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15 Cards in this Set

  • Front
  • Back
Lateral epicondylitis Causes and diagnosis
(tennis elbow)

Commonly occurs with activities that involve repetitive pronation and supination of the forearm with the elbow in near extension (backhand in tennis). The injury is initiated as a microtear at the origin of the extensor carpi radialis brevis (ECRB) but may also involve the origin of the extensor carpi radialis longus (ECRL) and extensor carpi ulnaris (ECU). Microscopic evaluation of this tissue shows angiofibroblastic hyperplasia. Diagnosis is clinical, with reproducible, localized tenderness at the extensor origin and reproduction of symptoms with resisted wrist extension.
Treatment of Causes and diagnosis
Treatment is predominantly nonoperative, with activity modification (slower playing surfaces, more flexible racquet, lower string tension, larger grip), physical therapy (stretching, ultrasound), anti-inflammatory medications, counterforce bracing, and up to three corticosteroid injections at the site of maximum tenderness, all achieving up to 95% success. Recalcitrant cases require open or arthroscopic d?bridement of the ECRB origin (Fig. 4–49). Excessive resection can jeopardize the LCL and should be avoided
Medial epicondylitis
(golfer's elbow)—This condition is classified as an overuse syndrome of the flexor/pronator mass. It is much less common and more difficult to treat than tennis elbow. Resisted forearm pronation and wrist flexion worsen the pain. Treatment is similar to that for lateral epicondylitis. Multiple corticosteroid injections and medial epicondylectomy should be avoided.
Distal biceps tendon rupture
Occurs almost exclusively in men after forceful, eccentric overload of the partially flexed elbow. Up to 50% loss of supination power has been documented after rupture.

Intraosseous tendon reattachment with the two-incision (Boyd-Anderson) technique has been traditionally favored.

A one-incision technique is coming back into favor with some by using a single-incision repair with an endobutton, suture anchors, or an interference screw. In a cadaveric model, the endobutton had the greatest load to failure when compared with the standard suture technique, suture anchors, and interference screw fixation. Cyclic loading did not show any statistically significant differences in gap formation among the fixation techniques. Care must be taken not to disrupt the syndesmosis. Complications include neurovascular injury, loss of motion, and heterotopic ossification.
Distal triceps tendon avulsion
—This extremely uncommon injury results from a deceleration force to the outstretched elbow and is associated with multiple corticosteroid injections or chronic olecranon bursitis. Repair with transosseous tunnels is mandatory for the restoration of extension power.
Ulnar collateral ligament (UCL) injury - Causes and diagnosis
—Repetitive, high-velocity valgus stress to the medial aspect of the elbow results in attenuation or rupture of the anterior band of the UCL. The late-cocking and acceleration phases of throwing are periods of high stress generation. Patients present with acute or chronic medial elbow tenderness and (frequently) associated ulnar nerve symptoms. The pain is localized to the course of the ligament from the medial epicondyle to the sublime tubercle. Valgus instability is demonstrable in only 50% of patients because it is usually a dynamic phenomenon (Fig. 4–50). The “moving valgus stress test” of O'Driscoll has been shown to have a high sensitivity and specificity in detecting UCL injury. An MR arthrogram is useful for confirmation of the diagnosis.
Ulnar collateral ligament (UCL) injury - Treatment
—Initial treatment is with rest, physical therapy, and maintenance of joint motion. Surgery is required only in high-level athletes who desire a return to sports. Ligament reconstruction is favored over direct repair, and treatment of chronic injuries has demonstrated better results than those of acute injuries. The ligament is reconstructed with a palmaris tendon graft woven in a figure-eight fashion (Tommy John procedure) (Fig. 4–51). Nearly 75-80% of patients return to sports at the same or better level 1 year after reconstruction. Complications include loss of motion, graft site morbidity, and neurologic injury.
LCL injury
—Typically the first ligament disrupted in elbow dislocation. Patients with LCL insufficiency may complain of clicking or locking with elbow extension and often demonstrate posterolateral rotatory instability (Fig. 4–52). Surgical reconstruction with a palmaris longus autograft and capsular plication is indicated for patients with recurrent instability, pain, or mechanical symptoms
Osteochondritis dissecans of the elbow
Typically occurs in the capitellum of the adolescent athlete engaged in repetitive overhead or upper extremity weight-bearing activities. The cause is thought to be related to vascular insufficiency and repetitive microtrauma. Plain radiographs and improvement with activity modification confirm the diagnosis. If the fragment is stable, this condition can be treated with activity modification and supportive methods. Separated fragments may be arthroscopically reduced and stabilized or excised and the defects drilled. Osteochondrosis of the capitellum is seen in younger patients (Panner's disease) and is associated with a more benign course.
Little Leaguer's elbow
—This condition is defined as a stress fracture of the medial epicondyle in adolescents due to repetitive valgus loading with throwing. Rest and limitation of the number of innings pitched per week help to reduce the incidence of complete fracture
Pitcher's elbow
—Involves medial tension, lateral compression, and posterior extension overload. Adaptive changes common to this condition include increased valgus, pronator mass hypertrophy, and loss of extension. Radiographic changes include posteromedial olecranon osteophytes and chondromalacia of the medial wall of the olecranon fossa.
Primary elbow osteoarthritis
—Primary elbow osteoarthritis disproportionately affects football linemen, participants in racquet sports, and throwers. These patients present with a decreased arc of motion and pain at the extremes of motion. Plain radiographs demonstrating joint space narrowing and osteophytic spurring confirm the diagnosis. Surgical treatment consists of arthroscopic d?bridement, soft tissue release, and loose-body removal. Persistent symptoms are treated with distraction/interposition arthroplasty, ulnohumeral arthroplasty, or total elbow arthroplasty.
Elbow Stiffness
The loss of motion and function results from capsular contracture; olecranon, coronoid, and radial fossa overgrowth; or heterotopic ossification about the elbow after a single acute injury or because of degenerative disease. Treatment involves open surgical d?bridement by means of a collateral ligament–sparing approach (Hastings-Cohen), olecranon fossa fenestration and d?bridement (Outerbridge-Kashiwagi procedure) (Fig. 4–54), or arthroscopic osteocapsular arthroplasty with resection of bone osteophytes and resection of the capsule. Success is largely dependent on a motivated patient. Loss of terminal extension is common after elbow dislocation and is usually managed with simple observation.
Portals for elbow arthroscopy
1. Anterolateral portal—Placed after joint distention 1 cm distal and 1 cm anterior to the lateral epicondyle. The lateral antebrachial cutaneous and radial nerves are at risk.
2. Anteromedial portal—Placed under direct visualization 2 cm distal and 2 cm anterior to the medial epicondyle. The medial antebrachial cutaneous and median nerves are at risk.
3. Posterolateral portal—Placed 2 cm proximal to the olecranon and just lateral to the triceps tendon.
Elbow Arthroscopy (indications and complications)
A. Indications—This procedure is typically indicated for diagnostic confirmation of suspected elbow pathology; removal of loose bodies; treatment of osteochondritis dissecans of the capitellum; osteophyte d?bridement (as seen with chronic valgus overload in pitchers); capsular release and d?bridement of the olecranon, radial, and coronoid fossa in the stiff elbow; and synovectomy. Successful arthroscopic intervention depends on technical expertise in elbow arthroscopy and thorough anatomic familiarity because vital neurovascular structures are proximal to the intra-articular space and are thus prone to injury, particularly with overexuberant d?bridement.
B. Risks—The “nick and spread” method of portal placement is used to minimize inadvertent neurovascular injury. The use of far-proximal portals may decre