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Elbow Arthroscopy

Elbow arthroscopy — portals, OCD, loose bodies, contracture release — FRCS/FRACS exam preparation

Core Procedure
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By OrthoVellum Medical Education Team

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High-yield overview

Portal Anatomy | OCD Capitellum | Contracture Release | 6 Nerve Danger Zones

Surgical Imaging

Cadaver elbow specimen with six pins marking standard arthroscopic portal positions
Standard elbow arthroscopy portal anatomy on cadaver specimen: six portal positions marked — proximal anteromedial (PAM), proximal anterolateral (PAL), midlateral (ML), posterolateral (PL), straight posterior, and accessory portals. Portal relationships to neurovascular structures are critical for safe access.Credit: Kim JW et al., Clin Orthop Surg 2016 (PMC4759879) — CC BY 4.0
Cadaver elbow dissection showing medial cutaneous nerve of forearm in relation to arthroscopic portal
Cadaver dissection demonstrating the medial cutaneous nerve of forearm (MCNF) course relative to the proximal anteromedial portal. The nerve passes within millimetres of this portal, highlighting the importance of correct portal placement with the elbow flexed to 90°.Credit: Kim JW et al., Clin Orthop Surg 2016 (PMC4759879) — CC BY 4.0
Clinical photograph of elbow with three portal sites labelled A, B, and C for arthroscopic contracture release
Portal sites for arthroscopic elbow contracture release: (A) proximal anterolateral; (B) midlateral/direct lateral; (C) posterolateral. The elbow is flexed during anterior portal placement to maximise anterior capsule distance from the median nerve.Credit: Kim SJ et al., Knee Surg Sports Traumatol Arthrosc 2017 (PMC5314153) — CC BY 4.0

Elbow Arthroscopy — 6 Neurovascular Danger Zones

Radial Nerve / PIN

Most commonly injured nerve. Posterior interosseous nerve (deep branch of radial nerve) lies only 7mm from the anterolateral portal with forearm in neutral. Distending the joint with 20–30 mL saline moves the nerve 6–10mm further away. Keep forearm supinated during anterolateral portal creation to move PIN anteriorly away from the portal.

Ulnar Nerve

At risk from posteromedial and medial portals. Palpate and mark the ulnar nerve in the cubital tunnel before ANY medial portal insertion. Flex the elbow to 90° — this moves the ulnar nerve posteriorly, increasing its distance from medial portal entry points. Never create medial portals with elbow extended.

Median Nerve + Brachial Artery

At risk from direct anterior portals and during anterior capsular release. The median nerve and brachial artery lie medial to the biceps tendon, only 5–10 mm from an anteromedial approach. The proximal anteromedial portal is safer than the direct anteromedial portal as it enters more proximally and less medially.

Lateral Antebrachial Cutaneous Nerve

Superficial sensory nerve — terminal branch of musculocutaneous nerve. Runs superficially on the lateral aspect of the forearm. At risk during portal insertion, particularly with the anterolateral portal if the stab incision is too deep or misdirected. Avoid excessive soft tissue dissection laterally.

Medial Antebrachial Cutaneous Nerve

At risk during medial portal placement. The medial antebrachial cutaneous nerve runs along the medial aspect of the forearm and can be injured by incautious stab incision when creating proximal anteromedial or direct anteromedial portals. Use blunt dissection after the skin incision to protect it.

Posterior Interosseous Nerve (Repeated)

Key exam fact — the PIN is at greatest risk. Specific distances: 7mm from anterolateral portal in neutral forearm, increases to 13mm in supination. Rule: distend first, supinate forearm, enter anterolateral portal with extreme care. Always identify it during any proximal radioulnar dissection.

Mnemonics

Mnemonic

PALMPALM — Portal Establishment Order

Hook:PALM reminds you to work from the safest portal inward — proximal anteromedial first, never anterolateral blind

Mnemonic

OCDLOCDL — OCD Capitellum Grading and Management

Hook:OCDL — from cartilage softening all the way to a Loose body — grade determines whether you fix or replace

Comprehensive Technique Guide

Indications for Elbow Arthroscopy

Elbow arthroscopy provides both diagnostic and therapeutic access to the elbow joint. The indications have expanded considerably since Andrews and Carson first described the technique in 1985.

