The Elbo · Ulnar nerve dislocation & injury 3]. proximal ulna fracture 4]. fracture of ulnar component 5]. impingement of the radial head 6]. hardware failure 7]. Loosening 8]. Wound

$Page 1: The Elbo · Ulnar nerve dislocation & injury 3]. proximal ulna fracture 4]. fracture of ulnar component 5]. impingement of the radial head 6]. hardware failure 7]. Loosening 8]. Wound$
The Elbow

Mohamed Sobhy

Anatomy Congenital Deformities Acquired Deformities OCD Arthritides Stiffness Operative

Ain-Shams University

[The Elbow] Page | 11

Applied Anatomy TTyyppee:: ................................................. Trochoginglymus Hinge joint OOssssiiffiicc CCeennttrreess aarroouunndd tthhee eellbbooww:: CCRRIITTOOEE

1]. Capitulum ......................... 6mo 2]. Radial Head .................... 5y 3]. Internal condyle ............ 7y 4]. Trochlea ........................... 9y 5]. Olecranon ....................... 11y 6]. External condyle ........... 13y

SSttaabbiilliizziinngg ffaaccttoorrss::

11]].. Joint conformity of the olecranon to the trochlea 22]].. MCL especially the anterior band 33]].. LCL especially the medial band 44]].. Radial head is a 2ry restraint to the valgus thrust

CCaarrrryyiinngg aannggllee The complex geometry of the elbow joint has a special orientation of the trochlea that allow

valgus attitude in extension; while in flexion the forearm comes to the same line of the arm This valgus angle is called the carrying angle = 15º in ♀ / = 10 in ♂ (this to accommodate for wider pelvis in females)

KKiinneemmaattiiccss:: Trochoginglymus the elbow is, premits flexion, extension & pronation supination The actual needed range of motion at most activities: 30º-130º & 45º-45º

22 | Page [The Elbow]

Congenital Deformities 11]].. CCoonnggeenniittaall DDiissllooccaattiioonn::

Usually bilateral Could be anterior or posterior Function is surprisingly excellent PXR: the radial head .................. dislocated and dome shaped ttt: only if lump limits elbow flexion

22]].. CCoonnggeenniittaall SSyynnoossttoossiiss Rare condition

1]. Humerus is fused to ulna or radius + FA deficiencies ttt: osteotomy

2]. Proximal radio-ulnar synostosis Causes loss of rotation only, and usually the limitation is mild

Acquired Deformities


DDIIFFFFEERREENNTT TTYYPPEESS OOFF CCHHOONNDDRROOSSEESS

OOSSTTEEOOCCHHOONNDDRROOSSIISS DDIISSEEAASSEE SSIITTEE AVN 1]. Legg –Clave-Perth es’ d isease. Upper Femoral Epiphysis Crushing 2]. K ien b o ck’s d isease Lunate

3]. Preiser’s d isease Scaphoid 4]. Pan n er’s d isease Capitulum 5]. Sch eu erm an n ’s d isease Vertebral Bodies 6]. K o h ler’s d isease Tarsal Navicular 7]. Freiberg’s d isease 2nd Or 3rd Metatarsal Head 8]. B lo u n t’s Knee ? 9]. Th eim an n ’s d isease Multiple Phalanges

10]. Fried rich ’s d isease Sternal End Of The Clavicle OCD 11]. OCD Knee

12]. OCD Talus 13]. OCD Patella 14]. OCD 1st MT Head 15]. OCD Capitulum 16]. B u sch ke’s d isease Medial Cuniform

Traction apophysitis 17]. Osgood –Sch latter’s d isease Tibial Tuberosity 18]. Johansson-Larsen syndrome Patella 19]. severs disease Calcanius 20]. Iselin ’s d isease Tuberosity Of 5th MT 21]. M an d l’s d isease Greater Trochanter

OCD Capitulum DDeeffiinniittiioonn

NNOONN IINNFFLLAAMMMMAATTOORRYY pathologic condition of the cartilage é IIMMPPEENNDDIINNGG OORR AACCTTUUAALL separation of a segment of cartilage é underlying subchondral bone

Tends to heal spontaneous in skeletally immature persons ÆÆttiioollooggyy::

