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Elbow Arthritis

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Elbow Arthritis

Basics

Description

Initial Tests (lab, imaging)

Follow-up tests & special considerations

Orthopedic consultation if nonsurgical treatment is ineffective in improving functionality after 3-6 months.

Early postoperative mobilization and physical therapy are vital to successful outcome.

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.

3.Wysocki RW, Cohen MS. Primary osteoarthritis and posttraumatic arthritis of the elbow. Hand Clin. 2011;27(2):131-137.

4.Papatheodorou LK, Baratz ME, Sotereanos DG. Elbow arthritis: current concepts. J Hand Surg Am. 2013;38(3):605-613.

5.Soojian MG, Kwon YW. Elbow arthritis. Bull NYU Hosp Jt Dis. 2007;65(1):61-71.

  • 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

  • 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).
  • 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 osteoarthritisUsually affects dominant arm of middle-aged males with history of repetitive arm use (throwing athletes, heavy laborers)Symptoms often due to osteophyte formation.
  • Rheumatoid arthritisInflammatory attack on synovium with eventual damage to cartilage and bone.
  • Posttraumatic elbow arthritisMost common in young malesMalunion 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.
  • Usually affects dominant arm of middle-aged males with history of repetitive arm use (throwing athletes, heavy laborers)
  • Symptoms often due to osteophyte formation.
  • Inflammatory attack on synovium with eventual damage to cartilage and bone.
  • 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.

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.
  • Assess timing and location of pain.
  • Assess limitations of range of motion (loss of flexion vs. extension vs. rotation).
  • Assess patient's functional limitations.
  • Swelling, instability, and pain throughout range of motion occurs in severe stages.
  • Assess for polyarthralgias (MCP, PIP, wrist) and extra-articular signs of rheumatoid arthritis.
  • Joint instability may occur in advanced rheumatoid arthritis.

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.
  • 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).
  • May be decreased with long-standing arthritis, disuse, or acute pain
  • 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

  • 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
  • Evaluate for osteophytes, joint space narrowing or erosion, cyst formation.
  • Look for posterior fat pad to rule out fracture of proximal radius.
  • 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

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.
  • Goals of treatment are to improve function and strength.

Medication

  • Rest, physical therapy, and activity modification (3)[C]
  • Pain medications (3)[C]
  • Intra-articular steroid injection once infection ruled out
  • Rheumatoid arthritisEarly treatment with disease-modifying antirheumatic drugs (e.g., methotrexate, sulfasalazine, hydroxychloroquine) or biologics (e.g., TNF inhibitors) to prevent progression of disease and joint destructionIntra-articular injections for acute flare
  • 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
  • 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).
  • Be wary of potential for development of ankylosis with prolonged immobilization.

Issues for Referral

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 patientsNot 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 reliefMay also increase range of motion and delay radiographic disease progressionHas risk for recurrence
  • Feasible option for young (age <60 years), active patients
  • Not indicated for severe arthritis
  • Postoperative restrictions include no golf, avoid lifting >5 lb, avoid repetitive lifting of >2 lb.
  • 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

Postoperative Complications

  • Ulnar nerve injury
  • Poor wound healing
  • Infection
  • Triceps disruption
  • Recurrent synovitis or pain
  • Stiffness
  • 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

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.