Arthroscopic‐guided ulnar distraction for the correction of elbow incongruency in four dogs

Four skeletally immature, small breed dogs (five elbows) with elbow incongruency were evaluated for forelimb lameness. Findings on clinical examination included pain, effusion and decreased range of motion of the affected elbow. Radiography, computed tomography and arthroscopy demonstrated elbow incongruency in all dogs. Fragmented medial coronoid process was diagnosed arthroscopically in three dogs (four elbows). Arthroscopic subtotal coronoidectomy was performed in all cases of fragmented medial coronoid process. Incongruency was corrected with acute ulnar lengthening under arthroscopic visualisation. The ulna was stabilised with a plate following correction. In two elbows an ostectomy of the anconeal process was performed to prevent impingement against the olecranon fossa. All dogs demonstrated improvement in lameness scores and client‐scored visual analogue scale scores. Postoperative computed tomography showed significant improvement in elbow incongruency in all dogs. Arthroscopic‐guided ulnar lengthening may be considered as a valid treatment in severe cases of elbow incongruency .     

Radiographic diagnosis and surgical management of fragmented medial coronoid process in dogs

The diagnosis of fragmented (ununited) medial coronoid process was made in 21 dogs, with 10 dogs having bilateral lesions. Ten of these dogs were presented to surgery. The diagnosis of fragmented medial coronoid process was made in young and middle-aged large- and giant-breed dogs with a history of intermittent or persistent lameness. Diagnosis was based on history as well as results of clinical examination and radiographic study of both elbows. Concomitant elbow lesions seen with fragmented medial coronoid processes were ununited anconeal process and osteochondritis dissecans of the medial humeral condyle. Avulsion of the medial epicondyle and posteromedial supracondylar ridge of the humerus were thought not to have occurred in these cases. Instead, dystrophic ossification of the synovial membrane and periosteal proliferation on the medial epicondyle and posteromedial supracondylar ridge had taken place. It was concluded that, with a questionable radiographic diagnosis of fragmented medial coronoid process, exploratory arthrotomy may be necessary to confirm the diagnosis. Without surgery, the eventual outcome of fragmented coronoid process is degenerative joint disease. Even with degenerative joint disease, however, clinical improvement was seen following removal of the fragment of the medial coronoid process.     

RADIOGRAPHIC FEATURES OF PRIMARY AND CONCOMITANT FLEXOR ENTHESOPATHY IN THE CANINE ELBOW

Primary flexor enthesopathy is a recently recognized elbow disorder and should be considered in the differential diagnosis of elbow lameness. For treatment planning purposes, it is important to make a distinction between primary and concomitant forms of the disease. The purpose of this prospective study was to compare radiographic findings for dogs with primary flexor enthesopathy (n = 17), concomitant flexor enthesopathy (n = 24), elbow dysplasia (n = 13), and normal dogs (n = 7). All dogs underwent a complete radiographic examination and each radiographic image was evaluated for the presence or absence of following characteristics: irregular medial humeral epicondyle, spur and calcified body. Additionally, the presence or absence of other elbow disorders (medial coronoid process disease, osteochondritis dissecans, ununited anconeal process, incongruity, subtrochlear sclerosis, and osteoarthritis) was recorded. Radiographic characteristics of flexor enthesopathy were found in 86% of painful joints in the primary flexor enthesopathy group and in 100% of painful joints in the concomitant flexor enthesopathy group. Radiographic characteristics of flexor enthesopathy were not found in sound elbow and elbow dysplasia groups. Frequencies and details of individual radiographic characteristics did not differ between primary and concomitant flexor enthesopathy groups. Findings support the use of radiography as a first screening method for detection of flexor enthesopathy, but not as a technique for distinguishing primary vs. concomitant forms.     

Fragmentation of the medial coronoid process of the ulna in dogs: A study of 109 cases

The results of a combined retrospective and prospective study of 130 cases of fragmented coronoid process (FCP) in 109 dogs are presented. Sixty-eight cases were treated surgically by medial elbow arthrotomy and 62 were treated medically (rest and anti-inflammatories). Case records were searched with the emphasis on the severity of lameness, physical abnormalities and in surgical cases, the appearance of the coronoid process lesion. Long term follow-up was obtained by a telephone survey. Analysis of case histories and physical data revealed no correlation between severity of lameness before treatment, severity of radiographic changes in the elbow joint and the type of lesion found at surgery. Surgical treatment did not decrease the incidence of post treatment lameness, but the surgically treated dogs were more active and less severely lame than those treated without surgery. It was concluded that young dogs with mild lameness due to FCP in the elbow probably do not benefit from surgical treatment but dogs with chronic, moderate to severe lameness have a better prognosis if treated surgically.     

