In front of a sequelled elbow, the history and the physical examination bring a bundle of diagnostic arguments.
The anamnesis concerns the reason for consultation:
The anamnesis concerns the reason for consultation (stiffness, pain, instability, sensation of fugitive attachment or true articular blockage, loss of strength …) and the traumatic history (lesional mechanism, modalities of management, functional evolution).
Functional signs:
The functional signs leading the patient to be consulted must be accurately assessed, both in terms of the intensity of the symptoms (ranging from permanent functional discomfort in everyday life to the alteration of certain sports gestures) and the type of symptoms, most often entangled.
Stiffness:
Stiffness is the most common reason for consultation; the actual functional impairment must be specified; it depends not only on the lost mobility areas, but also on the activities carried out and the possibilities of motor compensation, varying according to the condition of the joints underlying and underlying, as well as individual neurological faculties.
Pain:
Pain, often associated with stiffness, also has specific characteristics: schedules and circumstances of occurrence (specific gestures, prolonged effort), possible irradiations and associated signs of inflammatory, mechanical or neurological.
Thus, by way of example, a pain that appears after an interval free of any symptoms and linked to certain activities, is oriented towards suffering of ligamentary and / or osteochondral order, whereas an early, permanent pain persisting at rest and accentuated by the slightest spontaneous gestures, leads to fear in the first place a complication of septic order, requiring immediate medical and surgical management.
Parasitoses in the ulnar region, associated with a valgus deformation, may reveal the progressive decompensation of a lesion of the external console (in the context of, for example, resection of the radial head after comminuted fracture without prosthetic reconstruction) or a ligament lesion severe (postero-external and / or internal planes) or of an old vicious callus (fractures of the humeral palette).
The feeling of instability:
The description of the circumstances of the occurrence, the type of abnormal movement and the location of a possible surge guide the lesional diagnosis:
• instability of the elbow in valgus occurring during the javelin throw, or during tennis service, associated with a postero-external jump directed towards an attack of the internal ligament planes (medial collateral ligament), associated with a lesion of the postero-external planes with instability of the radial head (sequelae of postero-external dislocation of the elbow);
• an internal jumping sensation associated with dysesthesia of the auricular, as well as the ulnar border of the hand and ring finger may reveal instability of the ulnar nerve, secondary to internal lesion, or epitrochlea, or other sequelae of fracture of the humeral palette.
Other Symptoms:
Local distortion may be the reason for aesthetic consultation in a young adult in the context of trauma of childhood with vicious callus without major functional sequelae if the articular remodeling formed during the growth has preserved the indolence, mobility and stability compatible with activities performed during childhood. On the other hand, deformity is no longer the main reason for consultation if mobility is limited and painful in case of dislocation.
The true blockages evoke an osteochondral fragment incarcerated in the interlining, a cracking of the humerodial meniscus, when there is a thickened synovial fringe that remains a diagnosis of elimination.
The distinction is often difficult between the episodes of pseudoblocking, the sensations of articular attachment, and the perception of a jump in the surrounding soft tissues; these various symptoms may be indicative of osteochondral injury (joint splitting, fracture), tendon calcifications, or instability of the ulnar nerve.
Remote manifestations and loss of strength should not be neglected (stiffness and / or instability of the wrist, point of call in the ulnar area).
In the post-traumatic context:
It is necessary to determine the time elapsed since the accident and whether there was a free interval between the initial trauma and the functional discomfort for which the patient was consulted; it is necessary to specify also the occupational and sports activities practiced since the accident, as well as the rhythm and the intensity of the practice and the possible modifications of activity due to the functional discomfort (interruption, adaptation).
The lesional diagnosis chosen at the time of the accident may facilitate the recognition of complications related to the severity of the accident (cutaneous opening, infection factor and septic pseudarthrosis, polytrauma with cranial trauma, ankylosis factor due to para -osteo-calcifying arthropathies), or to the complexity of the initial lesions and the modalities of management. Has the initial treatment been functional, orthopedic or surgical?
Physical examination:
Always bilateral and comparative, the physical examination must take into account the dominant member. It includes an inspection time in search of possible joint or segmental deformity, the study of active and passive mobility (numerical dimensioning), the search for abnormal movements, analytical muscular testing, sensory balance and palpation (morphology of anatomical landmarks, pain points).
Inspection:
Local deformation:
Articular (elbow and / or wrist) or segmental (1/3 lower arm, 1/3 upper or 1/3 middle forearm); the observed deformation may be associated with a more or less pronounced alteration of the elbow and / or wrist mobility and at neurological call points:
• a pronounced deformation of the elbow, fixed in half-flexion, with shortening of the forearm and major functional impotence directed towards a dislocation;
• a segmental deformation (recurvatum, varus, valgus or rotational disorder), tends towards a vicious callus; the alteration of the mobility depends on the articular localization or, not, the fracture and the attack or, if not, the epiphyseal cartilages if the fracture occurred during the childhood;
• deformity of the forearm and / or wrist (dislocation of the ulnar styloid) may reveal a ligamentary, proximal and / or distal bone complex ligament lesion (Essex-Lopresti syndrome).
Analysis of mobility sectors:
Recall of the classical physiological amplitudes of elbow, forearm, and wrist mobility: 0/0/145 ~ 150 ◦ for elbow extension and flexion; 85 ~ 90 ◦ / 80 ~ 85 ◦ for functional prognosis rating of forearm ⇔ 0/5 ~ 10 ◦ / 175 ~ 180 ◦ in orthopedic supination and then pronation, according to the anatomical reference position; 60 ~ 90 ◦ / 0/50 ~ 80 ◦ , for palmar flexion then dorsal wrist; finally, 10 ~ 20 ◦ / 0/15 ~ 30 ◦ for the inclinations, radial and then ulnar.
