News Category: Elbow

Blood as a healing agent was first used in the 1990s for facial and plastic surgery and has since expanded in its application. Now it is used with a variety of orthopedic treatments as well. One of those procedures is as an injection into the elbow to help heal chronic tennis elbow.

Tennis elbow (also known as lateral epicondylitis) doesn’t always occur in tennis players. Anyone can develop tennis elbow. It is usually the result of overuse of the elbow. Not everyone who plays tennis or who engages the elbow in repetitive motions develops tennis elbow. There is evidence that abnormal healing responses combined with mechanical overload may be part of the problem.

Platelet-rich plasma (PRP) is one use of blood for healing. PRP is the plasma (clear) portion of the blood with eight times the number of platelets as regular whole blood. Platelets contain special growth factors that are normally released during a healing or tendon reparative process. Depending on how the platelet-rich plasma is prepared, there can be up to 25 times the normal number of growth factors available.

The use of autologous whole blood is another form of blood injection that has been tried in the healing of tendons. Autologous tells us that the patient’s own blood was used in the procedure. Both types of blood treatment have been shown to increase the number of cells needed to stimulate collagen production but without creating scar tissue. Collagen is the basic building material of tendons.

In this study, a group of 28 patients with chronic tennis elbow were involved. Everyone had symptoms of tennis elbow lasting more than three months. The patients were randomly divided into two equal groups and treated with blood injection. The groups were matched for age, hand dominance, occupation, sex (male versus female) and duration of symptoms.

The first group received a single injection of platelet-rich plasma. The second group received a similar single injection but of autologous whole blood. In both groups, the injection was placed where the wrist extensor tendons attach or insert into the bone along the lateral (outside aspect) of the elbow.

Ultrasound imaging helped guide the surgeon while using a peppering technique deep into the tendon. Peppering means the needle was only inserted in one place but the blood was delivered in tiny doses to multiple areas at that site. When the platelets make contact with the collagen tissue, activation of the growth factors occurs.

Everyone was treated with the same post-procedure program. They were told not to use the arm for any heavy lifting or repetitive motions for one full week. Then they were given an exercise program consisting of stretches and eccentric loading. Eccentric exercises place the wrist extensor muscles in full contraction with motion to slowly allow the muscle to lengthen.

The goal of this study was to compare the results and see if one method worked better than the other. They used pain as a primary measure but also examined range-of-motion, nerve function, and function as measurable outcomes. Everyone was re-evaluated six weeks after the injection and again after three months and six months.

They found that the platelet-rich plasma (PRP) group (with the higher concentration of growth factors) had better results at first (during the first six weeks). But after that, the results were about the same between the two groups. So PRP treatment gives earlier pain relief but no greater function in the end. Pain relief is still welcomed by anyone with chronic elbow pain.

In conclusion, platelet-rich plasma (PRP) injection is superior to autologous whole blood in the treatment of chronic tennis elbow. The study was small with its 28 patients so further testing and study are recommended. The authors suggest that the influence of white blood cells with and without platelets should also be investigated more closely.

The authors also point out that the group receiving the whole blood injection may have reported more pain after their injection because of the white blood cells that probably signaled a more intense inflammatory response. They also commented that previous studies have shown the importance of an eccentric exercise program so this is recommended no matter what other treatment is used.

Two microsurgeons use this case study of a fellow physician (anesthesiologist) to explain the diagnostic process of cubital tunnel syndrome or CubTS. Cubital tunnel syndrome is a condition that affects the ulnar nerve where it crosses the inside edge of the elbow.

The symptoms are very similar to the pain 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. There, the nerve runs through a passage called the cubital tunnel. When this area becomes irritated from injury or pressure, it can lead to cubital tunnel syndrome.

For this patient (the anesthesiologist), numbness and tingling of the ring and little fingers developed. At first, the symptoms were on and off. Sometimes there was also pain along the medial (inside next to the body) border of the elbow. Gradually, the symptoms became constant and weakness of the hand muscles developed. Grip strength decreased and the patient reported increased clumsiness when using that hand.

The cause of the symptoms was not obvious. The diagnostic team got busy trying to confirm a tentative diagnosis of cubital tunnel syndrome. First, they checked the past medical history. Was there anything that could contribute to these symptoms (e.g., previous elbow fracture, fall on the elbow, sleeping on that arm, repetitive elbow flexion)? The answer was ‘no’.

The physician examining the anesthesiologist performed several clinical tests to check for possible mechanical irritation, friction, or compression on the ulnar nerve. These tests are referred to as provocative maneuvers.

