ACQUIRED DEFORMITIES

1. CUBITUS VALGUS
The normal carrying angle of the elbow is 5–15 degrees of valgus; anything more than this is
regarded as a valgus deformity, which is usually quite obvious when the patient stands with arms
to the sides and palms facing forwards.

The commonest cause is longstanding non-union of a fractured lateral condyle; the deformity
may be associated with marked prominence of the medial condylar outline. The importance of
cubitus valgus is the liability to delayed ulnar palsy; years after the causal injury the patient
notices weakness of the hand, with numbness and tingling of the ulnar fingers. The deformity
itself needs no treatment, but for delayed ulnar palsy the nerve should be transposed to the Front
of the elbow. Great care is needed in performing the operation. Excessive dissection of the nerve
or rough handling can impair nerve function.

2. 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.

3. SUBLUXATION OF THE RADIAL HEAD

This is commonly associated with bone dysplasias in which the ulna is disproportionately
shortened (e.g.hereditary multiple exostosis). It usually causes little disability, but if it becomes
too troublesome the radial head can be excised after all growth has ceased.

14.4 Cubitus valgus (a) This man has excessive valgus of the right elbow. But his main
complaint was of weakness and deformity in the hand, which was caused by traction on the ulnar
nerve secondary to the elbow deformity. (b) Valgus deformity from an un-united fracture of the
lateral condyle.
14.5 Cubitus varus (a) Note that the elbows are normally held in 5–10° of valgus (the carrying
angle). (b) This young boy ended up with slight varus angulation after a supracondylar fracture
of the distal humerus. The deformity is much more obvious (c) when he raises his arms (gun-
stock deformity).

14.6 Dislocated radial head (a) Anterior dislocation from old Monteggia fracture; (b) posterior
dislocation, most likely congenital.

4. 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.

5. ‘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. There may be a history of the child being jerked by
the arm and 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. The radial head can be forcibly pulled out of the noose of
the annular ligament only when the forearm is pronated; even then the distal attachment of the
ligament is sometimes torn. If the history and clinical picture are suggestive, an attempt should
be made to reduce the subluxation or dislocation. While the child’s attention is diverted, the
 elbow is quickly supinated and then slightly flexed; the radial head is relocated with a snap.
(This sometimes happens ‘spontaneously’ while the radiographer is positioning the arm!)

STIFFNESS OF THE ELBOW

Stiffness of the elbow may be due to congenital abnormalities (various types of synostosis, or
arthrogryposis),infection, inflammatory arthritis, osteoarthritis or the late effects of trauma.
Most of these conditions are dealt with in other chapters. Here consideration will be given to
post-traumatic stiffness, which is an important cause of disability.

1. POST-TRAUMATIC STIFFNESS
For reasons that are not entirely clear, the elbow is particularly prone to post-traumatic stiffness.
The more obvious causes (as with other joints) are either extrinsic (e.g. soft-tissue contracture or
heterotopic bone formation), intrinsic (e.g. intra-articular adhesions and articular incongruity), or
a combination of these. Clinical assessment should include examination of all the joints of the
upper limb as well as an evaluation of the functional needs of the particular patient. 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.

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

OPERATIVE TREATMENT
The indication for operative treatment is failure to regain a functional range of movement
at 12 months after injury. There are a few caveats: the limb as whole should be useful; there
should be no over-riding neurological impairment; and the patient should be cooperative and
motivated. If there is heterotopic lossification, it is important to wait until the bone is‘mature’,
i.e. showing clear cortical margins and trabecular markings on x-ray. There is no point in a
softtissue release if the x-ray or CT shows that bone incongruity is blocking movement.
The objectives are determined by the type of pathology. Heterotopic bone can be excised.
Capsular release or capsulectomy (open or arthroscopic) may restore a satisfactory range of
movement. Intra-articular procedures include fixing of ununited fractures or correction of
malunited fractures.
Post-traumatic radio-ulnar synostosis sometimes follows internal fixation of fractures of
the radius and ulna. It is treated by resection when the synostosis has matured (this takes about
one year) followed by diligent physiotherapy.

