children and the second mostcommon type in adults followingshoulder dislocation. Sports activities account for almost50% of these injuries

21. DISLOCATION OF THEELBOWMechanism:Fall on the Outstretched hand.

22. DISLOCATION OF THE ELBOWClinical Dislocation can be anterior or posterior withposterior being the most common, occurring98% of the time . Associated injuries include fracture of the radialhead, injury to the brachial artery and mediannerve.

23. DISLOCATION OF THE ELBOWSymptoms Inability to bend the elbow. Pain in the shoulder and wristOn physical exam:The most important part of the exam is theneurovascular evaluation of the radial artery, andmedian, ulnar and radial nerves Plain AP and lateral radiographs

24. DISTAL BICEPS TENDONITISMechanismOverloading of the biceps tendon commonly due torepetitive elbow flexion and supination or resistedelbow extension.PathologyMicro tearing of the biceps tendon distally.

25. DISTAL BICEPS TENDONITISComplication Biceps tendon avulsionClinical Insidious onset of pain in the ante-cubitalfossa usually after an eccentric overload Audible snap with an obvious deformity,swelling, and ecchymosis if an avulsion issuspected

26. DISTAL BICEPS TENDONITISTreatmentConservative Relative rest, ice, NSAIDs. Physical therapy: Modalities. Correct improper technique.Surgical: Reattachment.

27. TRICEPS TENDON AVULSIONMechanismTendonitis:Overuse syndrome secondary to repetitive tricepsextensionAvulsion:A decelerating counterforce during active elbowextension

28. TRICEPS TENDONITIS/AVULSIONClinical Posterior elbow pain with tenderness at theinsertion of the triceps tendon Pain with resistive elbow extension orsudden loss of extension with a palpabledefect in the triceps tendon (avulsion)Imaging Plain films to rule out other causes, ifindicated

29. TRICEPS TENDONITIS/AVULSIONTreatment Conservative Surgical:Reattachment.

30. VALGUS EXTENSION OVERLOADSYNDROME OF THE ELBOWSynonymsBoxers elbow

31. Boxers elbowMechanismAn overuse disorder caused by repetitive anduncontrolled valgus forces demonstratedduring the throwing motion, especially in lateacceleration and deceleration.Also may be seen in boxers.PathologyOsteophyte and loose body formation occurssecondary to a repetitive friction of theolecranon against the fossa.

32. Boxers elbowClinical Posterior elbow pain with lack of full extension Catching or locking during elbow extensionImaging Plain films: AP/lateral may show a loose body orosteophyte formation at the olecranonTreatment Conservative Surgical: Removal of the loose body

33. ULNAR COLLATERAL LIGAMENTSPRAINMechanism A repetitive valgus stress occurring acrossthe elbow during the acceleration phase ofthrowing.Pathology Inflammation to the anterior band of theulnar collateral ligament.

34. ULNAR COLLATERAL LIGAMENT SPRAINClinical Significant medial elbow pain occurring after thethrowing motion A pop or click may be heard precipitating the pain Medial pain or instability on valgus stress with theelbow, flexed 2030 if the UCL is torn.Provocative Test Valgus stress test:Tenderness over the medial aspect of the elbow whichmay be increased with a valgus stress.

35. Imaging Plain films may reveal calcification and spurring alongthe UCL Valgus stress radiographs demonstrating a 2 mmjoint space suggestive of UCL injuryTreatmentConservative1. Rest, ice,2. NSAIDs3. Rehabilitation program for strengthening and stretchingSurgical reconstruction if needed

36. RADIAL COLLATERAL LIGAMENT (RCL)SPRAINMechanism Elbow dislocation from a traumatic eventClinical Recurrent locking or clicking of the elbow withextension and supination Lateral pain or instability on varus stress with the elbowflexed 2030 if the RCL is tornProvocative test Varus stress testTenderness over the lateral aspect of the elbow, whichmay be increased with a varus stress.

37. Imaging Varus stress radiographs demonstrating a 2 mm jointspace suggestive of RCL injuryTreatmentConservative: Rest, ice, NSAIDs Rehabilitation program for strengthening and stretching Establishing return to play criteriaSurgical reconstruction if needed.

38. PRONATOR SYNDROMEClinical1. Dull aching pain in the proximal forearm just distal to theelbow2. Numbness in the median nerve distribution of the hand3. Symptoms exacerbated by pronation

39. PRONATOR SYNDROMEMechanismMedian nerve compression at the elbow by thefollowing structures:1. Ligament .2. Supracondylar spur.3. Fibrosis.4. Pronator teres muscle.5. Between the two heads of the flexordigitorum superficialis (FDS).

40. PRONATOR SYNDROMEImagingPlain films: Rule out spurEMG/NCSTreatmentConservative Modification of activities Avoid aggravating factors Stretching and strengthening programSurgical:Release of the median nerve at the location of thecompression

41. ENTRAPMENT OF THE ULNARNERVESynonymsCubital tunnel syndrome

42. Cubital tunnel syndromeClinical An aching pain with paraesthesias, which may radiate distally tothe fourth and fifth digits Positive Tinels sign at the elbow Weakness in the ulnar musculature of the hand, demonstratedby a weak grip strength and atrophy and poor hand coordination.Mechanism A hyper mobility of the ulnar nerve, excessive valgus force orloose body/osteophyte formation, which aggravates the integrityof the ulnar nerve at the elbow.Pathology Hyperirritability of the ulnar nerve

43. Cubital tunnel syndromeEMG/NCSAbove and below the elbowTreatmentConservativeRelative rest, NSAIDs, elbow protection(splinting) and technique modification

44. OSTEOCHONDROSIS DISSECANSOF THE ELBOWSynonymsPanners disease.(involving epiphysial aseptic necrosis of thecapitellum)

45. OSTEOCHONDROSISDISSECANS OF THE ELBOW

46. FRACTURES FRACTURE OF THE HUMERAL SHAFT FRACTURE OF THE DISTALHUMERUS RADIAL HEAD FRACTURE FRACTURE OF THE OLECRANON