For example, gentle tapping over and around the nerve were positive for causing the symptoms to get worse. Putting the elbow in a fully flexed (bent) position for three minutes is positive if again the position causes the ring and small fingers to go numb. The anesthesiologist/patient had a positive flexion test.

Other typical clinical testing includes pressing on the nerve (called palpation) to see if it is tender. Palpation while moving the elbow may also show that the nerve moves in and out of the natural groove (cubital tunnel) in the bone where it should remain all the time. This type of nerve subluxation (partial movement out of the groove) or dislocation (nerve displaced out of the groove completely) can contribute to the problem.

The authors of this case report took the time to review published studies on cubital tunnel syndrome. They were looking for any evidence that these tests are actually sensitive enough and reliable enough to make a confirmed diagnosis of cubital tunnel syndrome.

They found a wide range of results reported by various surgeons conducting these tests on normal adults (normal meaning there were no previous symptoms of cubital tunnel syndrome). Some researchers just evaluated one test at a time. Others tried combining different tests to see if the results were more reliable that way.

One of the biggest problems in coming to any conclusions about testing for cubital tunnel syndrome is how much variation there is in conducting the tests. Judging the results (called interrater reliability) is another important factor. The lack of interrater reliability is one reason why these tests can’t be used alone to make the diagnosis.

There are electrodiagnostic tests that can be done. Nerve conduction studies check the speed at which the nerve transmits signals. Damaged, compressed, or irritated nerves may have abnormal conduction times. But studies of the validity and reliability of nerve conduction tests show limited sensitivity for these tests.

What about imaging studies such as ultrasound, MRI or CT scans? There haven’t been a lot of studies in this area. So far, it looks like MRIs show nerve compression before it is evident using electrodiagnostic testing.

But the best imaging choice may be ultrasound. Bouncing sound waves off the tissues creates a picture on a computer screen. It allows the surgeon to see any changes in the cubital tunnel. Ultrasound images reveal bone spurs or ganglions that are pressing on the nerve. Ultrasound also provides a view of the nerve to see if it is subluxed or dislocated from the cubital tunnel.

On the basis of their literature review on the diagnosis of cubital tunnel syndrome, these two microsurgeons make the following recommendations:

What do all these activities have in common? Feed yourself. Comb your hair. Button your shirt. Open a door. Tie your shoes. Rise up from a chair using your arms. You need pain free elbow motion to accomplish any one of these tasks. And that’s what an elbow joint replacement is supposed to provide. But complications can arise following elbow arthroplasty (another word for joint replacement).

In this study, surgeons from the Mayo Clinic report on the results of surgical treatment for 30 patients who had a bone fracture around the ulnar side of an elbow joint replacement. The ulna is the larger of two bones in the forearm.

The elbow implant inserts up into the humerus (upper arm) and down into the ulna. Bone loss around the implant causes it to loosen. Movement of the implant combined with the bone loss can result in bone fractures around the implant called periprosthetic fractures.

The fractures occurred in one of three places: at the olecranon, around the stem, and below the stem. The olecranon is a large, thick, curved part of the ulnar bone that forms what you feel as the back of the elbow.

This type of periprosthetic fracture is fairly uncommon and studies are few and far between. So this study is important in giving surgeons an idea of what to expect in terms of managing the problem and results of surgery to correct the problem.

There are several surgical options to choose from including strut allografts, allograft-prosthetic composites, and impaction grafting. These are all ways to augment (build up) the areas of weak, thin, or absent bone.

The specific method of surgical reconstruction used was based on the severity of bone loss. The surgeon removed the loose component, found the fracture site, and cleaned out any debris or loose fragments in the area.

Then bone graft material (struts or impaction grafting) was used to support the fracture until it could heal. Metal plates or wires were used to hold the graft in place. In the case of a prosthetic composite, a replacement implant is partially cemented into a bone graft. This unit is then placed inside the patient’s remaining ulna.

After surgical reconstruction, patients were followed at regular intervals. Results were measured using pain levels, number and severity of complications, and X-rays to show healing of the bone. They also looked at joint motion and function (ability to perform activities like eating, personal care, dressing, opening doors).

There were several patients who had complications. Infection, implant loosening, fracture (of the olecranon in one patient and the humerus in another), and nerve damage were reported in a total of seven of the 30 patients. Otherwise, the results were good-to-excellent for most of the patients. Three patients still had moderate elbow pain while the rest reported no pain or only mild pain.

The surgeons concluded that periprosthetic ulnar fractures can be managed with revision surgery. The use of bone grafts to build up the bone is helpful. But there’s a need to figure out why such severe bone loss occurs around the implants.

