ELBOW JOINT

ELBOW JOINT
(Modified hinge joint)
 ELBOW JOINT ARTICULATIONS
ARTICULATIONS • COMPONENTS
• Humeroulnar • Trochlea and trochlear notch
• Capitellum and radial head
• Humeroradial • Radial notch and radial head

Proximal radioulnar
 ARTICULATIONS
• Hinge joint(humeroulnar articulations)
• Pivot joint(radiocapitellar articulations)
• Axis of rotation for the elbow is centered through the trochlea and
capitellum and passes through a point anteroinfero on the medial
epicondyle
• Radial head should line up with capitellum at all arm positions with all
radiograpic views.
Medial collateral ligament plays an important role in valgus stability
Valgus stability is divided equally among the medial collateral ligament,the anterior capsule and
the bony articulation with the elbow in full extension
At 90 degree of flexion,the medial collateral ligaments provides 55% of the stability to valgus
stress with the anterior bundle being the primary stabilizer
•Valgus stability with the arm in pronation suggest that the anterior bundle of the UCL is intact.
•Anterior bundle is strongest of all ligaments
•Anterior band taut from 60 degree of flexion to full extension and posterior band taut from 60 -
120 degree of flexion
•Posterior bundle greatest change in length from flexion to extension
 LATERAL COLLATERAL
LIGAMENT
•Annular,radial and ulnar parts originates on the lateral humeral epicondyle
near the axis of elbow rotation
•LUCL attaches distally at ulna crista supinators (supinator crest)
•LUCL deficiency is manifested as posterolateral rotatory instability of the elbow
• LUCL has been described as the main lateral stabilizer ,taut in flexion and
extension
•Lateral collateral ligaments contributes only 14% of the varus stability of the
elbow with the joint in full extension and only 9% with the joint in 90 degree of
flexion
•The reminder of stability is contributed by the bony articular surfaces and the
anterior capsule with the bony surfaces supplying most of the stability
LIGAMENTS
• Osborne ligament stabilizes ulnar nerve in cubital tunnel
• Ligaments of struthers is variant anatomy attaching a supracondylar
process to medial epicondyle.
• potential site of median nerve compression.
 STABILIZERS
STATIC STABILITY
articular congruity
Capsule
Medial and lateral ligament

DYNAMIC STABILITY
Muscle tendon that cross the
elbow,biceps ,brachialis,triceps,wrist flexors and wrist extensors
STABILIZERS
PRIMARY CONSTRAINT
• Anterior medial collateral
ligament(AMCL)
• Lateral collateral ligament
complex(LCLC)
• Ulnohumeral articulations
SECONDARY CONSTRAINT
• Radiohumeral articulations
• Common flexor pronator tendon
• Common extensor tendon
• capsule
STABILIZERS
• PRIMARY • SECONDARY
• Anterior band of medial ulnar • Capsule
collateral ligaments • Ulnohumeral articulations
• Lateral collateral ligament complex • Radiocapitellar articulations
consisting of lateral collateral
ligament,
Annular ligament
Lateral ulnar collateral
ligament
MUSCLES
FLEXOR MUSCLES OF FOREARM
EXTENSORS MUSCLES OF FORE ARM
EXTENSOR
MUSCLES
EXTENSOR
MUSCLES
MOVEMENTS
• FLEXION
biceps brachii,brachilis,brachioradialis,pranator teres
• EXTENSION
Triceps brachii,anconeus
SUPINATION
biceps brachii,supinator,brachioradialis
PRONATION
Pronator teres,pronator quadratus,anconeus,brachioradialis
CUBITAL FOSSA
SYNOVIUM AND BURSA
• Synovial membrane envelops the elbow and superior Radioulnar
• Articulates and lubricates the deeper structure
• The two bursa are the bicipital bursa and olecranon bursa which form
the cushion
• Olecranon bursitis occurs as a result of injury or constant pressure in
the elbow .
• Leaning on hard surface can lead to olecranon bursitis
ARTICULAR CARTILAGE
CAPSULAR LIGAMENT
• Attachments
• Superiorly to lower end of humerus covering capitulum,trochlea,radial
fossa,coronoid fossa and olecranon fossa.
• Inferomedially attached to margins of trochlea notch of ulna
• Inferolaterally attached to annular ligament of superior radioulnar joint
CAPSULE
• Capsule allows maximum distension at approximately 70 t0 80 degree
of flexion which is why patients with effusion hold their arms in this
position which is more comfortable
• Anterior capsule attaches at a point approximately 6mm distal to the
tip of the coronoid
• Coronoid tip is an intraarticular structure that is visualized during
elbow arthroscopy
 Joint type

• radial head is covered by cartilage for approximately 240

degrees
• the lateral 120 degrees contains no cartilage
• this is crucial for internal fixation of radial head fractures
• axis and alignment
• anterior tilt
• the joint surface is anteriorly tilted approximately 30 degree relative to shaft of humerus
• Varus /valgus
• 6 degree of valgus
• rotation
• internally rotated by 5 degree
• axis of rotation
• is centered at trochlea and capitellum
• it passes through anteroinferior medial epicondyle
 Ligaments & Stability of Elbow
• Primary static stabilizers
• ulnohumeral joint (coronoid)
• loss of 50% or more of coronoid height results in elbow instability
• medial (ulnar) collateral ligament (MCL)  

• overview
• the MCL is composed of the anterior, posterior and transverse bundles
• the MCL provides resistance to valgus and distractive stresses
• anatomy
• origin
• posterior medial epicondyle
• insertion
• sublime tubercle of medial coronoid process
• components
• anterior bundle of MCL
• most important restraint against valgus stresses
• radial head is second most important
• posterior bundle of MCL
• the posterior bundle forms the floor of the
cubital tunnel
• primary restraint to valgus stress in maximal
elbow flexion
• if this is contracted, flexion may be limited 
• transverse bundle of MCL
lateral collateral ligament complex (LCL) 

