the acutely painful elbow

see also:

• the painful shoulder

• elbow pain is a very common presentation to the ED
• one needs to differentiate local injury or inflammation to that from referred pain

• a painful stimulus involving the diaphragm or the mediastinum commonly results in referred shoulder tip pain, usually on the same side, but can occasionally also cause pain referred distally down the arm.
• referred pain may also originate in the cervical nerves such as with cervical disc prolapse
• the patient with referred pain to the shoulder/elbow generally has full range of movement of the joints without increase in pain

• ischaemic chest pain - see the adult patient with chest pain in the ED
• cervical disc prolapse
• cervical radiculopathy
• carpal tunnel syndrome may cause referred pain proximally

• if the fracture is within the joint capsule, there is usually a palpable and radiologic haemarthrosis present
• see elbow fractures in children

• dislocation of the elbow joint usually results from a fall from a height onto outstretched hand, and is usually evident clinically
• see dislocation of the elbow joint

• this should be suspected in the presence of a non-traumatic elbow effusion with pain on flexing the elbow joint
• ensure septic arthritis is excluded before considering inflammatory causes such as gout
• a non-traumatic effusion may also be caused by a haemarthrosis in a patient with a coagulopathy such as haemophilia

• this is a clinical diagnosis and is usually very obvious from the inflamed, hot, red, swollen bursa overlying the olecranon region
• the main issue here is to exclude an infected bursa (eg. following an insect bite, puncture wound, etc) or localised cellulitis
• other causes include:
  • direct blunt trauma
  • prolonged pressure (eg. leaning on a hard surface eg. students, plumbers, air conditioning installers who must crawl in confined spaces)
  • rheumatoid arthritis
  • gout
• a large effusion in the bursa may be considered for diagnostic and palliative aspiration, however, aspiration does increase the risk of secondary infection within the bursa
• OrthoInfo

• inflammation over the common extensor origin over the lateral humeral epicondyle caused by an over-use injury
• it is also an occupational hazard for tradesmen such as plumbers and painters
• affects 50% of regular tennis players, especially those who play more than 2 hours per week, usually affecting their dominant arm
• mainly in those in their 4th-5th decades of life
• starts as a microtear in ECRB
• OrthoFracs

• the posterior interosseous nerve (a purely motor nerve) may be compressed where it passes through the supinator muscle in the proximal forearm (note that it can also be compressed at the lateral intermuscular septum of arm in which case it is called radial tunnel syndrome)
• symptoms are often worse with forced supination (i.e., turning the wrist up), or repetitive forearm use
• Rx is surgical decompression of the nerve by partly opening the supinator muscle

• recurrent painful clicking, snapping, clunking or locking of elbow due to past injuries causing instability and joint incongruencies
• see OrthoFracs

• usually does not have a significant effusion nor inflammatory changes
• OrthoInfo

• inflammation over the common flexor origin over the medial humeral epicondyle
• this may also be caused by strains to the insertion of these tendons such as by pulling heavy weights with flexed hand such as at a gym, or rock climbing
• over-use injury from forceful repetitive throwing may also cause this (eg. baseball pitcher's elbow, Little Leaguer's elbow)

• may occur in older children (10-15 years age) from repetitive throwing sports, and unlike Little Leaguer's elbow also caused from throwing, affects the lateral aspect of the elbow rather than the medial epicondyle
• it may also occur in gymnasts, racquet sports and weight lifting
• Emedicine

• occurs in children under age 6 years - see pulled elbow

• may complicate venipuncture or intravenous therapy

• pain from stretching of the ulnar nerve around the dorsum of the medial epicondyle due to prolonged elbow flexion (eg. during sleep) can be extremely problematic and usually occurs before paraesthesiae of the ulnar distribution
• aka cubital tunnel syndrome

• see rupture of biceps tendon