University of Iowa Family Practice Handbook, Fourth Edition, Chapter 16

Orthopedics: Elbow

1. Lateral Epicondylitis (tennis elbow). A very common inflammatory process of the extensor origin of the lateral epicondyle. May be secondary to overuse/repetitive use. Pain at the lateral epicondyle, with referred pain to the extensor surface of the forearm is typical. The pain is exacerbated by resisted extension of the wrist or fingers. Treatment includes avoiding exacerbating activities, NSAIDs, and placing a constrictive "tennis elbow" band just distal from the elbow. Occasionally immobilization of the wrist in a volar splint is required. Local steroid injection or orthopedic referral may be advised in recalcitrant cases.
2. Medial Epicondylitis. This results from repeated flexion activities of the wrist and fingers. Pain is at the medial epicondyle and exacerbated by resistant flexion of the fingers. Treatment is the same as that of lateral epicondylitis.
3. Radial Head Subluxation (nursemaid’s elbow).
   1. The mechanism is a sudden pull on the extended pronated elbow of a child less than 4 years of age (for example, when one picks up a child by the forearm or swings the child). The child holds his arm in pronation and usually refuses to move it with pain on supination and palpation of the radial head.
   2. Although radiographic findings are usually normal, one must be sure to rule out undisplaced supracondylar fracture. Frequently, the subluxation spontaneously reduces from x-ray positioning.
   3. Treatment is firm supination of the forearm, flexing the elbow gently to 90 degrees with pressure over the radial head. Reduction is achieved with a palpable click over the radial head, and the pain is immediately relieved. The patient should resume full activity within several minutes of reduction although some are hesitant. It may take an hour or so to resume full activity.
4. Little Leaguer’s Elbow. Results from overuse of an adolescent’s pitching elbow. On exam there is tenderness over the medial humoral epicondyle with mild swelling. An acute syndrome with sudden onset also occurs from the avulsion of a fragment of bone from the medial humeral epicondyle. Treatment includes rest for 3-6 weeks followed by rehabilitation. Loose bodies and locking elbow require referral.
5. Olecranon Bursitis (note: the same treatment and diagnostic modalities hold true for prepatellar bursitis as well).
   1. Clinically there is tenderness and swelling over the olecranon bursa. Olecranon bursitis may be secondary to trauma (e.g., lying on carpet with elbows propped up while watching TV) or may be infectious (Staphylococcal). Frequently, traumatic bursitis leads to infectious bursitis.
   2. Diagnosis. Must differentiate infectious from sterile bursitis. Tap the bursa and evaluate gram stain, cell count, crystals, and culture.
   3. Treatment consists of repeated aspiration until fluid no longer re- accumulates. Start antistaphylococcal antibiotics (e.g., amoxicillin/ clavulanate, nafcillin) if an infectious etiology is likely. May require admission for IV antibiotics the patient is toxic or there are comorbid conditions (e.g., immunosuppression, diabetes). If the etiology is not infectious, treat with NSAIDS, aspiration and compression dressings. Occasionally, an olecranon bursa must be opened surgically.

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See related Provider Topics Bones, Joints and Muscles, Elbow Injuries and Disorders or Injuries and Wounds.

See related Patient Topics Bones, Joints and Muscles or Injuries and Wounds.

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