One suggestion is that the problem comes from the type of implant used and in particular, the type of finish placed around the prostheses. Some have a sprayed on layer of titanium plasma. Others have a beaded surface or precoat with a thin layer of polymethylmethacrylate (PMMA). It’s possible that these surface finishes (designed to help bone fill in around the implant) actually cause bone loss.

The authors leave us with the idea that bone stabilization and reconstruction are possible in treating this problem. It’s a complex and challenging surgery. Complications may arise but the results are satisfactory in most cases. But prevention through improved implant design and surface finish is the key.

A simple elbow dislocation isn’t always so simple. By simple, we mean a dislocated joint that can be set back into its proper place. There’s no fracture and surgery isn’t needed to relocate the joint. The joint is stable. That’s all good. But how’s that elbow looking and working years later?

To answer this question, orthopedic surgeons from a trauma unit take a look back at their records and find 110 adults with a simple elbow dislocation. Patients included ranged in age from 15 to 88 years old. All were treated with closed reduction. That’s what it’s called when the elbow can be put back in place without an incision. The procedure was done while the patients were awake but sedated (relaxed).

The elbow dislocations occurred as a result of falls, assault, car accidents, and sports-related trauma. At the time of the injury after reduction, X-rays were taken to make sure everything was in order. Reduction was followed by immobilization in a splint (for no more than three weeks) and then early range-of-motion and movement.

Patients were advised to avoid certain movements (e.g., supination or a palm up position with the elbow fully extended) during the healing phase. No heavy lifting is allowed — this guideline is usually in place for six weeks after the injury. Physical therapy was prescribed if stiffness was a problem.

Everyone in the study filled out a survey of self-reported questions about their pain, physical activities, and level of function. Each patient was re-examined by an orthopedic surgeon to assess motion, strength, stability, blood supply, nerve function, and cosmetic appearance.

They discovered that although most patients were “satisfied” with the results of treatment, they didn’t have normal elbow motion or function. Pain and stiffness were the most common symptoms reported. Grip strength was reduced compared to normal. About 20 per cent of the group had to give up participation in sports that they enjoyed before the injury occurred.

Patients who lost elbow flexion (ability to bend the elbow fully) had poorer function. Patients with reduced elbow extension (ability to straighten the elbow all the way) had more pain. In either case, impaired motion was linked with poorer function and less satisfacton with the results.

Is it possible to tell who might develop these problems after a simple elbow dislocation? Actually, yes — when present, the factors just mentioned (elbow motion, pain, stiffness) predict a poorer outcome.

And there was one other significant predictive factor: female sex. The authors weren’t sure why there was a difference in long-term results comparing function between men and women. Surprisingly, the women with poorer outcomes weren’t more dissatisfied with their results compared with men.

In summary, simple elbow dislocations can result in some long-term residual symptoms and loss of function in a large percentage of adults. Despite reported pain, stiffness, and instability, affected individuals seem to function without limiting their daily activities. Levels of satisfaction don’t seem to fall despite what might be perceived as limitations by the examiners.

The next step in researching this area is to look at the results and responses based on different patient group types. For example, do the results of older adults who experience elbow dislocation from a low-stress impact (fall) differ from younger adults injured in a high-energy traumatic injury? What about manual workers verses office workers? Athletes? Housewives? Are there any significant differences in the long-term results for these various patient types?

Elbow joint replacement isn’t nearly as common as a hip or knee replacement. But when there’s a severe fracture or painful arthritis limiting function, it can be a life-saver. As with any joint replacement procedure, there can be complications. In fact, the risk of problems following elbow replacement is far greater than with a hip or knee replacement.

In this review article, surgeons from Harvard Medical School and Massachusetts General Hospital team up together to give us some details about this dilemma. They discuss six of the most common complications following total elbow arthroplasty (TEA). Arthroplasty is another word for joint replacement.

The six most recognized problems include loosening of the implant, fracture of the bone around the implant, implant failure, infection causing loosening of the implant, weakness of the triceps muscle, and nerve palsy. Let’s take a quick look at each one starting with the most common cause of implant failure: loosening.

Loosening of the implant can occur even when there hasn’t been an infection or fracture of the bone around the implant. It’s a complicated problem. Normal elbow function requires slight side-to-side motion with a little rotation even as the joint is bending and straightening.

Reproducing all of that with a metal implant is a challenge. The implant has to be placed in the right position with the correct angle and just the right amount of soft tissue tension. The alignment of the implant stem (placed down into the bone to anchor the implant) is another key feature that can affect elbow function.

The capsule and ligaments around the elbow along with the muscles and their tendon attachments contribute to elbow stability and function. Keeping all of this balanced after removing the diseased elbow and putting an implant in place requires considerable surgical technical expertise.