• consists of the 
• radial collateral ligament (RCL)
• lateral ulnar collateral ligament (LUCL)
• function
• primary restraint to varus and external stress during full arc of elbow motion
• origin
• posterior lateral epicondyle
• insertion
• Crista supinatoris of proximal ulna
 • annular ligament
• provides stability to the proximal radio ulnar joint
• anatomy
• the LCL arises from isometric point on lateral aspect of
capitellum
• function
• optimal stability is conferred with an appropriately
tensioned LCL repair
Secondary static stabilizers
• Radiocapitellar joint
• this functions as an important constraint to valgus stress
• the radial head provides approximately 30% of valgus stability
• this is most important at 0-30 degree of flexion/pronation
• capsule
• greatest contribution the capsule on stability occurs with the elbow extended
• origins of the flexor and extensor tendons
Dynamic stabilizers
• includes muscles crossing elbow joint
• Anconeus
• brachialis
• triceps
• biceps
LIGAMENTS
• Osborne ligament stabilizes ulnar nerve in cubital tunnel
• Ligaments of struthers is variant anatomy attaching a
supracondylar process to medial epicondyle.
• potential site of median nerve compression.
 SYNOVIUM AND BURSA
• Synovial membrane envelops the elbow and superior radioulnar joint
• Articulates and lubricates the deeper structure
• The two bursae are the bicipital bursa and olecranon bursa which form the
cushion
• Olecranon bursitis occurs as a result of injury or
constant pressure in the elbow .
• Leaning on hard surface can lead to olecranon
bursitis
CAPSULAR LIGAMENT
• Attachments
• Superiorly to lower end of humerus covering capitulum,trochlea,radial
fossa,coronoid fossa and olecranon fossa.
• Inferomedially attached to margins of trochlea notch of ulna
• Inferolaterally attached to annular ligament of superior radioulnar joint
CAPSULE
• Capsule allows maximum distension at approximately 70 to 80
degree of flexion that is why patients with effusion hold their
arms in this position which is more comfortable
• Anterior capsule attaches at a point approximately 6mm distal
to the tip of the coronoid
• Coronoid tip is an intraarticular structure that is visualized
during elbow arthroscopy
Carrying Angle
• The carrying angle is a valgus angulation of the forearm at the
elbow ranging from 11° in males to 14° in females, measured in
extension. This is caused by the trochlear axis, passing through
the trochlea and capitellum, which lies around 6° off the
perpendicular axis to the humeral shaft.
 Baumann angle,
• also known as the humeral-
capitellar angle, is used for the
evaluation of the displacement of
paediatric supracondylar humeral
fractures. It is measured on a frontal
radiograph, with elbow in extension.

• This angle is formed by the humeral

axis and a straight line through the
epiphyseal plate of the capitulum.
• A value between 64 - 81º is considered normal. But due to significant
variation between individuals, Baumann’s angle is better evaluated by
comparison to the contralateral side. And a difference of more than
5° between the two sides is considered abnormal.

• An increased Bauman's angle will occur with residual varus and

internal rotation deformities.
BLOOD SUPPLY
ANASTOMOSIS AROUND ELBOW
JOINT
Branch anastomosis in front of the medial epicondyle
• Anterior branch of inferior ulnar collateral artery
• Anterior branch of superior ulnar collateral artery
• Anterior ulnar recurrent branch of ulnar artery
Branch anastomosis behind medial epicondyle
• posterior branch of inferior ulnar collateral artery
• Posterior branch of superior ulnar collateral artery
• Posterior ulnar recurrent branch of ulnar artery
ANASTOMOSIS AROUND ELBOW
• Branch anastomosis in front of lateral epicondyle
• Radial recurrent branch of Radial artery
• Anterior descending branch of profunda brachii artery

• Branch anastomosis behind the lateral epicondyle

• Inferior ulnar collateral artery
• Interrosseous recurrent artery
• Radial collateral branch of profunda brachii artery
BLOOD SUPPLY
Musculocutaneous nerve
•  origin
• lateral cord of the brachial plexus
• anatomy at elbow
• it exits laterally, distal to the biceps tendon 
• innervation at elbow
• it supplies the biceps and brachialis
• the nerve runs between these muscles 
 Radial nerve

• origin
• posterior cord of the brachial plexus
• anatomy at elbow
• it leaves the triangular interval (teres major, long head of triceps and humeral shaft)
• found in spiral groove 13 cm above the trochlea
• pierces lateral intermuscular septum 7.5 cm above the trochlea
• this is usually at the junction of the middle and distal third of the humerus
• lies between the brachialis and the brachioradialis
• distally it is located superficial to the joint capsule, at the level of the radiocapitellar joint
Median nerve

• origin
• medial/lateral cords of the brachial plexus
• anatomy at elbow
• it courses with brachial artery, running from lateral to medial
• lies superficial to brachialis muscle at level of elbow joint
• innervation at elbow
• it gives branches to elbow joint
• it has no branches in upper arm
Ulnar nerve
• origin
• medial cord of brachial plexus
• anatomy at elbow
• runs medial to brachial artery, pierces medial intermuscular septum (at
the level of the arcade of Struthers) and enters posterior compartment
• it traverses posterior to the medial epicondyle through the cubital tunnel
• innervation at elbow
• it gives branches to elbow joint
• it has no branches in upper arm
• first motor branch to FCU is found distal to the elbow joint
• Cubital Tunnel Syndrome is a condition that involves pressure or
stretching of the ulnar nerve (also known as the “funny bone” nerve),
which can cause numbness or tingling in the ring and small fingers,
pain in the forearm, and/or weakness in the hand.  The ulnar nerve
runs in a groove on the inner side of the elbow. 
LYMPHATIC
• Superficial lymphatic vessel
• Arise from lymphatic plexus in skin of hand
• Ascends up in close proximity to major superfitial vein basilic and
cephalic vein
• Terminate into lateral axillary lymph node and apical axillary lymph
node
• Deep lymphatic vessel
• Follow major deep vein radial ulnar brachial vein and terminate in the
axillary lymph nodes
• Diagnostic Injections
• Intra-articular injection best given in soft spot formed by
• lateral epicondyle
• the olecranon
• radial head
• Arthrodesis
• Optimal position
• in a unilateral arthrodesis
• 90° of flexion
• 0-7° of valgus
• in a bilateral arthrodesis
• one elbow in 110 ° of flexion for feeding
• one elbow in 65 ° of flexion for perineal hygiene
APPLIED ANATOMY
Olecranon bursitis
Elbow sprains
Elbow dislocations
Medial epicondylitis
Lateral epicondylitis
Impingement of ulnar nerve
Cubitus Valgus
Cubitus Varus
Arthritis
Osteochondritis Dessicans
SURGICAL APPROACHES TO
THE ELBOW
 ELBOW
• classified according to the aspect of the joint exposed

• Posterior approach
• lateral Anterolateral approach
Posterolateral approach
• Medial approach
• Anterior approach of medial cubital fossa

