Elbow and forearm

Elbow and forearm

Sara D. Rynders

Anatomy

Bones: Figure 3-1

Figure 3-1. A, Anterior view of the elbow and forearm bony anatomy. B, Posterior view of the elbow and forearm bony anatomy. ECU, extensor carpi ulnaris. (From Chhabra AB: Elbow and forearm. In Miller MD, Chhabra AB, Hurwitz S, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, pp 63, 64.)

Ligaments: Figure 3-2

Figure 3-2. Ligaments of the elbow and forearm. Components of the elbow ligaments —ulnar collateral ligament: anterior band, posterior band, and transverse band; lateral collateral ligament: annular ligament, radial collateral ligament, accessory collateral ligament, and lateral ulnar collateral ligament. (From Chhabra AB: Elbow and forearm. In Miller MD, Chhabra AB, Hurwitz S, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, p 67.)

Muscles and tendons: Figure 3-3

Figure 3-3. A, Muscles and tendons of the anterior elbow and forearm: superficial and deep compartments. B, Muscles and tendons of the posterior elbow and forearm: superficial and deep compartments. (From Chhabra AB: Elbow and forearm. In Miller MD, Chhabra AB, Hurwitz S, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, pp 68, 69.)

Nerves and arteries: Figure 3-4 and table 3-1

Table 3-1.

Muscle Innervation and Testing

APB, abductor pollicis brevis; APL, abductor pollicis longus; DIP, distal interphalangeal; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU; extensor carpi ulnaris; EDM, extensor digiti minimi; EIP, extensor indicis proprius; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FPB, flexor pollicis brevis; FPL, flexor pollicis longus; IP interphalangeal.

Figure 3-4. A, Anterior view of the nerves of the elbow and forearm. B, Posterior view of the nerves of the elbow and forearm. C, Arteries of the elbow and forearm. APL, abductor pollicis longus; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; EIP, extensor indicis profundus; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FPL, flexor pollicis longus; PT, pronator teres. (From Chhabra AB: Elbow and forearm. In Miller MD, Chhabra AB, Hurwitz S, et al, editors: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders, pp 74, 75, 81.)

Surface anatomy: Figure 3-5

Figure 3-5. Surface anatomy of the anterior and posterior elbow and forearm. A, Anterior labels: a) antebrachial fossa, b) biceps tendon, c) common extensor tendons, d) common flexor tendons, e) medial epicondyle, f) lateral epicondyle. B, Posterior labels: a) medial epicondyle, b) lateral epicondyle, c) olecranon process, d) triceps tendon.

Normal radiographic appearance: Figures 3-6 and 3-7

Figure 3-6. Normal radiographs of the elbow. Anteroposterior (right) and lateral (left) views. (From Hart JA: Overview of the elbow. In Miller MD, Hart JA, MacKnight JM, editors: Essential orthopaedics, Philadelphia, 2010, Saunders, 2010, p 239.)

Figure 3-7. Normal radiographs of the forearm. Anteroposterior (left) and lateral (right) views.

Physical examination (table 3-2, 3-3, 3-4)

Inspect for edema, deformity, ecchymosis, biceps muscle.

Table 3-2.

Normal Elbow and Forearm Range of Motion

Extension	0 degrees
Flexion	135 degrees
Supination	90 degrees
Pronation	90 degrees

Table 3-3.

Neurovascular Examination

Table 3-4.

Differential Diagnosis of Elbow Pain

Medial-sided elbow pain	Medial epicondylitis Ulnar collateral ligament injury Arthritis Cubital tunnel syndrome
Lateral-sided elbow pain	Lateral epicondylitis Radial head fracture Lateral collateral ligament injury
Anterior elbow pain	Biceps tendinitis or biceps tendon rupture
Posterior elbow pain	Olecranon bursitis Triceps tendinitis
Forearm pain	Radial tunnel syndrome Muscle strain

• Medial epicondyle

• Ulnar nerve in cubital tunnel

• Lateral epicondyle

• Radial head

• Distal biceps tendon

• Brachial artery

• Common extensor muscles (also known as “mobile wad”)

• Olecranon and olecranon bursa

Lateral epicondylitis

Definition: tendinitis of the common extensor tendon origin, also known as tennis elbow

Lateral-sided elbow pain

Possible reported history of injury or repetitive trauma

Pain worse with lifting and gripping

Pain also possible at night when the elbow is moved from a resting position

Physical examination

Possible mild edema over lateral epicondyle

Point tenderness to palpation over lateral epicondyle

Pain with resisted wrist extension

Pain at the lateral epicondyle caused by grip strength testing with a dynamometer; pain worse when test performed with the elbow extended rather than flexed

Imaging: Figure 3-8

Figure 3-8. Magnetic resonance image of lateral epicondylitis. Edema and high-grade partial tearing of the common extensor tendon origin are visible (arrow).

