Intra-Articular Injection of the Elbow Joint

Indications and Clinical Considerations

The elbow joint is susceptible to developing arthritis from a variety of conditions that have the ability to damage the joint cartilage. Osteoarthritis of the joint is the most common form of arthritis that results in elbow joint pain. In the elbow, osteoarthritis is usually a result of previous trauma or on-the-job injury ( Fig. 55.1 ). However, rheumatoid arthritis, posttraumatic arthritis, and psoriatic arthritis are also common causes of elbow pain secondary to arthritis, with 35% of patients with rheumatoid arthritis affected. Less common causes of arthritis-induced elbow pain include collagen vascular diseases, infection, and Lyme disease. Acute infectious arthritis usually is accompanied by significant systemic symptoms, including fever and malaise, and should easily be recognized by the astute clinician and treated appropriately with culture and antibiotics, rather than injection therapy. The collagen vascular diseases generally manifest as a polyarthropathy rather than a monoarthropathy limited to the elbow joint, although elbow pain secondary to collagen vascular disease responds exceedingly well to the intra-articular injection technique described later.

The majority of patients with elbow pain secondary to osteoarthritis and posttraumatic arthritis pain report pain that is localized around the elbow and forearm. Activity makes the pain worse; rest and heat provide some relief. The pain is constant and characterized as aching. The pain may interfere with sleep. Some patients report a grating or popping sensation with use of the joint, and crepitus may be present on physical examination.

In addition to the previously mentioned pain, patients with arthritis of the elbow joint often experience a gradual decrease in functional ability with decreasing elbow range of motion, making simple everyday tasks such as using a computer keyboard, holding a coffee cup, or turning a doorknob quite difficult. With continued disuse, muscle wasting may occur, and an adhesive capsulitis with subsequent ankylosis may develop.

Plain radiographs are indicated for all patients with elbow pain. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Computed tomography, ultrasound, and/or magnetic resonance imaging of the elbow is indicated if joint instability or joint mice are suspected ( Fig. 55.2 ).

Clinically Relevant Anatomy

The elbow joint is a synovial, hinge-type joint that serves as the articulation among the humerus, radius, and ulna ( Fig. 55.3 ). The joint’s primary function is to position the wrist to optimize hand function. The joint allows flexion and extension at the elbow, as well as pronation and supination of the forearm. It is lined with synovium, and the resultant synovial space allows intra-articular injection. The entire joint is covered by a dense capsule that thickens medially to form the ulnar collateral ligament and laterally to form the radial collateral ligaments. These dense ligaments, coupled with the elbow joint’s deep bony socket, make this joint extremely stable and relatively resistant to subluxation and dislocation. The anterior and posterior joint capsule is less dense and may become distended if there is a joint effusion. The olecranon bursa lies in the posterior aspect of the elbow joint and may become inflamed as a result of direct trauma to or overuse of the joint. Bursae susceptible to the development of bursitis also exist between the insertion of the biceps and the head of the radius, as well as in the antecubital and cubital area.

The elbow joint is innervated primarily by the musculocutaneous and radial nerves, with the ulnar and median nerves providing varying degrees of innervation. At the middle of the upper arm, the ulnar nerve courses medially to pass between the olecranon process and medial epicondyle of the humerus. The nerve is susceptible to entrapment and trauma at this point. At the elbow, the median nerve lies just medial to the brachial artery and occasionally is damaged during brachial artery cannulation for blood gases.