1. ELBOW AND FOREARM
Dr.Raad Al-Shaibany

2. CONGENITAL DISLOCATION OF THE RADIAL HEAD
This may be anterior or posterior and is usually bilateral
palpable lump and can be felt to move when the forearm is rotated.
X-rays : the dislocated radial head is dome-shaped .
TREATMENT: Function is usually surprisingly good and pain is unusual. Surgery is therefore rarely required; however, if the lump limits elbow flexion it can be excised

3. CONGENITAL DISLOCATION OF THE RADIAL HEAD

4. CONGENITAL SYNOSTOSIS
Humero-ulnar or radial synostosis.
Proximal radio-ulnar synostosis causes loss of rotation, but elbow flexion is retained and the inconvenience is often only moderate. Surgery to regain rotation rarely succeeds. A rotational osteotomy can give a more suitable angle of pronation–supination tailored to the individual patient’s needs.

5. CONGENITAL SYNOSTOSIS

6. CUBITUS VALGUS
The normal carrying angle of the elbow is 5–15 degrees of valgus.
The commonest cause is longstanding non-union of a fractured lateral condyle.
The importance of cubitus valgus is the liability to delayed ulnar palsy
Years after the causal injury the patient notices weakness of the handwith numbness and tingling of the ulnar fingers.
TREATMENT:
The deformity itself needs no treatment, but for delayed ulnar palsy the nerve should be transposed to the front of the elbow

7. CUBITUS VALGUS

8. CUBITUS VARUS (‘GUN-STOCK’ DEFORMITY)
The deformity is most obvious when the elbow is extended and the arms are elevated.
The most common cause is malunion of a supracondylar fracture.
The deformity can be corrected by a wedge osteotomy of the lower humerus but this is best left until skeletal maturity.

9. CUBITUS VARUS

10. UNREDUCED DISLOCATION OF THE HEAD OF RADIUS
An unreduced Montegia fracture-dislocation will leave the radial head permanently dislocated. Open reduction and realignment of the ulna, together with soft-tissue reconstruction, may improve function.

11. unreduced Montegia fracture-dislocation

12. PULLED ELBOW
Downward dislocation of the head of the radius from the annular ligament is a fairly common injury in children under the age of 6 years.
clinical features:
There may be a history of the child being jerked by the arm.
subsequently complaining of pain and inability to use the arm.
The limb is held more or less immobile with the elbow fully extended and the forearm pronated; any attempt to supinate the forearm is resisted.
The diagnosis is essentially clinical, though x-rays are usually obtained in order to exclude a fracture.
Treatment:The radial head should be reduced by quick supination and flexion of elbow(the radial head is relocated with a snap) 

13. OSTEOCHONDRITIS DISSECANS
osteochondritis dissecans of the capitulum
Repeated stress following prolonged or unaccu- stomed activity but can occurspontaneously.
This may be due to repeated stress following prolonged or unaccustomed activity but can occur spontaneously.
usually a young male adolescent –
complains of aching which is aggravated by activity and relieved by rest.
On examination
there may be swelling, signs of an effusion, tenderness over the capitulum and slight limitation of movement.
If the fragment has separated, there may be intermittent locking.

14. IMAGING:
X-rays: may show fragmentation or, flattening of the capitulum.
CT and MRI: are more useful for defining the lesion.
Treatment:
usually symptomatic rest and analgesia.
.If the fragment has separated and is lying free in the joint, it should be removed.
A large loose fragment which is often still partly attached can be pinned back. (arthroscopically)

16. LOOSE BODIES Clinical features:
Loose bodies in the elbow may be due to:
(1) acute trauma (an osteocartilaginous fracture).
(2) osteochondritis dissecans;
(3) synovial chondromatosis (a cluster of mainly cartilaginous ‘pebbles’);
(4)osteoarthritis (separation of osteophytes).
Clinical features:
sudden locking and unlocking of the joint.
Symptoms of osteoarthritis may coexist.
A loose body is rarely palpable.

17. IMAGING:
X-rays may reveal the loose body or bodies
CT arthrogram will define the size and the number of loose bodies.
Treatment:
If loose bodies are troublesome, they should be removed by arthroscopic or open mean

18. STIFFNESS OF THE ELBOW
Stiffness of the elbow may be due to
congenital abnormalities (various types of synostosis, or arthrogryposis),
infection
inflammatory arthritis.
osteoarthritis .
late effects of trauma.