BONE SCINTIGRAPHY FOR THE DIAGNOSIS OF AN ABNORMAL MEDIAL CORONOID PROCESS IN DOGS

Few reports have been published regarding the use of scintigraphy in the diagnosis of elbow joint lameness in dogs. Some authors have speculated about the potential use of bone scintigraphy and its suspected high sensitivity for the early diagnosis of abnormalities of the medial coronoid process (MCP) in dogs. Scintigraphy is used routinely in our institution in dogs presented for thoracic limb lameness and/or suspected of abnormalities of the MCP when radiographic findings were equivocal. Radiographic, scintigraphic, and surgical findings of the elbow joints of 17 dogs with elbow joint lameness were compared with radiographic, scintigraphic, and necropsy findings of the elbow joints of 12 clinically healthy Labrador Retrievers. Quantitative evaluation of scintigraphic images was performed to determine relative radiopharmaceutical uptake in the region of the MCP. Maximum relative uptake of the coronoid process in the normal dogs was taken as a threshold value to classify elbows as positive or negative for an abnormal MCP after all 24 elbows of the 12 healthy dogs were confirmed as being normal at necropsy. All 17 elbows from lame dogs were positive on scintigraphy and confirmed as having chondromalacia, a fissure, or fragmentation of the MCP. Based on our results, bone scintigraphy may be a valuable diagnostic tool for the diagnosis of abnormalities of the MCP in dogs, and particularly in older dogs where clinical and radiographic changes may be ambiguous.     

Asynchronous Growth of the Canine Radius and Ulna: Surgical Correction following Experimental Premature Closure of the Distal Radial Physis

Marked lameness and elbow incongruity occurred in seven 21-week-old dogs following experimental premature closure of the distal radial physis at 10 weeks of age. Midradial transverse osteotomies and bone plate stabilization performed on five dogs resulted in marked reduction of elbow incongruity and forelimb lameness. Two dogs had no surgery and served as controls for the surgical procedure. At 50 weeks of age the proximal radial articular surface was displaced 5.3 mm farther from the coronoid process in control dogs as compared to dogs having transverse radial osteotomy. Markedly worse clinical, radiographic, and pathologic changes in the control group demonstrated the importance of reestablishing and preserving elbow congruity when treating asynchronous growth of the canine forelimb caused by premature closure of the distal radial physis. The technique described is recommended as one method to treat premature distal radial physeal closure clinically.     

Osteochondrosis of the elbow: a review of the pathogenesis and a new approach to treatment

SUMMARY To test the hypothesis that joint incongruity contributes to the pathogenesis of elbow osteochondrosis, the left and right radius and ulna of 20 young large breed dogs were measured to determine any variation in length and to observe any incongruity of the elbow joint. Both lame and normal dogs were included in the study. Nine of the 20 dogs had marked disparity in radial and ulnar lengths yet only one had obvious elbow joint incongruity. The use of a sliding osteotomy for the treatment of fragmented coronoid process and a lengthening osteotomy for the treatment of an ununited anconeal process is also discussed. All four dogs treated with a sliding osteotomy showed a marked clinical improvement, and two of the three dogs treated with a lengthening osteotomy showed radiographic fusion of the anconeal process.     

Sensitivity and specificity of radiography for detection of elbow incongruity in clinical patients

Elbow incongruity is an important factor regarding the treatment and prognosis of elbow dysplasia. Our purpose was to determine the sensitivity and specificity for radiographic detection of elbow incongruity in clinical patients, to establish inter- and intraobserver variation for different parameters, and to evaluate the possibility of radiographic grading of incongruity. Standard radiographic projections were acquired from 29 incongruent and nine congruent elbows of dogs of various ages and breeds. Computed tomography (CT) was used to diagnose and grade the incongruity. All radiographs were evaluated by four observers for detection and grading of elbow incongruity. Sensitivity, specificity, inter- and intraobserver variability were calculated. The mean sensitivity for detection of incongruity was very good (88.8%) with a mean specificity of 91.7%. Correct grading of incongruity was difficult. The radioulnar step and the widening of the humeroulnar and humeroradial joint space were seen most frequently. Intraobserver and interobserver variability were fair to excellent (Kappa = 0.372-0.809), depending on the investigated parameters. Radiography is valuable to screen for elbow incongruity. In over 91% of the patients, a clear distinction could be made between a congruent and an incongruent joint grading was not possible.     