The aim of a surgical approach to the elbow is to provide an adequate

extensile exposure with preservation of the neurovascular structures
while permitting early mobilization of a stable joint, which heals
without a joint contracture
 POSTERIOR APPROACH

INDICATION :-
1. ORIF of fracture of distal humerus
2. Removal of intra-articular loose bodies from elbow joint
3. Treatment of non union of distal humerus
4. Triceps tendon repair
POSITION OF PATIENT :- Prone position with adequate
padding. Exsanguination done by elevating for 3-5 min or
using exsanguinator. Tourniquet inflated and arm abducted
about 90 degrees

LANDMARK :- Olecranon process

INCISION :- Longitudinal incision over posterior aspect of
elbow begins 5cm above the olecranon in midline of posterior
aspect of arm .At the tip of olecranon its curved laterally.
Distally its curved again medially towards middle of ulna.
5cm above the
olecranon in
midline of
posterior
tip of olecranon its
curved laterally

medially towards
middle of ulna.
INTERNERVOUS PLANE:-None
Superficial surgical dissection :-
First palpate the ulnar nerve
And fully dissect it out Median cutenous
nerve

Incise the deep fascia in midline

The triceps is exposed
Depending upon the mobilization of
triceps so as to expose posterior
elbow
The posterior approach has various
eponyms

Olecranon osteotomy
Pre-drilling and tapping of olecranon is
done if osteotomy is planned( eg
Chevron for more stability or simply
tranverse
Osteotomy or step cut )
Mac Ausland transolecranon approach
the prototype posterior approach where
olecranon osteotomy is done by Pre-
drilling and tapping of olecranon is done
and osteotomy is done ( eg Chevron for
more stability or simply tranverse
Osteotomy or step cut )
DEEP SURGICAL DISSECTION :-
retract the olecranon with triceps
proximally
mininal Dissection done around medial and
lateral border of the bone to expose all the
distal fourth of the humerus ..
• Campbell midline triceps splitting
If the triceps muscle has not been contracted, divide the muscle and
aponeurosis longitudinally in the midline and continue the dissection through
the periosteum of the humerus, through the joint capsule, and along the lateral
border of the olecranon

• Campbell midline triceps aponeurosis tongue

When the triceps muscle has been contracted by fixed extension of the elbow,
free the aponeurosis proximally to distally in a tongue-shaped flap and retract it
distally to its insertion incise the remaining muscle fibers to the bone in the
midline.
Wadsworth extensile posterolateral approach

• Distally based tongue of triceps tendon with intact peripheral rim is

fashioned
 Modification of the posterior approach
• Bryan-Morrey triceps-reflecting approach is
• performed by releasing the triceps tendon,
forearm fascia, and periosteum as one unit from
medial to lateral off the olecranon
Alonso-Llames Approach
• primarily was described for treatment of supracondylar fractures in
children, and was termed the “bilaterotricipital approach” ,
noncomminuted T-intercondylar distal humeral fractures also can be
treated with this approach.
• Through a midline skin incision, the triceps muscle is approached
from the medial and lateral aspects and elevated from each
intermuscular septum
 Boyd Approach
• Provide a safe exposure of the proximal third of the
radius, by avoiding injury to the posterior interosseous
nerve.
• Used for Monteggia fracture-dislocations, distal biceps
brachii tendon avulsions, and contracture release^
• The anconeus and supinator muscles are then freed
from the posterior aspect of the interosseous
membrane, carefully protecting the posterior
interosseous nerve, which is within the substance of
the supinator muscle. By retracting these muscles, the
posterior joint capsule over the radial head is exposed,
allowing the repair of the posterior capsule and/or
annular ligament.
• Synotosis is the problem
STRUCTURES AT RISK :-
Ulnar nerve : Identify and protect.
Median nerve : Always safe to remain in subperiosteal plane
Radial nerve: dissection not to be carried too proximal at lateral
intermuscular septum
Brachial artery: Anteriorly located

Extension:-
Proximally– Not possible proximally than the distal third of humerus
Distally - can be extended along the subcutaneous border of ulna
 LATERAL APPROACH

• The lateral approach is an excellent approach to a fracture of the

lateral condyle because the common origin of the extensor muscles is
attached to the condylar fragment and need not be disturbed.
POSTEROLATERAL APPROACH
OF RADIAL HEAD
Indications: Radial head excision or prosthetic replacement
LCL reconstruction ,
coronoid fractures
POSITION OF PATIENT

- Supine on operating table with

affected arm over
chest ,pronate the forearm
LANDMARK :- Lateral humeral epicondyle. Olecranon tip
INCISION :- gentle curve beginning over the posterior
surface of the lateral humeral epicondyle
and continuing downward and
medially over the posterior
border of the ulna, at about 6 cm distal
to the tip of the olecranon.
• Begin the incision
approximately 5 cm
proximal to the lateral
epicondyle of the humerus
and carry it distally to the
epicondyle and along the
anterolateral surface of
the forearm for
approximately 5 cm OR
curve it medially and
posteriorly to end at the
posterior border of the
ulna (LATERAL J-SHAPED)
SUPERFICIAL SURGICAL APPROACHES
The deep fascia incised in line with the skin incision. To find the
intermuscular plane. The eponyms of the lateral approach are given based on
the intrermuscular palne

Kaplan

( kocher )
Limited kocher approach
• The limited Kocher approach between
anconeus and extensor carpi ulnaris is
shown. ECRB = extensor carpi radialis
brevis; ECRL = extensor carpi radialis
longus; EDC = extensor digitorum
communis; ECU = extensor carpi ulnari
extended Kocher approach
• The extended Kocher approach is
shown. The common extensor origin
is reflected mfrom the lateral
humerus, and the anconeus and
triceps are reflected from the
posterior humerus. ECRL = extensor
carpi radialis brevis; EDC = extensor
digitorum communis; ECU =
extensor carpi ulnaris; ECRB =
extensor carpi radialis brevis
 Kaplan approach

• The Kaplan approach is

shown between extensor
digitorum communis and
extensor carpi radialis
longus and brevis.