1- Repeated TTRRAAUUMMAATTAA (over head & WB activities) 2- Could be AAVVNN

PPaatthhooggeenneessiiss:: 1]. Intraosseous edema capillary compression ischemia 2]. Subchondral collapse arteriolar compression necrosis 3]. Fragmentation NBF

DDiiaaggnnoossiiss:: CClliinniiccaallllyy:: Aching pain; é activity, by rest Swelling &Effusion Tenderness ROM PPXXRR:: 1]. Fragmentation ± Flattening of capitulum 2]. Loose body TTCC uptake MMRRII MRI T1 ............................. signal lines MRI T2 ............................. Double line = Signal Margin & signal inner border

DDDDxx:: Pan n er’s d isease : <12y pitchers, disruption of capitellar physis painful flattening TTrreeaattmmeenntt::

1]. NNOONN OOPPEERRAATTIIVVEE TTRREEAATTMMEENNTT:: -- NWB SYMPTOMATIC TTT USUALLY THE RULE 2]. OOPPEERRAATTIIVVEE TTRREEAATTMMEENNTT:: if the Lesion dissects and became loose boy


Strain Syndromes 11]].. TTeennnniiss eellbbooww

Definition: painful lat humeral condyle 2ry to forceful repetitive wrist extension Etiology: repetitive forceful extension ECRB Tendinopathy Pathology:

o Attritional changes to ERCB origin ± ECRL, ECU o Small tears o Microscopic calcifications o Angio-fibroblastic hyperplasia o Fibrocartilaginous metaplasia

CP: o 30-40y é unaccustomed forceful gripping or wrist extension activity o Progressive dull aching pain, localized to LHC o é “TENNIS BACK HAND”, pouring tea, opening a door handle, lifting é pronated FA 1]. PAINLESS elbow flexion & extension 2]. PAINFUL passive elbow extension + pronation + wrist flexion (max stretch of ECRB) 3]. PAINFUL resisted active wrist extension 4]. TENDER LHC

PXR: usually normal except for rare calcification DDx: Radial tunnel syndrome ttt:

1. Activity modification, physiotherapy, US waves 2. Local steroids inj 3. Surgery: detachment of the CEO (common extensor origin) 4. ± synovial fringe & orbicular ligament excision

2]. GGoollffeerr’’ss eellbbooww Same, but affects .................................... CFO (flexor origin) & pronator origin Pain by ................................................. resisted pronation & wrist flexion

33]].. PPiittcchheerr’’ss eellbbooww:: 1]. Repetitive strong throwing ................ damage bone, soft tissue 1]. Lower humerus hypertrophy ............. Incongruity 2]. OA & Loose intra-articular bodies

44]].. LLiittttllee LLeeaagguueerrss’’ eellbbooww:: Partial avulsion of the medial humeral epicondyle ttt: ............................................................... Stay away from pitching

55]].. JJaavveelliinn tthhrroowweerrss’’ eellbbooww Over arm vigorous activity ð Olecranon tip avulsion ± MCL avulsion ttt: activity modification + rest

66]].. SSttuuddeennttss’’ eellbbooww 1]. Frictional olecranon bursitis 2]. Gout 3]. RA

7]. MCL injury: ð repetitive vigorous valgus stresses (late cocking and acceleration phases) Tender medial elbow aspect ............. ± ulnar n palsy Valgus instability (only 50%) ............. é Arm is held in ER + supination; apply valgus thrust ttt: rest + motion .................................... Docking procedure (MCL recon by Palmaris tendon)

88]].. LCL injury The 1st ligament to rupture in elbow dislocation Pain / clicking / locking / postero-lateral instability; all during extension Varus instability ..................................... é Arm is held in IR + pronation; apply varus thrust ttt: same as MCL


Arthritidies

Treatment:

1]. Prevention: early AACCTTIIVVEE ROM, serial splinting (avoid passive forced manipulation) 2]. Surgery:

o Rationale: a) Wait 1y of conservative ttt b) Choose compliant emotionally stable pt c) Heterotopic ossification & synostosis should be in the fully formed stage d) Exclude neuropathic cause

o Options: a) Capsular release b) Heterotopic bone excision c) Corrective osteotomies of a non or mal united fractures d) Proximal radio-ulnar synostosis excision e) OOuutteerrbbrriiddggee--KKaasshhiiwwaaggii olecranon fossa fenestration


