A Closer Look at Elbow Replacements

Elbow fractures, specifically radial head bone fractures, make up about five per cent of all fractures and are frequently caused by falling on an outstretched arm. If the fractured bones are aligned enough that they can heal on their own, the elbow is protected for a period of time, followed by physical therapy for full return to function. If the fractured bones are not well aligned then surgeons must go in and stabilize the bones with hardware.  

The elbow joint is made up of three bones, the ulna, radius (both forearm bones), and the humerus (your upper arm bone).  The end of the radial bone is shaped like a disc and articulates with the end of the humerus at a divot called the capitulum. Because of the unique shape of the radial head and the combined movements of the ulna and the radius, our elbows not only bend and straighten but our forearms are able to rotate as the radial head spins.  

Advancements in technology and surgical techniques now allow for actual replacement of the radial head.  This is appropriate in cases where the radial fracture is so bad that it cannot be reconstructed, incidences of elbow instability, poorly healed fractures, elbow arthritis, or when there is a combination of elbow dislocation and radial head fracture.

Several types of radial head implants are now available. Loose fitting prosthesis anatomically mimic the original radial head and are placed “loosely” in the radial bone.  They are thought to stabilize the joint by acting as a block between the joint. The loose fitting prosthesis is not believed to be able to further loosen or cause pain from implant placement and has a full arc of articulation with the capitulum. Out of 13 patients with a loose fitting prosthesis placement queried at 38 months after surgery, eight reported excellent results, three good, and two fair results.  Press-fit stems are another option. These are also modeled after the radial head in design. They are fitted as tightly as possible in the radial bone. Press fit stems tend to have good to excellent results but there is greater chance of implant loosening than with a loose fitting prosthesis. A bipolar implant consists of a fixed stem but a mobile head, which melds the two previously mentioned implants. The greatest benefit of a bipolar implant is the improved arc of contact between the implant and the capitulum, however the greatest complication is the implant can dislocate.

Complications from radial head replacement can include elbow stiffness, nerve damage, bone deposition in soft tissue, and pain. Authors point out, however that most of these reported complications are most likely due to the original trauma and not the elbow replacement surgery. Wear and tear on the neighboring bone, the capitulum, is a long-term complication that is currently unavoidable.

Rehabilitation following surgery focuses on restoring functional motion. The elbow is splinted for seven to 10 days followed by full active and assisted movement of bending and straightening the elbow. Elbow rotation (supination, pronation) is allowed with the elbow bent to 90 degrees.  If patients are lacking full range of motion at the six-week mark, then physical therapy is prescribed.  Elbows with instability are only allowed to move through a specific range prescribed by the surgeon for three weeks, followed with unrestricted movement after that time period.  
As implants and surgical techniques improve, success rate of radial head replacement surgery ultimately lies with the skill and knowledge of the surgeon and an excellent understanding of implant designs and indications.

Assessment and Treatment of Ulnar Fracture with Elbow Dislocation or Subluxation

The elbow joint consists of three bones, the upper arm, or humerus, and two bones in the forearm ,the ulna and the radius. The ulna forms the tip of the elbow, also known as the olecranon process. It is at the point where the ulna meets the humerus that an elbow dislocation or subluxation can occur; the dislocation can be with or without fracture of the ulna. Six major patterns have been described as causes of an ulnar fracture with subluxation or dislocation of the ulnohumeral joint.

The first is dislocation with radial head or neck facture, in which there is also injury to the lateral collateral ligament, LCL, and possibly the medial collateral ligament, MCL. A second injury is termed the terrible triad in which there is a fracture to the coronoid and radial head as well as injury to the LCL. Third is the varus posteromedial rotatory instability which involves fracture of the anteromedial facet of the coronoid with either LCL injury or olecranon fracture causing varus subluxation of the elbow. Fourth is an anterior olecranon fracture-dislocation when the proximal part of the ulna is fractured and an anterior dislocation of the forearm relative to the distal humerus occurs with no radioulnar dissociation. A fifth category is termed posterior olecranon fracture-dislocation in which the proximal ulnar fracture includes a posterior dislocation of the forearm. The two olecranon fracture-dislocations can be commonly misdiagnosed as a Monteggia fracture in which the fracture also results in a dislocation of the proximal radioulnar joint. The sixth and final category of ulnar fracture with dislocation is a dislocation with capitellar or trochlear fracture. The capitellum is fractured, with or without extension into the trochlea accompanied by injury to the capsule and ligamentous support resulting in ulnohumeral instability.

It is imperative to understand the categories of acute injury to the elbow in order for surgeons to anticipate what structures may be affected, particularly when assessing in a nonacute setting. Of the structure affected, understanding the coronoid fracture fragment is the most important when identifying the patterns of elbow instability with imaging, as research shows as significant association between the type of coronoid fracture and the type of fracture-instability pattern. There are three types of coronoid fracture: type I is a transverse fracture of the tip of the coronoid associated most commonly with terrible triad injuries, type II is a fracture of the anteromedial facet of the coronoid associated most commonly with varus posteromedial rotatory instability, type III is a fracture at the base of the coronoid associated most commonly with olecranon fracture-dislocation.

There are several factors that influence the outcome of an ulnar fracture with dislocation. Though it is uncommon to have an elbow fracture with persistent ulnohumeral subluxation or dislocation that has been left untreated for more than two weeks, it is clear that time from injury to treatment will effect outcomes. Patients treated within two weeks of injury have significantly better outcomes than those treated more than two weeks after injury when assessing range of motion, pain, and outcome measures. With this evidence, the acute period for treating elbow fracture with dislocation is within 2 weeks . If surgical management cannot take place in the first two weeks, an alternative is to reduce the joint and apply an external fixator. Type or extent of instability will also effect outcomes. Most acute simple dislocations are stable once the joint has been concentrically reduced, the ligaments will heal and function with early controlled motion. A nonacute simple dislocation, persisting beyond two weeks, can still be successfully treated with concentric reduction and early motion, however longer standing dislocations can also require surgical repair as the LCL is not successfully healing to the lateral epicondyle. These instabilities result in less favorable functional outcomes.

There is no consensus on what the optimal solution is for assuring stability of an elbow that has dislocated or subluxed. Temporary immobilization with either cross pinning or external fixation is most commonly used to help maintain elbow congruency while healing. An external fixator, however is difficult to apply, cumbersome to wear, can sometimes still allow the elbow to dislocate and can cause pin-site infection, pin breakage and/or radial nerve injury. Cross pinning of the joint is better at maintaining reduction, but the arm must be casted and there are risks of pin breakage and septic arthritis.

There are many side-effects to the treatment of ulnar fracture with dislocation or subluxation, Contracture and stiffness, particularly with weeks of immobilization, can co-exist with instability and heterotropic ossification, and can impede concentric reduction. Methods available to treat excessive contracture or stiffness include an open capsular release and excision of heterotropic ossification with or without radiation. One must be careful with these procedures as the contracture or ossification may be masking latent instability. Arthrosis develops in almost all patients with these injuries, though extent and symptoms are highly variable. Ulnar neuropathy can develop and negatively affect outcomes as can osseous and chondral erosion.

Aside from addressing the main injury to the ulna and humerus, there are other factors to consider with these an elbow subluxation or dislocation. It is most likely that both the LCL and MCL are damaged in an ulnar fracture with dislocation, thus it becomes important to assess and properly treat the radial head. The radial head can act as a secondary stabilizer when the MCL is insufficient and helps maintain valgus stability at the elbow to allow soft tissue structures to optimally heal. Prior to fracture healing, repair or prosthetic replacement of the radial head, depending on the number of fractures, is an important consideration. The coronoid must also be assessed. Research demonstrates that when more than fifty per cent of the coronoid is excised, or a combination of at least thirty per cent cornoid excision with radial head excision and lateral ulnar collateral ligament damage, there is a significantly greater chance of consistent dislocation. To repair these injuries, the radial head can be replaced and the discarded radial head bone can be used to repair the coronoid. The success rates largely depend on the original instability pattern and the size of the coronoid defect.