The Kaplan approach provides excellent exposure of the radial head without interruption of the lateral ulnar collateral ligament
LUCL. One pitfall of the Kaplan approach is locating it too anterior and causing inadvertent injury to the posterior interosseous
nerve (PIN). Another limitation of this approach is that distal extension can endanger the PIN.
The column approach is shown.
• The combined Kocher and Kaplan
muscle splitting approaches, which
leave the extensor digitorum
communis and extensor carpi ulnaris
attached to the humerus can be seen.
ECRB = extensor carpi radialis brevis;
ECRL = extensor carpi radialis longus;
EDC = extensor digitorum communis;
ECU = extensor carpi ulnaris.
DEEP SURGICAL EXPOSURES
The forearm is fully pronated so as
to move the posterior
interosseous nerve (PIN)
away from the operative
field . The capsule
of the elbow joint is incised
longitudinally to reveal
the underlying capitulum,
the radial head, and
the annular ligament. No dissection below annular
ligament as PIN within the supinator.
STRUCTURES AT RISK :-
Posterior interosseous nerve (PIN) :
Remain proximal to the annular ligament.
Pronate the Forearm to keep the PIN far from the operative field.
Place the retractors directly on the bone.
Avoid retractors directly opposite to the bicipital tuberosity
Radial nerve :
Don’t extend anteriorly
ANTEROLATERAL APPROACH
INDICATIONS :-
Open reduction and internal fixation of the capitulum #

Excision of proximal radius tumors

Treatment of aseptic necrosis of the capitulum

Drainage of septic elbow arthritis

Neural decompression :lesions of the proximal half of the PIN and of the
proximal part of the superficial radial nerve : access to the arcade Frohse, as
well as treatment of radial head fractures with paralysis of this nerve

Biceps tendon avulsion re-attachment to radial tuberosity

POSITION OF PATIENT :- Supine with arm on arm-
board

LANDMARKS :- Brachioradialis :palpable thick wad

Biceps tendon: easily palpable taut structure
INCISION :- curved S incision given around the
anterior aspect of the elbow. Begins at 5 cm
above flexor crease along lateral border of the
biceps muscle. The lower portion
curves over the medial border of
the brachioradialis muscle
INTERNERVOUS PLANE :-
Proximally
brachialis and
brachioradialis
Distally
the brachioradialis and
pro pronator teres
SUPERFICIAL SURGICAL DISSECTION :- Deep fascia is
incised along the medial border of the brachioradialis. The
lateral antebrachial cutaneous nerve (LCNFA) is identified and
preserved.
Blunt dissection with finger. Radial nerve between BR and
Brachialis. PIN enters supinator. SupercialRadialN is beneath the
Brachioradialis Motor branch to ECRB.
DEEP SURGICAL
DISSECTION :-
longitudinal
incision is made in the
anterior capsule of the
joint between the radial
nerve laterally and the
brachialis muscle medially
to expose the radial head
and capitulum. To expose
the radius further, forearm
is fully supinated &
supinator muscle removed
distally in a subperiosteal
manner
STRUCTURES AT RISK :-
Radial nerve : in brachioradialis and brachialis interval

Posterior interosseous nerve : Winding around the radial neck.

Lateral cutaneous nerve of forearm: LCNFA emerging from

brachioradialis and biceps brachii interval

Reccurent branch of radial artery: Ligation decreases post-

op bleed and chance of VIC
EXTENSION:-
Proximally: BR/Triceps
Distally: Along entire anterior surface of the radius between
BR/PT and further distally BR/FCR.
 MEDIAL APPROACH
INDICATIONS :-
1.Removal of loose bodies
2.ORIF of fractures of the corocoid process of the ulna
3.ORIF of fractures of the medial humeral condyle &
epicondyle
4.Medial capsular release of stiff elbows (Hotchkiss)
5.Reconstruction of medial collateral ligament injuries

Contraindications:
1. Exploration of elbow as poor access to the
lateral side
POSITION OF PATIENT:- Supine and arm supported
on arm-board/table. the
arm abducted & the
shoulder fully externally .
rotated. The
elbow flexed to90 degree.
Exsanguination.

LANDMARKS :- Medial epicondyle of humerus

INSICION :- Curved incision 8-10cm on the
medial surface of elbow is made centering on
medial epicondyle.
INTERNERVOUS PLANE :-

Proximally:
Brachialis &
Triceps

Distally:
Brachialis & Pronator
Teres
SUPERFICIAL SURGICAL DISSECTION
ulnar nerve is isolated. skin retracted anteriorly with the fascia to
uncover the common origin of superficial flexor muscles of
medial epicondyle. inteval between pronator teres and
brachialis muscle is used.
Subperiosteal elevation beneath MCL is done or medial epicondyle is
osteotomized with ligament attached to it.
DEEP SURGICAL DISSECTION
Medial side of the joint exposed after

incising medial collateral ligament and capsule

Hotchkiss approach
• The Hotchkiss
approach between
flexor pronator
origin and
brachialis and
flexor carpi ulnaris
and triceps is
shown. FCR = flexor
carpi radialis; PL =
palmaris longus;
FCU = flexor carpi
ulnaris.
The Taylor and Scham approach is shown. The flexor carpi ulnaris and flexor
digitorum profundus are reflected from the medial aspect of the proximal ulna, to the
level of the coronoid and brachialis insertion. FCR = flexor carpi radialis; PL = palmaris
longus; FCU = flexor carpi ulnaris; MCL = medial collateral ligament.
STRUCTURES AT RISK
Ulnar nerve.
Median nerve and its main branch AIN with vigorous traction of
medial epicondyle or superficial flexor muscles

EXTENSION
Proximally :
b/w triceps and brachialis muscle subperiosteally
Distally:
exposure provides adequate view of the
brachialis inserting into coronoid. it cannot offer a more distal
exposure but only upto the branching off of the median nerve.
 ANTERIOR APPROACH OF CUBITAL
FOSSA
INDICATIONS :-
Repair of lacerations to the
Median nerve
Brachial artery
Biceps tendon
Radial nerve
Biceps tendon re-insertion
Posttraumatic anterior capsular contractures release
Excision of tumors
POSITION OF PATIENT :- Supine position with arm
in anatomical position

LANDMARKS :- Brachoradialis: fleshy wad

tendon of biceps: taut
INSICIONS :-

Curved boat-shaped .Begins 5 cm above the flexor

crease on the medial side of the biceps. Crosssing
the crease at 90 degrees must avoided.
INTERNERVOUS PLANE :- proximally b/w the
brachioradialis muscle and
brachialis muscle distally b/w
the brachoradlialis and
pronator teres .
SUPERFICIAL SURGICAL DISSECTIONS :-
The deep fascia is incised in line with the skin incision and the
numerous veins that cross the elbow in this area are ligated. Lateral
cutaneous nerve of the forearm (LCNFA) in the interval between the
biceps tendon and the brachialis, is identified and preserved.
Lacertus fibrosus is identified as the brachial artery is immediately
under it.
Brachial vein and median nerve lie medial to the artery.
DEEP SURGICAL DISSECTIONS:-
Used to explore the NV structures. If anterior capsule
needs exposure then Biceps and brachialis retracted
medially and BR laterally.
 STRUCTURES AT RISK