19. STIFFNESS OF THE ELBOW

20. POST-TRAUMATIC STIFFNESS
either extrinsic ,intrinsic or a combination of these.
Clinical assessment
Most of the activities of daily living can be managed with a restricted range of elbow motion: flexion from 30 to 130 degrees and pronation and supination of 50 degrees each. Any greater loss is likely to be disabling

21. POST-TRAUMATIC STIFFNESS

22. aggressive passive manipulation may aggravate more than help.
NON-OPERATIVE TREATMENT
The most effective treatment is prevention, by earlyactive movement through a functional range.
If movement is restricted and fails to improve with exercise, serial splintage may help.
aggressive passive manipulation may aggravate more than help.

23. OPERATIVE TREATMENT
failure to regain a functional range of movement at 12 months after injury.
The objectives are determined by the type of pathology.
Heterotopic bone can be excised.
Capsularrelease or capsulectomy (open or arthroscopic).
Intra-articular procedures include fixing of ununited fractures or correction of malunited fractures.
Post-traumatic radio-ulnar synostosis resection when the synostosis has matured (this takes about one year) followed by diligent physiotherapy.

24. RECURRENT ELBOW INSTABILITY
Following a dislocation or severe sprain, the lateral collateral ligament can be stretched or ruptured.
Clinical features:
The patient may present with painful clunking and locking.
On examination: an apprehension response can be elicited by supinating the forearm while applying a valgus force to the elbow during flexion.
Treatment:
The lateral collateral ligament can be directly repaired or reconstructed with a tendon autograft (e.g. palmaris longus).

25. TENNIS ELBOW (LATERAL EPICONDALGIA)
Clinical features:
The patient is usually an active individual of 30 or 40 years.
Pain comes on gradually, often after a period of unaccustomed activity It is usually localized to the lateral epicondyle,
On examination:
localized tenderness at or just below the lateral epicondyle.
pain can be reproduced by passively stretching the wrist extensors (by the examiner acutely flexing the patient’s wrist with the forearm pronated) or actively by having the patient extend the wrist with the elbow straight.

26. TENNIS ELBOW

27. The first step is restrict, the activities which cause pain.
X-ray: occasionally shows calcification at the tendon origin.
 Treatment:
90 per cent of ‘tennis elbows’ will resolve spontaneously within 6–12 months.
The first step is restrict, the activities which cause pain.
Injection with corticosteroidand local anaesthetic
These measures failed surgery is indicated(The origin of the common extensor muscle is detached from the lateral epicondyle, division of the orbicular ligament or removal of a ‘synovial fringe’).
Surgery is successful in about 85 per cent of cases.

28. TENNIS ELBOW SURGERY

29. GOLFER’S ELBOW (MEDIAL EPICONDYLITIS)
This is similar to tennis elbow but about three times less common.
In this case it is the pronator origin that is affected.
Treatment is the same as for lateral epicondylitis but the outcome of surgery seems less predictable.

30. BASEBALL PITCHER’S ELBOW
Repetitive, vigorous throwing activities can cause damage to the bones or soft-tissue attachments around the elbow.
Professional baseball players may develop hypertrophy of the lower humerus and incongruity of the joint, or loose-body formation and osteoarthritis.

31. JAVELIN THROWER’S ELBOW
The over-arm action employed by javelin throwers places huge strain on the medial collateral ligament which can become either acutely injured or chronically attenuated.
Clinical features:
Pain.
There may also be symptoms of ulnar nerve impairment.
Treatment:
.. rest and modification of activities.
..An attenuated medial collateral ligament may need reconstruction with a tendon graft.

32. AVULSION OF THE DISTAL TENDON OF BICEPS
Clinical features
Usually man of about 45 years
The patient feels sudden pain and weakness at the front of the elbow after strenuous effort.
Failure to feel the distal biceps tendon while the patient flexes the elbow against resistance
Loss of supination power with the elbow flexed.
MRI helps to confirm the diagnosis but must not delay surgical treatment. Clinical diagnosis should usually suffice.

33. Treatment
Operative repair is not always necessary because some patients can manage with slightly reduced elbow flexion: there are other elbow flexors (brachioradialis, brachialis).
However, there will be a very obvious cosmetic defect and greatly reduced power of supination. For these reasons, many patients will choose repair. The best are achieved by operation within 2 weeks, before the tendon retracts and the interosseous tunnel becomes occluded
The results of early surgery and careful rehabilitation are usually verygood.

34. BURSITIS The olecranon bursa :causes;
1.continual pressure or friction; this used to be called ‘student’s elbow’. If the enlargement is a nuisance the fluid may be aspirated.
2.The commonest non-traumatic cause is gout.
3.In rheumatoid arthritis.(features of rheumatoid arthritis).
A chronically enlarged bursa may prove a severe nuisance and need to be excised. However, wound healing can be a problem

36. OA. OF ELBOW

37. RHEUMATOID ELBOW

38. Tuberculosis of the elbow

39. Thank You & Good Luck