It is apparent that there is a lot to consider when assessing an ulnar fracture with an elbow dislocation or subluxation. The initial questions to answer should be what is the original mechanism of injury, whether past surgical procedures were performed, what the state of the radial head may be, and where the ulnar nerve is located. The surgeon should be prepared to remove any implants and should know how they are affixed, location of heterotropic ossification must be noted, the ulnar nerve must be protected throughout the procedure, collateral ligaments should be preserved when possible, and the surgeon should be prepared to perform any necessary capsular release to treat joint stiffness. These many factors and considerations will direct the surgical procedure performed and success rate for favorable long term outcomes.

Options for Splinting as Treatment for Post-traumatic Elbow Contracture

Loss of range of motion due to capsular contracture of the elbow is not uncommon following traumatic injury to the joint. Nonsurgical options for treatment of the contracture include splinting and stretching exercises supervised by an occupational or physical therapist. Splinting can either be done statically or dynamically and may or may not include a turnbuckle feature.

Static progressive splinting does not allow the elbow to move and is typically used for short periods of time in a position that forces the elbow in one direction. The patient can control the force with guidance from their doctor and physiotherapist. Dynamic splints have a hinge at the elbow and a mechanism that allows some movement of the elbow while being stretched the rest of the time. These splints are worn for longer periods of time as they work by applying a low load prolonged stretch that typically causes little discomfort to the patient. The turnbuckle splint can be static or dynamic and allows the hand to pronate and supinate, or twist up and down.

The protocols for splinting vary greatly, but result in similar outcomes. Though static splints are typically worn for shorter periods of time, often in 30 minute increments several times a day, some protocols have the patient wearing the splint all day in varying positions. The range of motion gained with static splinting can vary, with reported results ranging from 26 degrees to 50 degrees. There is less research reporting protocols and results with dynamic splinting, but typically these splints are worn for at least six hours/day and often 24 hours a day. Range of motion gains vary from 20 to 47 degrees as reported in the literature.

Range of motion can continue to improve for up to a year after injury, with the greatest gains being made in the first three months. It is important that the patient understands this and prepares mentally to allow the stretching to take place in the early months. There is evidence that patients who have a protective attitude toward stretching in the first month of recovery gain less range of motion.

Design of Elbow Replacement Changing to Meet More Patients’ Needs

Joint replacement of hip, knee, and shoulder are commonplace now. Right behind those joints come ankle and elbow. This article focuses on past, present, and future total elbow arthroplasty (TEA) or replacement.

Elbow implants have been around for 30 years. They were first designed for adults with rheumatoid arthritis. But over the years, as the implant materials and technology have changed and improved, younger, more active adults with elbow arthritis following trauma, failed surgery to fix an elbow fracture, or after removal of tumors have become acceptable candidates as well.

Surgeons now have different pathology-specific implant options. In other words, they can choose the implant design that best suits the patient’s problem. For example, younger patients who place high-demand on their elbows might do best with a distal humeral hemiarthroplasty (DHH) with unicompartmental radiocapitellar arthroplasty. This implant is also the one of choice for acute traumatic conditions.

Distal humeral refers to the bottom part of the upper arm (which forms the upper part of the elbow) and unicompartmental tells us only one-side of the bottom portion of the elbow is replaced (radial head). Radiocapitellar refers to the place where the radius (one of the two bones of the forearm) meets the bottom of the humerus.

The goals of elbow replacement include: pain relief, improved elbow motion, and improved function. Total elbow arthroplasty (TEA) is also an option in cases where fractures have failed to heal or healed poorly resulting in malunion and deformity.

But elbow replacement is a challenging surgery to perform. The surgeon must position the implant correctly to restore the normal axis of motion and avoid overloading or wearing out the component parts. The use of computers to assist in accurate implant placement may help improve results.

The key area in need of improvement now is reducing complications associated with TEA. There is still a considerable amount of wear on the polyethylene (plastic) portion of the implant. Other complications and problems that can develop include loosening of the implant from osteolysis (bone cells dissolve), infection, bone fracture around the implant, and weakness of the triceps muscle, which is cut in order to put the implant in place.

Less severe but more common complications include wounds that don’t heal and damage during the surgery to the local nerves and blood vessels. Overall, studies show a complication rate as high as 43 per cent with a minimum of 27 per cent. Almost one-third of patients have a second (revision or reoperation) surgery.

What does the future hold for those individuals who may need a total elbow replacement? First of all, more people will qualify for this type of surgery. They will be younger, more active, and possibly have a history of earlier trauma.

Secondly, better anatomic replication of the normal elbow will be incorporated into the next generation of elbow implants. The use of joint resurfacing instead of total elbow replacement is already becoming a favored approach. Ligaments are preserved and less stress (force/load) is placed across the elbow. There may be less bone loss over time.

The hope for future implants is a more stable joint with a lower failure rate and fewer problems and complications. Studies with long-term results are not yet available (but eventually will be!) based on implants in current use to give us an idea of what is possible for these individuals.

Anatomic Considerations in Bicep Tendon Injuries

We have not come to the end of all that can be known about human anatomy. One example of new discoveries involves the biceps muscle of the upper arm. This particular muscle has two parts to its tendon: a long and short head. They have different insertion points on the humerus (upper arm bone). The long head of the biceps becomes part of the labrum, a rim of fibrous cartilage around the shoulder socket (glenoid). The labrum helps give the shallow glenoid greater depth.

Cadaver studies, arthroscopic examinations, and MRIs have helped identify the presence of distinct anatomic variations in these structures (i.e., the tendon insertion points, labral attachments). For example, sometimes the long head of the biceps begins along the posterior (back) aspect of the labrum. In some people, the pattern of origination of the long head of the biceps is more toward the middle (anterior/posterior) of the labrum. And in others, it can be seen entirely along the anterior (front) labrum.

Likewise, there can be anatomic variations of the glenoid labrum. These are seen as a hole (referred to as a sublabral foramen). Instead of a continuous ring of tissue around the glenoid, there is a space where the labrum is absent. The foramen or hole also varies in size and shape. At some point (further along on the edge of the shoulder socket), the fibrous cartilage continues.

It appears that these anatomic differences affect slightly more than 10 per cent of the general population (based on a study of 100 cadavers). The changes are likely formed during embryologic development (as the body was formed in the uterus). Such differences may lead to rotator cuff injuries because they allow the arm to more into internal rotation more than is normal.

Injuries that affect the labrum (e.g., superior labrum anterior and posterior or SLAP tears) can also involve the long head of the biceps if the labral tear occurs at the insertion point of the tendon. But the presence of the sublabral foramen can be misleading when the surgeon is trying to make a diagnosis. The patient with this anatomic variation looks like he or she has a labral tear when, in fact, none is present.

Magnetic resonance arthrogram (MRA) rather than magnetic resonance imaging (MRI) may be needed to make a clear distinction between a true labral tear and a normal anatomic variation of the labrum. When using arthroscopy as a diagnostic tool, the surgeon looks for indicators that there is an actual lesion, not just one of the anatomic variations described. Red, inflamed, and/or frayed tissue or frank hemorrhage are signs of a SLAP tear. Abnormal laxity or looseness of the biceps anchor (where the tendon attaches to the labrum) is another sign of a true labral lesion.

Surgery to repair SLAP tears may be needed if conservative (nonoperative) care is not successful. The placement and number of anchors to reattach the labrum and the biceps may depend on the severity of the tear as well as the patient’s individual anatomic differences. But studies have not been done to identify the optimal point of fixation for the sutures in order to obtain the best results. And failed surgeries with recurrent SLAP tears, continued pain, shoulder joint stiffness, and decreased throwing ability in overhead throwing athletes have been reported.

There are other anatomic differences from person to person affecting the biceps tendon. These include: (1) shape and depth of the bicipital groove (indentation where the tendon rests along the front of the humerus), (2) presence and strength of connective tissue that holds the tendon in the groove (called the vinculum), (3) changes in the bone (e.g., bone spurs) that can affect the tendon as it moves up and down over the bone during repetitive motions.

Each of these individual anatomic variations must be taken into consideration when deciding whether to perform surgery and what surgical procedure to choose. Conservative care with antiinflammatory medications and physical therapy are tried first. Surgery is advised most often in the case of shoulder instability, fraying of the tendon, rupture or entrapment of the long head of the biceps, or SLAP tears.

