History

The interrogation follows the usual lines suggested in Chapter 1. It is important to ascertain the exact site and distribution of the pain, and its nature. Pain arising locally in the humerus is easily confused with pain arising in the shoulder, which characteristically radiates to a point about half-way down the outer aspect of the upper arm. Elbow pain is localised fairly precisely to the joint, though a diffuse aching pain is often felt also in the forearm. When the ulnar nerve is interfered with behind the elbow the symptoms are mainly in the hand.

In the elbow, a history of previous injury, perhaps long ago in childhood, is often relevant. Injuries in this region are notoriously liable to have late effects in the form of impaired movement, deformity, arthritis, loose body formation, or interference with the ulnar nerve.

Movements at the elbow

The elbow joint has two distinct components: the hinge joint between the humerus above and the ulna and radius below, allowing flexion–extension movement; and the pivot joint between the upper ends of the radius and ulna, allowing rotation of the forearm. It should be remembered that free rotation of the forearm is dependent not only upon an intact superior radio-ulnar joint: it demands also free mobility between the radius and ulna throughout their length, and distally at the inferior radio-ulnar joint. Flexion–extension: The normal range is from 0 to 155 ° (0 = anatomical position, with the arm straight). Supination–pronation: Rotation movements must be tested with the elbow flexed to a right angle, to eliminate rotation at the shoulder (Fig. 15.1A). The normal range is 90 ° of supination (palm up) and 90 ° of pronation (palm down) (Fig. 15.1B). If the range of rotation is restricted possible causes must be sought in the forearm and wrist as well as in the elbow.

Fig. 15.1 A Examining rotation of the forearm. The elbow is flexed 90 ° to eliminate rotation at the shoulder. B Range of supination and pronation of the forearm.

ACUTE OSTEOMYELITIS (General description of acute osteomyelitis, p. 85)

Osteomyelitis is less common in the upper limb than in the lower. Nevertheless the humerus is a well’recognised site of haematogenous infection – especially its upper metaphysis.

Pathology. Except in time of war the humerus is seldom infected directly by organisms introduced from without, for compound fractures are rare. Infection is usually haematogenous, from a focus elsewhere in the body. This type of infection occurs mainly in children, and it usually begins in a metaphysis of the bone – more often the upper metaphysis than the lower. Since both the upper and the lower metaphyses are partly enclosed within the capsule of the shoulder and of the elbow respectively, a metaphysial infection is liable to spread directly to the adjacent joint, causing pyogenic arthritis (see Fig. 7.2).

Clinical features. There is constitutional illness, with pyrexia. Locally, there is severe pain at the site of infection. On examination there is intense and welllocalised tenderness over the affected area – usually near one end of the bone. Later, there may be swelling and increased warmth, and a fluctuant abscess may form. The adjacent joint is commonly swollen from an effusion of fluid (‘sympathetic’ effusion), even if the joint itself is not involved in the infection. In the absence of joint infection, however, movements are restricted only slightly, if at all.

Imaging. Radiographs do not show any abnormality at first. After about two weeks there are often localised rarefaction and subperiosteal new bone formation (Fig. 15.2), but these changes may be slight at first. Radioisotope scanning shows increased uptake in the affected area.

Fig. 15.2 Acute osteomyelitis of upper end of humerus. Radiograph 4 weeks after onset showing marked rarefaction of the bone, with patchy areas of destruction and much subperiosteal new bone formation.

Investigations and treatment are the same as for acute osteomyelitis elsewhere (p. 89).

CHRONIC OSTEOMYELITIS (General description of chronic osteomyelitis, p. 90)

As in other bones, chronic pyogenic osteomyelitis of the humerus is nearly always a sequel to acute osteomyelitis that has been neglected or has responded poorly to treatment. The bone is thickened, often throughout its whole length, and there may be a persistent or intermittent purulent discharge from a sinus, or recurrent flare-ups with local pain and induration. Radiographs show irregular thickening with patchy areas of sclerosis and cavitation, and sometimes a sequestrum.

