Elbow Arthritis

Abstract

Arthritis of the elbow refers to a loss of articular cartilage in the ulnotrochlear and radiocapitellar articulations and may also include excess bone formation in the form of osteophytes. These changes may result from inflammatory disease or from overuse or traumatic injury. Arthritis of the elbow typically causes joint pain and restricted range of motion. It is treated according to the severity and underlying cause. The spectrum of treatment includes rest, medications to decrease pain, rehabilitation, injections, and ultimately surgical interventions to improve pain and motion. Medications and injections may reduce inflammation and pain, and disease-modifying antirheumatic drugs may even retard the progression and symptoms of inflammatory elbow arthritis. Rehabilitation focuses on exercise to correct biomechanical imbalances and optimize upper extremity motion, injections to decrease inflammation and pain, and ultimately surgical interventions to improve pain and motion.

Keywords

Elbow arthritis, humeroulnar arthritis, post-traumatic arthritis, radiocapitellar arthritis, rheumatoid arthritis

Synonyms
Rheumatoid elbow Primary degenerative arthritis Osteoarthritis of the elbow Post-traumatic arthritis
ICD-10 Codes
M06.821	Rheumatoid arthritis, right elbow
M06.822	Rheumatoid arthritis, left elbow
M06.829	Rheumatoid arthritis, unspecified elbow
M19.021	Primary osteoarthritis, right elbow
M19.022	Primary osteoarthritis, left elbow
M19.029	Primary osteoarthritis, unspecified elbow
M19.221	Secondary osteoarthritis, right elbow
M19.222	Secondary osteoarthritis, left elbow
M19.229	Secondary osteoarthritis, unspecified elbow
M12.521	Traumatic arthropathy, right elbow
M12.522	Traumatic arthropathy, left elbow
M12.529	Traumatic arthropathy, unspecified elbow

Definition

In the simplest of terms, arthritis of the elbow reflects a loss of articular cartilage in the ulnotrochlear and radiocapitellar articulations. Arthritic changes include loss of cartilage and underlying subchondral bone as well as excess bone formation in the form of osteophytes. These changes may result from inflammatory or traumatic disruption of bony architecture, capsule, and ligaments. The spectrum of disease ranges from intermittent pain and mild restriction of motion with minimal changes detectable on radiographs to more advanced stages of arthritis with a limited, painful arc of motion and radiographic demonstration of osteophyte formation, cysts, and loss of joint space. Ultimately these destructive processes may result in complete ankylosis or total instability of the elbow.

Inflammatory Arthritis

Inflammatory arthropathies, most commonly rheumatoid arthritis (RA), are the major causes of elbow arthritis. RA is characterized by morning stiffness, symmetric polyarticular involvement (in which the elbow is included), arthritis of hand joints, synovitis and pannus formation, nodule formation, and radiographic changes. These include articular narrowing, periarticular osteoporosis, and progressive joint destruction. Arthritis of the elbow eventually develops in approximately 20% to 50% of patients with RA. Initially the patient with RA of the elbow may have only marked synovitis contributing to pain and restricted range of motion, which may improve spontaneously or with disease-modifying treatment. Synovitis can cause distension of the joint, destruction of the annular ligament, and instability of the radial head. Prolonged synovitis is associated with erosion of the articular cartilage, subchondral cyst, and osteophyte formation. This can damage the medial or lateral collateral ligamentous complexes and ultimately weaken the joint capsule and ligamentous supports, resulting in instability.

Other inflammatory conditions affecting the elbow joint are the seronegative spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and enteropathic arthritis), systemic lupus erythematosus, crystalline arthritis (gout and pseudogout), hemophilic arthritis, and even tuberculous arthritis, each of which has distinguishing features.