Following surgery, immobilization of the arm in a sling for two to three weeks is necessary to protect the sutures and allow healing of the soft tissues to occur. Too much movement, too soon, with too much force can cause the tendon/labrum to pull through the anchors. Activity, exercise, and return to full activities must be done with supervision, slowly, and with intent to protect the healing tendon.

Studies currently available report satisfactory results following operative care for biceps tendon injuries with or without involvement of the labrum. Pain relief and return of motion, strength, and endurance is expected. The majority of patients are able to resume full (manual) work and sports activities.

Comparing Different Injection Therapies for Tennis Elbow

Barbie dolls, Corvettes, and Easy-Bake Ovens aren’t the only things that have been around since the 1950s. Add steroid (glucocorticoid) injections for tennis elbow to that list. Since that time, other injectable treatments have been developed as well. In this systematic review and meta-analysis of the studies published so far, a comparison of results is provided for eight different injection treatments.

Tennis elbow (also known as lateral epicondylitis) is a fairly common work- or recreational-related problem caused by repetitive motions (e.g., gripping, bending wrist back into extension). Sometimes the elbow feels stiff and won’t straighten out completely. Men and women are just as likely to develop symptoms of tenderness and pain that starts on the outside bump of the elbow, the lateral epicondyle.

There were 17 studies included in this review. All were randomized controlled trials (RCTs) and reported before and after results based on pain intensity. Safety and adverse effects were also compared. A total of 1,381 patients were involved using one of the following treatments: 1) glucocorticoid, 2) botulinum toxin, 3) autologous blood, 4) platelet-rich plasma, 5) polidocanol, 6) glycosaminoglycan, 7) prolotherapy, and 8) hyaluronic acid.

The authors provide details on how studies were selected, how the data was retrieved (called data extraction), and how the results were analyzed (using a tool known as the Cochrane risk of bias tool).

A large table including characteristics of the 17 studies was presented in the article for those readers who might like more details. Reasons for NOT including certain studies were also mentioned (e.g., pain was not measured as an outcome, patients had a traumatic injury, study was not a randomized controlled trial, study included patients with golfer’s elbow or medial epicondylitis).

Final results of the overall analysis revealed some differences among the various injectable treatments. For example, although glucocorticoid (steroid) injections gave relief early on, the results after eight weeks were no different than if the person received a placebo (injection without the medication). Prolotherapy and hyaluronic acid worked better than a placebo injection. And the rest of the treatment choices resulted in the same outcomes as a placebo injection.

There were no serious side effects in any of the trial. Pain was felt at the time of injection and for a short time after injection for all eight treatment types. The steroid injections were most likely to cause skin atrophy and/or skin discoloration. Botulinum toxin (also known more commonly as BOTOX) caused temporary paralysis of the finger extensor tendons. But that’s how BOTOX works – it is a paralyzing agent designed to give the tendons/muscles a rest. This effect was gone three months later.

The authors conclude that all injection treatment for lateral epicondylitis (tennis elbow) appears to be safe. Glucocorticoid, which has been studied the longest and most often really isn’t any better than a placebo injection. The other types of injection therapies are still fairly new (developed in the last 10 years or so) and studies involving these agents are small or pilot studies and must be viewed with caution.

They suggest that further high quality, well-designed studies with low risk of bias of these newer treatments are needed before any firm treatment recommendations can be made. It would be helpful if results measured in terms of pain relief could be compared for the same number of injections over the same period of time from study-to-study. This type of approach would make it possible to pool data from several studies for greater statistical significance.

Best Surgical Treatment for Elbow Cubital Tunnel Syndrome

Cubital tunnel syndrome is a condition that affects the ulnar nerve at the elbow. The ulnar nerve passes through the cubital tunnel just behind the inside edge of the elbow. The tunnel is formed by muscle, ligament, and bone. You may be able to feel it if you straighten your arm out and rub the groove on the inside edge of your elbow.

Cubital tunnel syndrome has several possible causes. Part of the problem may lie in the way the elbow works. The ulnar nerve actually stretches several millimeters when the elbow is bent. Sometimes the nerve will shift or even snap over the bony medial epicondyle. (The medial epicondyle is the bony point on the inside edge of the elbow.) Over time, this can cause irritation.

What is actually happening to cause this condition? Experts think it’s a combination of compression (pressure) and traction (pull or stretch) on the nerve. Elbow flexion (bending the elbow) increases these effects. Frequent bending of the elbow, such as pulling levers, reaching, or lifting may contribute to the problem. Constant direct pressure on the elbow over time may also lead to cubital tunnel syndrome. The nerve can be irritated from leaning on the elbow while you sit at a desk or from using the elbow rest during a long drive or while running machinery. The ulnar nerve can also be damaged from a blow to the cubital tunnel.

The symptoms are very similar to the pain or electric shock sensation that comes from hitting your funny bone. When you hit your funny bone, you are actually hitting the ulnar nerve on the inside of the elbow. Numbness on the inside of the hand and in the ring and little fingers is an early sign of cubital tunnel syndrome. The numbness is often felt when the elbows are bent for long periods, such as when talking on the phone or while sleeping. The hand and thumb may also become clumsy as the muscles become affected.

Treatment begins with conservative (nonoperative) care, which often resolves the symptoms. But when symptoms persist and do not respond to splinting or stretching activities, then surgery may be needed. The surgeon has several choices when deciding how to do the surgery. The first is a local (called in situ) release of the structures pressing on the nerve.

The second is to move (transpose) the nerve to a new location (away from the structures pressing on it). The third is to perform a medial epicondylectomy (removal of the bone along the inside of the elbow). And the fourth is the subject of this article: the Hoffmann technique. The Hoffmann technique is an endoscopic approach from 10 centimeters (about four inches) below the elbow, releasing the nerve all the way up to 10 centimeters above the elbow.

The advantages of this surgical approach are that it enables the surgeon to look down on the nerve (and the soft tissues around it). Using the endoscope inserted into the forearm through the skin, the surgeon can have direct vision of the nerve. The ligament most often pressing on the nerve (arcuate or Osborne’s) is cut much like the in situ release. But the surgeon is also able to release other areas where the fascial bands (connective tissue) underneath the muscles are compressing or entrapping the nerve.

Not everyone is a good candidate for this surgical technique. But the Hoffmann technique can be considered for most patients who have not responded well to conservative care. The exceptions include anyone with osteoarthritis with loss of elbow motion due to bone spurs. It’s the bone spurs that are putting pressure on the nerve and these must be removed. A more open, extensive surgery is required to shave and smooth the bone.

Severe elbow deformity known as cubital valgus (increased angle of the elbow) as a result of osteoarthritis prevents the use of the Hoffmann technique. And patients whose ulnar nerve pops in and out of the tunnel with painful symptoms may only need an in situ procedure rather than the more extensive Hoffmann technique.

Surgeons who would like to read a full description of the Hoffmann technique will find this article helpful. Photos of patient position, incision, endoscopic entry, and intraoperative steps to release the fascia are provided. Instruments used do not touch (or barely touch) the nerve throughout the procedure.

The authors also provide tips on how to address all structures that cover and compress the ulnar nerve while avoiding complications. The most common surgical complication is damage to the cutaneous nerve and muscle branches that cross the fascia. Care must also be taken to protect the motor nerves to the muscles and blood vessels in the area.

Two Conditions Caused By Median Nerve Disorders

The median nerve innervates or supplies muscles of the forearm with messages needed for sensation and movement. Compression on the nerve or infection along the nerve can cause a condition known as neuropathy. The affected individual experiences painful symptoms along with numbness. Because the nerve moves through different muscles and ligaments along the course of the arm, median nerve neuropathy can present differently.

In this article, surgeons from the University of Connecticut compare and contrast two specific problems arising from median nerve neuropathies: pronator syndrome (PN) and anterior interosseous nerve syndrome (AIN). The anatomy of the nerve is presented by a written description along with drawings of the nerve as it passes through various soft tissue structures. Understanding where the problem occurs helps the reader understand the clinical presentation.