In the case of joint involvement, the amplitudes of active and passive mobility are similar, while a more pronounced alteration in the active tends towards an “ extra-articular “ lesion (neurological deficit or musculo-tendinous lesion). The comparative analysis of the amplitudes of articular mobility of the shoulder of the elbow and the wrist, active guided and then passive, makes it possible to evaluate and to specify the degree (s) of freedom the most reached (s) ) and hence the affected articular compartment (s).
The major loss of mobility in elbow flexion-elbow movements and prognosis with elbow deformity leads to an inveterate dislocation if it has been observed from the outset, or an iterative dislocation if there is a free interval of elbow any symptoms.
Preservation of amplitudes of mobility in pronosupination, combined with a strong limitation of flexion and extension, leads to a trochleosigmoid osteochondral lesion (articular fracture, displaced osteochondral fragment, extra-articular bone fragment or incarcerated foreign body).
A discrete limitation isolated from flexion, persisting at a distance from a fracture of the humeral palette, may reveal a vicious callus in recurvatum.
A residual flessum apparently isolated, at least as far as the alleged functional discomfort is concerned, must first seek an unknown joint fracture (fracture of the coronoid process, the radial head or the capitellum) complementary imaging (specific radiographic effects, computed tomography or arthroscanner if necessary).
Any alteration of the prognosis results in proximal and / or distal radioulnar and / or skeletal involvement; it may be a complication directly linked to the initial trauma or a progressive axial destabilization of the radius in the context of a complex lesion of the Essex-Lopresti type, constituted immediately or after resection of the radial head.
Progressive ankylosis, formed in a few weeks or months, in the context of head trauma, accompanied by local inflammatory signs transient without sepsis, reveals ectopic calcifications; the late stifling, preceded or accompanied by pain of the mechanical type oriented towards post-traumatic osteoarthritis secondary to osteochondral lesions constituted immediately or secondarily.
The search for abnormal movements:
The search for abnormal movements is essential to determine if there is joint instability and to define the type of laxity, frontal (in valgus most often, sometimes in varus), or rotatory (true postero-external instability, or hypermobility of the head radial).
Search for a frontal laxity:
There is normally no frontal elbow elbow in extension; in flexion there is a physiological laxity in valgus, more or less pronounced according to the individual ligament elasticity, usually symmetrical in the absence of a traumatic antecedent.
The search for residual internal laxity, at a distance from traumatism of the elbow, by humerocubital decoaptation, is done in extension and flexion, in soft passive frontal mobilization; the maneuver can be carried out either in a dump (the examiner supporting the forearm of the subject) or in charge (the patient then sitting at the edge of the table, arm abduction and bearing on the heel of the hand). The search for asymmetry of laxity at 30 ◦ of flexion makes it possible to detect the sequelae of a grade II sprain.
The finding of a laxity in valgus makes one look for possible signs of irritation of the ulnar nerve of sensory order; the motor deficit, later, should not be expected to request an electromyogram.
Search for postero-external instability:
Frontal laxity in varus is sometimes found, but never important.
The rotational instability test described by O’Driscoll makes it possible to affirm it; the straight jump of the radial head is often replaced by a notable apprehension during its search.
The patient is placed in supine position, arm in anterior elevation ( ~ 120 ◦ ); the examiner supports the forearm in order to achieve optimal muscle relaxation, while performing a combined maximal forearm supination movement using the distal hand (1/4 forearm), associated with a passive valgus motion of the elbow and external rotation of the two forearm bones, using the proximal hand (upper 1/4 of the forearm).
The neurological assessment may be normal or detect a discrete distal deficit:
The neurological assessment includes the analysis of simple tactile sensitivity, in search of a small zone of sensitive extinction focused, usually in cubital territory, more rarely radial or median.
This assessment must be systematic, a fortiori in the case of ascending nocturnal paresthesias, associated with a gestural awkwardness. Any neurological deficit detected as a result of traumatism of the elbow leads to seek a vicious callus of the humeral palette, an old dislocation, or the sequelae of a complex cubitoradial trauma.
In case of instability of the ulnar nerve, suspected on the data of the anamnesis and clinically perceived by the palpation of the epitrochlear region during the flexion-extension movements of the elbow (pre-epitrochlear dislocation of the ulnar nerve during the a dynamic static ultrasound may reveal this instability with local thickening of the nerve trunk, associated with rearrangements of the internal capsulo-ligament and tendon elements, close to their insertion on the epitrochlea.
The palpation makes it possible to locate the anatomical landmarks and to specify the painful points:
Classic anatomical landmarks: epitrochlea, olecranon, and epicondyle form an isosceles triangle when the elbow is flexed at 90 ◦ ; these points are aligned in full extension.
The palpation of the radial head and the humeroradial interlining of the internal and external para-olecranial gutters, as well as the common tendon of the epicondylians and the common tendon of the epitrochleans to their respective humeral insertions, make it possible to specify the osteoarticular origin or tendinous tendencies of certain pains, and direct the choice of complementary imaging.
At the end of this clinical review, these various elements of guidance make it possible to target complementary examinations (biological evaluation in certain cases, in particular in case of nocturnal recrudescence pain, x-ray images with specific incidences and computed tomography or magnetic resonance imaging according to the context), to support the etiological diagnosis of functional sequelae and to guide therapeutic behavior.