Snapping elbow-A guide to diagnosis and treatment

AIM To develop practical guidelines for diagnosis and treatment of the painful snapping elbow syndrome(SE). METHODS Clinical studies were searched in the databases Pub Med and Scopus for the phrases "SE", "snapping triceps", "snapping ulnar nerve" and "snapping annular ligament". A total of 36 relevant studies were identified. From these we extracted information about number of patients, diagnostic methods, patho-anatomical findings, treatments and outcomes. Practical guidelines for diagnosis and treatment of SE were developed based on analysis of the data. We present two illustrative patient cases-one with intra-articular pathology and one with extra-articular pathology.RESULTS Snapping is audible, palpable and often visible. It has a lateral(intra-articular) or medial(extra-articular) pathology. Snapping over the medial humeral epicondyle is caused by dislocation of the ulnar nerve or a part of the triceps tendon, and is demonstrated by dynamic ultrasonography. Treatment is by open surgery. Lateral snapping over the radial head has an intra-articular pathology: A synovial plica, a torn annular ligament or a meniscus-like remnant from the foetal elbow. Pathology can be visualized by conventional arthrography, magnetic resonance(MR) arthrography, high resolution magnetic resonance imaging(MRI) and arthroscopy, while conventional MRI and radiographs often turn out normal. Treatment is by arthroscopic or eventual open resection. Early surgical intervention is recommended asthe snapping can damage the ulnar nerve(medial) or the intra-articular cartilage(lateral). If medial snapping only occurs during repeated or loaded extension/flexion of the elbow(in sports or work) it may be treated by reduction of these activities. Differential diagnoses are loose bodies(which can be visualized by radiographs) and postero-lateral instability(demonstrates by clinical examination). An algorithm for diagnosis and treatment is suggested.CONCLUSION The primary step is establishment of laterality. From this follows relevant diagnostic measures and treatment as defined in this guideline.

Possibilities for arthroscopic treatment of the ageing sternoclavicular joint

AIM To investigate if there are typical degenerative changes in the ageing sternoclavicular joint(SCJ), potentially accessible for arthroscopic intervention.METHODS Both SCJs were obtained from 39 human cadavers(mean age: 79 years, range: 59-96, 13 F/26 M). Each frozen specimen was divided frontally with a band saw, so that both SCJs were opened in the same section through the center of the discs. After thawing of the specimens, the condition of the discs was evaluated by probing and visual inspection. The articular cartilages were graded according to Outerbridge, and disc attachments were probed. Cranio-caudal heights of the joint cartilages were measured. Superior motion of the clavicle with inferior movement of the lateral clavicle was measured.RESULTS Degenerative changes of the discs were common. Only 22 discs(28%) were fully attached and the discs were thickest superiorly. We found a typical pattern: Detachment of the disc inferiorly in connection with thinning, fraying and fragmentation of the inferior part of the disc, and detachment from the anterior and/or posterior capsule. Severe joint cartilage degeneration ≥ grade 3 was more common on the clavicular side(73%) than on the sternal side(54%) of the joint. In cadavers< 70 years 75% had ≤ grade 2 changes while this was the case for only 19% aged 90 years or more. There was no difference in cartilage changes when right and left sides were compared, and no difference between sexes. Only one cadaver-a woman aged 60 years-had normal cartilages. CONCLUSION Changes in the disc and cartilages can be treated by resection of disc, cartilage, intraarticular osteophytes or medial clavicle end. Reattachment of a degenerated disc is not possible.