Pronator syndrome can occur if and when the nerve is compressed in any of several places (e.g., between the two heads of the pronator teres muscle, at the proximal arch of the flexor digitorum surperficialis, at the ligament of Struthers, at the aponeurosis, or at the head of the flexor pollicis longus). Though you may not be familiar with those specific soft tissues, it gives you an idea of how the nerve comes in contact with many and various structures that could put pressure on it.

In the case of anterior interosseous nerve (AIN) syndrome, compression of the median nerve may not be the problem. Instead, there is new evidence that the condition is caused by a neuritis (inflammation of the nerve). The neuritis could be coming from a viral illness, immunizations, strenuous exercise, or pregnancy.

The result of AIN syndrome is a motor paralysis or “palsy” of some or all of the muscles innervated by the median nerve. This is a transient neuritis, which means “temporary” — given enough time, the nerve will usually recover.

Both of these conditions (pronator syndrome and anterior interosseous syndrome) are fairly rare. So the diagnosis requires a careful patient history, physical examination, and electrodiagnostic and imaging studies. The authors describe similarities and differences in clinical findings that may aid the surgeon in making an accurate diagnosis.

Specific tests that can be done to differentiate one from the other (e.g., pronator compression test, resisted flexion of the middle joint of the middle finger, Tinel sign, Kiloh-Nevin sign, OK sign, weakness of thumb to index finger pinch grip). Each test is described along with a description of what constitutes a positive or negative response.

Once the diagnosis is made, then the next step is developing an appropriate plan-of-care. Conservative (nonoperative) care is recommended for both conditions. Rest, muscle stretching exercises, activity modification, and antiinflammatory medications are tried for at least six months.

Surgery is only advised when nonsurgical intervention is unsuccessful after many, many months (up to a year or more). The exact surgical approach to take remains a point of considerable debate and discussion for both of these conditions. Although there is no formal evidence-based protocol, most surgeons release the median nerve along its entire course in the forearm for both conditions. Any places of restriction or obstruction are removed.

In summary, this article provides surgeons with a starting point for understanding these two conditions caused by impairments of the median nerve. Although much remains a mystery about the causes and best approach to management, this summary gives the surgeon an idea of current knowledge and understanding of both syndromes.

New News on the Treatment of Distal Biceps Tendon Ruptures

The biceps muscle of the upper arm is the muscle the cartoon character Popeye was always flexing to show his strength after eating a can of spinach. This muscle has an important role in bending the elbow. Ruptures of the biceps tendon at the elbow can be very disabling and often require surgical repair or reconstruction.

In this review article, hand surgeons from the University of Pittsburg Department of Upper Extremity Reconstructive Surgery provide an update on this problem. The “new news” about distal biceps tendon injuries has come about for three reasons:

1) Technology has made it possible to discover new understanding about the biceps tendon anatomic form and function.

2) Thirty years of improvements have been made on surgical techniques to reduce complications following surgery and to improve strength of the repair (referred to as tendon-to-bone fixation).

3) Studies over the last 30 years (since the mid-1980s) have given us enough data to see long-term results of both conservative (nonoperative) care and surgical management.

Form and function (mentioned in number one above) refers to the structure of the biceps tendon, “footprint” (where and how it attaches to the bone), and biomechanics (how it contracts and relaxes to create movement). Data mentioned in number three above has been collected on both acute and chronic injuries as well as partial and complete tears of the distal biceps tendon.

Through a series of illustrations, photos, and imaging studies (MRIs, X-rays), the authors bring us up-to-date on the basic science of biceps tendon, repair biology (how it heals), and the diagnosis of partial versus complete tears. The same approach is used to describe current methods of treatment. Here are a few highlights of new findings that may be of interest to surgeons:

  • The distal biceps tendon is two unique and separate units. This understanding replaces the former belief that there were two units that blended together to form one at the insertion point to the bone.
  • Accurate reattachment of the two tendon subunits to the bone must be done carefully. Anterior placement (forward of the original footprint) is no longer preferred. To gain the best results, the tendon must be reattached at its original anatomic site.
  • A posterior surgical approach is recommended. This technique gives the surgeon access to the footprint and allows for placement of the anchor or button (a fixation device used to hold the tendon in place) in an anatomic position.
  • Many patients heal with additional bone forming in the soft tissue. This effect called intrasubstance heterotopic bone does not seem to adversely affect final outcomes.
  • Partial tears are still treated conservatively at first; surgical repair can be saved for later if the nonoperative approach fails to give the desired results. Patients can expect some loss of strength and motion of the forearm/elbow with conservative care.
  • Chronically torn distal biceps tendons should be repaired with the elbow fully flexed (bent); this technique has been shown to decrease the need for a tendon graft.

    In addition to the details listed above, the reader will find information in this article about complications, complication rates, advice regarding surgical techniques, and pros and cons of conservative care versus surgical intervention. Summaries of treatment results from past studies on this topic of distal biceps tendon injuries and treatment are also provided.

  • Helping Surgeons Keep Abreast of Latest Information about Elbow Arthritis

    The Accreditation Council for Continuing Medical Education (ACCME) has approved this article on elbow arthritis as a continuing education course for orthopedic surgeons. Anyone who reads the material and answers the questions correctly can earn two continuing education credits. In the process, the reader will gain an understanding of current thinking and orthopedic practice in the treatment of elbow arthritis.

    Of course, anyone can read this review of current concepts related to elbow arthritis to keep up-to-date without taking the test or applying for the credits. The review is broken down into two major sections: diagnosis and management.

    Recent developments in the treatment of elbow arthritis are the main focus of the review. Learning objectives include understanding function of the elbow and forearm, causes of elbow arthritis, types of patients who have this condition, and treatment (nonsurgical and surgical) of the problem.

    As with all medical conditions, the diagnosis of elbow arthritis requires a careful patient history and clinical examination. Special tests (neurologic exam, examination of alignment, blood work) and imaging (X-rays, CT scans, or MRIs) are part of the evaluation process. X-rays are usually enough to identify joint damage, loss of joint space, and the presence of bone spurs or any “loose bodies” (fragments of bone or cartilage) inside the joint. More advanced imaging such as CT scans or MRIs are more likely ordered when surgery is being planned.

    The physician must differentiate between rheumatoid (inflammatory) arthritis and osteoarthritis (degenerative disease). Recognizing differences in the signs and symptoms and patient history/patient type is important in making this distinction. For example, someone with rheumatoid arthritis of the elbow will have pain and stiffness throughout the full elbow range-of-motion.

    A patient with osteoarthritis is more likely to have difficulty at the point of full elbow flexion or elbow extension. Pain through the entire range of elbow motion doesn’t develop with osteoarthritis until the condition is very severe (considered “advanced” disease).

    The patient’s history can be very telling. Trauma to the elbow or a history of heavy use of the arm (e.g., weight lifting, construction work, throwing athletes) is linked with osteoarthritis. Patients with rheumatoid arthritis (RA) may have a family history of RA but no history of overuse to suggest osteoarthritis (OA).

    The plan of care for anyone with elbow arthritis is to relieve pain and improve or restore function for daily activities. That sounds simple enough but there are many ways to approach this. The first is always with conservative (nonoperative) care. This can include medications, rest, physical therapy, and modification of activities. Treatment of osteoarthritis in manual laborers can be more challenging as they are unable to stop working or even change the way they use the arm because of the job requirements.

    In the case of rheumatoid arthritis (RA), 10 per cent of patients will get full recovery with early diagnosis and aggressive treatment with disease modifying anti-rheumatic drugs (DMARDs) and other biologic therapies. Surgery for elbow arthritis is only recommended when patients fail to improve with nonsurgical care. Surgical options include synovectomy, arthroscopic debridement, and joint replacement (called arthroplasty).

    The choice of which surgical procedure to perform depends on whether the condition is inflammatory (rheumatoid) arthritis or degenerative (osteoarthritis). Other considerations include type of work (use or physical demands placed on the elbow), severity of the arthritis, and the age of the patient.

    This continuing education review includes a detailed section on each surgical treatment option — how to perform the procedure, when to use it, and what to expect in terms of outcomes or results. It is readily recognized that treatment is different for each person. Patient expectations are important to consider.