Established Indications:

1. OCD of the Capitellum

  • First-line surgical treatment for unstable lesions in skeletally immature athletes
  • Bexkens et al. (2017, AJSM) reported good Oxford Elbow Scores after arthroscopic debridement and microfracture for advanced capitellar OCD, with 62% returning to sport — open physis, loose-body removal, and shorter symptom duration predicted better outcome
  • Lu et al. (2018, Int Orthop) systematic review/meta-analysis found 91.4% return to sport in the arthroscopic group vs 86.4% open, with no complications recorded in the arthroscopic cohort

2. Loose Body Removal

  • Most common indication historically — synovial osteochondromatosis, post-traumatic loose bodies
  • Arthroscopic removal superior to open surgery for multiple loose bodies
  • Anterior and posterior compartments must both be inspected

3. Arthrofibrosis / Contracture Release

  • Post-traumatic stiffness is the most common cause of elbow contracture in young adults
  • Ball et al. (JSES 2002) reported flexion improving from 117.5° to 133° and extension from 35.4° to 9.3° after arthroscopic capsular release; in patients with a preoperative arc under 100° the mean arc improved from 69° to 119°, with no neurovascular complications
  • Cohen and Hastings (JBJS Br 1998) showed open lateral collateral ligament-sparing release improved total ulnohumeral movement from 74° to 129°
  • Appropriate for extrinsic capsular contractures without bridging heterotopic ossification occupying the joint space; Lindenhovius et al. (JSES 2007) showed motion gains are greater when motion-blocking HO is removed than with capsular contracture alone

4. Radial Head Excision

  • Comminuted radial head fractures not amenable to fixation (Mason Type III) in selected patients
  • Arthroscopic technique reduces soft-tissue morbidity vs open excision

5. Lateral Epicondylitis (Refractory)

  • Arthroscopic debridement of the ECRB origin after failure of 6 months conservative treatment
  • Allows simultaneous assessment of intra-articular pathology

6. Synovitis / Plica Removal

  • Rheumatoid synovitis — arthroscopic synovectomy delays progression
  • Posterolateral plica syndrome — arthroscopic resection is definitive treatment
  • Pigmented villonodular synovitis

7. Diagnostic Arthroscopy

  • When imaging is inconclusive (unexplained elbow pain, suspected chondral injury)
  • Staging of articular pathology before definitive treatment planning

Evidence Base:

StudyIndicationKey FindingLevel
Andrews JR, Carson WG (Arthroscopy 1985)Portal techniqueFirst systematic description of elbow arthroscopy portals; loose-body removal gave the best resultsIV
Lynch GJ et al. (Arthroscopy 1986)Nerve anatomyCadaveric mapping of neurovascular structures to portals; emphasised injury from wrong portal, entry direction or elbow positionIV
Stothers K et al. (Arthroscopy 1995)Portal safetyProximal medial and proximal lateral portals safer than anteromedial/anterolateral — recommended as standard anterior portalsIV
Ball CM et al. (JSES 2002)Contracture releaseArthroscopic release: arc under 100° improved from 69° to 119°; no neurovascular complicationsIV
Bexkens R et al. (AJSM 2017)OCD capitellumArthroscopic debridement + microfracture in 75 elbows; 62% return to sport; open physis predicted better outcomeIV
Kelly EW, Morrey BF, O'Driscoll SW (JBJS Am 2001)Complications473 cases: 0.8% serious (infection), 11% minor; transient nerve palsies linked to rheumatoid arthritis and contractureIV

Elbow Arthroscopy — Exam Viva Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

Scenario 1: OCD Capitellum in a 15-Year-Old Throwing Athlete

CLINICAL PROMPT

"A 15-year-old elite baseball pitcher presents with 4 months of lateral elbow pain and locking. MRI shows a 12mm Grade 3 OCD lesion of the capitellum with a partially detached articular fragment in situ. Describe your management."

