Bjerre Jonathan Jetsmark, Johannsen Finn Elkjær, Rathcke Martin, Krogsgaard Michael Rindom
Section for Sportstraumatology M51, Bispebjerg-Frederiksberg Hospital, Copenhagen NV DK-2400, Denmark.
Institute for Sportsmedicine M81, Bispebjerg-Frederiksberg Hospital, Copenhagen NV DK-2400, Denmark.
World J Orthop. 2018 Apr 18;9(4):65-71. doi: 10.5312/wjo.v9.i4.65.
To develop practical guidelines for diagnosis and treatment of the painful snapping elbow syndrome (SE).
Clinical studies were searched in the databases PubMed 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.
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 as the 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.
The primary step is establishment of laterality. From this follows relevant diagnostic measures and treatment as defined in this guideline.
制定疼痛性弹响肘综合征（SE）的诊断与治疗实用指南。
在PubMed和Scopus数据库中检索关于“SE”“肱三头肌弹响”“尺神经弹响”和“环状韧带弹响”的临床研究。共识别出36项相关研究。从中提取有关患者数量、诊断方法、病理解剖学发现、治疗方法及结果的信息。基于数据分析制定SE的诊断与治疗实用指南。我们展示两个典型病例——一个为关节内病变，另一个为关节外病变。
弹响可闻及、可触及且常可见。其有外侧（关节内）或内侧（关节外）病变。肱骨内上髁处的弹响由尺神经脱位或肱三头肌腱的一部分引起，动态超声可证实，治疗采用开放手术。桡骨头外侧弹响有关节内病变：滑膜皱襞、环状韧带撕裂或胎儿期肘部类似半月板样残余物。病变可通过传统关节造影、磁共振（MR）关节造影、高分辨率磁共振成像（MRI）及关节镜检查显示，而传统MRI和X线片通常结果正常。治疗采用关节镜或最终开放切除。建议早期手术干预，因为弹响可损伤尺神经（内侧）或关节内软骨（外侧）。如果内侧弹响仅在肘部反复或负重伸展/屈曲时（如在运动或工作中）出现，可通过减少这些活动进行治疗。鉴别诊断包括游离体（可通过X线片显示）和后外侧不稳定（通过临床检查显示）。提出了诊断与治疗的算法。
首要步骤是确定病变侧别。据此遵循本指南中定义的相关诊断措施和治疗方法。