Osteoarthritis

Osteoarthritis (OA) is a noninflammatory arthropathy characterized by loss of joint space, development of osteophytes resulting in loss of motion. Initial pain and motion loss typically affects terminal flexion and extension but may also affect pronation and supination. This is related to osteophytes of the coronoid and olecranon and their respective fossae. Primary OA of the elbow is uncommon, responsible for less than 5% of elbow arthritis, and linked to repetitive strenuous arm use. Primary elbow arthritis usually affects the dominant arm of men in their 50s and has been reported in heavy laborers as well as weight lifters and throwing athletes. Post-traumatic arthritis is far more common than primary OA and may result from any trauma to the elbow. This includes intra-articular fractures of the elbow, most commonly the distal humerus or radial head. Studies have found a high incidence of arthritis, up to 80%, after internal fixation of distal humeral fractures. Similarly, after radial head fracture, the incidence of elbow arthritis is as high as 76% when managed conservatively and 88% to 100% when managed surgically with radial head resection. Fractures of the proximal ulna and fracture dislocations have also been associated with the later development of elbow OA.

Atraumatic OA has been identified in the capitellum, epicondyles, trochlea, and radial head in patients receiving corticosteroid therapy. This can ultimately lead to joint destruction and is often attributed to osteochondrosis, osteonecrosis, and synovial chondromatosis. In the pediatric population, Panner disease is an osteochondrosis of the capitellum of the elbow that causes pain and stiffness in the affected elbow. It may resemble osteonecrosis but has a much better prognosis. Synovial chondromatosis is another rare cause of elbow arthritis.

Symptoms

As many causes of elbow arthritis are not limited to the elbow joint itself, a thorough history is essential in helping to identify the underlying disease process. Regardless of etiology, the most common complaint associated with elbow arthritis is pain with motion and loss of end-range extension. The severity and characteristics of the pain, presence of stiffness, restriction or pain with motion, mechanical catching, and instability should be clarified. It is crucial to localize the specific affected region of the elbow joint and to distinguish pain at end range or throughout the entire range. Pain throughout the arc of motion implies advanced arthritis. The final stages of arthritis, irrespective of cause, can include severe pain and decreased motion, hindering activities of daily living apart from the cosmetic deformity of a flexed elbow posture.

Certain elements in the patient’s history can raise suspicion of specific etiologies including inflammatory arthropathy, post-traumatic arthropathy, primary osteoarthropathy, or septic arthritis. A thorough history should include other organ systems that mostly affect systemic inflammatory diseases such as those causing skin, vision, or genitourinary symptoms. Patients with inflammatory arthritis of the elbow, as in RA, complain of a swollen, painful joint with morning stiffness. Progressive loss of motion or development of joint instability is seen in later stages. Severe pain, swelling, warmth, and limited motion may represent crystalline arthritis of the elbow, but an expedient evaluation to rule out septic arthritis is warranted in such cases. Pain at night or at rest is concerning for an underlying infectious process and should be evaluated carefully.

In contrast, post-traumatic or primary OA of the elbow features painful loss of motion but without the significant effusions, warmth, or constant pain associated with synovial inflammation. These patients usually complain of pain at the terminal flexion or extension secondary to osteophyte impingement.

A history of occupational activities (such as manual labor) and sports activities that increase demands on the elbow can influence the risk of progression. Previous surgical procedures and any complications should be noted, as well as nonoperative treatments including corticosteroid injection, as intra-articular steroid injections introduce the risk of iatrogenic infection and may cause chondrocyte damage.

Patients may also describe neuropathic symptoms related to elbow arthritis. Symptoms of ulnar neuropathy (at the ulnar groove or cubital tunnel) include numbness in the fourth and fifth digits, atrophy of hand intrinsic muscles, clawing, loss of hand dexterity, and aching pain along the ulnar aspect of the forearm. Ulnar nerve symptoms may occur, given the course of the ulnar nerve around the elbow joint and increased risk of entrapment at the elbow or cubital tunnel (see Chapter 27 ). Compression of the posterior interosseous nerve by rheumatoid synovial hyperplasia can occasionally produce radiating pain to the forearm and the inability to extend the fingers.