PRACTICAL APPROACH
This is an unstable OCD lesion of the capitellum (Grade 3 — partially detached in situ) in a skeletally immature overhead athlete. This requires surgical intervention — conservative management has a poor prognosis for unstable lesions. **Preoperative Assessment:** - Review MRI carefully for fragment size, fragment viability (T2 signal within fragment — low signal indicates avascular), and subchondral bone defect dimensions - Weight-bearing radiographs including radial head views - Patient and family counseling regarding realistic return-to-throwing timeline (9–12 months) **Surgical Plan — Elbow Arthroscopy with Fragment Fixation:** I would perform elbow arthroscopy in lateral decubitus position under general anaesthesia with tourniquet. **Positioning and Setup:** - Lateral decubitus with arm over bolster, elbow at 90° - Mark medial epicondyle, lateral epicondyle, radial head, olecranon, and ULNAR NERVE before draping - Tourniquet positioned high on the arm **Portal Establishment:** 1. Distend joint with 20–30 mL saline through the soft-spot (direct lateral) confirming intra-articular placement 2. Proximal anteromedial portal FIRST — 2 cm proximal to medial epicondyle, blunt trocar, advance to anterior humerus, enter joint 3. Insert arthroscope and confirm anterior compartment visualisation 4. Anterolateral portal UNDER DIRECT VISION — forearm supinated (PIN moves to 14 mm distance), insert 18-gauge needle first under arthroscopic view, then blunt trocar **Arthroscopic Assessment of the OCD Lesion:** - Assess fragment size, stability (probe testing), fragment viability (cartilage colour and turgor) - Grade 3 confirmed: partially attached posterolateral edge, mobile with probing, articular surface intact **Fixation Technique:** - Debride fibrous tissue from beneath the fragment using a small curette - Drill multiple 1.0-mm channels in the lesion bed to promote vascular ingrowth - Reduce the fragment anatomically - Fixation with 1–2 headless compression screws (Herbert-Whipple) or bioabsorbable poly-L-lactic acid pins in retrograde or antegrade technique under fluoroscopic guidance - Confirm fragment stability by probing arthroscopically after fixation - Check full radiocapitellar motion — no block to rotation **Post-op:** - Posterior slab 4 weeks - Week 4–6: active ROM, no throwing - Month 3–4: interval throwing programme begins - Month 9–12: return to full competition Evidence for arthroscopic treatment of capitellar OCD: Bexkens et al. (AJSM 2017) reported 62% return to primary sport after arthroscopic debridement and microfracture, with an open capitellar physis and shorter symptom duration predicting better outcomes; Lu et al. (Int Orthop 2018) meta-analysis found 91.4% return to sport in arthroscopically treated patients.
CLINICAL SCENARIOStandard

Scenario 2: Post-Traumatic Elbow Contracture — 50° Flexion Deficit

CLINICAL PROMPT

"A 32-year-old manual worker sustained a terrible triad injury 18 months ago treated non-operatively. He now has elbow ROM of 45°–95° flexion. He cannot straighten his elbow (missing 45° terminal extension) and cannot flex beyond 95°. He has no ligamentous instability on examination. Describe your operative management."