    And surgeons must take into consideration illness behavior that often accompany disability from elbow pain, stiffness, and loss of motion and function. Illness behavior describes patients who are afraid to use the arm because of the pain, individuals seeking secondary gain from job-related injuries, and a concept known as catastrophizing. Catastrophizing refers to patients who blow the symptoms and losses (motion, function) out of proportion or who see the situation from a negative view (what they cannot do rather than what they can do).

    One final note about this review and continuing education tool: the material is not intended to represent the only methods or best procedures for elbow arthritis. Rather, it provides a helpful review of current approaches used successfully by many orthopedic surgeons. The final exam consists of two questions. The answers are easily found in the text.

    Patterns and Mechanisms of Traumatic Elbow Dislocations

    Thanks to You Tube we now know that elbow dislocations don’t occur the way previous investigations using cadavers led us to believe. In the past, researchers had no choice but to rely on cadavers (human bodies preserved after death) to study the patterns and mechanisms of elbow dislocation. And those studies suggested that forces placed on the flexed (or bent) elbow led to traumatic elbow dislocation.

    But a review of 62 You Tube videos clearly showed that most acute elbow dislocations occur when the elbow is extended (relatively straight). A closer look at all aspects of elbow dislocation revealed some interesting information.

    For example, more than two-thirds (68 per cent) of cases, the forearm is pronated (palm down) with shoulder abduction (arm away from the side). That makes sense because the person is usually reaching the arm out to brace from a fall.

    The body is rotated inwardly with the palm planted on the floor or ground. The result is external rotation of the forearm. The arm is also usually forward with load and impact translated from the hand through the wrist and forearm to the elbow. Of course, the force must be enough to overcome stabilizing structures like ligaments (e.g., medial collateral ligament).

    Dislocation events filmed and available on You Tube tend to be from sporting events such as wrestling (most common), skateboarding, martial arts, football, basketball, and weightlifting. Less often, elbow dislocations associated with rugby, gymnastics, and rollerblading were presented. After analysis of all the videos, there were four distinct patterns of elbow dislocation based on shoulder position, elbow position, and direction of the force.

    The most common pattern (half of all acute elbow dislocations) is as described above: shoulder flexed and abducted (arm forward and out to the side) with the elbow pronated and extended (palm down and straight). The pattern is one of axial force (up through the forearm) and from the outside of the elbow inward toward the body (called a valgus force). Valgus and axial forces are enough in this pattern to tear the medial collateral ligament on the inside of the elbow (side next to the body). Wrestlers and football players had this pattern of elbow dislocation.

    One-third of the cases were with shoulder extension and abduction and forearm supination (palm up) and extension. Once again, the loading forces were axial and valgus (through the forearm and across the elbow). This pattern was most often seen in inline skaters. Other much less common patterns (usually in weightlifters) were variations and combinations of these two patterns.

    In summary, cadaver studies do not accurately mimic true force, pattern, and mechanisms of acute elbow dislocations. As this collection of You Tube videos showed, the key differences are not only position of the arm but also (and most especially) biomechanical stability of the anterior portion of the medial collateral ligament.

    The authors do acknowledge the limitations of using You Tube videos as evidence of these observations. They suggest further study to prove whether the presence of medial collateral ligament instability before the dislocation injury may be a contributing factor. It is possible that ligamentous instability is part of the cause and effect rather than just a result of deforming forces from the fall.

    Best Treatment for Tennis Elbow

    The best, most effective treatment for lateral epicondylitis, otherwise known as “tennis elbow” remains unknown. Many things have been tried including antiinflammatory drugs, exercise, bracing or splinting, injection therapy, and surgery. Short-term pain relief may be obtained but no long-term benefit has been reported.

    In this study, the results of three different types of treatment were compared on 60 patients who had lateral epicondylitis. Painful symptoms along the outside of the elbow (and diagnosed as tennis elbow) had been present for more than three months for each person in the study. Twenty patients received a single injection of platelet-rich plasma, 20 received an injection of saline (salt water for a placebo treatment), and 20 people got a steroid injection. Change in pain was the main outcome measured.

    Platelet-rich plasma (PRP) refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets and growth factors. This treatment enhances the body’s natural ability to heal itself. PRP is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

    If you have ever experienced tennis elbow or known someone who has had this condition, then you know it doesn’t necessarily have anything to do with playing tennis. Any repetitive activity (especially with force) can cause overloading, microtearing, and inflammation of the tendon at the elbow.

    In fact, this is a fairly common problem in the work place. Workers with strenuous jobs in various industries are often affected. And since an episode of lateral epicondylitis can last six months to two years, effective treatment is a must to keep workers on-the-job, productive, and earning a living.

    In this study, one surgeon performed all of the procedures. In each case, the physician knew what type of injection was being given but the patients did not. In fact, they were blindfolded during the treatment. Results were measured at three, six, and 12 months after treatment using an ultrasound test of tendon thickness and pain intensity. Function was also evaluated by having the patients fill out a survey called the Patient-Rated Tennis Elbow Evaluation (PRTEE).

    The authors reported a very high dropout rate from this study in the first three months. The patients said they left the study because the treatment didn’t work. At the end of 12 months, only 16 or the original 60 patients were still participating. Their overall findings are summarized below:

  • Steroid injection gave the best pain relief and improved function in the first month.
  • At the end of three months, there was no difference in treatment results between the three choices for pain and disability measures.
  • Tendon thickness increased with PRP (blood injection therapy) and saline. Tendon (and skin) thickness decreased (atrophy) with the steroid injection.
  • Platelet-rich plasma (PRP) injections were the most painful (additional pain lasting up to three weeks in some cases). That is because PRP requires five to seven pokes into the tissue as opposed to only one with steroid or saline injections.

    The authors concluded that their study repeated what other studies have shown regarding steroid injections: they provide early pain relief but have a thinning effect on the soft tissues (skin and tendon). Results using platelet-rich plasma (PRP) were not as favorable as has been reported in other studies. In this study, PRP wasn’t any better than a placebo treatment. And so, the search for a successful treatment for tennis elbow continues.

  • New Approach Proposed to the Old Problem of Tennis Elbow

    A new treatment has been proposed for tennis elbow also known as lateral epicondylitis. Pain along the outside (lateral) elbow from chronic overuse and repetitive activities can be ended by interrupting the nerve pathways. In this study, a partial nerve denervation was tested as a possible alternative to the more common treatment approaches.

    By cutting the tiny nerve branches to the lateral epicondyle (side of the elbow away from the body), the authors hoped to provide pain relief without altering elbow function. They used pain and grip strength as their main tests of treatment effectiveness.

    Thirty elbows were included in this study. All patients had tried more than six months of conservative (nonoperative) care without success. They took antiinflammatory medications. They tried bracing and physical therapy. They had at least one cortisone shot into the tendon at fault. Nothing changed their pain significantly enough to be considered effective.

    The reason chronic tennis elbow doesn’t get better sometimes is because the tiny microtears of the extensor tendons that are involved don’t heal fully. A partial repair gets interrupted and ends in distortion of the collagen fibers and degeneration of the tendon fibers. Many microscopic studies have proven there is a lack of actual inflammation in these chronic cases.

    Many times when nonoperative treatment fails, surgery to release the tendon from its attachment to the bone is suggested. But in this study, hand surgeons tried a different approach. They used a small open incision to carefully identify the tiny nerve branch to the lateral elbow, injected it with a numbing agent, and then cut it. They moved the nerve branch up into the main belly of the triceps muscle (along the back of the upper arm) where it could not reconnect or cause any further pain.

    Before trying this approach, each of these patients did respond well with pain relief and improved grip strength to a temporary diagnostic nerve block. The specific area numbed (and later cut) was the posterior cutaneous nerve of the forearm just above the lateral humeral epicondyle (outside of the elbow bone). None of the patients had any previous elbow surgery or nerve blocks before this study.

    Everyone was followed for at least two years. Early follow-up included assessment of pain and testing grip strength. Final follow-up was done using an emailed survey of pain and level of patient satisfaction. Each patient contacted was also asked if they would have this same type of (denervation) surgery if the other elbow developed chronic tendonitis.