There are different types of implants that seem to work better with the soft tissues than others. Research efforts are being directed toward improving the implant design in order to reduce the number of complications from loosening.

Then there’s periprosthetic fractures another possible complication in up to 29 per cent of cases. Periprosthetic fracture refers to cracks in the bone around the implant or fracture lines down the shaft of the bone.

These can develop as a result of trauma, poor implant alignment, or as a direct consequence of the patient’s activities. Patients are given guidelines for what they can and can’t do until full healing takes place but they don’t always follow those guidelines. Doing too much too soon can be very detrimental.

Implant failure refers to some aspect of the implant wearing out causing squeaking, pain, and poor elbow movement. Increased stress on the implant from poor alignment can cause what’s called fatigue fracture. The implant itself breaks. Elbow deformity may be occur as a result of any of these problems.

Infection after total elbow arthroplasty develops in a fair number of patients. Studies report a three to eight per cent rate of infection. Detected and treated early with antibiotics, this complication is more manageable than some of the other problems that require additional surgery. In extreme cases, surgery to remove and replace the implant may be needed.

The patient who can’t reach overhead or push a door open may have weakness of the triceps muscle referred to as triceps insufficiency. The triceps muscle located along the back of the upper arm helps extend (straighten) the elbow.

In order to get to the joint, the triceps muscle may be cut and moved out of the way. Of course, it is reattached but cutting it at all can lead to problems. Newer surgical techniques have been developed to spare this muscle and prevent postoperative weakness (and the need for another surgery to fix the problem).

One last problem to consider: nerve palsy. There are two important nerves to the hand that are located on either side of the elbow: the radial and ulnar nerves. The ulnar nerve is at greatest risk when putting an implant in while the radial nerve is at risk when taking the implant out.

The nerves aren’t deliberately cut during the procedure, so that’s not the issue. Pulling on the nerve and exposure to heat from the cement used to hold the implant in place are two factors in nerve irritation or damage. Fortunately, the problem is transient or temporary. It takes a couple of weeks, but the symptoms usually go away.

Any and all of these problems can be treated successfully. Patients should be aware that such problems can develop and that treatment usually involves additional surgery. Further complications from the revision or replacement procedures are also possible. That all sounds like bad news.

The good news is that newer implants with improved designs have reduced implant-related complications. Total elbow arthroplasties (TEAs) are lasting longer while providing improved elbow motion and function.

Early diagnosis and treatment of any problems that occur after surgery is the key to a good outcome. Adopting a wait-and-see approach is not advised. Patients must be encouraged to see their surgeons as soon as any symptoms develop.

Elbow pain from using a strong grip or repeated wrist movements is called lateral epicondylitis or tennis elbow. This type of pain responds well to a new injection treatment that may replace steroid injections.

Plasma taken from the patient’s own blood with high concentrations of platelets is used. The platelet-rich plasma (PRP) releases growth factors into the soft tissues. The result is a faster, more effective healing response.

In this study from the Netherlands, researchers report on the two-year results of a group of 100 patients with elbow pain. Treatment was with either a steroid injection to the elbow or platelet-rich plasma injection. The one-year results were previously published using pain and physical function as the main measures of change.

Platelet-rich plasma may or may not include leukocytes. Leukocytes are better known as white blood cells. There are five different types of leukocytes in the human body. Each one has its own unique function but the overall effect is to fight bacteria and jump-start healing. Some platelet-rich plasma is prepared without leukocytes. The platelet-rich plasma used in this study did have leukocytes.

Daily use of the elbow was assessed using a well-known tool (the DASH or Disabilities of the Arm, Shoulder, and Hand). The DASH is a self-report questionnaire with 30 items including symptoms, social and psychologic effect of symptoms, and physical function. Pain and daily use of the elbow had to improve by at least 25 per cent for either injection treatment to be considered successful.

The group of patients who received platelet-rich plasma injections had better overall results. And the improvements in pain and function were still present two years later. The steroid group experienced some improvement but the positive results didn’t last. By the end of this study, the steroid group was back to their baseline (pretreatment) level of pain and disability.

The authors conclude that platelet-rich plasma (PRP) injection for lateral epicondylitis is easy, safe, and effective. Patients given PRP have an initial response of increased pain as the tissues respond with an inflammatory flare-up but then progressively improve. Benefits last up to two years. The recurrence rate was much lower for the PRP group.

When the standard recommended treatment of physical therapy and bracing is not successful, PRP should be considered before steroid injections or surgery. Only one injection of either type was used in this study.

