Basics
Description
- Results from destruction of articular surface between radiocapitellar and ulnotrochlear joints
- Characterized by pain and loss of motion, with swelling and instability in later stages
Epidemiology
Prevalence
- Elbow arthritis is uncommon.
- Affects males and females equally
- Primary osteoarthritis affects <5% of the general population (1).
- Rheumatoid arthritis of the elbow affects 0.5-1% of general population (2).
- 20-50% of patients with rheumatoid arthritis will have elbow involvement (2).
Etiology and Pathophysiology
- Primary osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, septic arthritis, crystalline arthropathy, inflammatory arthritis
- Primary osteoarthritis
- Usually affects dominant arm of middle-aged males with history of repetitive arm use (throwing athletes, heavy laborers)
- Symptoms often due to osteophyte formation.
- Rheumatoid arthritis
- Inflammatory attack on synovium with eventual damage to cartilage and bone.
- Posttraumatic elbow arthritis
- Most common in young males
- Malunion of displaced intra-articular radial head fracture leads to radiocapitellar osteoarthritis.
- Malunion of intra-articular distal humerus or proximal ulna fracture may also occur.
- Other inflammatory conditions: systemic lupus erythematosus, psoriatic arthritis, reactive arthritis, ankylosing spondylitis, etc.
Risk Factors
- History of strenuous, repetitive arm use
- Rheumatoid arthritis or other inflammatory state
- Prior elbow trauma or fracture
- History of septic arthritis
Diagnosis
History
- Pain and stiffness are primary presenting complaints.
- Assess timing and location of pain.
- Assess limitations of range of motion (loss of flexion vs. extension vs. rotation).
- Assess patient's functional limitations.
- Primary osteoarthritis often presents with pain at extremes of flexion and extension. Loss of extension is more common than flexion.
- Swelling, instability, and pain throughout range of motion occurs in severe stages.
- Rheumatoid arthritis presents with swelling, morning stiffness, pain throughout range of motion.
- Assess for polyarthralgias (MCP, PIP, wrist) and extra-articular signs of rheumatoid arthritis.
- Joint instability may occur in advanced rheumatoid arthritis.
- Pain at rest or at night or with passive range of motion may suggest infection.
Physical Exam
- Inspect joint for contractures, effusion, prior surgical scars.
- Assess active and passive range of motion.
- Normal adult range of motion is 0-150 degrees extension/flexion, 75 degrees pronation, and 85 degrees supination (1).
- Functional range of motion of elbow is 30-130 degrees extension/flexion and 50 degrees pronation and supination (1).
- Assess strength.
- May be decreased with long-standing arthritis, disuse, or acute pain
- Assess stability with varus/valgus stress.
- Assess neurovascular status.
- Ulnar nerve irritation may be reproduced with Tinel sign over ulnar cubital tunnel or acute flexion of elbow for 30-60 seconds.
Differential Diagnosis
- Fracture
- Capsular contraction
- Medial or lateral epicondylitis
- Cervical radiculopathy
- Paraneoplastic disease
- Acute viral arthritis
- Bursitis
Diagnostic Tests & Interpretation
Initial Tests (lab, imaging)
- Anteroposterior and lateral x-rays usually sufficient for diagnosis (3)[C].
- Evaluate for osteophytes, joint space narrowing or erosion, cyst formation.
- Look for posterior fat pad to rule out fracture of proximal radius.
- Labs: CBC with differential, C-reactive protein, erythrocyte sedimentation rate
Follow-up tests & special considerations
- CT for evaluation of loose bodies or suspected fracture malunion not visible on x-ray (3)[C]
- MRI for diagnosis of suspected osteonecrosis or infection (3)[C]
- Electromyelography (EMG) for evaluation of possible neurologic injury
- Blood cultures if septic arthritis suspected
Diagnostic Procedures/Other
Consider arthrocentesis to rule out septic or crystalline arthritis.
Treatment
General Measures
- Initial treatment depends on underlying etiology, degree of pain, and functional limitation.
- Goals of treatment are to improve function and strength.
- Nonsurgical treatment preferred initially.