Operative AArrtthhrroossccooppyy PPoorrttaallss::

1]. Antero-lateral: 1cm antero-inferior to LEC 2]. Antero-medial: 2cm antero-inferior to MEC 1]. Postero-lateral: 2cm prox to olecranon and just lat to triceps

IInnddiiccaattiioonnss:: 1]. Debridement 2]. Capsular release 3]. Synovectomy 4]. Osteophytes and loose body removal 5]. OCD drilling

AArrtthhrrooppllaassttyy TTyyppeess::

1]. Resection: lower humerus, olecranon notch, radial head excised 2]. Interposition: same é a tissue in-bet to motion & ankylosis; e.g. fat, muscle, fascia lata 3]. Implant arthroplasty:

oo Constrained .......................... failure rate ð loosening oo Unconstrained ..................... unstable oo Semiconstrained .................. better results (Coonrad-Morrey pro)

IInnddiiccaattiioonnss:: 1]. Incapacitating pain 4]. Bilateral ankylosis 2]. Rheumatoid 5]. ROM & stability 3]. OA 6]. Non united fracture humerus

CCoonnttrraaiinnddiiccaattiioonnss:: 1]. Infection 2]. Severe laxity 3]. Previous radial head resection (if unconstrained prosthesis is used) 4]. > 2 cm of distal humeral bone loss (may require customized prosthesis)

TTeecchhnniiqquuee: (using the Coonrad-Morrey prosthesis - semiconstrained); 1]. Approach: PPOOSSTTEERRIIOORR TTRRIICCEEPPSS RREEFFLLEECCTTIINNGG AAPPPPRROOAACCHH

o Ulnar n is identified and is transposed ant o Medial half of triceps is reflected é post capsule o The extensor mechanism is reflected laterally o Tip of the olecranon + portion of the MCL are removed for better exposure o MCL & LCL are released if a semiconstrained is used (their repair is not necessary) o Pitfalls: avoid ant capsulotomy 4 correction of flexion contractures

2]. HHUUMMEERRAALL PPRREEPPAARRAATTIIOONN:: o Only the diaphysis is needed for fixation; i.e. absent epicondyle INBD (is not a big deal) o Medullary reaming is done alignment stem is put é a cutting block o Cutting block: set to remove an appropriate amount of distal humerus o Best is press fit fixation with a circumferential plasma spray

3]. UULLNNAARR PPRREEPPAARRAATTIIOONN:: o Medulla is entered é a high speed drill via the previously removed olecranon tip o Sequential rasping is performed (care not to # prox ulna) o Best is PE cemented ulnar component;

4]. CCEEMMEENNTT &&CCOOMMPPOONNEENNTTSS IINNSSEERRTTIIOONN:: o Use a cement gun to insert cement o Humeral & Ulnar components are inserted o Ulnar component is articulated é humeral component before seating o Allow cement to seat in extension; (even post op 3days to allow healing) o BG is placed behind the anterior flange to prevent posterior & rotational instability o Maximal stresses are anterior, at the insertion site of humeral component. After BG

incorporates, the thickened cortex will resist these forces


CCoommpplliiccaattiioonnss 1]. Instability; posterior elbow dislocation ~ 10% é unconstrained arthroplasty 2]. Ulnar nerve dislocation & injury 3]. proximal ulna fracture 4]. fracture of ulnar component 5]. impingement of the radial head 6]. hardware failure 7]. Loosening 8]. Wound dehiscence & triceps rupture 9]. Infection ......................................................... (1-10%)

All bushing need to be removed Staged removal debridement re-implantation of the

same components (unless staph epidermidis infection) Resection arthroplasty erradication of infection, but has

poor function

AArrtthhrrooddeessiiss PPoossiittiioonnss

1]. 100 ................................................................. Feeding 2]. 45 .................................................................... perineal hygiene

FFiixxaattiioonn Usually by compression plate

Documents

The Elbo · Ulnar nerve dislocation & injury 3]. proximal ulna fracture 4]. fracture of ulnar component 5]. impingement of the radial head 6]. hardware failure 7]. Loosening 8]. Wound