The most common nonarticular syndromes of the
elbow include epicondylitis, olecranon bursitis, and ulnar nerve entrapment.
Epicondylitis is caused by an inflammation at
the origin of the tendons and muscles serving the forearm; it is usually caused
by overuse or by repetitive activity.
Patients typically complain of elbow and
forearm pain with activity. When the extensor muscles are involved (i.e.,
tennis elbow), tenderness is maximal over the lateral epicondyle and aggravated
by extension of the wrist against resistance. A similar, less common process
may affect the flexor muscles originating at the medial epicondyle (i.e.,
golfer's elbow).
Epicondylitis usually responds to rest, local
heat or ice, NSAIDs, and forearm support to reduce tension at the epicondyle.
Local infiltration of glucocorticoids and lidocaine often results in more rapid
improvement than other measures in the first month or two but does not appear
to affect the outcome over 6 to 12 months.[35,36]
Olecranon bursitis presents as a discrete
swelling with palpable fluid over the tip of the elbow. Traumatic bursitis is
characterized by minimal heat or surrounding erythema. The fluid aspirated is
noninflammatory and often contains multiple red cells. Infectious
bursitis--usually caused by gram-positive skin organisms--is accompanied by
heat, erythema, and induration. When infection is suspected, prompt aspiration
and culture of the fluid are mandatory. Antibiotics should be started
empirically, and the bursa should be reaspirated frequently until the fluid no
longer reaccumulates and cultures are negative.[37] Olecranon bursitis may
also be part of rheumatoid arthritis or gout, usually in a patient in whom a
diagnosis has already been made. On occasion, an initial diagnosis of gout is
made by examination of bursal fluid for urate crystals.
Ulnar nerve entrapment is caused by
compression of the ulnar nerve as it passes through the ulnar groove at the
elbow[38] [see 11:II Diseases
of the Peripheral Nervous System]. Patients typically complain of pain and
numbness that radiates from the elbow to the little finger and the medial side
of the hand. An increase in paresthesia with elbow flexion is helpful in making
the diagnosis, but nerve conduction studies are often needed to confirm the
diagnosis. Conservative therapy with a loose cast may help limit elbow flexion
and improve symptoms in some patients; surgical decompression is indicated in
patients with disabling pain or weakness.
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