Previous studies have repeatedly shown that steroid injections only provide temporary pain relief for most patients. The results of this study are very favorable for a single injection of PRP. Future studies should study the results when using more than one PRP injection.

Surgeons will want to take a look at this article. Two surgeons from the Department of Orthopaedic Surgery at Washington University in St. Louis (WUSTL) provide an in-depth review of surgical treatment of the stiff elbow.

The authors begin by discussing when to do arthroscopic surgery versus an open procedure. Then they move on to surgical technique including equipment, patient positioning, and a description of various techniques (e.g., capsular release, debridement, manipulation). Photos provide visual aids before and during the arthroscopic approach.

In the third section, postoperative care, complications, and outcomes are covered. The final segment labeled: pearls and pitfalls summarize what the authors consider the bottom-line or take home message for surgeons treating patients with a stiff, contracted elbow.

Let’s start with how this condition of a stiff elbow gets started in the first place. The most common problem leading to a stiff elbow is an elbow fracture with dislocation. Most often, these complex injuries also have nerve damage, muscle tears, and/or ligament ruptures.

Sometimes a condition called heterotopic ossification (HO) develops and further complicates matters. HO is the formation of bone in soft tissues where it doesn’t belong (e.g., inside the muscle).

There are other causes of a stiff elbow that are not as likely to respond to surgery. Patients with burns, spinal cord injury, brain injury, or neuromuscular diseases like cerebral palsy can also present with elbow stiffness that limits motion and function.

In order to qualify for arthroscopic surgery for a stiff elbow, the patient must complete at least two to three months of therapy. A hand therapist (occupational or physical therapist) provides a host of different treatment techniques. The goal is to restore normal motion and function. When that just isn’t possible (for whatever pathologic reason), then referral to a surgeon is in order.

The surgeon will evaluate each patient carefully in order to determine the best way to conduct the arthroscopic surgery. The surgeon can enter the joint from the front (anterior approach) or from the back of the elbow (posterior). Swelling in the joint and/or scar tissue from previous surgeries can dictate which way the surgeon will begin.

When entering from the front, special care must be taken to avoid injury to any of the nerves in that area. Before beginning the operation, the surgeon may mark the skin of the patient. A black marker is used to identify all of the important soft tissues. During the procedure, fluid may be injected into the joint. This step helps increase the distance between nerves and other soft tissues.

Entering the joint from the back (posterior approach) gives the surgeon an entirely different view compared with an anterior approach. A different part of the capsule can be released from this direction.

The capsule around the joint has to be released to allow the surgeon access into the joint. Special surgical tools called retractors are used to pull the capsule away from the bone and allow the surgeon a better view inside the joint.

Whichever approach is used (and sometimes both anterior and posterior approaches are required), once inside, the surgeon gets busy. Any areas of debris, loose fragments of tissue, or scar tissue are cleaned up. Bone spurs are shaved off. This part of the procedure is called debridement.

Scar tissue from around the nerve is carefully scraped or cut away. This portion of the operation is the decompression. The surgeon will move the arm through its full motion while the patient is under anesthesia (manipulation). Anything that keeps the elbow from moving normally and fully is addressed.

The patient leaves the operating area with a soft dressing and a splint on the arm. Early movement is advised and hand therapy to reduce pain and swelling while maintaining and possibly improving motion begins immediately. Patients can expect to continue in physical therapy for four to six weeks with a very active home program of exercise as well.

How well does this all work? Experts agree that treating the stiff elbow (for whatever reason it develops) can be difficult with a high risk of complications. For example, infection and damage to the nerves and blood vessels are not uncommon problems. It seems the patients who have the best results start out with mild-to-moderate elbow stiffness and without heterotopic ossification.

But for carefully selected patients, arthroscopic treatment of the stiff elbow can be very effective. Patients should not expect a perfectly normal elbow after surgery. But they can expect an elbow that moves enough to restore basic function. Patients can expect to work hard everyday to get smooth motion back and to keep it. In some cases, results are less than optimal and open surgery is still required later.

What about those “pearls and pitfalls”? Surgeons must keep in mind that a contracted, stiff elbow must be entered with the arthroscope carefully and with the intent to avoid punching through blood vessels or nerves. Scar tissue and fibrotic tissue can make normal entry with the scope difficult.

The surgeon should be prepared for distortion of the normal anatomy when there are fractures, dislocations, contractures, and fibrosis. More than one portal (entry way into the joint) may be needed to help improve what the surgeon can see inside the joint.

Proper handling of the surgical instruments will help prevent accidental injuries to vital soft tissue structures. And finally, there is a particular order in which each procedure should be done to give the best results (e.g., debridement before capsular release, tendon/muscle release last).

