Elbow Pathologies

The biceps is a muscle that allows the flexion of the elbow and the movement of supination (used, for example, to turn a key in a lock).

A rupture of this tendon can occur during elbow flexion against excessive resistance (eccentric flexion). This injury can be partial or complete and mostly affects men in their forties.

Clinically, during this movement against resistance, a snapping sensation may be felt, accompanied by sharp pain in the biceps. Visually, the biceps muscle retracts, and an asymmetry is visible compared to the shape of the biceps in the other arm (called the Popeye sign). A hematoma may also appear.

A complete rupture of the distal biceps leads to a loss of supination strength of 40-50% and a loss of flexion strength of 30%.

The diagnosis is primarily clinical. An MRI is also prescribed to evaluate the percentage of tendon rupture (in the case of partial injury), assess tendon quality, and document the degree of retraction. This MRI, to optimize the analysis of the biceps tendon, should be performed in a specific position of the elbow (flexed and supinated).

Treatment depends on the patient’s age and functional demand. Partial injuries are most often treated conservatively. In the case of a complete rupture in a young patient, surgical intervention is necessary, preferably within 2-3 weeks of the trauma. Indeed, the longer the delay between the trauma and the surgery, the more the tendon will be retracted. This will prolong the recovery time and reduce the healing potential. Postoperatively, in cases of rupture with a highly retracted tendon, residual stiffness with a slight deficit in elbow extension may occur.

The triceps is the muscle located on the back of the arm and is responsible for extending the elbow. In the case of a fall or repeated microtraumas, this tendon can be injured.

For partial injuries, especially if the lesion is small (<50%), a conservative treatment approach can be implemented.

In the case of a complete injury, surgical intervention should be considered to recover the function and strength of the arm in extension. After surgery, the arm is immobilized in an articulated brace for 6 weeks to gradually regain elbow function while promoting tendon healing.

This is the most common fracture around the elbow and typically occurs when there is a fall onto an outstretched hand with the arm extended.

If the fracture is minimally displaced, only a short period of immobilization may be needed. To prevent long-term stiffness of the joint, elbow mobilization (performed by the patient and in physical therapy) is started very soon after the injury. Conservative treatment is possible in the majority of cases.

When the fracture is significantly displaced, surgery is recommended. The type of surgery depends on the severity of the fracture and any associated injuries (present in 30% of cases).

It’s important to note that regardless of the type of treatment, there is a risk of long-term arthritis.

This type of fracture is less common than radial head fractures but more disabling, often requiring surgical intervention.

It typically occurs during a fall onto the elbow in a flexed position. The patient experiences sharp pain and difficulty extending the elbow. Clinically, the tip of the elbow is displaced upward (pulled by the triceps muscle), and active extension is limited or impossible.

Various types of osteosynthesis are available depending on the fracture type (number and size of fragments). After surgery, the elbow is immobilized in a cast with gradual mobilization. Removal of the osteosynthesis material can be considered after 1 year postoperatively if the patient experiences discomfort (as the material is located just under the skin in this anatomical area and may cause irritation or discomfort).

In patients aged 75 and older, clinical studies have shown that surgery (osteosynthesis) has poor outcomes due to secondary displacement of the osteosynthesis material caused by diminished bone quality, non-union, skin issues related to the presence of osteosynthesis material in an area where the skin is more fragile, and the risk of infection. Therefore, beyond a certain age, conservative treatment with a cast may be preferred.

This type of fracture is associated with a risk of long-term arthritis.

The dislocation of the elbow can occur following a fall on the outstretched hand. Depending on the severity of the trauma, the dislocation can cause, in this order: a lesion of the lateral collateral ligament (the main stabilizer on the lateral side of the elbow), followed by the anterior capsule of the elbow, and eventually, the medial collateral ligament.

A dislocation is termed “simple” when there are “only” ligamentous injuries. A dislocation is termed “complex” when it is also associated with one or more fractures. The terrible triad of the elbow is a complex elbow fracture. It is characterized by elbow dislocation associated with a fracture of the head and a fracture of the coronoid process of the ulna. In the context of this “terrible triad,” ligament damage is associated with fractures that increase elbow instability.