    As it turned out, 80 per cent of the group reported good to excellent results with pain relief and improved grip strength. The treatment was considered a “failure” if the patient still had significant persistent pain and/or had to have another surgery. Because a superficial nerve (to the skin) was cut, some of the patients had numbness along the forearm for a while. This was temporary for all but one patient but no one was bothered by it because the pain was gone!

    Of the five patients who had a “failed” response, four of them also had a condition known as radial tunnel syndrome. Radial tunnel syndrome happens when the radial nerve is squeezed where it passes through a tunnel near the elbow. The symptoms of radial tunnel syndrome are very similar to the symptoms of tennis elbow (lateral epicondylitis). There are very few helpful tests for radial tunnel syndrome, which can make it hard to diagnose.

    It is possible that the radial tunnel syndrome is really the reason why these few patients did not respond fully to the denervation procedure. Further study of this problem is needed to determine whether additional treatment of this second problem will eliminate the painful symptoms and weakness.

    But for now, this study showed that a partial denervation is a simple and effective, alternative way to treat persistent lateral epicondylitis. And it showed that using a diagnostic local numbing agent is a good way to tell who might benefit from partial denervation. Patients may prefer this partial nerve denervation treatment over epicondylectomy (to remove the damaged tendon and bone). They can get back to daily activities right away and return to work faster without the need for rehab.

    The Optimal Program for Rehab of Elbow Tendon Injury

    Overhead athletes (e.g., tennis players, javelin throwers, baseball pitchers, volleyball players) can lose significant function of the arm after an elbow tendon injury. Physical therapists are often in charge of getting these players back to full force in hitting, pitching, serving, and spiking.

    But what is the optimal rehabilitation program for athletes who injure their elbows? In this article, an expert in sport rehabilitation and research addresses the current recommendations for treatment of elbow tendon injury. The basic idea presented is that physical therapists must first know the specific pathologic process going on in the injured tendon. And second, it is equally important to understand the healing mechanism occurring throughout the rehab process.

    To accomplish step one (recognize and diagnose elbow injury), it involves an examination of the entire arm (upper extremity), baseline X-rays, and specific clinical tests applied to the arm. For example, it’s not enough to just measure the available elbow range of motion. The physical therapist must evaluate individual motions of the shoulder, scapula (shoulder blade), and wrist. It’s not unusual for athletes to lose motion in one direction while gaining motion in another. Asymmetries (differences in strength and motion from one arm to the other) can create significant problems in stability and mobility.

    There may be ligamentous laxity (looseness) in the elbow joint that put increased stress on the nearby muscle tendons that are trying to compensate. When the muscle/tendon unit has to do the job of the ligament (to stabilize the joint), it can’t do its own job (move the arm). Eventually, other problems will develop as the body adapts but loses optimal function.

    The physical therapist views each athlete as a total person — not just the elbow or the arm. The clinical evaluation takes into consideration other structures and injuries (or compensations) in other areas of the body. The therapist must determine what phase of injury and healing the player is in and provide treatment that 1) protects function, 2) restores strength, and when appropriate, 3) returns the player back to full sports activity.

    The author provides detailed instructions in how to accomplish these three goals in treatment. Specific applications of exercise for elbow tendon rehabilitation are described with photos of athletes demonstrating exercise concepts. Before returning an athlete to activity, it is advised that strength and motion on the injured side equal the other arm. Athletic equipment such as tennis racquets and golf clubs must be inspected and modified. The author gives instructions for both.

    The goals of physical therapy in the rehabilitation of tendon injuries are to restore strength, endurance, and flexibility. Failure to eliminate pain while restoring function through conservative (nonoperative) efforts may result in the need for surgery, postoperative rehab, and ultimately, further delays in return-to-sport.

    Need a Refresher on Elbow Arthroscopy?

    Dr. J. Michael Bennett from Texas Orthopedic Hospital in Houston has written a short but very complete review of elbow arthroscopy. This surgical technique is used routinely now for the evaluation and treatment of many elbow problems. So, a refresher update is a helpful way to keep patients and physicians informed.

    Dr. Bennett begins by reviewing indications (when to use this technique) and contraindications (when NOT to use elbow arthroscopy) then moves through the actual surgical technique. Using words to describe the process along with photos, the reader gains a clear understanding of the procedure. The final section is a presentation of complications the patient might develop.

    First, who is best served by having an arthroscopic examination or procedure? Since the first arthroscopic elbow treatment became available, the ways and reasons to use this tool have expanded. Now surgeons use it to clean the joint out from any infection, remove any loose bodies (fragments of bone, soft tissue, cartilage), and repair defects (holes or other lesions) in the bone.

    Next, who shouldn’t be treated with arthroscopy but rather treated with open incision surgery? Anyone with abnormal or distorted anatomy and anyone with severe heterotopic ossification (bone formation in the soft tissues). Patients with burns or who have skin grafts are not good candidates for this type of procedure because of the danger of damage to the nerves and blood vessels.

    The procedure itself is usually done with the patient under general anesthesia. The patient will be relaxed and comfortable. If there is concern for postoperative nausea from the anesthesia, then a regional anesthesia (just the arm is numbed) can be used. Using a nerve block like this has one major disadvantage. The surgical staff cannot assess the patient’s neurologic status for quite some time after surgery (until the nerve block wears off).

    Dr. Bennett makes his recommendations for size of scope and type of cannula and trocars he uses for elbow arthroscopy. Careful patient positioning is important to give the surgeon the best view inside and around the joint. Depending on the procedure, the patient may be supine (on his or her back) with the arm suspended by traction or prone (face down) with the arm hanging off the table in a special arm holder. Advantages and disadvantages of each position are discussed.

    A detailed description of portal placements is provided with particular concern for reducing the risk of damage to the neurovascular structures (nerves and blood vessels). Photos of patients are provided with the skin marked-up to demonstrate where the portal sites should be. Direction of scope placement is also reviewed; once again, in an effort to help the surgeon avoid damaging vital structures.

    Though elbow arthroscopy is a well-used procedure now, it still takes expertise and experience on the part of the surgeon to be successful. There are many factors to take into consideration including knowledge of the elbow anatomy and correct patient positioning. Inserting the scope into the joint also requires careful selection of placement to avoid complications.

    As you might guess from what has been said already, the most commonly reported complication is nerve injury. Damage to the nerve usually results in a temporary neurologic injury but sometimes the nerve gets cut completely. This is more likely to cause permanent damage. Infection and damage to the soft tissues are the other most common problems surgeons must try and avoid. Good surgical technique and proper portal placement go a long way in preventing complications.

    In summary, this short but very complete review of elbow arthroscopy is packed with detailed information about this particular surgical procedure. Anyone who would like to understand the basics of elbow arthroscopy will find this article of interest.

    Helping Surgeons Keep Up with Elbow Ligament Injuries

    Continuing education takes many different forms and approaches for the health care professional. In this article, orthopedic surgeons are brought up-to-date on the diagnosis and treatment of lateral collateral ligament (LCL) injuries of the elbow. After reading the information on this condition, each surgeon can take a short exam in order to earn continuing education credits.

    The article presented many facets of management of an elbow lateral collateral ligamentous injury. It was designed to create understanding, reflection, and thought on the part of the surgeon treating these kinds of problems. The authors made use of patient photos, X-rays, drawings of the soft tissue anatomy (muscles and ligaments), and even photographs of dissected cadavers showing specific locations of muscles, nerves, tendons, and ligaments.

    Topic areas discussed included functional anatomy, etiology (cause), classification (how to describe the extent of injury), clinical examination and findings, as well as diagnostic imaging. The second half of the article addressed surgical considerations for reconstructive surgery and post-operative care.

    The two main causes of lateral collateral ligament (LCL) damage are injury (e.g., torn or stretched joint capsule and/or ligaments) and dislocation (e.g., fall on the outstretched arm). Chronic, recurrent dislocation is referred to as instability and requires surgery. The surgeon uses tendon grafts to restore elbow joint stability and tries to return normal motion of the bones of the forearm.

