EXAMINATION OF THE ELBOW/SURGERY FOR STIFF ELBOW
From the University of Toronto’s 24th Annual Upper Extremity Update
Shawn W. O’Driscoll, MD, PhD, Professor of Orthopedics, Mayo Clinic, Rochester, MN
Educational Objectives
| The goal of this program is to improve orthopaedists’ ability to perform examination of the elbow and surgical treatment of stiff elbow. After hearing and assimilating this program, the clinician will be better able to: |
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1. Diagnose medial and posterior elbow pain. |
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2. Diagnose lateral and posterior elbow pain. |
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3. Identify the functional arc of motion in the elbow. |
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4. Perform arthroscopic capsular release for stiff elbow. |
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5. Avoid injuring the ulnar nerve while surgically treating the stiff elbow. |
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Dr. O’Driscoll was recorded at 24th Annual Upper Extremity Update, presented April 11, 2008, in Toronto, ON, by the University of Toronto Faculty of Medicine. The Audio-Digest Foundation thanks the speaker and the sponsor for their cooperation in the production of this program.
| A PRACTICAL GUIDE TO EXAMINATION OF THE ELBOW |
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Medial collateral ligament tear (MCL) and tendinitis |
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Test: moving valgus stress test; while applying valgus stress to elbow in flexion, extending elbow to 90° to 95° reproduces pain experienced when throwing; symptoms within arc of 70° to 120° diagnostic; if outside arc, not MCL problem; bending of ligament generates internal sheer stresses; if test positive and MCL not lax, stage-1 debonding injury present; if MCL lax, whether tear partial or complete determined on surgical exploration; need for surgery—normally, when pain correlates with ligament pathology; but patient may have terrible pathology and no pain, with surgery not needed; or no pathology and terrible pain requiring surgery |
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Role of video: often made by patient’s family; helpful in diagnosis |
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Test: tennis elbow shear test (pressing extended fingers against cheek may cause medial-side pain); stresses common flexor group; resisting flexion and pronation while quickly extending elbow reproduces pain; “very hot” elbow intensely painful; without resistance, patient grips as if preparing to punch, and reaches out |
| Ulnar neuritis: tenderness at medial side; Tinel’s sign and subluxation may be present; subluxation of medial triceps tendon—after surgical management (including transposition of nerve, snapping and pain persists; snipping out medial triceps tendon eliminates pain) |
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Test: push-up test (triceps resistance test); palpation on medial side detects 2 snaps (ulnar nerve; triceps tendon as elbow flexed) |
| Medial elbow pain (due to posteromedial trochlear chondral erosion): typically seen in baseball pitchers; uncommon |
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Test: trochlear shear test; essentially moving valgus stress test with pain in arch from 10° to 40° (may be ≤60°); reproduces pain |
| Posteromedial impingement |
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Test: posteromedial impingement test; snapping arm into terminal extension reproduces pain; pain caused by fracture of osteophyte at back of olecranon (fractured osteophyte represents nonunion) |
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Posterolateral rotatory |
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Test: posterolateral rotatory drawer test: sensitivity 93%; lateral pivot shift apprehension test difficult to perform, and sensitivity ≈45%; with arm overhead, flexing and subluxating elbow forms bump and dimple, which reduces with clunk as elbow flexed further; patient experiences dramatic apprehension |
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Tennis elbow: same as on medial side |
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Test: tennis elbow shear test; resist extension as patient punches out; as patient flexes wrist, while grabbing wrist to block extension against hand, patient punches out quickly into space; reproduces pain |
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Plica: may occur anteriorly, posteriorly, or both |
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Test: flexion-pronation test: while pronating forearm with slight valgus torque, pop elbow up into flexion; at end point, plica palpable over radial head, causing snapping and some radial pain |
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Posterior interosseous nerve (PIN) entrapment: speaker speculates that PIN caused by forearm band worn for tennis elbow; condition never seen in patient not using forearm band; no other instance of primary pathology associated with problem in seemingly unrelated nerve located elsewhere in limb; constantly squeezing (shearing) tissues around nerve causes irritation; speaker stopped using bands |
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Osteochondritis dissecans |
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Capitellar shear test: similar to moving valgus stress test, but with pain maximal at ≈45° and on lateral side of elbow |
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Posterior impingement: common; occurs in weight lifters and athletes with hypertrophic early arthritic changes in elbow; causes—loose bodies; triceps tendinitis or tendon rupture; fractured osteophytes (behave like fracture); patient complaint—unable to extend or flex (or both) elbow; actually experience pain at end point of motion; measuring range of motion—numbers highly variable; usually measured with arm straight forward (shoulder in internal rotation); measure motion with arm in supinated position (arc in plane perpendicular to your eye and goniometer) |
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Biceps tendon avulsion: late diagnosis seen in 50% of biceps tendon repairs |