X-rays are necessary before any joint reduction procedure to determine whether it is a “simple” or “complex” dislocation.

Simple dislocations require reduction in the emergency department and immobilization after reduction (a cast immobilizing the elbow and wrist, elbow flexed at 90 degrees, called BAB cast: brachial-antibrachial cast). X-rays are also taken after reduction, in the cast, to confirm joint reduction and exclude associated fractures.

According to the clinical examination, wrist X-rays are also necessary to exclude associated injuries.

In the case of a fracture associated with dislocation, orthopedic consultation should be sought before any reduction procedure.

Elbow dislocation, whether associated with a fracture or not, requires evaluation by an orthopedic surgeon. Additional assessment by a CT scan may be necessary. The type of treatment will be decided based on the type of dislocation and secondary elbow stability after reduction.

Conservative treatment involves a period of strict immobilization for 7 to 10 days, followed by a removable splint for approximately 4-5 weeks to allow daily flexion-extension mobilization exercises. This helps regain range of motion (the elbow tends to stiffen after this type of trauma). Lifting weights is prohibited for 3 months to allow ligament healing.

Surgical treatment is indicated for fractures affecting elbow stability and involves open reduction and internal fixation of fractures. Depending on the cases and the assessment of elbow stability during surgery, ligament repair or reconstruction may be performed.

This type of fracture is complex and causes sequelae. Expect residual stiffness regardless of the treatment instituted, as well as long-term arthritis. Residual instability may also occur.

Osteoarthritis corresponds to the progressive wear and tear of the joint, leading to the complete disappearance of the cartilage that normally covers the joint surfaces. It is a degenerative disease with multifactorial origins.

The main causes include:

Post-traumatic (following a fracture or dislocation, for example)
Inflammatory (caused, among other factors, by inflammatory diseases such as rheumatoid arthritis)
Related to ligament insufficiency or joint overload (wear due to heavy and repetitive work)
Associated with osteochondromatosis (a rare and benign disease where the synovial tissue covering the joint develops abnormally, producing small cartilage nodules called osteochondromas. These nodules can irritate or damage the joint).

Primary osteoarthritis (i.e., with an unknown cause) is relatively rare (prevalence of approximately 2%).

Osteoarthritis can cause pain, progressive loss of mobility, and sometimes painful joint blockages (as in osteochondromatosis). Depending on the extent of osteoarthritis, it can irritate the ulnar nerve (tingling and/or decreased sensitivity in fingers 4 and 5, the ring and pinky fingers).

The primary diagnostic tool is X-rays. In some cases, a CT scan or arthrogram (CT scan combined with arthrography) may be necessary.

Treatment initially involves conservative measures with the use of pain relievers (anti-inflammatories) and activity modification (to reduce inflammation). Strict immobilization is not recommended in cases of osteoarthritis as it can worsen joint stiffness. Depending on the degree of osteoarthritis, cortisone injections may also be considered.

Surgical treatment may be considered in certain cases. The type of surgical treatment depends on the severity of osteoarthritis, predominant symptoms (pain versus loss of mobility), and the patient’s age.

a) Debridement with capsular release:

This involves resecting osteophytes (bony outgrowths that can cause movement limitations) and removing loose bodies (such as osteochondromas). This technique is indicated in cases of disabling mechanical blockages and moderate loss of mobility. The main complications are neurological injury (ulnar nerve injury) and the risk of recurrent stiffness.

b) Humero-ulnar interposition arthroplasty:

It involves applying a tendon graft (often fascia lata or Achilles tendon) as a “spacer” between the two main bones of the elbow joint (humerus and ulna, also called the cubitus). This prevents friction between the two bones, which are no longer covered with cartilage, and reduces pain.

c) Radial head prosthesis:

In cases of isolated osteoarthritis, for example, after a fracture of the radial head, a partial elbow prosthesis, at the level of the radial head, may be considered.

d) Total elbow prosthesis:

This surgery is indicated only in patients over 65 years of age with severe osteoarthritis and low demand for functionality. After this type of prosthesis, lifting heavy loads is strongly limited as it can cause loosening of the prosthesis over time. The indication for this type of prosthesis is therefore very limited.

The elbow is often defined as an "intermediate joint."