Physical Examination

Physical examination findings of the elbow vary according to the cause and stage of the elbow arthritis. Examination of the elbow starts with inspection for deformity as well as noting the carrying angle. Effusions, synovial thickenings, and erythema are commonly noted in the inflammatory arthropathies during acute flares.

The examiner should aim to identify the specific pain generators and maneuvers that trigger pain. Palpation may elicit tenderness specifically over the joint lines, but the patient may also have tenderness over the radial head, olecranon, olecranon bursae, muscles, and tendons attaching around the elbow.

Thorough examination of range of motion is crucial. Normal adult elbow range of motion in extension-flexion is from 0 degree to about 150 degrees; pronation averages 75 degrees, and supination averages 85 degrees. A functional range of motion is considered to be 30 to 130 degrees, with 50 degrees of both pronation and supination. Primary or post-traumatic arthritis of the elbow results in stiffness, and a flexion contracture is frequently present. Crepitus may be palpable throughout the arc of motion or with forearm rotation. In contrast, RA often leads to restriction in all planes of motion, as the synovitis affects all of the articulating surfaces. Pain, motion restriction, and crepitus worsen as the disease progresses. The range of motion should be monitored at the initial examination and at subsequent follow-up examinations. Wrist and shoulder motion must also be considered, as they come into play in adaptive strategies for patients with restricted elbow motion.

Provocative maneuvers for the elbow include assessment of instability or laxity. Recall that RA can result in instability due to destruction of the joint structure, including the capsule and ligaments. This is often perceived by the patient as weakness or mechanical symptoms. Laxity with varus and valgus stress testing or posterior instability may also be seen.

In the absence of associated neuropathies, neurologic examination including deep tendon reflexes and sensation are typically normal. Strength of elbow and wrist flexors and extensors may be impaired in long-standing elbow arthritis because of disuse or due to pain. Associated ulnar nerve irritation can lead to pain or a positive Tinel sign over the cubital tunnel. There may be diminished sensation in the fifth digit and ulnar half of the fourth digit (see Chapter 27 ). A positive elbow flexion test with paresthesias, provoked by acute flexion of the elbow for 30 to 60 seconds, may also be elicited. Weakness, especially of the hand intrinsic muscles, may also be noted in the presence of associated neuropathies.

Functional Limitations

The elbow functions to position the hand in space. Significant loss of extension can hinder an individual’s ability to interact with the environment. Activities that require nearly full extension, like carrying groceries or briefcases, can become painful. Significant loss of flexion can interfere with activities of daily living, such as eating, shaving, and hygiene. A normal shoulder can compensate well for a lack of pronation, whereas a lack of elbow flexion requires a normal shoulder, wrist, and cervical spine to compensate. There is no simple solution for a significant lack of elbow extension; the body must be moved closer to the desired object. Compensatory mechanisms are often impaired in patients with RA because of involvement of other joints. This magnifies the impact of the elbow arthritis on function.

Diagnostic Testing

Radiographic assessment is usually sufficient for the diagnosis of elbow arthritis, including anteroposterior, lateral, and oblique radiographic views. The radiographs should be inspected for joint space narrowing, osteophyte and cyst formation, bone destruction, evidence of prior injury and healing, hardware integrity, and loose or foreign body. Joint space may appear preserved centrally with osteophytes anteriorly and posteriorly. For the rheumatoid patient, the Mayo Clinic radiographic classification of rheumatoid involvement is useful ( Table 21.1 ). Dramatic loss of bone is evident as the disease progresses ( Fig. 21.1 ). This pattern of destruction is not seen in patients with post-traumatic or primary OA. Radiographic features in these patients include spurs or osteophytes on the coronoid and olecranon, loose bodies, and narrowing of the coronoid and olecranon fossae ( Fig. 21.2 ).

Table 21.1

Radiographic Classification of Rheumatoid Arthritis

Grade I	Synovitis with a normal-appearing joint
Grade II	Loss of joint space but maintenance of the subchondral architecture
Grade IIIa	Alteration of the subchondral architecture
Grade IIIb	Alteration of the architecture with deformity
Grade IV	Gross deformity