Treatment was described on page 91.

TUMOURS OF BONE

Malignant tumours (General description of malignant bone tumours, p. 112)

Primary malignant tumours

Primary malignant tumours of bone are much less common in the upper limb than in the lower, and examples are seen only infrequently. However, osteo-sarcoma, chondrosarcoma, Ewing’s tumour, and multiple myeloma should all be considered as possible causes of painful destructive bone lesions in the humerus.

Metastatic tumours

Metastatic tumours, by comparison, are common, especially in the proximal part of the humerus (Fig. 15.3). Carcinomatous deposits from tumours of the lung, breast, prostate, kidney, and thyroid are common and usually occur near the upper end of the shaft, where there is much vascular marrow. Such metastases are a common cause of pathological fracture and may require internal fixation as well as adjuvant treatment with radiotherapy.

Fig. 15.3 Metastatic tumour in the humerus from primary carcinoma of the lung. This is a common site for metastatic tumours, which often lead eventually to pathological fracture.

BONE CYST

Both simple bone cysts and aneurysmal bone cysts can occur in the humerus and were described on page 126. The humerus is the commonest site of simple bone cyst, which occurs especially in children or adolescents, and at the upper end of the bone. The cyst replaces the normal bone structure and may lead to pathological fracture as the presenting symptom in over 50% of cases. (Fig. 15.4A). Small cysts may simply be kept under observation, since the majority heal spontaneously in adult life (Fig. 15.4B). A large cyst which might lead to fracture, should first be aspirated and injected with corticosteroid solution or autogenous bone marrow. Most fractures through cysts heal with conservative treatment and internal fixation is rarely required in the humerus.

Fig. 15.4 A Radiograph showing a pathological fracture through a simple bone cyst in the shaft of the humerus in an adolescent patient. Cortical fragments have fallen into the multilocular cystic cavity. B Same patient nine months later showing the fracture has healed spontaneously and the cyst is showing evidence of infilling with dense sclerotic bone.

CUBITUS VALGUS

The normal elbow, when fully extended, is in a position of slight valgus – usually 10 ° in men and 15 ° in women. This is known as the carrying angle. If the angle is increased, so that the forearm is abducted excessively in relation to the upper arm, the deformity is known as cubitus valgus (Fig. 15.5).

Fig. 15.5 Cubitus valgus (left elbow). The deformity predisposes to friction neuritis of the ulnar nerve.

Cause. Cubitus valgus is usually a consequence of previous disease or injury in the elbow region. The most frequent causes are:

Clinical features. Apart from the visible deformity there are no symptoms unless secondary effects develop.

Secondary effects. The most important sequel of cubitus valgus is interference with the function of the ulnar nerve. When valgus deformity is marked, the nerve is angled sharply round the prominent medial part of the joint, and repeated friction may lead to fibrosis of the nerve trunk. Symptoms develop insidiously over a long period: there are tingling and blunting of sensibility in the ulnar distribution in the hand, with weakness and wasting of the ulnar-innervated small hand muscles (p. 291).

Treatment. Slight uncomplicated deformity is best left alone. If angulation is severe, correction by osteotomy near the lower end of the humerus is justified. If the function of the ulnar nerve is impaired the nerve should be transposed from its post-humeral groove to a new bed at the front of the elbow.

CUBITUS VARUS

Cubitus varus is the opposite deformity to cubitus valgus. The carrying angle, or normal angle of valgus at the fully extended elbow, is decreased or reversed.

Cause. The causes are similar to those of cubitus valgus:

Clinical features. There are usually no symptoms other than the visible deformity, which may be embarrassing, especially to a child.

Treatment. Minor degrees of deformity can safely be left uncorrected. If the angulation is severe it may be corrected by osteotomy through the lower end of the humerus.