Computed tomographic features of incomplete ossification of the canine humeral condyle

Objectives— To describe computed tomographic (CT) features of canine elbows with incomplete ossification of the humeral condyle (IOHC) and investigate co-existing incongruence in the elbow joint.
Study Design— Case control study.
Animals— Dogs with IOHC (n=20; 38 elbows) and 25 normal elbows.
Methods— Elbows with IOHC and normal elbows were assessed by CT. Standardized dorsal and sagittal reconstructions were created at 3 levels using image analysis software to obtain single measurements of the humero-radial and humero-ulnar joint spaces. On dorsal plane reconstructions, joint space measurements were obtained at the center point of the humero-radial and humero-ulnar articulations. Joint incongruity was defined as the difference between the humero-radial and the humero-ulnar joint spaces.
Results— Nineteen dogs (95%), all Spaniel breeds, had either bilateral IOHC demonstrable as a saw-toothed intercondylar complete or incomplete hypoattenuating defect with hyperattenuating margins, or IOHC with contralateral humeral condylar fracture (HCF). Joint incongruity values for IOHC were compared with those of normal elbows. Significant differences were noted at the levels of the medial coronoid apex ( P <.0001) and base ( P <.004) indicative of humero-ulnar incongruence. Evidence of medial coronoid disease in 10 elbows (26%) and degenerative joint disease in 30 elbows (79%) was also found.
Conclusions— Presence of elbow incongruence may be an underlying factor in failure of ossification centers to fuse leading to IOHC.
Clinical Relevance— IOHC is clearly defined by CT, and it should be considered in larger Spaniel breeds, with a chronic forelimb lameness or HCF.     

Use of the distomedial-proximolateral oblique radiographic view of the elbow joint for examination of the medial coronoid process in dogs

OBJECTIVE: To describe and evaluate a new radiographic view of the elbow joint in dogs that would potentially enhance observation of the medial coronoid process (MCP). SAMPLE POPULATION: 20 cadaver limbs from 10 dogs and clinical examination of 100 elbow joints of 53 dogs. PROCEDURE: Twenty elbow joints from 10 cadavers were imaged by use of mediolateral, flexed mediolateral, craniocaudal, craniolateral-caudomedial oblique (Cr15L-CdMO), and distomedial-proximolateral oblique (Di35M-PrLO) radiographic views before and after placement of 3 lead pellets placed on the cranial, medial, and craniodistal aspect of the MCP. Three examiners independently reviewed these radiographs. One hundred elbow joints of 53 dogs with forelimb lameness and signs of pain elicited on palpation of the elbow joint were examined. These joints were radiographed and treated by use of arthroscopy. Three examiners independently graded the radiographs. RESULTS: The MCP was identified on all Di35M-PrLO views made during the anatomic study. The Di35M-PrLO view had the largest area under the receiving operating characteristic (ROC) curve for detection of abnormalities of the MCP. Fractured and nonfractured MCP could only be significantly differentiated on Di35M-PrLO and mediolateral views. The Di35M-PrLO view had a higher agreement between examiners than other radiographic views for detection of fractures of the MCP. CONCLUSION AND CLINICAL RELEVANCE: The Di35M-PrLO view enhances the identification of anomalies and fragmentation of the MCP in dogs, compared with other radiographic views. The Di35M-PrLO view may be of benefit for early screening of dogs potentially affected with elbow dysplasia.     