• 1. LCNFA a sensory branch of musculocutaneous nerve at distal ¼ of

the arm. Emerges between biceps & brachialis.
• 2. Radial artery
• 3.PIN
Eponymous Approaches
Eponymous Approaches
Eponymous Approaches
Elbow instability
ANATOMY
SOFT TISSUE ANATOMY

• Lateral collateral ligament complex:

• Lateral ulnar collateral ligament
• Radial collateral ligament
• Annular ligament
• Accessory lateral collateral ligament
 SOFT TISSUE ANATOMY
• Medial collateral ligament complex:
• Anterior bundle (valgus stress 30-120)
• Posterior bundle./ Bardinet ligament (2ry resistant to valgus stress) :
best at 90’
• Transverse ligament /ligament of cooper : limited to ulna.
STABILIZING FACTORS
STATIC STABILIZERS DYNAMIC STABILIZERS

• PRIMARY:
• Ulno humeral joint • ANCONEUS
• MCL
• LCL
• TRICEPS
• SECONDARY: • BRACHIALIS
• RADIAL HEAD
• CFO&CEO
• CAPSULE
 PATHOMECHANICS
• common mode of trauma :fall on out stretched hand

• Mechanism of injury:

• Extension of the elbow till contact

• Upon contact ; flexion will begin

• External rotation of the UHJ (triceps effect)

• Internal rotatio of humerus against forearm

• Valgus moment (mechanical axis)

• Combination of ER., valgus and axial compression…….

Instability.
• Functional ROM : 30° to 130 flexion(full ROM is 0-150 degrees)
• (50° supination & 50° pronation) 80/80
• Normal valgus carrying angle (M:7° & F:13° ) diminishes with flexion 
• Axial loading in extended elbow 
• 40% of weight is through ulnohumeral joint
• 60% of weight is through radiohumeral joint
• LCL : 14% varus stability (full extension)
• : 9% @ 90 degree flexion
• MCL @ 90 degree flexion : 55% valgus stability
• In extension :
• Ant. Capsule: 70% restraint to distraction
• Valgus stress test : equally divided with MCL,
CAPSULE AND JOINT SURFACE
• Varus stress test is limited equally by LCL, CAPSULE
AND JOINT SURFACE
• In flexion:
• MCL : 1ry stabilizing str. Resisting valgus.
• Radial head: 2ry
• Joint articulation : 75% stabilizing in varus strain
CLASSIFICATION

Can be based on:

• ARTICULATION INVOLVED

• DIRECTION OF DISPLACEMENT

• DEGREE OF DISPLACEMENT

• TIMING

• SIMPLE OR COMPLEX
• HORII CIRCLE OF DISRUPTION

• 3STAGES:
▫ 1: Postero lateral rotatory subluxation
▫ 2: incomplete dislocation
▫ 3: a: AMCL intact
▫ 3:b: no ligaments intact
▫ 3:c :flexor pronator origin affected
• Traumatic types
• A. Acute elbow dislocation .
• Simple
• Complex ( associated with fractures )

• B. Chronic / Recurrent .
• Lateral elbow instability
• Medial elbow instability
• Recurrent elbow dislocation
• Chronic non reduced elbow dislocation

• Non-traumatic types :
• Rheumatoid arthritis
• Connective tissue disorders
• Gouty arthritis
DIAGNOSIS & MANAGEMENT

• Diagnosis of acute dislocation

• Diagnosis of Postero-lateral instability

• Diagnosis of complex instability

• Diagnosis of valgus instability

DIAGNOSIS
ACUTE DISLOCATIOAN
• Radiological finding of AP, LAT and OBL views.

• Assessment of instability through ROM

• If unstable, test for varus and valgus stability:

• Full pronation for the valgus stress test

• Internal rotation of the shoulder for varus test.

• Both should be examined in full extension and 30 deg. Flexion

• Stress x-ray views are important.

DIAGNOSIS
POSTEROLATERAL INSTABILITY
• Symptoms:
• Variable presentation
• Pain, clicking popping and snapping on certain positions.
• History of trauma or surgery.

• Signs:
• Lateral pivot shift.
• Drawer test
• Table top relocation test
• Active floor push up sign
• Chair sign
Clinical tests for posterolateral rotatory instability
of the elbow
• Patient supine,
affected limb
overhead. forearm
supinated, valgus and
axial loading applied,
elbow is flexed from
full extension.
In posterolateral
rotatory instability as
the
• elbow is flexed the
radial head
subluxes/dislocates
posterolaterally.
Posterolateral rotatory drawer test
Active floor push-up sign
Chair sign
Table-top relocation test
DIAGNOSIS
POSTEROLATERAL INSTABILITY
• Radiological evaluation:
• A)x-ray:
• For associated fractures( head radius and coronoid)
• Impression fracture
• Drop sign of the elbow
• Imaging during pivot shift
• B) MRI:
• Of little value
• Arthroscopic diagnosis:
• Shows widening of lateral edge of the joint, elongation of lateral ligament.
• IT IS A CLINICAL DIAGNOSIS
MANAGEMENT
POSTEROLATERAL INSTABILITY
• The key is to regain the function of
LCL.
• It is done by:
• Correction of bony element if present.
Surgical repair : (in acute cases :No
good results)
Reconstruction with tendon graft and
fixation( different fixation tech.)
Recently, arthroscopic assisted
reconstruction or electro thermal
shrinkage.
Treatment of lateral elbow instability
• Acute lateral ligament repair
• Depicting transosseous repair
with a running, locking suture
passed through the humeral
isometric point and tied over
the posterior humeral column
 Treatment of medial elbow instability
• Classic Jobe ulnar collatereal
ligament reconstruction.
•The docking
technique creates
a humeral tunnel
that accepts both
limbs of the graft
with tensioning
performed
through superior
exit holes
HINGED EXTERNAL FIXATOR
• DYNAMIC OR STATIC
• STATIC FIXATOR : Easily applied , no elbow motion
• DYNAMIC FIXATOR: demanding frame , active and passive.
• Indiations:
• Temporary stabilization
• persistent elbow instability
• protection of comminuted radial head or capitellum
• Maintenance of elbow stability in the setting of comminuted coronoid fractures
• Hinged fixators also hava role in providing stability in chronic unreduced elbow
DIAGNOSIS
COMPLEX INSTABILITY

• Elbow dislocation associated with bony element.