Not always necessary for diagnosis; considered if history of injury

Elbow: anteroposterior (AP), lateral, oblique views

Diagnosis confirmed by magnetic resonance imaging (MRI)

Differential diagnosis

Lateral collateral ligament (LCL) sprain

Radial tunnel syndrome (compression of the posterior interosseous nerve [PIN] in the supinator)

Distal humerus fracture

Initial treatment

Patient education

Lateral epicondylitis is also known as tennis elbow and is a form of tendinitis. It is an inflammatory condition. Treatment revolves around decreasing the inflammation, using proper lifting techniques, and strengthening the musculature. Because the tendons that are inflamed are responsible for wrist extension, the pain is worse with grip and lifting.

First treatment steps

Patient education and activity modification are paramount to successful treatment.

Good results are reported in the literature after 12 months of conservative management.

Measures include avoidance of aggravating activities and repetitive lifting and gripping, correction of improper lifting or gripping techniques, a nonsteroidal antiinflammatory drug (NSAID) regimen if tolerated, possible use of transdermal anesthetic patches, heat and ice modalities with stretching, and occupational therapy referral.

Some advocate use of a wrist brace to limit wrist extension during activities.

Treatment options

Nonoperative management

Conservative management is reserved for patients with no previous treatment or whose previous treatment was successful but the problem recurred after several months or years.

In addition to initial treatments listed earlier, a cortisone injection may be performed (see p. 107 for lateral epicondyle injection).

Avoid multiple repeat injections over a short time because they can result in local tissue destruction and possible tendon or ligament rupture.

Advise the patient on a period of rest and activity modification after injection.

If referring patient to occupational therapy, the referral should include instructions to provide elbow stretching, gradual protected strengthening, counseling on lifting techniques, and use of local modalities for inflammation.

If the patient notes no improvement or diminishing improvement in symptoms with injections, consider an MRI scan to evaluate for any other causes of lateral elbow pain such as an LCL injury. Lateral epicondylitis may be described on an MRI as “high-grade partial tearing of the common extensor tendon origin.”

Interest in the use of platelet-rich plasma (PRP) injections is increasing, but no definitive data on its efficacy are available, and this treatment is still considered experimental.

Operative management

Codes

ICD-9 code: 726.32 Lateral epicondylitis

CPT code: 24359 Débridement of soft tissue and/or bone at lateral epicondyle

Operative indications

Conservative management for at least 1 year has failed.

Indications and techniques vary, and more studies are necessary for an evidence-based approach.

Informed consent and counseling

Surgical débridement has shown good results in the literature, but the risk of partial or no relief of symptoms is approximately 15%.

The surgical procedure is not likely to be successful if the patient fails to modify activities or cease repetitive trauma postoperatively.

The patient will require a 2- to 3-month recovery period with monitored progressive occupational therapy.

Anesthesia

Regional block with sedation, or general anesthesia

Patient positioning

Supine with the arm on an arm board, with the shoulder internally rotated and the elbow flexed

Nonsterile tourniquet high on the brachium

Surgical procedures

Lateral approach for tendon débridement

Arthroscopy with débridement

Lateral epicondyle débridement

An oblique incision is made just anterior to the lateral epicondyle and common extensor tendon origin. Care is taken to avoid injury to the lateral antebrachial cutaneous nerve.

The lateral epicondyle is identified, and a split is made in the common extensor tendon origin parallel to the fibers. The tissue is divided in layers until the underlying joint capsule is identified.

A rongeur or curette is used to débride the dysvascular tissue and to stimulate bleeding. Avoid injury to the underlying LCL. Sometimes, a Kirschner wire (K-wire) is used to puncture the lateral epicondyle several times and stimulate bleeding at the origin of the tendon.

Once débridement has concluded, the common extensor tendon is repaired in layers using a suture. The fascia is also closed followed by the subcutaneous tissues and the skin. Most surgeons immobilize the patient in a long-arm posterior splint for 10 to 14 days.

Estimated postoperative course

Postoperative days 10 to 14

• Perform a wound check and suture removal.