Baseball enthusiasts love to watch the clock that shows how fast the pitch was delivered. But those speeds of up to 100 miles per hour can come at a cost for the pitcher. Stress, force, and load on the shoulder and elbow can cause injuries. And for the injured athlete, these forces can add stress to a healing injury that may compromise the player’s return to play.

What can be done to prevent throwing injuries and/or protect the healing tissues in an injured player? That is the topic of a study done by physical therapists with college-level baseball pitchers.

The hope was to develop improved guidelines for safe pitching. Understanding the forces on a pitcher’s shoulder and elbow with different types of baseball throws could be an important key in not only preventing injuries but also improving performance.

The study took place at the American Sports Medicine Institute in Birmingham, Alabama. Seventeen (17) healthy college athletes participated. No one in the study had any previous shoulder or elbow pitching injuries or problems. Information on pitching was collected using a three-dimensional (3-D) motion analysis system.

Measurements of shoulder rotation, trunk position, and elbow motion and velocity were compared for two different pitches: from the pitcher’s mound and on the flat surface. Comparison of joint forces and torques for pitches from these two locations were made. Measurements were taken with the arm in a cocked position (ready to throw) and at the point of ball release.

Why are these comparisons important? Throwing the ball while on flat ground is often used to warm-up for mound pitching. But there’s some concern that flat-toss throwing requires different shoulder and elbow biomechanics that may actually harm the pitcher. This study was meant to see if there is a difference in force, load, and stress from one style of pitching to the other.

Here’s what they found: 1) pitchers leaned farther forward when trying to pitch to a maximum distance, 2) maximum-distance throws also required greater elbow flexion and shoulder external rotation, 3) elbow extension velocity (speed of elbow moving from flexion to extension) was greater for maximum-distance throwing, and 4) long distance throwing changed foot mechanics.

Coaches, physical therapists, and sports trainers know that the use of proper throwing mechanics is essential in training programs for baseball pitchers. This is especially true for the recovering player who is in rehabilitation for a shoulder or elbow injury. The results of this study support the continued use of flat-ground (long toss) throwing as a safe and effective rehabilitation exercise.

But caution is advised when throwing as far as possible during the early phases of rehab and recovery after injury. Throwing for distance requires the pitcher to lean forward much farther. This position increases the amount of force placed on the arm and may not be tolerated by injured tissue that is still on the mend.

Further study is needed to determine how soon and how often greater distance throws can be used in training exercises for pitchers recovering from an arm injury. Physical therapist will continue studying movement patterns during pitching. The goal is to help athletes prevent injuries, boost performance, and when injured, recovery quickly and completely.

Throwing programs are needed to help players gain greater arm strength, flexibility, and pitch speed. Additional studies are planned to compare exact throwing distances that are safe versus distances that may be harmful for recovering baseball pitchers.

Swelling or a boggy lump around the point of the elbow is often caused by a condition known as chronic olecranon bursitis. The swelling might increase and decrease but it never goes away fully. Some people have elbow pain or tenderness (especially if there is an infection) but many do not. Elbow range-of-motion may be limited but full motion is often present.

How can this be treated when there is no infection? That’s the question answered in this review of chronic olecranon bursitis. A bursa is a sac made of thin, slippery tissue. Bursae occur in the body wherever skin, muscles, or tendons need to slide over bone. Bursae are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts.

The olecranon bursa is located between the tip, or point, of the elbow (called the olecranon) and the overlying skin. This bursa allows the elbow to bend and straighten freely underneath the skin. Treatment may depend on what is causing the bursitis.

In some cases, a direct blow or a fall onto the elbow can damage the bursa. This usually causes bleeding into the bursa sac, because the blood vessels in the tissues that make up the bursa are damaged and torn. In the skin this would simply form a bruise, but in a bursa blood may actually fill the bursa sac. This causes the bursa to swell up like a rubber balloon filled with water.

The blood in the bursa is thought to cause an inflammatory reaction. The walls of the bursa may thicken and remain thickened and tender even after the blood has been absorbed by the body. This thickening and swelling of the bursa is referred to as (acute) olecranon bursitis.

Chronic olecranon bursitis can also occur over a longer period of time. People who constantly put their elbows on a hard surface as part of their activities or job can repeatedly injure the bursa.

This repeated injury can lead to irritation and thickening of the bursa over time. The chronic irritation leads to the same condition in the end: olecranon bursitis but there may no longer be an active inflammatory process going on.

Other causes of chronic olecranon bursitis include gout, rheumatoid arthritis, lupus, or other systemic diseases. In some cases, the cause simply can’t be identified. We call this idiopathic chronic olecranon bursitis.

