Most elbow injuries are the result of overuse activities involved in upper limb sports.

Osteochondritis Dissecans

The aetiology is a combination of vascular and micro traumatic factors seen in throwing type sports or gymnastics. There may have been a valgus or hyperextension load applied to the arm

There is an insidious onset of vague elbow pain; in the adolescent, locking or catching may also occur; in the adult arthritic symptoms x-rays may show diffuse fragmentation of the distal humeral epiphysis (Panner's Disease) or an osteochondral fragment (Fig. 45). In the older or arthritic changes.

In the young patient with diffuse epiphyseal fragmentation (Panner's Disease), rest and activity modification. Mechanical symptoms related to loose bodies may require drilling and fixation or removal. Arthritis in later years is treated with activity modification, NSAID’s and surgery.

Mechanism of injury

Medial epicondyle avulsion or any number of conditions causing medial sided elbow pain. A valgus force and resistance load on the flexor muscles occurring during throwing are the main cause.

There is medial sided elbow pain and tenderness with pain on loading the flexor muscles (Fig. 6). X-rays may show a separation of the medial epiphysis from the distal humerus (Fig. 47).

Rest and activity modification and rarely surgery.

Mechanism of injury

A lateral epicondylitis from repetitive use of the arm especially with a clenched fist. Most cases are not due to tennis.

Local tenderness and pain with resisted and passive extension of the wrists.

Rest, activity modification and NSAID’s and physiotherapy will relieve most cases. Changing the grip size of the tennis racquet should be considered (Fig. 48). Only in refractory cases surgery.

Patients are involved with racquet or club swinging and may jar their elbow or simply overuse the arm.

Medial elbow pain with local tenderness and pain on loading the flexor muscles.

Rest, activity modification, NSAID’s and physiotherapy, only rarely surgery.

Valgus stress on the elbow occurs with a throw. There may be a single throw or after repetitive throwing or occasionally a fall.

In the acute case there is local swelling and pain over the medial side or transient paraesthesia of the ulna nerve. Valgus stress testing with the arm at 30° of flexion shows increased laxity and pain (Figs 49). X-rays may show loose osseous bodies (Fig. 50).

Rest, activity modification, NSAID’s and physiotherapy or later surgery.

Mechanism of injury

Usually a fall onto the outstretched hand or direct trauma.

With elbow dislocation there may be associated neurological (usually a neuropraxia) and/or vascular injury (Fig. 52). X-rays may show an obvious fracture or dislocation (Fig. 51) however with small or difficult to see fractures the only clue may be the Fat Pad Sign.

Reduction is a surgical emergency. Extra-articular fractures need reduction; intra-articular fractures need precise anatomic reduction.

Mechanism of injury

Most often these arise as a consequence of old trauma, degenerative arthritis or osteochondritis dissecans (Fig. 53).

Pain and locking are the predominant features.

The symptoms of locking are treated by removal of the loose bodies and treat underlying condition.

of injury

Most often occurs in throwing athletes from the excessive valgus load on the elbow during the cocking phase of throwing and rarely direct trauma. Previous trauma with resultant cubitus valgus predisposes the elbow to ulnar nerve problems

Tingling and numbness in the distribution of the ulnar nerve (Fig. 55). This may occur during or after throwing a ball or with prolonged elbow flexion.

Correction of throwing style associated with forearm strengthening is recommended. If the problem persists or there is weakness and wasting then surgery.

Mechanism of injury

Causes include trauma (both major and repetitive micro), osteochondritis dissecans and associated synovial disease such as chondrometaplasia.

Pain, stiffness and locking. X-rays demonstrate osteophytes and loss of joint space (Fig. 56).

Rest, physiotherapy, NSAID’s with modification of activity and later surgery.

Mechanism of injury

Occurs with a sudden extension force while contracting the biceps. Pain and weakness result. Surgically repair.

Sudden onset of pain with swelling in the forearm. Weakness of flexion is evident. X-rays are often normal.

In most cases surgical repair is indicated.

Distal triceps rupture

Sudden forced extension while the elbow is being flexed (Fig.57). In most cases surgical repair is indicated.

Nerve compression syndromes (cubital tunnel, pronator syndrome, posterior inter osseous, anterior inter osseous)

Occasionally there is a fracture around the elbow. In many cases no major trauma has occurred and the condition is of gradual onset. (Localised ganglia or enlarged bursae about the joint.)

Localised sensory or motor changes. Do careful clinical examination to detect partial changes (e.g. with anterior interosseous nerve injury there is loss of deep flexors and small muscles of the hand without loss of flexor superficialis and wrist flexors). Loss of 'OK' sign. X-ray and nerve conduction studies are indicated (Fig. 58).

Early diagnosis is important. Many nerve injuries are neuropraxias and will resolve. If the nerve conduction study shows compression then exploration is indicated.