Elbow joint

Elbow joint

'TENNIS ELBOW‘ lateral epicondylitis :
It is tendinitis of the common extensor origin, it is
common well defined entity. Most cases follow minor tear to tendon and repair ,usually associated
with occupational stress or unaccustomed activity, such as house painting, carpentry or other activities.
Clinically :
Pain is felt over the outer side of the elbow, It is initiated or aggravated by movements such as pouring out tea , turning a stiff door-handle, shaking hands or lifting with the forearm.

The elbow looks normal and flexion and extension are full and painless. Tenderness is localized to a spot just below the lateral epicondyle, and pain is reproduced by getting the patient to extend the wrist against resistance, so as to stretch the common extensors.
Treatment:
Rest, analgesia, physiotherapy, and splintage may be used. If pain is severe, the area of maximum tenderness is injected with a mixture of corticosteroid and local anaesthesia . Persistent pain surgery with detachment origin at the humeral epicondyle is indicated .

Golfer's elbow

Pain around the medial epicondyle at attachment of the common tendon of origin of the wrist flexors. Pain is reproduced by passive extension of the wrist. It is treated by rest, avoiding the precipitating activity, if pain is severe, the area of maximum tenderness is injected with a mixture corticosteroid and xylocaine. Persistent pain treated surgically.

PULLED ELBOW “Nursemaids Elbow”

It is a common in young children between 1 and 4 years of age. It is rare beyond the age of 5 years. Head of radius slip out of annular ligaments by longitudinal traction and ligament entrapped between head of radius and lateral condoyle.
This is not considered a dislocation of the elbow. It commonly occurs when child being pulled suddenly and forcefuly by the wrist. A child will begin to cry right after the injury, and cannot move the affected forearm because of the pain.
The forearm is held in pronation and the child stop using his limb.
Treatment : is by traction and supination , a click is often felt
The child will start using the arm soon afterwards. To prevent recurrence of pulled elbow: avoid lifting or pulling a child by the hands, wrist or forearms.


Pulled elbow

OLECRANON BURSITIS :

The most common swelling around elbow is in the olecranon bursa at the back of the elbow. Pressure and friction may cause swelling of olecranon bursa. Infection ,gout, rheumatoid arthritis may cause swelling of bursa. The underlying cause must be treated . Septic bursitis may need local drainage. If bursitis persist for long time, bursa may need surgical excision.
Deformities of elbow:
1- cubitus varus.
2-cubitus valgus.

Wrist and hand

Wrist malformations.
Radial club hand : The infant is born with the wrist in marked radial deviation. There is absence of the whole or part of the radius, and usually also the thumb.
Ulnar club hand: The infant is born with the wrist in marked ulnar deviation. There is absence of the whole or part of the ulna.
Madelung's deformity : The carpus is deviated forwards, leaving the ulnar head projecting on the back of the wrist. Deformity is seldom marked before the age of 10 years, function is usually excellent, in the worst cases the deformity may have to be corrected by Osteotomy.


Madelung`s deformity

Radial club hand

X- ray Radial club hand

Hand congenital deformities :

• 1- failure of formation.
• 2- failure of differentiation. e.g. syndactyly.
• 3- focal defect. e.g..polydactyly.
• 4- overgrowth. E.g. Giant finger.
• 5- generalized malformation. Marfan’s syndrome ( spider hand’s ), achondroplasia (trident hand).

Polydactyly syndactyly giant finger spider hand

Acqired deformities :

Volkmann's ischaemic contracture:
It is post-compartment syndrome contracture, characterized by flexion deformity of the wrist and extension of metacarpo-phalangeal joints , flexion of interphalangeal joints , it results from fixed contracture of flexor muscles of forearm following ischemia after fractures, other injuries, and tight cast. It occurs commonly in children following untreated compartment syndrome, weeks or months later. Passive flexion of wrist relaxed the flexor tendons and the range of extension at the finger joints is increased.

To reduce the incidence of this serious complication, all effort should be done to prevent and to treat compartment syndrome early. In established Volkmann's ischaemic contracture restoration to normal is impossible, but remaining function can improved. Mild cases can be treated by physiotherapy, more severe cases can be treated by muscles lengthening through proximal muscles detachment and sliding or bone shortening. Tendon transfer and joint arthrodesis can be used to improve hand function sometimes.

Volkmann`s ischemic contracture

Rheumatoid arthritis of wrist and hand:

Rheumatoid arthritis commonly affects the wrists and hands and causes serious loss of function and deformities. After the metacarpo-phalangeal joints, the wrist is the most common site of rheumatoid arthritis. Pain, swelling and tenderness may at first be localized to the joints or to the tendon sheaths. In late cases the wrist and fingers are deformed and unstable.

Ulnar deviation of the fingers and subluxation of the metacarpo-phalangeal joints in rheumatoid arthritis. Swan-neck deformity (malet finger) and boutonniere deformities may occur in rheumatoid arthritis. Mallet’s finger result from rupture or injury of the extensor tendon of terminal phalanx.

Kienbock's disease

The lunate bone develop a patchy avascular necrosis. A predisposing factor of Kienbock’s disease may be relative shortening of the ulna.
The patient, usually a young adult, complains of ache and stiffness, tenderness is localized to the centre of the wrist on the dorsum, wrist extension may be limited.
Imaging : Typical x-ray signs are increased density and fragmentation in the lunate. The earliest signs of osteonecrosis can be detected only by MRI, later osteoarthritis of the wrist may occur.

Treatment: During the early stage, while the shape of the lunate is more or less normal, shortening osteotomy of the distal end of the radius may reduce pressure on the bone and thereby protect it from collapsing. In late cases, partial wrist arthrodesis may be the only option.

DeQuervain’s disease (stenosing tenosynovitis)

It is tenovaginitis ( tenosynovitis); inflammation and thickening of tendon sheath of the first dorsal compartment ( extensor pollicis brevis and abductor pollicis longus) due to overuse, is usually seen in women between the ages of 30 and 50 years. There may be a history of unaccustomed activity.
Clinical features: The condition is common in women aged 30-50,who complain of pain in radial side of the wrist. There may be a swelling along the course of the thumb tendons, it may be hard and thic

Crepitus during thumb movement may palpable. Tenderness is most acute at the tip of the radial styloid. The pathognomonic sign is abduction of the thumb against resistance are painful , or passive adduction of the thumb across the palm (Finkelsteins test ) are painful.

Finkelsteins test

Treatment: In early cases, symptoms can be relieved by avoid predisposing overuse, rest , and NSAID, sometimes combined with splintage of the wrist, or ultrasound therapy. If symptoms persist a local corticosteroid injection into the tendon sheath. In resistant cases Operation, which consists of slitting the thickened tendon sheath. Care should be taken to prevent injury to the dorsal sensory branches of the radial nerve, which may cause intractable pain.