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Hook test: patient places elbow horizontally at 90° and looks at palm; place opposite index finger over biceps tendon and hook it from lateral side; normal hook test—tendon behind tendon where finger hooked; abnormal hook test—absence of tendon behind which to hook finger; brachialis tendon prominent; explanation—when biceps tendon ruptures and pulls proximally, brachialis tendon takes its place (appears to be biceps tendon); hook test detects 2 tendons, and finger can be hooked behind 1 tendon; operation restores hook test to normal |
| SURGICAL TREATMENT OF STIFF ELBOW |
| Functional arc of motion: 30° to 130° of flexion and extension; 50°/50° pronation/supination; for normal routine activities |
| Open release: simple contractures simple to treat; complex contractures require more experienced surgeon; results—≈95% of patients gain some motion; ≈90% obtain within 10° of functional arc; complications in 10% to 30%, corresponding to severity of original problem |
| Arthroscopic release: procedure of choice for surgeon able to perform; efficacy probably better; complication rate probably lower |
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Mechanized approach: as with total hip or total knee arthroplasty; in sequence, by compartments, start posteriorly working around to front; in each compartment, stepwise approach—1) get in and establish view; 2) create space in which to work; ability to perform first 2 steps enables surgeon to execute procedure; bony work—eg, osteophyte removal; capsulectomy—restore motion |
| Get in and establish view: be certain anatomy and orientation as expected |
| Create space in which to work: debulking volumes of tissue; retracting tissues |
| Bone removal: characteristic pattern of osteophytes; osteocapsular arthroplasty—3-dimensional reshaping of bone closer to original shape; in posterolateral corner and medial side; ulnar nerve in medial gutter, lying directly on posterior bundle of MCL |
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Risk to ulnar nerve: burr can “wrap up” tissues, transecting nerve |
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Arthroscopic exploration of ulnar nerve: ulnar nerve can be released arthroscopically or with open approach; speaker recommends mini-open approach, especially for inexperienced surgeons; incision— speaker creates 1.5-cm incision; can be 3 to 4 cm |
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Osteophyte removal: safer to open small window to access osteophytes |
| Capsular release: performed in 4 stages, as in other compartments |
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Points on procedure: needle brought in through anterolateral portal, retractor through proximal-lateral portal; portals can be created safely with inside-out technique |
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Get in and establish view: confirm orientation and anatomy |
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Create space in which to work: elevate soft tissues off humerus; debulk tissues; retract tissue; remove loose tissue impeding access |
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Capsulectomy: insert arthroscope through lateral side, shaver through proximal-anteromedial portal; release along supracondylar ridge; cauterize collateral vessel to avoid substantial bleeding; arthroscopic release more precise and extensive than open approach (magnification improves performance); incise capsule on both sides and “bite and peel” capsule off brachialis tendon; proprioceptive feedback—process develops “muscle memory” routine (as in sports); brain registers 3-dimensional space; protecting ulnar nerve—no suction used near nerve; site of radial nerve—within triangle of fat |
| Arthroscopic release effective: based on data in literature and accumulated experience; speaker finds more effective than open release in most circumstances; true for complex and simple cases |
| Factors modifying difficulty: degree of contracture; severity of osteophyte formation; extensive scarring; altered anatomy |
| Safety: external independent review of 42 consecutive arthroscopic releases performed by speaker; findings include—12 transient intraoperative nerve palsies (3 from prolonged tourniquet time (probable cause of 3 more); 1 from excessive retraction (resolved within 5 days); no permanent nerve injuries; nerves put at risk by—use of burrs nearby; improper use of retractors; capsular extension |
| Factors affecting risk: complexity of operation; adversity (“when things are going not quite right” for surgeon); surgeon’s complexity curve—may change over time; “know your curve and stay below it” |
| Delayed-onset ulnar neuropathy: in typical patient, after arthroscopic or open release; neural examination normal postoperatively; ulnar neuropathy develops between days 3 and 12; progressive increase in pain and decrease in motion; flexion affected more than extension; due to compression of ulnar nerve and cubital tunnel; speaker’s response—routine prophylactic release of ulnar nerve; “just about abolished” problem |
Suggested Reading
Antuna SA et al: Snapping plicae associated with radiocapitella chondromalacia. Arthroscopy 17:491, 2001; Jupiter JB et al: The assessment and management of the stiff elbow. Instr Course Lect52:93, 2003; O'Driscoll SW et al: Arthroscopy of the elbow. Diagnostic and therapeutic benefits and hazards. J Bone Joint Surg Am 74:84, 1992; O'Driscoll SW et al: Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg Am 83-A:1358, 2001; O'Driscoll SW et al: The "moving valgus stress test" for medial collateral ligament tears of the elbow. Am J Sports Med 33:231, 2005; O'Driscoll SW et al: The cubital tunnel and ulnar neuropathy. J Bone Joint Surg Br 73:613, 1991; O'Driscoll SW et al: The hook test for distal biceps tendon avulsion. Am J Sports Med 35:1865, 2007; Epub 2007 Aug 8.O'Driscoll SW: Arthroscopic treatment for osteoarthritis of the elbow. Orthop Clin North Am 26:691, 1995; O'Driscoll SW: Ulnar collateral ligament of the elbow. Arthroscopy 22:578; author reply 578, 2006; Papandrea RF et al: Reconstruction for persistent instability of the elbow after coronoid fracture-dislocation. J Shoulder Elbow Surg 16:68, 2007; Epub 2006 Oct 25. Sanchez-Sotelo J et al: Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am 89:961, 2007; Spinner RJ et al: Medial or lateral dislocation (snapping) of a portion of the distal triceps: a biomechanical, anatomic explanation. J Shoulder Elbow Surg 10:561, 2001; Stans AA et al: Operative treatment of elbow contracture in patients twenty-one years of age or younger. J Bone Joint Surg Am 84-A:382, 2002.
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