PRACTICAL APPROACH
This patient has post-traumatic elbow contracture with significant functional deficit — missing 45° terminal extension and 35° flexion is a combined 80° loss of arc. Normal functional arc is 30°–130° (100° range). This degree of contracture warrants surgical release. **Preoperative Assessment:** - CT scan to exclude heterotopic ossification (HO) — presence of HO changes management (may need open excision after bone maturation) - Bone scan to confirm HO maturity if present (cold scan = mature HO) - Check for ulnar nerve symptoms (cubital tunnel changes post-trauma) - Ensure patient has completed physiotherapy programme (minimum 3–6 months post-injury) Assuming CT shows extrinsic contracture (capsular and soft-tissue primarily, no significant HO), I would proceed with arthroscopic capsular release. **Contraindications to Pure Arthroscopic Release:** - Bridging heterotopic ossification (requires open excision) - Severe post-traumatic arthrosis (may need arthroplasty) - Active infection **Positioning:** Lateral decubitus, arm over a bolster. **Portal Establishment and Neurovascular Safety:** 1. Palpate and mark ulnar nerve through cubital tunnel BEFORE draping 2. Mark medial epicondyle, lateral epicondyle, radial head, olecranon 3. Distend joint through soft-spot with 30 mL saline (distension may be limited in contracted joint — 10–15 mL may be all that enters) 4. Proximal anteromedial portal first — difficult in contracted joint, stay close to anterior humerus 5. Anterolateral portal under direct vision — forearm supinated, PIN 14 mm distanced **Anterior Compartment Release:** - Identify the anterior capsule — in contracture it is thickened (3–5 mm vs normal 1–2 mm) and opaque - Using radiofrequency ablator or arthroscopic blade, perform anterior capsulectomy: - Start laterally at the lateral capsular recess (furthest from PIN medially) - Work medially keeping the blade close to the anterior humerus - Release from lateral to medial staying anterior to the anterior band of MCL - Lateral capsulectomy: resect anterior capsule from lateral epicondyle medially to trochlea - CRITICAL: Do NOT violate the lateral capsule/LUCL (destabilises elbow) - Coronoid fossa debridement — remove fibrous tissue and osteophytes obstructing coronoid **Posterior Compartment Release:** - Switch arthroscope to posterior central portal - Posterolateral portal as working portal - Posterior capsulectomy: resect posterior capsule transversely - Olecranon fossa debridement — remove loose bodies, osteophytes, fibrous tissue - Olecranon tip osteophytes — resect with shaver or burr if impinging - POSTEROMEDIAL portal (if needed for medial gutter): ulnar nerve must be identified and protected — consider ulnar nerve transposition if any preoperative ulnar nerve symptoms **Intra-operative Assessment:** - Check terminal extension gained: target within 15° of full extension - Check flexion gained: target greater than or equal to 120° **Post-op — CRITICAL:** - Begin active ROM physiotherapy within 24–48 hours — this is the most important determinant of outcome - Dynamic extension splinting (Dynasplint or turnbuckle) at night from Day 2 - Physiotherapist-guided ROM 3 times daily - Target: full functional arc 30°–130° by week 6–8 - Indomethacin 75 mg/day for 6 weeks (HO prophylaxis) Ball et al. (JSES 2002) reported that arthroscopic capsular release improved the arc of motion from 69° to 119° in patients with a preoperative arc under 100°, with no neurovascular complications and high patient-reported satisfaction; Cohen and Hastings (JBJS Br 1998) demonstrated comparable gains (74° to 129° ulnohumeral movement) with an open lateral collateral ligament-sparing release.
CLINICAL SCENARIOAdvanced

Scenario 3: Intraoperative Complication — Fluid Extravasation / Compartment Concern

CLINICAL PROMPT

"You are 45 minutes into an elbow arthroscopy for loose body removal. The scrub nurse notes the limb looks swollen and firm. The anaesthetist reports a sudden difficulty maintaining the pulse oximeter reading on the ipsilateral hand. Describe your immediate management."