PYOGENIC ARTHRITIS OF THE ELBOW (General description of pyogenic arthritis, p. 96)

Pyogenic arthritis is usually an acute infection with suppuration, but it may occur in subacute or even in chronic form.

The causation, pathology, clinical features and treatment of the condition are similar to other large joints and are described on page 97.

TUBERCULOUS ARTHRITIS OF THE ELBOW (General description of tuberculous arthritis, p. 98)

Tuberculous arthritis is much less common in the elbow than it is in the large weight-bearing joints such as the hip and knee.

The pathological and clinical features of joint tuberculosis were described on page 98, and further description is not required here. Biopsy may be required to establish the diagnosis.

RHEUMATOID ARTHRITIS OF THE ELBOW (General description of rheumatoid arthritis, p. 134)

One or both elbows are commonly affected in rheumatoid arthritis, usually in conjunction with several other joints, and may result in considerable pain and functional disability.

Pathology. The pathological changes are like those of rheumatoid arthritis elsewhere. Beginning as a chronic inflammatory thickening of the synovial membrane, it tends later to involve the articular cartilage, which may eventually be almost totally destroyed. The subchondral bone may also be eroded by the synovial pannus formation.

Clinical features. As in other joints, the main symptoms are pain, swelling from thickening of the synovial membrane, abnormal warmth of the overlying skin, and impairment of movement, particularly of rotation of the forearm. In the later stages there is commonly a fixed flexion deformity.

Imaging. Radiographic examination. At first there are no changes. Later, there is diffuse rarefaction in the area of the joint. In long-established cases the cartilage space is lost and there may be considerable erosion of the bone ends (Fig. 15.6).

Fig. 15.6 A and B Radiographs of elbow affected by chronic rheumatoid arthritis. There is almost complete destruction of the articular surfaces of radius, ulna and humerus with subluxation of the joints.

CT scanning may be useful in pre-operative planning to determine the amount of bone available for prosthetic support.

Treatment. Primary treatment is along the lines suggested for rheumatoid arthritis in general (p. 137).

Operative treatment. If extensive destruction of the articular cartilage leads to persistent disabling pain with bone destruction and deformity, operation must be considered. If pain is largely at the lateral side of the joint the simple operation of excision of the head of the radius, with a limited synovectomy, often gives good relief. Replacement arthroplasty, by the fitting of a hinged prosthesis with long stems cemented into the humerus and ulna, has now been largely abandoned because of the risk of loosening and fracture. Improved results have been obtained by non-linked replacements of the articular surfaces with metal and plastic liners. The long’term functional results are not as good as with hip and knee replacements, but offer satisfactory pain relief.

OSTEOARTHRITIS OF THE ELBOW (General description of osteoarthritis, p. 140)

Osteoarthritis seldom occurs in an elbow that was previously normal. In nearly every case a predisposing factor has been present for several years. This is usually a damaged articular surface from previous fracture involving the joint, or from osteochondritis dissecans.

Clinical features. There is slowly increasing pain in the elbow, worse on heavy use of the limb. The patient may also notice that movement is impaired. In some cases there are attacks of sudden locking, suggesting the presence of a loose body in the joint. There is often a history of previous injury or disease involving the elbow – for instance, osteochondritis dissecans. On examination there is palpable thickening at the joint margins, from osteophytes. Flexion and extension are impaired but rotation is often full. There is coarse crepitation on movement.

Radiographs show narrowing of the cartilage space and pointed osteophytes at the joint margins (Fig. 15.7). Loose bodies (formed from detached osteophytes or from flakes of articular cartilage) may be present.

Fig. 15.7 Osteoarthritis of the elbow. Note the narrowed cartilage space and pointed osteophytes at the joint margins. In this case osteoarthritis was secondary to osteochondritis dissecans occurring many years before.