Radiographic findings of the medial humeral epicondyle in 200 canine elbow joints

Objectives: To determine the frequency and radiographic aspect of medial humeral epicondylar lesions as a primary or concomitant finding and to evaluate the association with osteoarthritis. Methods: Medical records of dogs diagnosed with elbow lameness were reviewed. Inclusion criteria for this study were a complete clinical examination, a complete set of digital radiographs and a final diagnosis made by computed tomography or magnetic resonance imaging and arthroscopy. Changes of the medial humeral epicondyle were recorded and correlated with the radiographic osteoarthritis and final diagnosis. Results: Eighty of the 200 elbows showed changes of the medial humeral epicondyle. In 12 of these 80 elbows, changes of the medial epicondyle were the only findings within the joint, and these elbows were diagnosed with primary flexor enthesopathy. In the remaining 68 elbows, other concomitant elbow pathologies were found. In those cases of concomitant epicondylar changes, high grades of osteoarthritis were recorded, while most elbows with primary flexor enthesopathy showed a low grade of osteoarthritis. Clinical significance: Changes of the medial humeral epicondyle are often considered clinically unimportant and are regarded as an expression of osteoarthritis. This study showed the relatively frequent presence of epicondylar changes of which the majority were considered concomitant to a primary elbow problem. If changes of the medial humeral epicondyle are the only pathologic finding (primary flexor enthesopathy) they should be considered as the cause of lameness and not as a sign of osteoarthritis.     

Canine elbow dysplasia and primary lesions in German shepherd dogs in France

Five hundred and twenty German shepherd dogs were screened for elbow dysplasia. The following primary lesions were analysed: joint incongruity (JI), fragmented medial coronoid process (FCP), osteochondrosis or osteochondritis of the medial humeral condyle and ununited anconeal process (UAP). Three radiographic views were used for each joint to achieve a definitive diagnosis. The prevalence of elbow dysplasia was 19.4 per cent. The most frequent lesion was JI (16.3 per cent), followed by FCP (11.3 per cent). UAP was diagnosed rarely (1.1 per cent). Combinations of lesions were very frequent (42.2 per cent of the dysplastic elbows). Although these results may be biased due to prescreening of dogs with UAP, it should be highlighted that JI and FCP occur frequently in German shepherd dogs and are probably the most common primary lesions of elbow dysplasia, although they have been under-reported until now.     

The intra‐ and intertester repeatability of radiographic elbow incongruity grading is high in chondrodystrophic dog breeds

Elbow incongruity is a form of elbow dysplasia that causes osteoarthritis, pain, and lameness, and it is common in chondrodystrophic dog breeds. The objective of this retrospective secondary analysis study was to evaluate the intra‐ and interobserver repeatability of a novel radiographic incongruity grading system for assessing elbow incongruity in three chondrodystrophic dog breeds—the dachshund, Skye Terrier, and Glen of Imaal Terrier. We conducted an observer agreement study that included 220 mediolateral antebrachial radiographs from 110 dogs with the elbow in 90° flexion. The radiographs were independently assessed by three observers at three time points, using a four‐stepped grading scale. The proportion of agreement and Kappa coefficient were calculated. Both the intra‐ and interobserver proportions of agreement were substantial when three grades were required to be identical (.705‐.777 and .609, respectively), and almost perfect for two identical grades (.991‐1.000 and .991, respectively). Some differences in repeatability between breeds were noted; specifically, the intraobserver repeatability was higher in the dachshund, and the interobserver repeatability was lower in the Glen of Imaal Terrier. Our study showed that the radiographic imaging protocol and incongruity grading system have high repeatability when assessing elbow incongruity in chondrodystrophic dog breeds.     

Meniscal injury following initial cranial cruciate ligament stabilization surgery in 26 dogs (29 stifles)

OBJECTIVE: To describe clinical signs, arthroscopic findings, and outcome in a group of dogs undergoing second look arthroscopy for the treatment of meniscal tears following original surgery to correct a CCL deficient stifle joint. METHODS: The medical records of 26 dogs from the Veterinary Teaching Hospital at Texas A&M University and the Veterinary Orthopedic Center (Round Rock, Texas) that had second look arthroscopy for lameness following an original surgical procedure were reviewed. Pre-operative clinical findings, 2nd look arthroscopic findings and owner assessed outcome were documented. RESULTS: Postliminary bucket handle tears of the medial meniscus were detected in 22 (75.9%) cases. Other postliminary meniscal injuries included frayed caudal horn tears of the medial meniscus 6 (20.7%), and longitudinal tears of the lateral meniscus 1 (3.4%). An audible or palpable click was present in 27.6% of cases. An improvement or resolution of lameness was reported in 96.5% of cases reported. In conclusion, tears of the medial meniscus are a significant cause of lameness in dogs subsequent to surgery for cranial crucial ligament ruptures. Increased lameness or acute onset of lameness after surgery for cranial crucial rupture is a consistent finding. In rare cases, a palpable or audible click will be appreciated. Arthroscopic evaluation and partial meniscectomy improve or resolve lameness in the majority of cases. CLINICAL SIGNIFICANCE: Sudden or increased lameness in dogs with historical CCL stabilization surgery should be evaluated and treated arthroscopically for postliminary meniscal injury if another cause for lameness can not be determined.     