PRACTICAL APPROACH
This is a potentially serious intraoperative complication — significant fluid extravasation with concern for developing forearm compartment syndrome. This requires immediate, systematic management. **Immediate Actions (First 60 Seconds):** 1. STOP the procedure — remove all instruments and cannulas 2. STOP the fluid pump — turn off the arthroscopy pump immediately 3. Release the tourniquet if applied 4. Inform the anaesthetic team of the suspected complication 5. Ask an assistant to assess the limb while I prepare to examine **Clinical Assessment of the Limb:** - Inspect: Is the forearm visibly swollen, tense, and discoloured? - Palpate: Is the forearm tense and firm (compartment pressure elevated)? - Neurological: Assess passive stretch of fingers — pain on passive extension of fingers is the earliest sign of compartment syndrome - Vascular: Check radial pulse, pulse oximetry, capillary refill - Check the axilla and upper arm for fluid tracking proximally **Differential Diagnosis of Pulse Oximetry Loss:** - Fluid extravasation compressing compartments (most likely given context) - Tourniquet effect - Probe displacement - Vasospasm from hypothermia - True vascular injury (rare) **If Compartment Syndrome Suspected — Immediate Management:** - Measure compartment pressures: use a compartment pressure monitor in the volar forearm and dorsal forearm - Compartment syndrome threshold: absolute pressure greater than 30 mmHg OR within 30 mmHg of diastolic pressure (Delta P less than 30 mmHg) - If threshold met: IMMEDIATE 4-compartment forearm fasciotomy (volar and dorsal) - Do not wait for pressure measurement if clinical picture is unambiguous (tense rigid arm, pain on stretch, neurological change) **Fasciotomy Technique if Required:** - Volar approach: curved incision from antecubital fossa to wrist, release flexor compartment including deep flexors - Dorsal approach: linear dorsal incision, release extensor compartment - Carpal tunnel release if wrist compartment also involved - Leave wounds open with VAC dressing **If Fluid Extravasation Without True Compartment Syndrome:** - Elevate the limb - Remove compressive dressings - Observe closely for 30–60 minutes - If arm softens and neurological exam remains intact: no further intervention, monitor for 24 hours - Consider splinting in elevated position **Post-event Management:** - Document the event meticulously in the operative record - Inform patient post-op regarding what occurred and the management - Close clinical follow-up at 24–48 hours - Medico-legal documentation **Prevention of Fluid Extravasation:** - Use gravity inflow where possible - Limit pump pressure to 40 mmHg maximum for elbow (lower than shoulder/knee) - Set a time limit: less than 90 minutes operative time - Monitor arm during procedure — scrub nurse should regularly check limb - Avoid excessive fluid volume - Small portal incisions reduce fluid leakage tracks

ELBOW ARTHROSCOPY — EXAM CHEAT SHEET

Clinical summary

Key Evidence

Arthroscopy of the elbow

Level IV
Andrews JR, Carson WG • Arthroscopy (1985)
Clinical Implication: The foundational technique paper for elbow arthroscopy — loose-body removal remains its most reliable indication and the case for meticulous portal technique was made from the outset.
Verify on PubMed (PMID 4091924)

Neurovascular anatomy and elbow arthroscopy: inherent risks

Level IV
Lynch GJ, Meyers JF, Whipple TL, Caspari RB • Arthroscopy (1986)
Clinical Implication: Landmark cadaveric study establishing why portal placement, entry direction and joint position determine nerve safety in elbow arthroscopy.
Verify on PubMed (PMID 3768116)

Arthroscopy of the elbow: anatomy, portal sites, and a description of the proximal lateral portal

Level IV
Stothers K, Day B, Regan WR • Arthroscopy (1995)
Clinical Implication: Provides the anatomical justification for establishing a proximal (anteromedial) portal first, the safest viewing portal, before any lateral working portal.
Verify on PubMed (PMID 7575879)

Complications of elbow arthroscopy

Level IV
Kelly EW, Morrey BF, O'Driscoll SW • J Bone Joint Surg Am (2001)
Clinical Implication: The benchmark complication series — most complications are transient and minor, but nerve palsy risk rises sharply in inflammatory arthritis and contracture cases, who warrant extra caution and counselling.
Verify on PubMed (PMID 11205854)

Arthroscopic treatment of post-traumatic elbow contracture

Level IV
Ball CM, Meunier M, Galatz LM, Calfee R, Yamaguchi K • J Shoulder Elbow Surg (2002)
Clinical Implication: Supports arthroscopic capsular release as a low-morbidity alternative to open release for extrinsic post-traumatic contracture, with substantial arc gains in the most stiff elbows.
Verify on PubMed (PMID 12469091)

Clinical outcome after arthroscopic debridement and microfracture for osteochondritis dissecans of the capitellum

Level IV
Bexkens R, van den Ende KIM, Ogink PT, van Bergen CJA, van den Bekerom MPJ, Eygendaal D • Am J Sports Med (2017)
Clinical Implication: Arthroscopic debridement and microfracture gives good function for advanced capitellar OCD, but return to sport is not universal — counsel patients realistically, especially those with a closed physis.
Verify on PubMed (PMID 28520461)

References

  1. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy. 1985;1(2):97–107. PMID: 4091924. DOI: 10.1016/s0749-8063(85)80038-4. — First systematic description of elbow arthroscopy portals and technique; loose-body removal gave the best results.