• Therapy: Start therapy for gentle elbow ROM. The patient should avoid lifting with the operative extremity.

Postoperative 6 weeks

• Perform a motion check. Evaluate and document whether the patient has tenderness to palpation at the lateral epicondyle.

• Therapy: Start a graduated strengthening program.

Postoperative 3 months

• Perform a motion and strength check. Evaluate and document whether the patient has tenderness at the lateral epicondyle, and test for pain with resisted wrist extension.

• If the patient is asymptomatic, release him or her to regular activities.

Suggested readings

Buchbinder R, Johnston RV, Barnsley L, et al: Surgery for lateral elbow pain, Cochrane DataBase Syst Rev 16(3):CD003525, 2011.

Dorf ER, Chhabra AB, Golish SR, et al: Effect of elbow position on grip strength in the evaluation of lateral epicondylitis, J Hand Surg Am 32:882–886, 2007.

Faro F, Wolf JM: Lateral epicondylitis: review and current concepts, J Hand Surg Am 32:1271–1279, 2007.

Hall MP, Band PA, Meislin RJ, et al: Platelet-rich plasma: current concepts and application in sports medicine, J Am Acad Orthop Surg 17:602–608, 2009.

Jobe FW, Ciccotti MG: Lateral and medial epicondylitis of the elbow, J Am Acad Orthop Surg 2: 1–8, 1994.

Nirschl RP, Ashman ES: Elbow tendinopathy: tennis elbow, Clin Sports Med 22:813–836, 2003.

Medial epicondylitis

Definition: tendinitis of the common flexor tendon origin, also known as golfer’s elbow

Medial-sided elbow pain

Possible reported history of injury or repetitive trauma

Possible patient-reported associated paresthesias in the fourth and fifth fingers (possible simultaneous cubital tunnel syndrome resulting from inflammation)

Physical examination

Possible mild edema over medial epicondyle

Point tenderness to palpation over medial epicondyle

Pain with resisted wrist flexion

Elbow stable to stress testing of the ulnar collateral ligament (UCL)

Evaluation of the ulnar nerve at the cubital tunnel for subluxation or neuritis (see p. 84 for cubital tunnel syndrome)

Imaging: Figure 3-9

Figure 3-9. Magnetic resonance image of medial epicondylitis. Edema and high-grade partial tearing of the common flexor tendon origin are visible (arrow).

Not necessary for diagnosis but possibly warranted if history of recent trauma or examiner suspects arthritis

Elbow AP, lateral, and oblique views

MRI of the elbow can aid in diagnosis and evaluation for other causes of medial-sided elbow pain

Differential diagnosis

Cubital tunnel syndrome

Distal humerus fracture

Initial treatment

Patient education

Medial epicondylitis is also known as golfer’s elbow and is a form of tendinitis. It is an inflammatory condition, and treatment revolves around decreasing the inflammation and strengthening the musculature. Because the tendons that are inflamed are responsible for wrist flexion and pronation, the pain is occasionally worse with gripping, lifting, and twisting.

First treatment steps

Patient education and activity modification are paramount to successful treatment.

Measures include avoidance of aggravating activities and repetitive activities, correction of improper techniques, NSAID regimen if tolerated, heat and ice modalities with stretching, and occupational therapy referral.

Some advocate use of a wrist brace to limit wrist flexion during activities.

If fourth and fifth finger paresthesias are present, consider obtaining an electromyography and nerve conduction study (EMG/NCS) to evaluate for concomitant cubital tunnel syndrome.

Treatment options

Nonoperative management

Conservative management is reserved for patients with no previous treatment or whose previous treatment was successful but the problem recurred after several months or years.

In addition to initial treatments listed earlier, a cortisone injection may be performed (see p. 108 for medial epicondyle injection).

Avoid multiple repeat injections over a short time because this can result in local tissue destruction and possible tendon or ligament rupture.

A relative contraindication to injection is a subluxating ulnar nerve.

Advise the patient on a period of rest and activity modification after injection.

If referring the patient to occupational therapy, the referral should include instructions to provide elbow stretching, gradual protected flexor-pronator strengthening, and use of local modalities for inflammation.

If the patient notes no improvement or diminishing improvement in symptoms with injections, consider an MRI scan to evaluate for any other causes of medial elbow pain such as a UCL injury.

Operative management

Codes

ICD-9 code: 726.31 Medial epicondylitis

CPT code: 24359 Débridement of soft tissue and/or bone at medial epicondyle

Operative indications

Conservative management for at least 1 year has failed.

