Epicondylitis

Short-term management of acute ankylosing spondylitis, acute and subacute bursitis, acute nonspecific tenosynovitis, acute gouty arthritis, psoriatic arthritis, rheumatoid arthritis, post-traumatic osteoarthritis, synovitis of osteoarthritis, epicondylitis... 

Rheumatic disorders Adjunctive therapy for short-term use (acute episode or exacerbation) in psoriatic arthritis rheumatoid arthritis (RA), including juvenile RA ankylosing spondylitis acute and subacute bursitis acute, nonspecific tenosynovitis acute gouty arthritis posttraumatic osteoarthritis synovitis of osteoarthritis epicondylitis. 

Miscellaneous (tendinitis, epicondylitis, ganglion) In tendinitis or tenosynovitis, inject into the tendon sheath rather than into the substance of the tendon. In epicondylitis, outline the area of greatest tenderness and infiltrate the drug into the area. 

LBP, stiff shoulder, epicondylitis and tendonitis. In soft tissue rheumatism pain at rest and/or during activity, stiffness, tenderness, and disability are the predominant features. Physical deformities are minimal but disabilities are major problems. 

Scapulohumeral periarthritis, periarthritis of hip, bursitis, tendinitis, synovitis, tenosynovitis, tarsalgia, metatarsalgia, epicondylitis, Du-puytren s contracture, Peyronie s disease, cystic tumors of aponeurosis or tendon (ganglia). 

FIGURE 49.25 Very small locus of instant center of rotation for the elbow joint demonstrates that the axis may be replicated by a single line drawn from the inferior aspect of the medial epicondyle through the center of the lateral epicondyle, which is in the center of the lateral projected curvature of the trochlea and capitellum. (From Morrey B.F. and Chao E.Y.S. 1976. /. Bone Joint Surg. 58A 501. With permission.)... 

Lateral epicondylitis (tennis elbow) Tendons attaching to the epicondyle of the humerus bone become irritated. 

Musculoskeletal disorders are disorders of the muscles, nerves, tendons, ligaments, joints, cartilage and spinal discs not caused by slips, trips, falls, motor vehicle accidents or other similar accidents. Examples are carpal tunnel syndrome, rotator cuff syndrome, De Quervain s disease, trigger finger, tarsal tunnel syndrome, sciatica, epicondylitis, tendinitis, Raynaud s phenomenon, carpet layers knee, herniated spinal disc, and low back pain. 

Epicondylitis This disorder results from the combined action of pronation of the hand and ulnar deviation. For example, swinging a hammer involves this combination of motions. Symptoms include pain in the elbow, forearm and hand. Epicondylitis also has activity-related names, such as carpenter s elbow or tennis elbow. 

Fig. 16.3 Schema of lateral surface of the femoral condyle. The proximal and posterior area is covered by the attachment of lateral head of the gastrocnemius (pink area). Tunnel outlets are often located at this area with the transmedial portal technique. Deep knee bend > 135° is needed to move the tunnel outlets to the area that is not covered with thick soft tissues green area). Red dot. Lateral epicondyle. Blue line Attachment of the joint capsule...

Fig. 16.5 (a) Simulation of aperture for 9-irun diameter tunnel blue oval) placed on the ACL footprint red area) to cover the footprint area as much as possible, (b) Arthroscopic view of single-bundle reconstruction covering the ACL footprint with the oval-shaped tunnel aperture. The diameter of the socket is 8 mm. (c) Schema of lateral view of the femoral condyle. Lines of 45 and 60° anterior from the proximal-distal axis are drawn from the lateral epicondyle red dot). An area around 2 cm from the lateral epicondyle on the lines is indicated green area). Pink area Attachment of the lateral head of gastrocnemius. Blue line Attachment of the joint capsule... 

Sleeve avulsion fractures are a particular form of avulsion injury seen in the unossified skeleton which differs from avulsions in adults because the sleeve of periosteum which is pulled off can continue to form bone if not treated. The typical location is at the lower pole of the patella, but the upper pole of the patella, the olecranon and the medial epicondyle can also be affected. Ultrasound demonstrates a sleeve of cartilage that has been avulsed usually with a small fragment of bone (Hunt and Somashekar 2005). In some cases a double cortical sign may be present, indicating elevation of a superficial layer of cortex from the underlying bone. There maybe associated haemarthrosis and patella alta (Fig. 4.14). 