Treatment for idiopathic bursitis may be slightly different than the type caused by another condition. Treating the arthritis, gout, or lupus may help resolve the elbow problem. But with idiopathic bursitis, there’s no known cause to address. Instead, conservative (nonoperative) care is the first step in treatment.

The surgeon may advise patients with this problem how to treat just the symptoms. If it is painful or tender, use cold. If it is actively swelling, apply a compressive wrap. If work or daily activities require pressure on the elbow, then a protective pad can be applied over the tip of the elbow.

Surgeons don’t rush in to more aggressive treatment with steroid injections or surgery. The risk of infection, skin problems, or creating a chronic draining opening outweighs the benefit of the treatment. Instead, patients are given advice about how to manage the problem with these conservative measures.

If nonoperative care doesn’t work and the symptoms are interfering with daily function, then the surgeon might consider aspirating (withdrawing fluid from) the joint. Aspiration reduces the swelling and improves motion and function. But the fluid may build up again, so it’s often a temporary solution.

Surgery is an option when conservative care has been applied diligently and the symptoms (especially swelling) are still present three (or more) months later. Any more specific recommendations for treatment beyond this are not possible. The lack of evidence supporting (or disproving) treatments and combinations of treatments just isn’t available.

The authors strongly suggest there is a need for more research in this area. It would be good to know how many adults are bothered by this problem. It’s likely there are more than we think because many people don’t seek care for it.

Surgeons need more information on what happens if the condition is not treated — this is called the natural history of a problem. And different trials of various treatments and treatment combinations are needed to find out what works best and when to use it. The true role of modification of activity, use of nonsteroidal antiinflammatory drugs (NSAIDs), compression wrap, no treatment, and steroid injections must be studied further.

Elbow joint replacement (called Total Elbow Arthroplasty or TEA) is possible but not a common procedure. Getting data on results of the TEA procedure can be difficult. In this study from California, surgeons used information from the California Discharge Database to get a picture of short- and long-term outcomes for patients of all ages, race/ethnicity, and diagnosis (e.g., rheumatoid arthritis, osteoarthritis, traumatic arthritis). Although both males and females were treated, there were twice as many females as males in the study.

Discharge records maintained over a period of 10 years (1995-2005) were analyzed. Problems were tallied for patients while still in the hospital (inpatient period) and for short-term (first 90-days) and long-term post-operative periods.

Type of measures used to gauge success versus failure of the total elbow arthroplasty (TEA) included rates of infection, delayed wound healing, and need for revision surgeries or reoperations. Deaths (usually from blood clots) in the first three months were reported at a rate of 0.62 per cent. Other serious complications such as amputation and conversion to joint fusion were also included.

The overall complication rate was fairly high at 10.5 per cent. Infections, wound complications, and blood clots headed the list of serious complications requiring hospital readmission. By nature of the thin soft tissues around the elbow, the rate of infection tends to be a problem no matter how careful the surgeon is. Most of these problems occurred early and meant the patient had to go back to the hospital for further care.

Surgeons are alarmed by these findings. They are especially concerned because this database doesn’t include other complications that can be disabling such as nerve injuries, implant loosening, and fractures. On the positive side, 92 per cent of the implants did just fine and were still working well four years after being put in.

There were a few other issues that might have skewed results one way or the other. For example, patients from military hospitals or VA hospitals weren’t included. Only patients treated in California were included, so the results may not be typical of other regions.

Even within the California system, the number of cases is probably under reported and surgeons don’t always include the diagnosis, so it was impossible to compare results for the different types of elbow arthritis. That’s unfortunate because it’s possible that one group is at greater risk than another for complications just based on the type of problem (traumatic arthritis vs. rheumatoid arthritis vs. osteoarthritis).

Other studies have reported on the use of different types of implants available for the elbow. Although outcomes based on implant type weren’t a focus of this study, the authors did report that comparisons haven’t shown a difference in results based on implant design. In all cases, the database does not report patient satisfaction, which is a key outcome measure.

There’s plenty of room for further studies to fill in and round out what we know about short- and long-term results of total elbow arthroplasty (TEA). The conclusion of this regional study (California only) was that complications are higher than expected or desired.

Patient results may be improved and costs decreased with further studies to find out why rates of failure, revision, and reoperation are so high (not to mention mortality or death rates). In this study, patient factors (age, sex, race/ethnicity) did not have an effect on death. A closer look at patient characteristics may also be helpful in reducing mortality and rates of other serious short- and long-term complications.