Indications and techniques vary, and more studies are necessary for an evidence-based approach.

Informed consent and counseling

The surgical procedure is not likely to be successful if the patient fails to modify activities or cease repetitive trauma postoperatively.

The patient will require a 2- to 3-month recovery period with monitored progressive occupational therapy.

Anesthesia

Regional block with sedation, or general anesthesia

Patient positioning

Supine with the arm on an arm board, with the shoulder externally rotated and the elbow flexed

Nonsterile tourniquet placed high on the brachium

Surgical procedures

The medial approach is used for tendon débridement.

If cubital tunnel syndrome is present, an ulnar nerve transposition can be performed simultaneously with this procedure (see p. 84 for cubital tunnel syndrome).

Medial epicondyle débridement

An oblique incision is made just anterior to the medial epicondyle. Care is taken to avoid injury to the medial antebrachial cutaneous nerve and ulnar nerve in the cubital tunnel.

The medial epicondyle is identified, and a split is made in the common flexor tendon origin parallel to the fibers. The tissue is divided in layers until the underlying joint capsule is identified.

A rongeur or curette is used to débride the dysvascular tissue and to stimulate bleeding. Avoid injury to the underlying UCL. Sometimes, a K-wire is used to puncture the medial epicondyle several times to stimulate bleeding at the origin of the tendon .

The common flexor tendon is then repaired in layers using a suture. The fascia is also closed followed by the subcutaneous tissues and the skin. Most surgeons immobilize the patient in a long-arm posterior splint for 10 to 14 days.

Estimated postoperative course

Postoperative days 10 to 14

• Perform a wound check and suture removal.

• Therapy: Start gentle elbow ROM. The patient is to avoid lifting with the operative extremity.

Postoperative 6 weeks

• Perform a motion check. Evaluate and document whether the patient has tenderness to palpation at the medial epicondyle.

• Therapy: Start a graduated strengthening program.

Postoperative 3 months

• Perform a motion and strength check. Evaluate and document whether the patient has tenderness to palpation at the medial epicondyle, and test for pain with resisted wrist flexion.

• If the patient is asymptomatic, release him or her to regular activities.

Suggested readings

Ciccotti MG, Ramani MN: Medial epicondylitis, Tech Hand Up Extrem Surg 7:190–196, 2003.

Jobe FW, Ciccotti MG: Lateral and medial epicondylitis of the elbow, J Am Acad Orthop Surg 2:18, 1994.

Mierisch C: Golfer’s elbow (medial epicondylitis). In Miller MD, Hart JA, MacKnight JM, editors: Essential orthopaedics, Philadelphia, 2010, Saunders, pp 247–248.

Cubital tunnel syndrome

Definition: Ulnar nerve compression at the elbow

Medial-sided elbow pain

Numbness and tingling in the fourth and fifth fingers

Achy pain radiating down the ulnar side of the forearm to the wrist and hand

Worse when the elbow is flexed or while leaning on the elbow; possibly while sleeping

Hand weakness (late finding)

Physical examination

Tenderness over the ulnar nerve at the cubital tunnel

Positive Tinel sign over the ulnar nerve at the cubital tunnel, with symptoms radiating to the fourth and fifth fingers

Placement of the elbow into flexion and palpation for subluxation of the ulnar nerve over the medial epicondyle

Altered or decreased sensation to touch (or two-point discrimination) of the ulnar border of the fourth finger and the entire fifth finger

Inspection for intrinsic muscle atrophy in the hand, or claw deformity (late finding)

Wartenburg test: Figure 3-10

Figure 3-10. Wartenburg test.

This test evaluates for weakness of the adductor digiti minimi, which is the earliest sign of muscle weakness.

Ask the patient to adduct all fingers together.

A positive test result is when the fifth finger remains in an abducted position.

Froment sign: Figure 3-11

Figure 3-11. Froment sign.

This test evaluates for weakness of the adductor pollicis muscle caused by ulnar nerve injury.

Ask the patient to hold a piece of paper between the thumb and index finger while the fingers are extended. The examiner then tries to remove paper from the patient’s grip.

A positive sign is when the patient flexes the thumb interphalangeal joint and thereby activates the flexor pollicis longus (a median nerve innervated muscle) to hold the paper, instead of using the adductor pollicis.