• Uncommon, poor prognosis.

• Most common: radial head and coronid fracture

• Others include: transolecranon , terrible triad & posterior monteggia

VALGUS INSTABILITY
• Mainly occurred in throwing athletes.1st discovered 1946.
• MCL injury is the cause.
• Diagnosis based on :
• History
• +ve valgus stress test( baseball player ….+ve)
• MRI . MR arthrography with gadolinium.
• Dynamic ultrasonography
• contraindicated (for surgery ):
• Asymptomatic athletes who will quit the game
• Patient associated with HumeroUlnar arthritis.
complications:
• Vascular injury
• Nerve palsy
• Re dislocation
• Residual Subluxation
• Residual instability
• Elbow stiffness ( early ROM)
• Heterotopic ossification
TAKE HOME MESSAGE
• Stability of the elbow is gained by osseus and soft tissue.

• Ulnar lateral collateral and anterior band of medial collateral are the
passwords for elbow stability.

• Horri circle will define the degree of displacement.

• Homework of elbow dislocation does not end by reduction the

stability before going home.

• X-ray is important to assess simplicity of dislocation.

• Instability of the elbow is mainly a clinical entity

ELBOW DISLOCATION
 EPIDEMIOLOGY
• Elbow dislocation accounts for 11 to 28 % of elbow injuries
• Posterior dislocation is most common accounts for 80 to 90 %
• Simple dislocations are purely ligamentous with no associated
fractures
• The elbow is the second most commonly dislocated joint in the adult
• Complex dislocations less than 50% of elbow dislocations
• Highest incidence occurs in the 10 to 20 year old age group
• Elbow dislocation is usually is a high energy episode with severe soft
tissue injury
• Residual loss of motion is common
• Half of dislocations are result of sports with males at highest risk
during football
• Females during gymnastics and skating
• Recurrent dislocation is uncommon
 STABILITY
• Lateral collateral ligament of
elbow arises from the
epicondyle and inserts on
annular ligament
• Lateral ligamentous complex
• Disruption lateral complex
results in posterolateral rotatory
instability
• Lateral collateral ligament contributes
• 14% of varus stability of elbow with the joint in full extension
• Only 9% with the joint in 90 degree of flexion
The remainder of stability is contributed by the bony articular surface and the
anterior capsule
• Medial collateral ligament plays
important role in valgus stability
• MCL has three
parts(anterior,posterior,transverse
oblique)
• Valgus stability is divided equally
among MCL,anterior capsule,and
bony articulation
• At 90% of flexion ,MCL provides 55%
of stability to valgus stress
• Anterior bundle being the primary
stabilizer
 MECHANISM
• Simple elbow dislocations are typically the result of fall on an
outstretched hand
• Valgus ,axial,and posterolateral force that results in the typical
posterolateral dislocation
• Soft tissue injury begins on the lateral side of elbow with disruption of the
lateral collateral ligament(LCL)
• Than capsule to the medial side with medial collateral ligament(MCL)
• MCL may remain intact in some injuries
• Less commonly varus,axial and posteromedial force ,injury begins from
medial to lateral resulting in anteromedial coronoid fracture
CLASSIFICATION
• Simple elbow dislocation are often described based on direction of
dislocation
• The majority of dislocations are posterior and posterolateral
• However, anterior ,medial,lateral and divergent dislocations are
possible
• They can be classified as acute,subacute(less than 6 weeks)and
chronic
• Simple verses complex(associated with fracture)
FRACTURE-DISLOCATIONS
• Associated radial head fracture-5 to 11 % of cases
• Associated medial and lateral epicondyle fracture-12 to 34%
• Associated coronoid process fracture-5 to 10 % secondary to avulsion
by brachialis muscle and are most common with posterior dislocation
REGAN AND MORREY
• Type 1:avulsion of tip of
coronoid process
• Type 2:single or comminuted
fragment involving 30 % of
coronoid process or less
• Type 3:single or comminuted
fragment involving greater than
50 % of coronoid process
TERRIBLE TRIAD INJURIES
• occur by posterolateral rotatory displacement of ulna ,resulting in elbow
subluxation or dislocation
• The proposed mechanism is a fall onto an outstretched arm,with
supination,valgus,and axial-directed force
• The trochlea causes a shear fracture of the coronoid and is accompanied by
an LCL injury and/or radial head fracture
• Open reduction and internal fixation includes fixation or replacement of
radial head ,faxation of coronoid fragment and repair of LCL
• The elbow is than evaluated intraoperatively for residual instability to
determine if MCL repair is required or rarely if an external fixator is needed
 RADIOGRAPHIC EVALUATION
• Anterolateral,lateral and 45
degree oblique
radiograph(radiocapitellar joint
and trochlear joint)
• Drop sign(widening of
ulnohumeral joint) represent
significant capsular disruption
and persistent subluxation
• Lateral radiograph is obtained to
show opening on medial side of
elbow to gravity stress
• Godolinium-enhanced MRI or CT (T
sign as a leak of contrast material
around the humerus or ulna
without extracapsular leakage)