Use of a radiographic scoring technique for the assessment of dogs with elbow osteochondrosis

A retrospective study was made of 335 dogs with elbow osteochondrosis that had been seen at the Royal Veterinary College in 1977 to 1987. The most commonly affected breeds were the labrador, retriever and rottweiler. Males were affected more often than females. The condition was bilateral in 50 per cent of cases and the peak age for the onset of lameness was four to six months. In rottweilers, the lesions found at exploratory arthrotomy were predominantly abnormalities of the coronoid process, while in retrievers and labradors lesions most commonly affected the medial humeral condyle or the coronoid process. A scoring system for grading the standard projection (lateral and postero-anterior) radiographs was devised and the score was correlated with the lesion found at surgery. Some cases were reviewed radiographically and any alteration in the degree of periarticular arthrosis, seen as an increase in radiographic score, was noted. The exact extent of the lesion found at surgery was recorded diagrammatically in 65 cases. It did not prove possible to predict from the radiographic score the nature and extent of the lesion and no correlation could be found between the radiographic score [and clinical degree of lameness. The scoring system did have some merit for reviewing cases because an increase in score indicated the extent to which joint changes had advanced.     

Effects of electrostimulated acupuncture on ground reaction forces and pain scores in dogs with chronic elbow joint arthritis

OBJECTIVE: To determine whether use of electrostimuluated acupuncture (ESA) would result in significant improvements in ground reaction forces and lameness scores in dogs with chronic elbow joint osteoarthritis secondary to elbow joint dysplasia. DESIGN: Randomized, controlled, crossover clinical trial. ANIMALS: 9 dogs with chronic forelimb lameness and radiographic evidence of elbow joint osteoarthritis. PROCEDURES: All dogs had a 3-week control acclimation period during which gait analysis was performed weekly. Dogs then received ESA once weekly for 3 weeks followed by a sham treatment once weekly for 3 weeks or received the sham treatment followed by ESA. Gait analysis was repeated prior to each treatment, and owners were asked to provide pain scores by use of a visual analog scale method. RESULTS: Treatment (control, acupuncture, or sham) did not have a significant effect on ground reaction forces for any limb. Owners of 8 of the 9 dogs were able to correctly guess the time period when ESA was delivered. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that ESA did not have any significant effects on severity of lameness, as determined by measurement of ground reaction forces, or severity of pain, as determined by visual analog scale pain scores, in dogs with chronic elbow joint osteoarthritis secondary to elbow joint dysplasia.     

Prospective evaluation of techniques for differentiating shoulder pathology as a source of forelimb lameness in medium and large breed dogs

Objective— To assess lameness evaluation, shoulder abduction angles, radiography, and ultrasonography for determining presence, location, and severity of forelimb pathology. Study Design— Prospective cohort study. Animals— Dogs ≥20 kg (n=30). Methods— Each dog was assigned lameness scores. Shoulder abduction angles were determined. Radiographs of shoulders and elbows were subjectively graded for pathology. One investigator unaware of dog history (lameness, radiographic findings) performed ultrasonographic assessment of shoulders with subjective grading of pathology. Another investigator unaware of dog history (lameness, radiographic, ultrasonographic findings) performed arthroscopic assessment of shoulders with subjective grading of pathology. Elbows were disarticulated and evaluated for gross pathology. Histologic pathology scoring of shoulder tissues was performed. Data were compared for differences among groups, sensitivities, specificities, positive and negative predictive values, and positive and negative likelihood ratios were calculated. Results— Twenty‐seven forelimbs were considered clinically normal, 26 had shoulder pathology, 5 had elbow pathology, and 2 had pathology of both the shoulder and elbow. Dogs with shoulder pathology were twice as likely to be lame compared with dogs with elbow pathology. Limbs with medial shoulder instability had significantly higher abduction angles than normal limbs and those with elbow pathology. Radiographs were clinically useful for diagnosing elbow, but not shoulder, pathology. Ultrasonography was clinically useful for diagnosing shoulder pathology other than instability. Abduction angles, ultrasonographic evaluation, and arthroscopic assessments had strong, significant correlations with reference standards. Conclusions— Clinically relevant diagnostic techniques yielded characteristic, repeatable differences in objective and subjective assessments for distinguishing presence, location, and severity of forelimb lameness in dogs. Clinical Relevance— The diagnostic approach to forelimb lameness in dogs should include shoulder pathology as a differential with multiple assessments used to determine the clinical cause of lameness.     