Imaging

Not necessary for diagnosis; considered only if symptoms are trauma-related

Additional tests

Electromyography and nerve conduction study

EMG/NCS can identify ulnar nerve compression at the cubital tunnel and can determine severity of compression. Ask the electromyographer to evaluate for the differential diagnosis, which includes carpal tunnel syndrome, cervical radiculopathy, and peripheral neuropathy. Sometimes an “inching study” is performed across the elbow to identify an area of compression.

Differential diagnosis

Medial epicondylitis

Cervical radiculopathy

Ulnar tunnel syndrome: compression of the ulnar nerve at the hand

Carpal tunnel syndrome

Initial treatment

Patient education

Cubital tunnel syndrome is compression of the ulnar nerve or “funny bone” as it crosses behind the elbow. If left untreated, this condition can result in permanent loss of sensation to the fourth and fifth fingers and permanent weakness of the hand with a claw deformity. Sometimes, simply avoiding flexing the elbow and leaning on the elbow can eliminate the problem.

First treatment steps

Provide the patient with education about how to avoid leaning on the elbow and flexing it for long periods of time.

Discuss activity modifications.

Suggest that the patient obtain an elbow pad to protect the nerve and possibly refer the patient to an occupational therapist to have a night-time splint made. Wrapping a towel around the elbow at night can also work to prevent flexion and protect the nerve from compression.

Treatment options

Nonoperative management

Conservative management is reserved for patients with no evidence of muscle wasting on EMG/NCS or physical examination and for those without any previous treatment.

Patient education is key. Discuss in detail how the patient should avoid leaning on the elbow and flexing the elbow repetitively or for long periods of time. Discuss sleep posture.

NSAIDs can help with pain.

Attempt nonoperative management for at least 6 weeks.

Rehabilitation

Refer the patient to an occupational therapist for ulnar nerve gliding exercises, night splinting with the elbow in 45 degrees of flexion, and discussion of activity modifications.

Operative management

Codes

ICD-9 code: 354.2 Lesion of ulnar nerve

CPT code: 64718 Ulnar nerve neuroplasty and/or transposition at elbow

Operative indications

Nonoperative management has failed.

Patient has evidence of severe ulnar nerve compression and/or muscle denervation on EMG/NCS.

Surgical treatment may be appropriate for patients with evidence of intrinsic wasting on physical examination, to prevent further progression.

Informed consent and counseling

Care will be taken to avoid injury to the cutaneous nerves at the elbow, but some residual numbness occasionally occurs near the incision site at the elbow.

The purpose of the surgical procedure is to relieve the sites of compression, and the goal is to prevent progression of nerve damage; if the patient has advanced disease, the operation may not restore normal sensation to the fingers, and strength may never return.

The patient can expect to have limited use of the arm for about 6 to 8 weeks.

Anesthesia

Regional upper extremity block, with sedation or general anesthesia

Patient positioning

Supine, with the shoulder abducted and externally rotated and the arm on the hand table

Nonsterile tourniquet high on the brachium

Surgical procedures

Medial approach over the ulnar nerve at the elbow

Ulnar nerve decompression or decompression and transposition of the ulnar nerve

Nerve transposed subcutaneously (best reserved for those with adequate subcutaneous fat) or submuscularly

Endoscopic ulnar nerve decompression gaining popularity

Ulnar nerve transposition (subcutaneous or submuscular): Figure 3-12

Figure 3-12. Intraoperative photograph of a transposed ulnar nerve. The nerve now lies anterior to the medial epicondyle and is held in place by lengthened flexor-pronator fascia.

Instruments: Vessel loops are used to hold the nerve gently during dissection.

A longitudinal incision is made over the medial elbow. Take care to identify and protect the medial antebrachial cutaneous nerve. Elevate the subcutaneous flaps off the fascia overlying the flexor-pronator mass. Identify the medial epicondyle. Just posteriorly, identify the ulnar nerve within the cubital tunnel. With tenotomy scissors and smooth forceps, the ulnar nerve is carefully decompressed. Minimal traction and manipulation of the nerve are ideal, and a vessel loop can be used to retract and control the nerve gently while operating.

All sites of ulnar nerve compression at the elbow are addressed: arcade of Struthers, medial intramuscular septum of the triceps, Osborne ligament, the flexor carpi ulnaris (FCU) fascia, and the heads of the FCU.

If transposing subcutaneously, a sling is created within the medial subcutaneous flap. The nerve is transposed, and then a suture is used to tack the subcutaneous tissue back down to the flexor pronator fascia, thus securing the nerve anterior to the medial epicondyle.