Medication
First Line
- Rest, physical therapy, and activity modification (3)[C]
- Pain medications (3)[C]
- Intra-articular steroid injection once infection ruled out
- Rheumatoid arthritis
- Early treatment with disease-modifying antirheumatic drugs (e.g., methotrexate, sulfasalazine, hydroxychloroquine) or biologics (e.g., TNF inhibitors) to prevent progression of disease and joint destruction
- Intra-articular injections for acute flare
Second Line
- No proven effectiveness of viscosupplementation (4)
- In some cases, braces and splints may be beneficial (e.g., instability, contractures).
- Be wary of potential for development of ankylosis with prolonged immobilization.
- Ultrasound and iontophoresis may be beneficial for pain control (1).
Issues for Referral
Orthopedic consultation if nonsurgical treatment is ineffective in improving functionality after 3-6 months.
Surgery/Other Procedures
- Surgical options depend on etiology, severity of symptoms, patient age, and activity level.
- Debridement arthroplasty and loose body excision is option for osteoarthritis with impinging osteophytes (5)[C].
- Feasible option for young (age <60 years), active patients
- Not indicated for severe arthritis
- Total elbow arthroplasty is option for severe arthritis (4)[C].
- Postoperative restrictions include no golf, avoid lifting >5 lb, avoid repetitive lifting of >2 lb.
- Arthroscopic or open synovectomy is option for rheumatoid arthritis (2)[C].
- Generally effective for pain relief
- May also increase range of motion and delay radiographic disease progression
- Has risk for recurrence
Ongoing Care
Follow-up Recommendations
Early postoperative mobilization and physical therapy are vital to successful outcome.
Postoperative Complications
- Ulnar nerve injury
- Poor wound healing
- Infection
- Triceps disruption
- Recurrent synovitis or pain
- Stiffness
Patient Monitoring
- Patients with rheumatoid arthritis should undergo x-rays every 6-12 months to assess disease progression.
- Monitor patients on disease-modifying antirheumatic drugs or biologics for signs or symptoms of drug toxicity.
References
1.Cassidy C, Chow C. Elbow arthritis. In: Frontera WR, Silver JK, Rizzo TD, eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2008:97-103.2.Studer A, Athwal GS. Rheumatoid arthritis of the elbow. Hand Clin. 2011;27(2):139-150.
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3.Wysocki RW, Cohen MS. Primary osteoarthritis and posttraumatic arthritis of the elbow. Hand Clin. 2011;27(2):131-137.
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4.Papatheodorou LK, Baratz ME, Sotereanos DG. Elbow arthritis: current concepts. J Hand Surg Am. 2013;38(3):605-613.
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5.Soojian MG, Kwon YW. Elbow arthritis. Bull NYU Hosp Jt Dis. 2007;65(1):61-71.
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Codes
ICD09
- 716.92 Arthropathy, unspecified, upper arm
- 715.92 Osteoarthrosis, unspecified whether generalized or localized, upper arm
- 714.0 Rheumatoid arthritis
- 716.12 Traumatic arthropathy, upper arm
- 711.02 Pyogenic arthritis, upper arm
ICD10
- M13.829 Other specified arthritis, unspecified elbow
- M19.029 Primary osteoarthritis, unspecified elbow
- M06.829 Other specified rheumatoid arthritis, unspecified elbow
- M12.529 Traumatic arthropathy, unspecified elbow
- M00.829 Arthritis due to other bacteria, unspecified elbow
SNOMED
- 439656005 Arthritis of elbow (disorder)
- 239866002 Osteoarthritis of elbow (disorder)
- 201769002 Rheumatoid arthritis of elbow (disorder)
- 201944007 Traumatic arthropathy of elbow (disorder)
- 445495007 Infective arthritis of elbow (disorder)
Clinical Pearls
- Arthritis of the elbow is uncommon.
- Typical causes include osteoarthritis, rheumatoid arthritis, posttraumatic arthritis.
- Consider etiology, severity of symptoms, and patient's functionality when determining treatment.
- Nonsurgical treatment is preferred initially.
- Septic arthritis is a do-not-miss diagnosis.