Treatment. Many patients with early arthritis, causing only intermittent pain and minimal loss of movement, can be managed by re-assurance and modification of activities. Others may require conservative treatment with analgesics and physiotherapy in the form of short’wave diathermy and mobilisation of the joint. Where pain becomes severe on a daily basis, or locking and joint stiffness limit function, surgery is usually indicated. Open or arthroscopic debridement to remove osteophytes and any loose bodies from the joint may be effective, but excision of the radial head may also be required to restore forearm rotation. In only a few cases is prosthetic joint replacement required to replace the humeral and ulnar surfaces using the techniques described for rheumatoid arthritis. It is important that the ulnar nerve is transposed anteriorly at the time of surgery to avoid the risk of later neuropraxia.

NEUROPATHIC ARTHRITIS OF THE ELBOW (General description of neuropathic arthritis, p. 147)

In neuropathic arthritis (Charcot’s osteoarthropathy) of the elbow the joint becomes disorganised in consequence of a loss of sensibility to pain. It is a rare form of arthritis.

Cause. The usual underlying cause of the disease in the elbow is syringomyelia, but any other affection that leads to loss of sensibility (e.g. diabetic neuropathy) may be responsible.

Pathology, clinical features and treatment are similar to other affected joints. Treatment is conservative with elbow bracing as operation is inappropriate.

HAEMOPHILIC ARTHRITIS OF THE ELBOW (General description of haemophilic arthritis, p. 145)

Haemophilic arthritis affects the elbow more often than any other joint except the knee. As in other joints, the main feature is intra-articular haemorrhage, often recurrent, with consequent irritation and, later, degeneration of the joint.

The clue to the diagnosis is a history of previous bleeding or of a haemophilic tendency in the family. Haemarthrosis without major injury should always arouse suspicion of haemophilia. A prolonged blood clotting time is an important confirmatory finding.

Treatment (for fresh haemarthrosis). If antihaemophilic factor is available it should be given in adequate dosage and the joint should be aspirated. The elbow is supported by crepe bandages and a removable light plaster or plastic splint. Gentle exercises are resumed after 2 weeks. If antihaemophilic factor is not available reliance must be placed on splintage, without aspiration. In this event, particularly after repeated haemarthrosis, permanent damage with fibrosis of the synovial membrane and the formation of intra-articular adhesions must be expected in the long term.

OSTEOCHONDRITIS DISSECANS OF THE ELBOW (General description of osteochondritis dissecans, p. 153)

After the knee, the elbow is the most frequent site of osteochondritis dissecans. The disorder is characterised by necrosis of part of the articular cartilage and of the underlying bone, with eventual separation of the fragment to form an intra-articular loose body (Fig. 15.8).

Fig. 15.8 Osteochondritis dissecans. A fragment of the capitulum is separating. This is the typical site of osteochondritis dissecans in the elbow.

Cause. The precise cause is unknown. Impairment of blood supply to the affected segment of bone and cartilage by thrombosis of an end artery has been suggested. Injury probably plays a part.

Pathology. The part of the elbow affected is nearly always the capitulum of the humerus. The necrotic segment of articular surface varies in size; commonly its surface area is about a centimetre in diameter and its depth less than half a centimetre. A line of demarcation forms between the avascular segment and the surrounding normal bone and cartilage, and after an interval of months the avascular segment separates as a loose body (sometimes two or three), leaving a shallow cavity in the articular surface which is ultimately filled with fibrous tissue. The damage to the joint surface predisposes to the later development of osteoarthritis.

Clinical features. In the early stages, before the fragment has separated, the symptoms are those of mild mechanical irritation of the joint – namely, aching after use and intermittent swelling (from fluid effusion). On examination at this stage there is often an effusion of clear fluid into the joint, and there is slight limitation of flexion or extension.

When a loose body has separated, the main features are recurrent sudden painful locking of the elbow and subsequent effusion of fluid.

Imaging. Plain radiographs in the early stages show an area of irregularity on the affected subchondral bone, usually of the capitulum. Later a shallow cavity, whose margins are demarcated clearly from the bone within it, is seen (Fig. 15.8). Eventually the bony fragment separates from the cavity and lies free within the joint, usually in the lateral compartment. MR scanning in the earlier stages of the disease may be valuable in determining the possibility of operative treatment prior to separation of the bony fragment.