If transposing submuscularly, the flexor-pronator fascia may be lengthened using a steplike incision. A trough may also be created in the musculature and the nerve transposed anterior to the medial epicondyle. The fascia is then sutured back together over the nerve but in a lengthened position.

Once the nerve has been transposed, the elbow is placed through ROM to ensure that the nerve no longer subluxes with flexion, has no areas of compression, and is not under tension. The wound is then irrigated and the skin closed. A Jackson-Pratt (JP) drain or similar drain may be placed into the wound to be removed before discharge home or on postoperative day 1. Most surgeons place the patient in a postoperative long-arm posterior splint with the elbow at 90 degrees and the forearm in neutral.

Estimated postoperative course

Postoperative days 3 to 5

• Some clinicians advocate for an early therapy session for gentle elbow ROM and edema control to prevent stiffness. A removable thermoplastic long-arm posterior splint may be fabricated to support the arm between therapy sessions.

Postoperative days 10 to 14

• Sutures are removed, and ROM is assessed.

• Inquire about and document changes in preoperative paresthesias.

• Check and document Froment and Wartenburg signs.

Postoperative 6 weeks

• Reassess ROM.

• Perform a wound check, and evaluate for hypersensitivity.

• Inquire about and document changes in preoperative paresthesias.

• Check and document Froment and Wartenburg signs.

• The patient can start strengthening exercises between 6 and 8 weeks and gradually return to everyday activities without restrictions.

Suggested readings

Cobb TK: Endoscopic cubital tunnel release, J Hand Surg 35:1690–1697, 2010.

Palmer BA, Hughes TB: Cubital tunnel syndrome, J Hand Surg Am 35:153–163, 2010.

Szabo RM, Kwak C: Natural history and conservative management of cubital tunnel syndrome, Hand Clin 23:311–318, 2007.

Zlowodzki M, Chan S, Bhandari M, et al: Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome: a meta-analysis of randomized, controlled trials, J Bone Joint Surg Am 89: 2591–2598, 2007.

Olecranon bursitis

Definition: inflammation or infection of the olecranon bursa

Possible history of elbow trauma, repetitive activity, or abrasion

Patient-reported edema and sometimes pain over the posterior elbow

Possible erythema and warmth

Possible pain with ROM

Physical examination

Evaluation of the posterior elbow reveals an inflamed olecranon bursa.

Note the presence of any erythema and whether it is localized to the bursa or extends to the surrounding tissues in a cellulitic pattern.

Palpation of the bursa reveals bogginess and mild tenderness. Severe tenderness could indicate infection.

Evaluate ROM and assess whether it is painful. Painful ROM could suggest deeper joint infection.

Imaging

This is generally not necessary for diagnosis and is indicated only to evaluate for any underlying elbow joint injury or if a septic joint is suspected. Elbow, AP, and lateral views are used.

Classification system: Inflammatory versus infectious

Sometimes the difference can be subtle.

Infectious olecranon bursitis generally appears as beefy red, taut skin and looks very aggressive. It is generally more painful with palpation and ROM and is more likely to have associated surrounding cellulitis.

Inflammatory olecranon bursitis generally has localized erythema, and edema is isolated to the bursa itself. Usually, this type of bursitis is less tender to palpation.

Both conditions can have warmth.

Differential diagnosis

Rheumatoid nodules

Elbow joint effusion

Gouty arthritis or gouty tophi

Pigmented villonodular synovitis

Initial treatment

Patient education

Olecranon bursitis is a condition of inflammation or infection of the olecranon bursa. It can occur from repetitive leaning on the elbow or from mild trauma. The bursa can be filled with sterile serous fluid or infection. Recurrences are possible and may require repeat aspiration, but nonoperative treatment is successful most of the time. If the bursitis is mild and clinically deemed to be aseptic, avoid aspiration, to reduce the risk of iatrogenic infection.

First treatment steps

Determine whether bursitis is inflammatory or infectious.

This distinction may be made by physical examination and history, or an aspirate may be necessary to identify a pathogen.

If possible, avoid aspiration and treat conservatively.

Treatment options

Nonoperative management

For mild inflammatory bursitis: Suggest ice, NSAIDs, an elbow pad or elastic (Ace) wrap for compression, and avoidance of leaning on the elbow. These treatments may take several weeks to be successful.

For symptomatic inflammatory bursitis:

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Tags: Orthopaedics for Physician Assistants

Jun 7, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

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