RECURRENT ELBOW INSTABILITY

Following a dislocation or severe sprain, the lateral collateral ligament can be stretched or
ruptured. 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.
The lateral collateral ligament can be directly repaired or reconstructed with a tendon
autograft (e.g. palmaris longus).
 Medial instability is less frequent after trauma; a chronic instability can develop in javelin
throwers and baseball players. Ligament reconstruction with a tendon graft and careful graduated
rehabilitation can give very good results.

EPICONDALGIA
The elbow is prone to painful disorders of the tendon attachment. Sometimes this occurs
spontaneously, sometimes after sudden unaccustomed use. These conditions have acquired
names derived from the activities in which they were encountered when they were first
described.

1. TENNIS ELBOW (LATERAL EPICONDALGIA)

Pain and tenderness over the lateral epicondyle of the elbow (or, more accurately, the bony
insertion of the common extensor tendon) is a common complaint among tennis players – but
even more common in non-players who perform similar activities involving forceful repetitive
wrist extension. It is the extensor carpi radialis tendon (which automatically extends the wrist
when gripping) which is pathological in tennis elbow (Fig. 14.16). Like supraspinatus tendinitis,
it may result in small tears, fibrocartilaginous metaplasia, microscopic calcification and a painful
vascular reaction in the tendon fibres close to the lateral epicondyle.

14.16 Tennis elbow (a) Tenderness over the anterior aspect of the lateral epicondyle; (b) pain
provoked by resisted wrist extension; (c) tennis elbow surgery – the abnormal extensor carpi
radialis brevis origin is excised.

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 involving forceful gripping and wrist extension. It is usually
localized to the lateral epicondyle, but in severe cases it may radiate widely. It is aggravated by
movements such as pouring out tea,turning a stiff doorhandle, shaking hands or lifting with the
forearm pronated. Among tennis players it is usually blamed on faulty technique.
The elbow looks normal, and flexion and extension are full and painless.
Characteristically there is 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. X-ray is usually normal, but occasionally shows calcification
at the tendon origin.
Diagnosis
In patients with longstanding symptoms which do not respond to treatment, the possibility of a
painful radial nerve entrapment (‘radial tunnel syndrome’) should be considered (see Chapter
11).

Treatment
Many methods of treatment are available but the benefits of most are unclear; it is well to
remember that 90 per cent of ‘tennis elbows’ will resolve spontaneously within 6–12 months.
The first step is to identify, and then restrict, those activities which cause pain. Modification of
sporting style may solve the problem. A tennis elbow clasp is helpful. The role of physiotherapy
and manipulation is uncertain. Injection of the tender area with corticosteroid and local
anaesthetic relieves pain but is not curative.

OPERATIVE TREATMENT
Some cases are sufficiently persistent or recurrent for operation to be indicated. The origin of the
common extensor muscle is detached from the lateral epicondyle. Additional procedures such as
division of the orbicular ligament or removal of a ‘synovial fringe’ are sometimes advocated;
they probably make very little difference to the outcome. Surgery is successful in
about 85 per cent of cases.

2. 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. Often there is an associated ulnar nerve neuropathy. A medial
collateral ligament injury should be excluded.
Treatment is the same as for lateral epicondylitis but the outcome of surgery seems less
predictable. The abnormal tissue at the flexor–pronator origin is excised, great care being taken
to preserve the medial collateral ligament. The medial antebrachial cutaneous nerve must be
respected during the skin incision to avoid a troublesome postoperative neuroma.
3. 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. The junior equivalent
(‘little leaguer’s elbow’) is due to partial avulsion of the medial epicondyle. The only remedy –
however grudgingly accepted – is to stay off baseball until the condition clears up completely.
4. JAVELIN THROWER’S ELBOW
The over-arm action employed by javelin throwers may avulse or cause impingement upon the
tip of the olecranon process. However, this sport (like other throwing sports) places huge strain
on the medial collateral ligament which can become either acutely injured or chronically
attenuated. There may also be symptoms of ulnar nerve impairment. The pain usually settles
down after a period of rest and modification of activities. However, an attenuated medial
collateral ligament may need reconstruction with a tendon graft.