Treatment. If the fragment is small, operation is delayed until the fragment of bone and cartilage is ripe for separation or has actually separated. The fragment is then removed. If the fragment is large and is identified prior to separation it may be fixed in place with a fine screw or pin until fixation to the underlying bone occurs.

LOOSE BODIES IN THE ELBOW

Causes. There are four important causes of loose bodies in the elbow:

PATHOLOGY AND CLINICAL FEATURES

Osteochondritis dissecans was described on page 153 and osteoarthritis on page 140.

Loose body after fracture. A fragment may rarely be detached from the capitulum. Sometimes the medial epicondyle is detached and sucked into the joint, retaining its attachments to the flexor muscles. (Strictly this is not a loose body because it retains soft tissue attachments, but it behaves as one.)

Synovial chondromatosis (osteochondromatosis). This is a rare disease of synovial membrane in which numerous synovial villi become pedunculated and transformed into cartilage; eventually they are detached to form a large number of loose bodies, many of which become calcified (Fig. 15.9).

Fig. 15.9 A and B Multiple loose bodies in the elbow. A case of synovial chondromatosis.

Clinical features. Many so-called loose bodies are ‘silent’ – that is, they do not cause symptoms. Often in such cases the fragment is not in fact loose, but has soft-tissue attachments that prevent its moving about the joint.

The characteristic symptom of a freely movable loose body is sudden locking of the elbow during movement, with sharp pain. The joint is usually unlocked after an interval, either spontaneously or by the patient’s manoeuvres. Several hours later the joint swells because of effusion of fluid within it. The symptoms subside within a few days, but repeated attacks are to be expected.

Examination in the stage of swelling shows the joint to be distended with fluid – a clear, pale, straw-coloured effusion. Between attacks a loose body may sometimes be felt. There is often a history or clinical evidence to suggest the cause of the loose body formation.

Radiographs show the loose body or bodies (Fig. 15.9A) and usually indicate the nature of the primary condition.

Treatment. Symptomless loose bodies may usually be safely left alone; but if a loose body causes locking it should be removed by operation. In cases of synovial chondromatosis, with numerous loose bodies, removal of the bodies should usually be supplemented by excision of as much of the synovial membrane as is easily accessible, to minimise the risk of recurrence.

TENNIS ELBOW (Lateral epicondylitis)

‘Tennis elbow’ is a common and well’defined clinical entity. It is an extra-articular affection characterised by pain and acute tenderness at the origin of the extensor muscles of the forearm from the lateral epicondyle. A similar but less common condition is ‘golfer’s elbow’ at the origin of the muscles at the medial epicondyle.

Cause. It is believed to be caused by strain of the forearm extensor muscles, particularly the extensor carpi radialis brevis, at the point of their origin from the bone. Although it sometimes occurs after playing tennis or golf, other repetitive activities such as wheelchair use are just as likely to be responsible.

Pathology. It is assumed that there is incomplete rupture of aponeurotic fibres at the muscle origin, which is a region plentifully supplied by nerve endings. Histology shows no evidence of acute inflammation, but an angio-fibroblastic tendinosis is suggestive of repetitive micro injury with attempted healing. The elbow and radio-humeral joints are unaffected.

Clinical features. Patients are usually in the 30–50 age group presenting with pain at the lateral aspect of the elbow often radiating down the back of the forearm.

On examination there is tenderness precisely localised to the front of the lateral epicondyle of the humerus (Fig. 15.10). Pain is aggravated by putting the extensor muscles on the stretch—for example, by flexing the wrist and fingers with the forearm pronated. Movements of the elbow are full.

Fig. 15.10 A and B In tennis elbow the point of greatest tenderness is at the front of the lateral epicondyle, not over its greatest prominence. To be curative, injection must be made precisely at the point of greatest tenderness.

