Elbow (acute & chronic).

Initial Diagnosis

First visit: with Primary Care Physician MD/DO (100%)
Determine cause: Initial Evaluation:
- Determine the type of trauma (e.g., fall, repetitive motion, twisting, etc.)
- Determine whether the problem is acute, subacute, chronic, or of insidious onset.
- Determine the severity and specific anatomic location of the pain.
- Assess the ability of the patient to use the elbow, from no to full ability.
- Search for any evidence of an open or penetrating wound.
- Test the range-of-motion of the joint (normal, mild restriction, severe restriction).
- Search for any evidence of vascular or nerve injury distal to the injury.
- Determine any present medication.
- Determine any previous medical history, history of systemic disease, previous elbow injury or disability, job requirements, and hobbies.
Initial diagnosis (Refer to the original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes):
- Traumatic (Go to Fractures and Dislocations):
  - Fracture or dislocation
- Other (Go to Initial Conservative Treatment):
  - Sprain or contusion
  - Laceration
  - Epicondylitis, medial
  - Epicondylitis, lateral
  - Olecranon bursitis
  - Pronator syndrome
  - Ulnar nerve entrapment (Cubital tunnel syndrome)
  - Radial nerve entrapment

Fracture or Dislocation of Elbow (35% of cases)

Definitive Evaluation:
- Search for any evidence of an open wound in the vicinity of the fracture; if there is an open wound, treat for infection and examine for the presence of foreign bodies (visual, x-ray, etc.)
- Perform a clinical examination for deformity, tenderness, or ecchymosis, or associated nerve, neurovascular, or tendon injury. Also look for the inability to perform spontaneous movement of the elbow.
- Search for any evidence of dislocation and arterial vascular compromise (cold, dusky hand and forearm with loss of sensation). If found, an immediate reduction should take place (prior to x-rays if necessary).
- X-ray the elbow. Special views should be obtained when necessary.
Initial Therapy
- Simple, undisplaced, stable fractures of the elbow can be treated by the primary care physician.
- Apply a sling and/or a posterior splint with medial and lateral gutter splints. A portion of patients should be converted to a long arm cast after 10 to 14 days.
- Ice and elevation whenever lying down for the first 72 hours
- Analgesics and/or nonsteroidal anti-inflammatory drugs for up to two weeks
- Aspirating the radiohumeral joint and injection of local anesthetic to evacuate hematoma is appropriate to relieve pain in selected cases of radial head fractures.
- Physical therapy (3 to 6 visits) to teach patient range-of-motion and muscle-strengthening exercises out of the splint should begin as soon as tolerated at two to four weeks.
- Recheck at seven days, then at two-week intervals until healed. Repeat x-rays at seven days and at two weeks to assure that the fracture has not slipped. X-ray again at five weeks.
- Complex, displaced, or unstable fractures should be immobilized and referred to an orthopedic surgeon. Compound fractures, when appropriate, should have a tetanus toxoid injection before being referred to a surgeon.
- Dislocations of the elbow are accompanied by significant ligament injuries. Even if full reduction has been achieved, orthopedic referral is appropriate.

Official Disability Guidelines (ODG) Return-To-Work Pathways - Fracture

Stable, clerical/modified work: 2 days

Stable, manual work: 14 days

Reduction/manipulation, clerical/modified work: 14 days

Reduction/manipulation, manual work: 28 days

Reduction/manipulation, heavy manual work: 42 days

ODG Return-To-Work Pathways - Dislocation

Non-dominant arm, clerical/modified work: 0 days

Non-dominant arm, manual work: 10 days

Non-dominant arm, heavy manual work: 21 days

Dominant arm, clerical/modified work: 7 days

Dominant arm, manual work: 21 days

Dominant arm, heavy manual work: 42 days

(See ODG Capabilities & Activity Modifications for Restricted Work under "Work" in the Procedure Summary of the original guideline document)

Secondary evaluation for patients with persistent symptoms or minimal improvement after six weeks of therapy
- Review for compliance of the employee and employer to therapy programs and job modifications and restrictions. Also review for insurance company cooperation.
- Evaluate for delayed union, malalignment, or signs of associated tendon or nerve injury.
- Promptly refer to an orthopedic surgeon if one of these conditions is found.