    The authors lead the reader through the details of the complex anatomy and coordination of all the soft tissues of the elbow. These are required to move the elbow and forearm through its full motion. This concept is referred to as functional anatomy. An understanding of functional anatomy is important because the surgeon will be called upon to return the patient’s anatomy to as normal as possible. The goal is to help the patient once again regain full, smooth, and coordinated motion, strength, and function.

    Based on the findings of the physical examination, X-rays (plain and stress radiographs), and MRIs, the surgeon will decide what is the best way to repair or reconstruct the anatomy to achieve these goals of restoration just described. There are many key factors to think about when planning the surgical procedure.

    For example, the surgeon evaluates whether there are any fractures that must be addressed. Are there other soft tissues (besides the LCL) that are torn or damaged? What was the patient’s anatomy like before the injury? There are always variations in shape, symmetry, and position of bone and soft tissues from person to person.

    The surgeon must decide: is this going to be a repair procedure or reconstructive surgery? Studies have not been done to compare results of these two approaches. Therefore, the surgeon does not have evidence-based research on which to base his or her decisions in these matters. There are some studies reported. There just isn’t enough evidence to support one approach over another.

    Repair techniques becomes another area of surgical decision-making. What type of sutures should be used (bone anchors with nonabsorbable sutures are preferred by many surgeons). Should the sutures be placed through tunnels that require drilling through the bone? Even the position the arm is placed in during surgery becomes an important consideration.

    Likewise, reconstruction techniques are being investigated. A table representing study results from 1991 to the present date is provided. Type of reconstruction, graft type, outcomes, and complications reported for 12 different studies are summarized for the reader’s consideration.

    And finally, a focus on postoperative protocols (i.e., how to treat the patient after surgery) concludes this continuing education document. Another table is presented summarizing treatment after surgery for the 12 studies mentioned above.

    Elbow immobilization in a splint or brace was common for anywhere from one to six weeks. Position of the elbow in the device was reported and also varied from 45 degrees of elbow flexion up to 90 degrees with either full or slight forearm pronation (palm down position). Range-of-motion activities, progression through strengthening exercises, and return to sports (usually six months after surgery) were also reported for these 12 studies.

    Anyone interested in the diagnosis, treatment, and follow-up for patients with recurrent lateral instability of the elbow due to lateral collateral ligament damage of the elbow will find this article of interest. Those who want to gain some continuing education credits can earn up to two credits.

    Update on the Evaluation and Treatment of Radial Head Fractures

    The elbow is a complex joint with two bones in the forearm (the radius and the ulna) that work together and the upper arm (humerus) meeting those two bones to form the joint. So long as everything lines up properly, the elbow bends and straightens and the forearm rotates (palm up and palm down). But a fracture of the radial head can alter the entire biomechanics of the elbow.

    In this article, hand surgeons from the Hand and Upper Limb Centre in Ontario, Canada bring us up to date on the evaluation and treatment of radial head fractures. A complete evaluation includes taking a thorough history, examining the patient’s entire arm carefully, and using imaging to identify all bony and soft tissue damage.

    Some fractures can be difficult to see on X-rays so CT scans and MRIs may be needed. Most of the time, X-rays are enough to diagnose fractures and dislocations. But occasionally it is necessary to investigate further because the patient’s symptoms and clinical presentation suggest one or more associated injuries (e.g., ligament tears, other fractures, involvement of the articular (joint) surface).

    Gathering all of this information is important before forming a final plan of care. Nonoperative care may be possible with good results if the elbow is stable, there are no dislocations, no soft tissue damage, and no bleeding into the joint. But complex injury patterns and any instability points to the need for surgical repair or reconstruction.

    One injury in particular, called the terrible triad always requires surgery. Patients with the terrible triad have a posterior elbow dislocation, radial head fracture, and fracture of the coronoid (the end of the humerus that helps form the hinge portion of the elbow joint).

    The authors use the Mason classification of radial head fractures to help in planning treatment. There are four groupings described as follows: Type 1 the fracture is not displaced (separated). Type 2 is displaced. With Type 3 the whole radial head is broken into tiny pieces and Type 4 represents any fracture of the radial head with elbow dislocation.

    Some experts make one other distinction: they suggest Type 2 radial head fractures can also describe fractures with more than a two millimeter separation between the fractured ends and more than one-third of the joint being involved.

    The authors provide X-rays and CT scans to show how they evaluate and surgically treat various types of radial head fractures. Every effort is made to preserve the joint but sometimes it is necessary to either remove the radial head and replace it or perform an entire elbow joint replacement. Follow-up rehab and complications are also described for all postoperative patients.

    Simple Type 1 radial head fractures (no displacement, no dislocation, no associated injuries) may not need any follow-up rehabilitation. But when stiffness of the joint or surrounding soft tissues prevents normal motion and function, then physical therapy is advised.

    The therapist and surgeon work together to design the best program for each patient. Motions that are allowed or prohibited depend on which soft tissues are damaged and the type of surgery that was performed. It may take some time, but most patients have good-to-excellent results.

    Total Elbow Replacement: Not for the Young and Active

    Joint replacements are available now for the elbow. But it’s a tricky joint made up of three separate bones and two distinct joints. And it is responsible for repetitive motion of the hand and arm as well as rotation of the forearm, and weight-bearing activities through the hand and wrist.

    Because of the high activity demand on a replacement implant and its limited lifespan, total elbow replacement (TEA) isn’t usually recommended for young patients. In fact, it is considered a salvage procedure — in other words, only used as a last resort to save the joint.

    Before considering a total elbow replacement (TEA) in anyone younger than 40 years of age, all other avenues of treatment should be explored. This usually consists of conservative (nonoperative) care as well as surgery. Conservative care starts with medications (antiinflammatories) or injections (e.g., steroid or hyaluronate injections). Physical therapy to reduce pain, increase joint motion, and improve function should be tried. If three to six months of conservative care fail to bring the desired results, then surgery may be the next step.

    Surgical procedures available to the surgeon (and patient, of course) include: 1) debridement (surgical cleaning) of the joint, 2) interpositional arthroplasty (remove part of the joint and fill in with tendon or other graft tissue), or 3) partial arthroplasty (only part of the joint is replaced). These approaches are used in the management of young adults who have developed degenerative arthritis following injury to the elbow.

    How does the surgeon decide which procedure to use for each patient? Well, the key is to evaluate each and every patient individually. Do not try to apply a one-solution-fits-all kind of treatment or management approach. As with conservative care, the goals of surgical treatment are to reduce pain and improve elbow function.

    Patients can be divided into two groups based on history and physical examination. The first group are individuals who have a painful, stiff elbow joint at the end-ranges of motion (full flexion and/or full extension). These patients seem to do best with the less invasive debridement procedure. Debridement can be done arthroscopically (minimally invasive approach) or with an open incision.

    Patients with pain any time they move the elbow and who have X-ray or CT signs of advanced joint degeneration are better candidates for a more involved surgical procedure. With many choices for surgical approaches, the surgeon must carefully review all aspects of each case.

    For example, are there any loose fragments inside the joint? What is the status of the joint surface (i.e., are there any holes or defects? do the joint surfaces match up)? Where is the joint stiffness coming from: the joint capsule? loose fragments inside the joint? damaged and now scarred ligaments? Has any nerve damage developed as a result of the original trauma or injury?

    The surgeon must match the patient’s lifestyle and activity level with treatment. Removing the head of the radial bone where it meets the elbow joint (a procedure called resection) eliminates one portion of the arthritic joint. This procedure also reduces the amount of force that is transferred into and through the joint. Activities (especially weight-bearing activities) must be limited. Long-term results using this method for younger patients are unknown.

    Joint resurfacing, partial joint replacement, and interpositional arthroplasty are considered next. Each has their limitations and restrictions. For example, a partial joint replacement involves removing the radial head and replacing it with a metal implant.

    In some cases, the radial head can be resurfaced, saving more of the bone while restoring the ability of the joint surface to slide and glide during motion. Joint stability may be only partially restored and there is a chance the implant will sink down into the bone or come loose altogether. Long-term studies using these techniques for degenerative post-traumatic elbow arthritis in younger patients are not available either.

    One other intermediate procedure that can be done before total elbow replacement is the interposition arthroplasty. The surgeon rebuilds the joint surface by removing the diseased bone and placing graft material in its place.

