Elbow osteoarthritis

Original Editor - George Prudden

Lead Editors-

George Prudden;

Contents

Clinically Relevant Anatomy

The elbow joint is a synovial hinge joint. Three bones are involved in the articulation of the joint: the distal end of the humerus and proximal ends of the radius and ulna. Similar to other hinge joints articular surfaces are reciprocally shaped, there are strong collateral ligaments and muscles are grouped at the sides so not to impede movement.

The trochlea at the distal end of the humerus, projects anteriorly and inferiorly at an angle of 45o. The trochlea notch at the proximal ulna, projects anteriorly and superiorly at an angle of 45o. The orientation of these articular surfaces allows a large amount of flexion. It achieves this by delaying contact between the humerus and ulna and providing space for musculature.

The carrying angle describes the lateral deviation of the ulnar axis from the humerus. Aproximately in males it is 10o - 15o and in females 20o - 25o.[1]

Pathophysiology

There are two predominant causes of elbow osteoarthritis: primary and post-traumatic.[2]

Primary

Primary osteoarthritis is uncommon and associated with those who take part in excessive sport or manual work. It is most commonly seen in the dominant arm. Initially degenerative changes and osteophytes occur at the olecranon and coronoid processes and respective articular surface whereas the central surfaces remain intact. This pattern manifests itself as patients' commonly complaining of pain the end of range of motion for both flexion and extension. As the disease progresses to the intrinsic articular surfaces, pain is experienced throughout the range of motion as well as a loss in range of motion due to enlarged osteophytes and capsular contracture. Isolated primary osteoarthritis is uncommon at the humeroradial joint.  

Post-traumatic

Any trauma to the elbow joint could lead to post-traumatic osteoarthritis. Abnormal kinematics of a joint are thought to cause arthritic changes. Following trauma, the articular surfaces can become incongruent because of malunion of a fracture site or ligamentous instability. Patients tend to report pain and crepitus associated with movements of flexion and extension or forearm rotation.

Epidemiology

In an study from 1965, Ruelle et al.[3] report that only 0.56% rheumatology clinic has elbow OA. The symptoms described by the patient were mild, and two thirds of patients had no pain. Reduced range of motion was the most common symptom with loss of extension early in the disease and loss o fpronation and supination later on. In 15.5% of those with elbow OA, ulnar nerve was also reported

Clinical Presentation

  • Joint pain with or with loss of range of motion. Early stages of the disease is associated with pain at the extremes of range whereas once advance pain can be felt throughout range.
  • Extension is the most common direction for loss of range post-trauma whereas in primary OA loss of motion is variable.
  • Trauma predominant cause of elbow OA. Important to gather management history.
  • Ulnar neuropathy is a often a finding associated with elbow OA. The clinician should attempt to identify changes to hand function, neuropathic pain, weakness, or changes to sensation.
  • Red flags include infection associated with any surgery and septic arthritis.[2]

Diagnostic Procedures

Physical examination

  • Observation of the upper extremity with comparisons to contralateral side. Look out for deformity, swelling, and muscle atrophy. 
  • Range of motion. Conisder joints above and below.
  • Neurovascular examinaton, the ulnar nerve is commonly effected.
  • Ligamentous stability, varus and valgus test of collateral ligaments are commonly performed.[2]

Imaging

X-ray is most commonly used when imaging the elbow joint. Expect to see projections for anteroposterior, lateral and oblique directions. On viewing an x-ray the central joint space is usually preserved with osteophytes typically located at the anterior and posterior aspects. It is important to review previous images especially when there is a history of trauma. With such a history, clinicians should look out for malalignment, incongurency of the joints, or evidence of heterotopic ossification. Stress radiographs are sometimes used when there is a history of instability.

CT is useful in complex cases such as heterotopic ossification, intra-articular loose bodies, bony deformity or malunion is suspected in the setting of previous fracture.

MRI has a limited role in diagnosis and is used only in rare occasions.[2]

Outcome Measures

Management / Interventions

Non-operative management is the predominant initial treatment for both forms of osteoarthritis of the elbow. Medicines management can include nonsteroidal anti-inflammatory analgesia and intra-articular corticosteroid injections. Patients may find sleeves or compression bandages useful for comfort.[2]

There is a paucity of literature regarding physiotherapy management of elbow OA. However, principles of OA rehabilitation used at other joints are likely to be effective with the elbow. The most common approach is a combination of exercise therapy and education. Manual therapy could be considered.

On failing conservative management surgery can be considered.

Surgical options

  • Surgical debridement
  • Total elbow arthroplasty
  • Arthroscopic radial head resection
  • Radiocapitellar arthroplasty

Differential Diagnosis

  • Ligament sprain/tear
  • Lateral epicondyle tendinopathy
  • Medial epicondyle tendinopathy
  • Ulnar neuropathy
  • Undiagnosed fracture
  • Referred pain from cervical spine

Resources

Recent Related Research (from Pubmed)

References

  1. Palastanga NP, Soames RW, Anatomy and human movement: Structure and function. 6th ed. Edinburgh: Churchill Livingstone; 2011 Sep 27. ISBN: 9780702035531.
  2. 2.0 2.1 2.2 2.3 2.4 2. Biswas D, Wysocki RW, Cohen MS. Primary and Posttraumatic arthritis of the elbow. Arthritis. 2013;2013:1–6.
  3. Ruelle JL, Debeuckelaere M, Raynal L. Introduction à l’étude ducoude. Journal belge de rhumatologie et de médecine physique 1965;20:161–7
  4. Smith MV, Calfee RP, Baumgarten KM, Brophy RH, Wright RW. Upper Extremity-Specific Measures of Disability and Outcomes in Orthopaedic Surgery. The Journal of Bone and Joint Surgery American volume. 2012;94(3):277-285. doi:10.2106/JBJS.J.01744.