Initial Conservative Treatment of Disorders Other than Fractures (65% of cases)

Definitive Evaluation:
- Typical symptoms of lateral epicondylitis ("tennis elbow") include pain in the lateral aspect of the elbow with pain or burning radiating to the forearm (and occasionally proximal radiation). With medial epicondylitis ("golfers elbow") the pain is on the inside of the elbow (versus outside of the elbow for tennis elbow). There may be loss of grip strength due to forearm pain with hand grip. Pain is usually insidious in onset but may be provoked by an acute trauma or strain. Initial complaints may be vague, such as a dull forearm ache.
- Specific attention should be directed towards confirming occupational risk factors, such as repetitive, sustained, or forceful wrist dorsiflexion, power grip, exposure to vibration, repetitive extended elbow reach with forceful pulling, and repetitive pronation and supination of the forearm against resistance.
- Rule out non-occupational activities that could be causing or aggravating the condition, such as activities that require gripping or hyperextending the wrist.
- Olecranon bursitis may be secondary to systemic illness.
- A physical examination should be performed with documentation of the following findings:
  - Inspection for deformity, swelling, or erythema
  - Provocative maneuvers, such as the presence or absence of pain with resisted dorsiflexion of the wrist, passive wrist flexion with the elbow in full extension, resisted supination of the forearm, and Tinel's sign
  - Range of motion: elbow flexion and extension, pronation and supination, wrist flexion and extension. Note any flexion contracture deformity of the elbow.
  - Palpation: Document the presence or absence of the following: elbow deformity, tenderness, heat, or crepitus (including olecranon process and medial epicondyle). Also check the forearm for deformity, heat, or tenderness.
  - Muscle strength testing of the entire upper extremity should be performed as relevant.
  - Appropriate distal extremity exam should include neurological testing. A routine examination of the shoulder, neck, wrist, and hand (palpation, range of motion, strength testing) should be performed.
  - A differential diagnosis should be considered at this point, such as radiculopathy or shoulder pathology with referred pain.
- As a rule, the diagnosis of elbow problems does not require an imaging study.
- Appropriate laboratory studies should be considered if there is evidence of an infectious or diffuse inflammatory process as a contributing or causative factor.
- Nerve conduction studies may be indicated for elbow problems associated with neurological deficits.
- Aspiration of the olecranon bursa is not routinely indicated unless there is suspicion of infection or metabolic disease.
Initial Treatment
- The purpose of the initial treatment is to reduce symptoms, optimize healing/function, and increase work, with appropriate modifications to minimize the risk factors that contributed to the injury.
- All injured workers should receive instruction concerning the nature of their condition, its risk factors, preventive measures, and goals of initial therapy. The injured worker should be instructed on how to eliminate or modify any aggravating non-occupational activities and sports during treatment.
- Work restrictions or modifications that reduce the injured worker's exposure to the etiologic or aggravating activity are of central importance. Examples of such restrictions include preclusion from or reduction in time performing tasks requiring repetitive, sustained, or repetitive forceful wrist or hand activities, repetitive elbow motion, prolonged elbow positioning, or prolonged exposure to vibration.
- Nonsteroidal anti-inflammatory agents (NSAIDs) can be used. Acetaminophen is an analgesic that may be used as an adjunct or alternative to NSAIDs.
- Physical treatments and passive modalities: If there is no improvement after 2 weeks, the treatment should be modified. Use of thermal modalities in conjunction with physical treatment may be useful. Physical treatments for pain management, splinting, and/or functional retraining and instruction in a graded exercise program. Appropriate exercises may include, but are not limited to 1) gentle muscle stretching, 2) flexibility, and 3) graduated strengthening. Care should be taken while incrementing exercises so that the condition is not aggravated. Appropriate manual therapies may include manipulation, or joint or soft tissue mobilization, supplemented by physical modalities and exercise.
- Acupuncture: Use of acupuncture in the first 4 weeks of treatment as a part of an overall treatment plan.
- Protective devices: The use of an elbow and/or wrist support for immobilization may be indicated for a brief period. The use of a splint at work must be carefully considered, as it may put the injured worker at risk for further musculoskeletal injury by forcing the adoption of awkward compensatory postures. A forearm strap can be aggravating in the acute stage, so its use should be individualized. It is contraindicated in the presence of nerve compression symptoms. Night splinting may be indicated for nerve entrapment syndromes.
- Local corticosteroid injection: Local corticosteroid injections of the myofascial areas or bursae may be appropriate, especially if the pain is moderate to severe. Before the injection, it is important to be aware that the olecranon bursa may be the site of infection. In such an instance, a steroid injection would be contraindicated. Refer to an orthopaedic surgeon if infection is present.
- Surgery is rarely indicated.
Secondary Assessment
- A reconsideration of the initial diagnosis is necessary at this stage, and a differential diagnosis should be reviewed: cervical radiculopathy, shoulder pathology with referred pain and nerve entrapment.
- Diagnostic imaging: Radiographic studies of the elbow and forearm may be considered if, on re-evaluation, the physician suspects morphologic pathology. The use of magnetic resonance imaging (MRI) and arthrography is rarely indicated except for the evaluation of intraarticular pathology.
- Laboratory studies: Laboratory studies may be performed if there is evidence of an infectious or diffuse inflammatory process as a contributing pathology.
- Electromyography/nerve conduction studies (EMG/NCS) to rule out other conditions: Electrodiagnostic studies should be considered if there is clinical evidence of nerve entrapment or cervical radiculopathy as alternative diagnoses.
- Surgical referral: Orthopaedic surgical consultation may be recommended after failure of conservative treatment and indication of a surgically correctable condition.