    This approach is technically challenging for the surgeon but has three advantages for the patient. 1) It can be used for more active patients, 2) the person doesn’t have to limit how much he or she uses the elbow or how much weight is put through the arm, and 3) if this procedure fails, it’s not the end of the line. Patients can still have other surgical options such as the elbow replacement. To qualify for interpositional arthroplasty, the patient must have good bone density, no infection, and no elbow deformity or dislocation.

    And finally, we come to the total elbow replacement (TEA) option. Remember, the most appropriate candidates for TEA are patients with painful elbow motion and X-ray evidence of joint destruction. Before using an elbow implant to replace the diseased, degenerated joint, the patient must agree to limit lifting to less than 10 pounds for a single item and less than two to five pounds for repetitive loads. Activities and weight-bearing restrictions will also be advised.

    The patient who receives a TEA can expect a stable joint with near normal elbow motion. Complications and problems are fairly common though and the patient must be prepared for this possibility. The implants just haven’t held up on long-term studies. Loosening requiring revision (a second surgery) happens more often than anyone would like. Patients often outlive their implants. The bushings wear out, the parts crack and break apart or come loose. Any of these events will require another surgical procedure.

    In summary, young adults who suffer a serious injury to the elbow often develop post-traumatic elbow arthritis at an early age. Living with daily, constant pain and loss of motion that results in decreased function (sometimes to the point of disability) is no picnic. Treatment options range from pain relieving medications to surgery to replace the joint. But the bottom-line is that evidence so far suggests total elbow arthroplasty (TEA) is not the best way to go for these patients. All other avenues of treatment should be explored first before resorting to TEA as a salvage procedure.

    Report on Results of Rare Elbow Fracture

    In this report, two orthopedic surgeons from the University of Michigan help other surgeons classify and manage a rare fracture of the elbow. The fracture is called a coronal shear fracture of the distal humerus.

    Distal humerus refers to the bottom end of the upper arm bone, which forms the top half of the elbow joint. This lower end of the humerus bone is shaped with a round knob called the capitellum. Next to this knob is a spool-shaped area called the trochlea. A coronal shear fracture tells us that the fracture has separated one or both of these two areas of the bone.

    Classification of the fracture is based on severity and is important to help guide treatment. There are three basic types of fractures, depending on whether the fracture affects the medial side of the capitellum (type one), the capitellum and trochlea broken off as one piece (type two), or there is a fracture line on either side of the trochlea making three separate pieces (type three).

    The classification scheme has an additional subgrouping to describe a clean fracture or one with tiny bone fragments (called communition). The fracture may be impacted (bony ends pushed together) or displaced (bony ends separated). If the fracture is displaced, the bone may be shifted posteriorly (back away from the humerus). X-rays and CT scans are used to identify all areas of damage and determine the type of classification. This information is essential in making treatment decisions.

    Treatment for any of these types of coronal shear fractures of the distal humerus requires surgery. Studies show too many problems develop when the nonsurgical approach is taken. Without surgical correction, patients end up with chronic pain, painful clicking of the elbow, and mechanical instability.

    Surgery to pin the bones together with metal plates and screws or just screws alone has the best results. This procedure is called open reduction and internal fixation (ORIF). In fact, it is estimated that good-to-excellent results are obtained in more than 90 per cent of all cases treated with ORIF. Patients end up with a stable, durable joint with smooth joint function. There can be complications (e.g., arthritis, stiffness, infection, nonunion or malunion), but these are rare.

    The goals of surgery are to match up the joint surfaces, allow for early joint motion, and reduce the risk of posttraumatic problems. Matching up joint surfaces (called restoring articular congruity) can be a challenge because the bottom of the humerus (where it meets the other half of the elbow) has five different shapes. Each of those five surfaces must slide and glide evenly to provide normal motion and prevent wear and tear and eventual joint degeneration.

    Surgeons interested in treatment approaches and best methods of fixation to achieve optimal outcomes will find this article helpful. The authors provide drawings, descriptions, and X-rays to help the surgeon visualize the potential problems and create a plan of care for each patient.

    Although research has not been done to reach agreement on the optimal method of fixation, they recommend a variable-pitch, headless compression screw. They also offer advice regarding placement of screws and avoidance of complications like damage to nerves and/or blood vessels.

    Major and Minor Problems After Surgery for Distal Biceps Rupture

    A distal biceps rupture occurs when the tendon attaching the biceps muscle to the elbow is torn from the bone. This injury occurs mainly in middle-aged men during heavy work or lifting. A distal biceps rupture is rare compared to ruptures where the top of the biceps connects at the shoulder. It is estimated that distal biceps ruptures make up between three and 10 percent of all biceps tendon ruptures.

    The biceps muscle goes from the shoulder to the elbow on the front of the upper arm. Tendons attach muscles to bone. Two separate tendons connect the upper part of the biceps muscle to the shoulder. One tendon connects the lower end of the biceps to the elbow.

    The lower biceps tendon is called the distal biceps tendon. The word distal means that the tendon is further down the arm. The upper two tendons of the biceps are called the proximal biceps tendons, because they are closer to the top of the arm.

    The distal biceps tendon attaches to a small bump on the radius bone of the forearm. This small bony bump is called the radial tuberosity. Surgery to repair the tear brings the torn end of the tendon back to the bump if possible. If the tear is too extensive and the arm has to be bent 70 degrees or more to bring the torn end back to the bone, then a tendon graft is used to extend the tendon long enough to reattach it to the radial tuberosity.

    Many patients are content to let the torn tendon heal where it retracts (pulls back) to. But if cramping continues or the loss of strength affects daily function, then surgery is advised. Surgery is not without possible problems and patients need to be aware of what those complications might be. That’s what this study offers.

    Surgeons from four large sites in Florida combined their research efforts to create a large patient data base. A total of 178 medical files of patients were reviewed. Each patient had a distal biceps tendon surgical repair. Only those patients who had a fracture, elbow dislocation, or traumatic laceration (cut) to the biceps were excluded from the study.

    Information collected from the patient charts included age, sex (male or female), time between injury and surgery, surgical technique used, and post-operative complications. Anyone who had surgery 30 or more days after the injury was considered to have a chronic injury. Those patients who had surgical repair in the first 29 days after injury were labeled acute.

    The problems that developed after surgery were divided into two categories: minor and major. Analysis of the information collected showed that slightly more than one-third (36 per cent) of all patients experienced some problems after surgery. Most of these were minor and temporary. Numbness from nerve injury and skin infections were the most common minor complications.

    Major complications occurred much less often (eight per cent of the total) and included more serious nerve injury, painful heterotropic ossification, and rerupture. Heterotropic ossification refers to the formation of bone tissue in the tendon and muscle causing stiffness, loss of motion, and pain. Most of the reruptures were caused by trauma because of patients who did not follow the surgeon’s instructions.

    Although there were five different surgeons who did the surgeries, there were no significant differences in results from one to another. The number of complications was the same no matter what surgical approach or technique was used. Patients with chronic injuries had slightly higher rates of postoperative problems but not enough to be considered statistically significant.

    Even though the study had more patients (178) than most other studies examining complication rates after distal biceps tendon repair, some of the factors weren’t found to be significant. That’s because statistically speaking, there weren’t enough people in the study for full analysis. For example, the use of a tendon graft and chronic injuries that were years (not months) old might be risk factors or predictive factors for complications.

    This study is important because it helps surgeons see what might be causing problems after surgery for distal biceps tendon rupture and therefore, prevent such events from happening. If it looks like the procedure is too risky due to the possibility of damage to nearby blood vessels and nerves, then the surgeon might advise the patient to avoid surgery and treat the problem conservatively.

    And knowing that more chronic injuries have a greater chance of significant complications may assist surgeons in planning earlier surgical repairs. Whenever possible, surgery should be done within the first 30 days after injury.

    This series confirms what other studies have shown in that chronic injuries (repaired more than 30 days later) have the highest rate of postoperative complications. It’s easier for the surgeon to find the end of the torn tendon, pull it back to the bone where it belongs, and reattach it if the procedure is done before scar tissue and contracture (stiffness) occurs at the tendon/muscle interface.