Phenotypic and genetic evaluation of elbow dysplasia in Dutch Labrador Retrievers, Golden Retrievers, and Bernese Mountain dogs

Canine elbow dysplasia encompasses four developmental diseases: ununited anconeal process, osteochondrosis of the medial part of the humeral condyle, fragmented medial coronoid process (FCP), and incongruity of the elbow joint. Four radiographic views per joint were used to evaluate 2693 Labrador Retrievers (LRs), 1213 Golden Retrievers (GRs), and 974 Bernese Mountain Dogs (BMDs) for the presence of elbow dysplasia between 2002 and 2009 in the Netherlands. The views were also graded for signs of osteoarthritis and sclerosis. FCP was diagnosed most frequently in LRs, GRs and BMDs, with an incidence of 6%, 5%, and 15%, and a heritability of 0.17, 0.24, and 0.06, respectively. Heritabilities were estimated using a sire model and all available ancestors. Sclerosis at the base of the medial coronoid process was the radiographic sign most strongly correlated with FCP (r=0.95, 0.92, and 0.95 in LRs, GRs and BMDs, respectively). The sex of the dog was significantly correlated with the presence of osteoarthritis in LRs, but not in GRs and BMDs. Male LRs were 1.7-fold more frequently, but not more severely, affected by osteoarthritis than female dogs. Age at radiographic examination was significantly associated with osteoarthritis in all three breeds. The heritability estimates in Retrievers were high enough to warrant including FCP findings in the breeding policy, but until the biomechanical and genetic background of elbow dysplasia are better understood, correct phenotyping with a sensitive technique is essential.     

Radiographic assessment of humeroulnar congruity in a medium and a large breed of dog

Elbow joint incongruity is recognized as an important factor in the development, treatment, and prognosis of canine elbow dysplasia. Elbow incongruity has been measured based on radiographic joint space widths, however these values can be affected by the degree of elbow joint flexion. Recent studies have reported radiographic curvature radii as more precise measures of humeroulnar congruity in dogs. The aim of this prospective observational study was to describe radiographic curvature radii measured from flexed and extended elbow radiographs for a sample of dogs representing a medium breed (Portuguese Pointing Dog) and a large breed (Estrela Mountain Dog). The curvature radii from the ulnar trochlear notch and humeral trochlea were measured in 114 mediolateral elbow extended radiographic views (30 Portuguese Pointing Dog and 27 Estrela Mountain Dog), and 84 mediolateral flexed views (22 Portuguese Pointing Dog and 20 Estrela Mountain Dog). The sampled animals' ages ranged from 12 to 84 months (34.6 ± 17.8 months). Good agreement was observed between curvature radii measurements for flexed vs. extended views in both breed groups. Ulnar trochlear notch curvature radii measurements were greater than humeral trochlea curvature radii measurements in both breed groups. Both curvature radii were greater in the large‐breed dog group vs. the medium‐breed dog group. Both breed groups had ulnar and humeral curves with similar typology. However, the large breed group had greater intermediate differences between the humeroulnar surface curvature radii. Results from this study supported the use of curvature radii as measures of humeroulnar congruity in mediolateral flexed elbow radiographs of medium and large breed dogs.     

Arthroscopically‐assisted removal of an osteochondral fragment from the equine elbow using a caudo‐medial approach

An 8‐year‐old Polo pony mare was admitted for investigation of lameness related to swelling of the elbow. An intra‐articular fragment from the proximo‐medial radius was identified on radiographic examination. The fragment was removed arthroscopically under general anaesthesia via a caudo‐medial approach to the elbow joint.