ODG Return-To-Work Pathways – Sprain

Moderate, clerical/modified work: 4 days

Moderate, manual work: 21 days

Severe, clerical/modified work: 7 days

Severe, manual work: 35 to 42 days

ODG Return-To-Work Pathways - Contusion

Superficial contusions: 0 days

Deep contusions, clerical/modified work: 5 days

Deep contusions, manual work: 21 days

ODG Return-To-Work Pathways - Laceration

Minor: 0 days

Major, clerical/modified work: 3 days

Major, manual work: 8 days

ODG Return-To-Work Pathways - Epicondylitis, Medial

Without surgery, modified work: 0 days

Without surgery, regular manual work: 7 days

Without surgery, heavy manual work: 42 days

ODG Return-To-Work Pathways - Epicondylitis, Lateral

Without surgery, modified work: 0 days

Without surgery, regular manual work: 7 days

Without surgery, heavy manual work: 42 days

Without surgery, heavy manual vibrating work, if cause of disability: indefinite

With surgery (rare), modified work, non-dominant arm: 6 days

With surgery (rare), modified work, dominant arm: 21 days

With surgery (rare), regular work, non-dominant arm: 28 days

With surgery (rare), regular work, dominant arm: 42 days

Acupuncture (3 to 6 treatments): 7 to 21 days

ODG Return-To-Work Pathways - Olecranon Bursitis

Without surgery, modified work: 0 days

Without surgery, regular manual work: 4 days

Without surgery, heavy manual work: 35 days

ODG Return-To-Work Pathways - Ulnar Nerve Entrapment

Without surgery, modified work: 0 days

Without surgery, regular work: 14 days

With surgery, modified work: 14 days

With surgery, regular work, non-dominant arm: 21 days

With surgery, regular work, dominant arm: 49 days

ODG Return-To-Work Pathways - Radial Nerve Entrapment

Diagnostic testing: 0 days

Treatment, clerical/modified work: 14 days

Treatment, manual work: 42 days

Complete Summary

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