  2. Lynch GJ, Meyers JF, Whipple TL, Caspari RB. Neurovascular anatomy and elbow arthroscopy: inherent risks. Arthroscopy. 1986;2(3):190–197. PMID: 3768116. DOI: 10.1016/s0749-8063(86)80067-6. — Landmark cadaveric study mapping neurovascular structures to portals; injury driven by portal placement, entry direction and elbow position.

  3. Poehling GG, Whipple TL, Sisco L, Goldman B. Elbow arthroscopy: a new technique. Arthroscopy. 1989;5(3):222–224. PMID: 2775398. DOI: 10.1016/0749-8063(89)90176-x. — Prone position with a proximal medial portal improving scope mobility and visualisation.

  4. Stothers K, Day B, Regan WR. Arthroscopy of the elbow: anatomy, portal sites, and a description of the proximal lateral portal. Arthroscopy. 1995;11(4):449–457. PMID: 7575879. DOI: 10.1016/0749-8063(95)90200-7. — Proximal medial and proximal lateral portals safer than anteromedial/anterolateral; recommended as standard anterior portals.

  5. Cohen MS, Hastings H 2nd. Post-traumatic contracture of the elbow. Operative release using a lateral collateral ligament sparing approach. J Bone Joint Surg Br. 1998;80(5):805–812. PMID: 9768890. DOI: 10.1302/0301-620x.80b5.8528. — Open LCL-sparing release improved total ulnohumeral movement from 74° to 129°.

  6. Ball CM, Meunier M, Galatz LM, Calfee R, Yamaguchi K. Arthroscopic treatment of post-traumatic elbow contracture. J Shoulder Elbow Surg. 2002;11(6):624–629. PMID: 12469091. DOI: 10.1067/mse.2002.126770. — Arthroscopic release: arc under 100° improved from 69° to 119°; no neurovascular complications.

  7. Lindenhovius ALC, Linzel DS, Doornberg JN, Ring DC, Jupiter JB. Comparison of elbow contracture release in elbows with and without heterotopic ossification restricting motion. J Shoulder Elbow Surg. 2007;16(5):621–625. PMID: 17644008. DOI: 10.1016/j.jse.2007.01.005. — Motion gains greater when motion-blocking HO is removed than with capsular contracture alone.

  8. Bexkens R, van den Ende KIM, Ogink PT, van Bergen CJA, van den Bekerom MPJ, Eygendaal D. Clinical outcome after arthroscopic debridement and microfracture for osteochondritis dissecans of the capitellum. Am J Sports Med. 2017;45(10):2312–2318. PMID: 28520461. DOI: 10.1177/0363546517704842. — 75 elbows; 62% return to sport; open physis predicts better outcome.

  9. Lu Y, Li YJ, Guo SY, Zhang HL. Is there any difference between open and arthroscopic treatment for osteochondritis dissecans (OCD) of the humeral capitellum: a systematic review and meta-analysis. Int Orthop. 2018;42(3):601–607. PMID: 29349503. DOI: 10.1007/s00264-018-3768-3. — 91.4% return to sport arthroscopic vs 86.4% open; no complications in arthroscopic group.

  10. Kelly EW, Morrey BF, O'Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am. 2001;83(1):25–34. PMID: 11205854. DOI: 10.2106/00004623-200101000-00004. — 473 cases: 0.8% serious (infection), 11% minor; transient nerve palsy linked to rheumatoid arthritis and contracture.

  11. Safran MR. Ulnar collateral ligament injury in the overhead athlete: diagnosis and treatment. Clin Sports Med. 2004;23(4):643–663. PMID: 15474227. DOI: 10.1016/j.csm.2004.05.002. — Overhead-athlete elbow pathology relevant to the throwing population presenting with OCD and loose bodies.

  12. Johnson JA, Beingessner DM, Gordon KD, Dunning CE, Stacpoole RA, King GJW. Kinematics and stability of the fractured and implant-reconstructed radial head. J Shoulder Elbow Surg. 2005;14(1 Suppl S):195S–201S. PMID: 15726082. DOI: 10.1016/j.jse.2004.09.034. — Radial head excision markedly alters elbow kinematics/stability — relevant when considering arthroscopic radial head excision.