• USG to evaluate the ulnar collateral

ligament in relaxed and stressed
positions
 SIGNS AND SYMPTOMS
• Pain
• Deformity
• Swelling
• Medial ecchymosis sign of MCL
disruption
• Radial pulse examination
• Serial neurological examinations
if compartment syndrome is at
risk
• Tenderness and swelling 2 to 3 cm distal to olecranon tip indicate
olecranon stress fracture
• Active and passive range of motion
• Valgus stress with forearm in supinated and pronated position and
elbow in about 30 degree of flexion(medial opening,firmness of end
point,medial pain should be noted)
• Valgus extension overload test(elbow is passively extended from 30
degree down) is most accurate test for ulnar collateral ligament
competence
GENERAL TREATMENT PRINCIPLES
• Restore the inherent elbow stability
• Restore the trochlear notch of ulna particularly the coronoid process
• Radiocapitellar contact is very important for stability
• LCL is more important than MCL in setting of traumatic dislocations
• The trochlear notch(coronoid and olecranon),radial head and LCL
should be repaired
• MCL will usually heal properly with active motion and its repair is not
necessary for stability
NONOPERATIVE TREATMENT
• Acute simple dislocation should undergo CR under sedation
• Correction of medial or lateral displacement followed by longitudinal
traction and flexion is successful for posterior dislocation
• For stable elbow early ROM is indicated
• For unstable elbow,an elbow splint is used to control ROM
• Blocking extension at 45 degree 1 week,30 degree for next week and
allowing full motion thereafter
NONOPERATIVE TREATMENT
• INDICATION
• Closed elbow dislocation
• RELATIVE CI
• Open dislocation
• Vascular injury
• Instability after closed reduction
 REDUCTION TECHNIQUE
• PARVIN’S METHOD
patient lies prone on stretcher
physician applies gentle downward
traction of wrist for few minutes
As the olecranon begins to slip
distally ,the physician lifts up gently on the
arm
No assistant and anesthesia is required
• MEYN and QUIGLEY’S METHOD
• Only the forearm hangs from the
side of the stretcher
• As gentle downward traction is
applied on the wrist
• Physician guides reduction of
olecranon with the opposite hand
OPERATIVE TREATMENT
• INDICATIONS
• If elbow redislocates when flexed to less than 30 degree
• Inability to maintain a concentric elbow joint after closed reduction or a
recurrent dislocation
• Unstable dislocations that require prolonged immobilization
• Open dislocations
• Vascular disruption
• Irreducible dislocations
• Intra-articular entrapment of fracture fragment
OPERATIVE TREATMENT MODALITIES
• Open reduction with direct repair of ligaments, capsule and muscle
origin
• Static or hinged external fixation
• Cross-pinning of joint
• Temporary bridge plate
POSITIONING
• Supine on operating table
• Posterior midline incision
• A full thickness lateral flap is elevated on deep fascia
• Kocher interval between the anconeus and ECU for exposure of LCL
• If medial structures require repair,full thickness elevation of medial
flap is performed and ulnar nerve is identified and protected
EXTERNAL FIXATION
• Hinged fixator (dynamic) or static fixator
• The key to hinged fixator is an understanding
of axis of elbow rotation
• Care must be taken not to damage the ulnar
nerve while inserting axis pin and
• Radial nerve while inserting the humeral pins
• Elbow motion is initiated postoperatively
within first week
• Frame is kept in place for 4 to 6 weeks
depending upon
• stability of elbow ,associated pin tract
problems
CROSSED-PINS OR SCREW
• It is reserved for use only as a salvage
procedure
• Used where an external fixator is not
available or patients are not candidate
for external fixator
• The elbow is concentrically reduced and
a screw or pin is placed from posterior
aspect of ulna ,across the joint,exiting
on posterior border of humerus
• 4.5 mm cortical screw is appropriate
• The elbow is placed into cast for 3 to 4
weeks and then screw is removed
• Alternatively a steinman pin can be
used
BRIDGE PLATE
• In patients with residual instability that are not candidates for external fixator
• Morbid obese patients and patients with neurologic injuries such as spasticity
or flaccid paralysis
• After repair of collateral ligaments ,a narrow 4.5 mm large fragment locking
plate is bent to 90 degree
• A triceps splitting approach is used proximally to identify and protect the
radial nerve
• Three to four locking screw are placed in ulna and distal humerus avoiding
articulation and fossae
• The plate is removed at 4 weeks
RECONSTRUCTION SURGERY
• MRI evaluation are used to delineate the soft tissue and bony
anatomy
• Surgical intervention is directed towards the side of greatest
instability ,generally the lateral side
• Repair of capsule,primary ligamentous reconstruction and the
reattachment of the tendon origins usually is necessary to obtain a
stable joint
• Significant fractures that result in joint instability must always be
repaired
POSTOPERATIVE CARE
• Splint with elbow at 90 degree of flexion and forearm in pronation
• Ideally the dressing will be removed and motion begun 48 hours after
surgery unless static fixation
• The precise rehabilitation protocol will depend on the integrity of
ligaments
• If MCL is intact and LCL requires protection ,forearm is kept in
pronation
• Varus positioning of arm should be avoided in patients with LCL
injuries
PITFALLS AND PREVENTION
• Residual instability after inadequate or failed repair of lateral structures
may lead to persistent dislocation
• Early recognition and extensive reconstruction including elbow release
and LCL and MCL reconstruction can decrease residual instability
• Early postoperative motion is mandatory to prevent stiffness(may require
elbow release or excision of heterotopic bone ,use of endomethacin)
• Nerve palsies are uncommon but ulnar and radial nerves art risk with
placement of external fixator can be minimized by direct visualization of
bone while placement of pin
COMPLICATIONS
• Elbow stiffness
• Redislocation
• Residual subluxation
• Brachial artery is most commonly disrupted during injury
• Ulnar nerve is most commonly involved
• Persistent instability incidence is increased in terrible triad of elbow
• Compartment syndrome(volkmann contracture) from massive swelling due to soft
tissue injury
• Arthrosis may result from persistent elbow instability ,greater association with fracture
dislocation
• Heterotopic bone/myositis ossificans
TENNIS ELBOW
Introduction

▪ Also known as Lateral epicondylitis

▪ The most common overuse syndrome

▪ More common : in non tennis players
▪ Incidence: 1-3%
▪ Men=Women
▪ Usually in people early 5th decade
 History
▶ A British surgeon, Mr. R. S. Garden , reported in a paper published in 1961 that a German physician, F. Runga,
described the condition in 1873
▶ Originally described as “the lawn tennis arm,” in which frequent use of the backstroke leads to a sprain of the
“pronator radii teres” muscle which is now called extensor carpi radialis brevis (ECRB)
 Pathophysiology
▶ In a thorough Histo-pathological analysis, specimens of injured tendon from areas of chronic overuse did not
contain large numbers of lymphocytes, macrophages, and neutrophils. So lateral epicondylitis is a misonomer

▶ Nirschl and Pettrone in 1979, studying the origin of the ECRB, described the pathoanatomy of the area as an
angiofibroblastic tendinosis.

▶ Tendinosis is a degenerative process characterized by large populations of fibroblasts, disorganized collagen,

and vascular hyperplasia
Clinical features
History

▶ Common age group: 40-50 yrs

▶ Pain over lateral elbow, usually is exacerbated by

resisted wrist dorsiflexion and forearm supination.
▶ Difficulty in holding heavy objects.