Fig. 7.17. a Irregular ossification centre for the trochlea is projected over the joint space with rotation (arrow). This also produces simulated dislocation of the ossification centre for the medial epicondyle (arrowhead), normally sited on the AP view (b)... 

In children repetitive traction forces can result in microtrauma to the apophysis, for example injury to the physis of the internal epicondyle of the elbow. This occurs in gymnasts and in activities with repetitive throwing giving it the name little leaguers elbow . 

An estimation of the distribution of fracture patterns about the elbow is supracondylar (70%), lateral condyle (15%), medial epicondyle (10%), olecranon (5%), radial neck (1%), medial condyle (1%), capitel-lum (1%), T condylar (<1 %). 

Medial epicondyle 5-8 Years 7-9 Years 20 Years 20 Years... 

Lateral epicondyle (extracapsular) 8-11 Years 9-13 Years Puberty Puberty... 

The medial and lateral epicondyles are extracapsular and fractures of these structures are not associated with capsular distension or displacement of the fat pads. 

Avulsion fractures of the medial epicondyle are seen between the ages of 9 and 15, after the apophysis becomes a separate ossification nucleus from the epiphysis of the distal humerus and before it fuses with the distal humerus. The medial epicondyle is a traction apophysis for the flexor group of forearm muscles, and also serves as an attachment for the ulnar collateral ligaments and the joint capsule. This injury accounts for up to 10% of elbow fractures. 

Based on AP and lateral radiographs, the normal curve following around the medial condyle is disrupted. In type III injuries, it can be easy to misinterpret the radiographs as normal, since the fragment may be difficult to identify, particularly on the AP view. It is important that the acronym CRITOE is used to assess the ossification centres about the elbow joint. The medial epicondyle ossifies before that of the trochlea. If the trochlea is seen then the medial epicondyle must be present (Fig. 18.14). A displaced medial epicondyle lying within the elbow joint should not be confused with the ossification centre of the trochlea. The diagnosis should always be considered if the epicond)de cannot be visualised at an age when it should be present. 

With Rang types III and IV, open reduction is required when the apophysis has become entrapped in the elbow joint following a dislocation (Fig. 18.16). Intra-articular fragments may be washed out and the ulnar nerve explored. In the case of elbow dislocation, if following reduction, the epicondyle is... 

Chronic stress injury of the medial epicondyle can cause degeneration of the common flexor tendon and enlargement, sclerosis, fragmentation and phy-seal widening around the medial epicondyle. It is often found in children involved in throwing sports due to repeated valgus stress around the elbow. It is often called little leaguers elbow . 

Clinically, there may be a palpable mobile epicondyle, crepitus and tenderness. 

Fig. 18.14. AP radiograph showing a displaced medial epicondyle within the joint mimicking the trochlea. The epicondyle was replaced at surgery...

Fig. 18.15a,b. Two children with moderately a and minimally b displaced fractures of the medial epicondyle... 

Fig. 18.16. a Fracture of the medial epicondyle associated with dislocation of the elbow (type IV). b Image intensifier radiograph demonstrates reduction of the elbow but the epicondyle is stuck in joint rather than in an anatomical position - arrowed, c Epicondyle fixed in correct position. 

Fractures of the radial neck maybe isolated injuries but can occur in association with medial epicondyle avulsions, fractures of the olecranon and dislocations of the elbow joint. 

Metaphyseal fractures can be classified according to mechanism of injury. The majority of injuries occur with the elbow in extension, the olecranon locked in the olecranon fossa and the maximum stress developed in the proximal metaphyseal region leading to fracture. When a valgus stress is applied, there may be asso ciated compression fractures of the radial neck and avulsion of the medial epicondyle. Varus stress is associated with radial head subluxation. 

B Extension Valgus Ulnar metaphysis fracture +/- medial epicondyle avulsion +/-radial neck fracture... 

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