Imaging. Radiographs do not show any alteration from the normal except for occasional calcification at the muscle origin in chronic cases. However, MRI scans may demonstrate local oedema and thickening in the extensor muscle origin.

Course. In about 80% of patients the symptoms eventually subside spontaneously after 1–2 years. In cases resistant to modification of activities more active treatment may be required.

Treatment. A large number of treatment methods, both conservative and surgical, have been applied to the condition but none have proved reliable in every case.

Conservative treatment. Where rest and non-steroidal anti-inflammatory drugs have failed to provide relief, injection of the muscle origin with local anaesthetic and hydrocortisone is frequently employed. Repeat injections may be required on one of two occasions, but usually give relief for up to 6 weeks. However, results from randomised trials with longer follow-up showed no greater improvement than achieved with other conservative measures. Orthotic devices, such as the proximal forearm band splint to reduce tension at the extensor origin are popular with those wishing to continue sporting activities, but their long-term benefit remains uncertain. Other local treatment modalities such as sonic shock wave therapy and eccentric strengthening exercises provide equally uncertain long-term results.

Operative treatment. If severe disabling pain fails to respond to any of these conservative treatments, operation may have to be considered. The operation requires a small incision over the extensor origin which is stripped from its attachment to the lateral epicondyle, thereby detaching the pain-sensitive fibres from the bone while allowing natural healing to occur. With modern technology this procedure can now be carried out through an arthroscope without the need for open release. Long-term results have reported pain relief in over 80% of patients but some local discomfort may persist.

OLECRANON BURSITIS

The bursa behind the olecranon process is liable to traumatic bursitis, septic bursitis, and gout.

Traumatic bursitis. In traumatic bursitis (‘student’s elbow’) the bursa is distended with clear fluid (Fig. 15.11). Treatment at first should be by aspiration, followed by the injection of hydrocortisone into the bursa. If the swelling recurs the bursa should be excised.

Fig. 15.11 Olecranon bursitis.

Septic bursitis is treated by incision to secure adequate drainage. This should be conbined with an appropriate antibiotic to treat the underlying infecting organism.

Gouty bursitis. In gouty bursitis there is acute or subacute inflammation, and whitish deposits of sodium biurate (tophi) may be visible through the walls of the bursa. If the symptoms are troublesome the bursa may be excised.

FRICTION NEURITIS OF THE ULNAR NERVE

The ulnar nerve is vulnerable where it lies in the groove behind the medial epicondyle of the humerus. Its function may be interfered with either by constriction or by recurrent friction while in tension. Constriction is usually secondary to osteoarthritis, with encroachment of osteophytes upon the ulnar groove. Friction under tension occurs especially when the carrying angle of the elbow is increased (cubitus valgus, p. 282). This latter type is often a late sequel of a supracondylar fracture of the humerus sustained in childhood (‘tardy ulnar palsy’). In both cases the nerve undergoes fibrosis, and unless the mechanical fault is relieved without undue delay the changes may eventually become irreversible.

Clinical features. The patient complains of numbness or tingling in the area of sensory distribution of the ulnar nerve, and often of clumsiness in performing fine finger movements, as for instance in such activities as playing musical instruments.

On examination in the fully developed condition the following signs are present: Sensory—There is blunting or loss of sensibility along the ulnar border of the hand and in the little finger and medial half of the ring finger. Motor – There are wasting and weakness of the ulnar-innervated small hand muscles. Sweating – The skin in the ulnar territory is drier than normal because sweating is impaired. In doubtful cases nerve conduction studies may be carried out on the ulnar nerve, to detect any slowing of impulses at the elbow level.

Treatment. Whenever the ulnar nerve is interfered with by a lesion at the elbow operation should be undertaken. The operation will consist in decompression of the nerve by division of the overlying aponeurosis of the flexor carpi ulnaris; or, if deformity is present, by transposing the nerve to a new bed in front of the medial epicondyle of the elbow.