▶ h/o repeated wrist extension activity.

Clinical features
Examinatioin
▶ LOOK: Swelling over lateral elbow ( Very rare)
▶ FEEL: Maximal tenderness 5mm distal to origin of ECRB at lateral
epicondyle

▶ Special tests:
Cozens
Thomsons
Mills
Chair
Maudsley
 Clinical examination

Cozen’s test

▶ Elbow stabilized by
thumb on lateral
condyle of humerus
▶ 1st ask patient to make
fist – pronate forearm –
extend the wrist
applying resistance by
examiner.
▶ Positive: when there is
sudden severe pain in
that area.
Thomsen’s Test:

▶ Ask patient to
clench the fist ,
dorsiflex the wrist
and extend the
elbow. Examiner
gives forceful
palmar flexion
against patient’s
resistance.
▶ Positive : pain over
area
Mill’s Test
(Passive)

▶ While palpating
lateral
epicondyle – flex
the elbow and
fully pronate the
hand, now
extend the
elbow.
▶ Positive: pain
over area
Chair test :

▶ Asked patient to
lift a chair with
elbow straight and
shoulder flexed at
60 degree
▶ Difficulty to
perform this with
pain over lateral
aspect : positive
Maudsley’s Test

▶ Resists extension
of 3rd and 4th digit
of the hand ,
stressing
extensor
digitorum muscle
and tendon.
▶ Positive test:
pain over lateral
epicondyle
Investigations
1. Laboratory: Not useful
2. Imaging: Rarely needed.
Plain X ray if the patient's symptoms persist
despite adequate treatment or to evaluate for
osteophytes/degenerative joint disease
MRI shows ECRB tendon thickening at lateral
epicondyle with increased T1 and T2 signal intensity.
Musculoskeletal USG : Emerging as useful
modality
Differential diagnosis
▶ RADIAL TUNNEL SYNDROME ( compression of PIN)
▶ RADIAL NECK FRACTURE
▶ BURSITIS
▶ CHRONIC IRRITATION OF THE RADIOHUMERAL JOINT OR
CAPSULE
▶ CERVICAL RADICULOPATHY ( any pathology to the cervical
nerve roots)
▶ RADIOCAPITELLAR CHONDROMALACIA OR ARTHRITIS
▶ PANNER’S DISEASE ( Osteochondrosis of the capitellum of the
elbow )
▶ LITTLE LEAGUE ELBOW ( Avulsion of medial epiphyseal plate )
▶ OSTEOCHONDRITIS DISSECANS OF THE ELBOW (loss of B/S to
elbow cartilage)
Radial Tunnel Syndrome
▶ It occurs by intermittent compression on the radial
nerve as it passes from the radial head to the inferior
border of the supinator muscle, without obvious
extensor muscle weakness

▶ The main clinical feature of RTS is a localized

tenderness over the radial nerve 5 cm distal to the
lateral epicondyle.
CURRENTLY USED TREATMENT
▶ 1. Conservative bracing

▶ 2. Eccentric strengthening exercises

▶ 3. Dry needling / acupunture

▶ 4. Nitrate patches

▶ 5. Physiothearpy/Shock wave treatment (Ultrasound,

iontophoresis, electrical stimulation)

▶ 6. Cortisone injections

▶ 7. Platelet Rich Plasma/ Autologous blood injection

▶ 8. Surgery
Conservative: 95%

▶ 1. Activity modification.

▶ 2. Ice , rest and NSAIDS with decreasing supination-

pronation, and heavy weight lifting can be modified or
eliminated.
▶ 3. Avoidance of grasping in pronation with control
supination lifting.
▶ 4. Lifting should be done with palm up whenever
possible and both extremities should be used in a
manner that reduces forcible elbow extension ,
supination and wrist extension.
▶ Counterforce Bracing:

A. Used only during actual aggravating activity.

B. some authors recommend 6-8 weeks use in a
wrist splint positioned at 45 degres of dorsiflexion.
C. Range of Motion Exercises.
 Local injections of steroid
➢ 1 or 2 local injections of steroid preparation at
maximum area of tenderness. (complete the lesion )
OTHER TREATMENT
▶ Physiotherapy : extracorporeal shock wave
therapy/ultrasound therapy/TENS/SWD helps in most of
the cases but gave uncertain results in some of them.
▶ Autologous blood injection has been shown to be
beneficial in certain patients.

▶ Platelet-rich plasma (PRP) injections have been

reported to be more effective than corticosteroid
injections.
▶ Autologous blood injections were more successful than
PRP.
Operative Treatment
▶ Boyd and McLeod
excision of the proximal portion of the annular
ligament, release of the entire extensor origin, excision of
an adventitious bursa (if found), and resection of
hypertrophic synovium in the radiocapitellar articulation.

▶ NIRSCHL,MODIFIED
Currently, we favor a more limited approach, which
consists of exposure of the diseased ECRB origin, resection
of degenerative tissue, and direct repair to bone.
▶ Patients who will improve after surgery do so within 3
to 4 months. 1 year is a reasonable period to consider
repeat intervention if symptoms have not improved.

▶ Percutaneous lateral release has been reported to be

as effective as open release. (does not remove diseased
tendon, but it may trigger the inflammatory cascade,
which leads to the resolution of symptoms.)
▶ Arthroscopic
release has been
reported to
obtain results
equal to those of
open procedures
with several
advantages.
ACTIVITY INJURIES

Bowling :Biceps tendinosis, radial tunnel syndrome

Boxing: Triceps tendinosis
Friction in football, wrestling or basketball :Olecranon bursitis
Golf : Golfer's elbow (trailing arm), radial tunnel syndrome
Gymnastics :Biceps tendinosis, triceps tendinosis
Posterior dislocation : Posterolateral rotatory instability
Racquet sports :Pronator syndrome, triceps tendinosis, olecranon stress
fracture,
lateral tennis elbow, radial tunnel syndrome,
golfer's elbow, ulnar nerve entrapment
Rowing/Swimming: Radial tunnel syndrome
Skiing: Ulnar nerve entrapment
Throwing :Pronator syndrome, triceps tendinosis, olecranon impingement,
olecranon stress fracture, radiocapitellar chondromalacia,
ulnar collateral ligament sprain, golfer's elbow, ulnar nerve
entrapment
Weight lifting : Biceps tendinosis, triceps tendinosis,
anterior capsule strain, radial tunnel syndrome, ulnar nerve
entrapment