When it comes to ulnar collateral ligament (UCL) injuries in overhead throwing athletes, the authors of this study bring a wealth of experience to the table. After performing surgery on 1,281 patients, their success rate is much higher than reported in other published studies.

The ulnar collateral ligament is located at the elbow. It supports the humerus-to-radius connection and helps stabilize the elbow. The humerus is the upper arm bone. The radius is one of the bones in the forearm. Without this ligament, the force generated by the throwing motion on the medial side of the elbow (side closest to the body) is enough to potentially dislocate the joint.

So, why did the patients in this study do so well compared to others? Well, the authors no longer just repair the damaged ulnar collateral ligament. Instead, they perform a reconstructive procedure called the Tommy John surgery.

In this operation, the ulnar nerve is moved away from the bone and a piece of fascia (connective tissue) is used like a sling to hold the nerve in its new place. During the same procedure, the damaged ulnar collateral ligament (UCL) is replaced with a piece of graft tissue.

After years of trying various tendon grafts, these surgeons have settled on using the palmaris longus tendon from the wrist and forearm. This tendon is easy to harvest, stabilizes the nerve well, and is easier than other tendon grafts to get the correct tension. For patients who do not have a palmaris longus tendon, the gracilis (hamstring) tendon or plantaris tendon in the foot can be used instead.

Most of the patients in this study were baseball pitchers. The Tommy John surgery was used when the loss of an intact ulnar collateral ligament resulted in an unstable elbow joint. Overhead throwing athletes must have a stable, intact elbow in order to have the speed and accuracy needed for the wind up, cocking, acceleration, deceleration, and follow-through phases of overhead pitching.

The goal of this type of reconstructive surgery is to return the athlete to his (or her) previous top level of performance (i.e., performance level before injury). Of the 942 patients in this study, 83 per cent were able to get back to their sport at full participation. Besides baseball pitchers, a smaller number of athletes were included. There were baseball catchers, outfielders, and infielders. Athletes involved in other sports included football players, javelin throwers, tennis players, wrestlers, soccer players, gymnasts, cheerleaders, and pole vaulters.

The surgery was done after at least a three-month trial of conservative (nonoperative) care. Rest, pain relieving medications, and rehab exercises were part of the nonsurgical treatment. Some athletes made the decision for an earlier surgical date based on where they were in the season (beginning, in-season, post-season).

Surgery was always preceded by magnetic resonance arthrograms (MRAs). This type of MRI uses a contrast dye injected into the area to show the presence of bone spurs or other damage. The surgeon could address any of these additional problems at the time of the reconstructive procedure. Arthroscopic exam before surgery was also done to confirm elbow instability.

Surgery wasn’t the end of treatment. Rehabilitation in four phases began right after surgery and continued until the athlete was able to resume full sports participation. The rehab program used at this facility was based on research performed by a well-known physical therapist (Kevin Wilk). Working with a physical therapist, the athlete can expect to get full, painfree motion back five to six weeks after surgery.

Strengthening, stretching, and sport-specific exercises were carried out during the next phase. The entire upper extremity is involved in the rehab program (not just the elbow). By the end of the rehab program, the athletes were involved in activities and exercises that integrate the entire body (arms, legs, trunk, abdomen). Stability, strength, motion, and endurance were all restored fully before returning to sports action.

Not only was there an 83 per cent success rate (athletes returning to pre-injury level of play), almost half of the patients (41 per cent) advanced to a higher level of play. Some of the athletes were able to move from a minor league to major league; others moved up from amateur to professional baseball. Only a small number of patients (11 per cent) did not return to sports participation at all.

The time from surgery to throwing was about four and a half months. Some patients advanced to throwing skills as early as the third month. Others took up to a full year to achieve this milestone. Full participation at a competitive level was longer in coming (ranging from three to 72 months).

It should be noted that despite these good results, there was a fairly high rate of complications (20 per cent or one in every five players had a problem after surgery). Some of the problems were minor and temporary (e.g., loss of ulnar nerve function). Others suffered more major sensory and motor loss with numbness and weakness. Fracture of the bone through which a tunnel was drilled to place the tendon graft was reported in five patients. The fracture complication rate was only 0.5 per cent.

The authors conclude by saying that ulnar collateral ligament (UCL) injuries of the elbow in throwing athletes are so common, it’s being labeled an “epidemic”. With their opportunity to treat more athletes with UCL injuries has come the chance to develop an improved technique and better final results.

Diagnosis can be difficult and delayed because the symptoms of UCL tear are not always the same from player to player. But once discovered, instead of putting a player out of the game permanently, the Tommy John procedure makes it possible to restore players to full function once again.

Future studies are needed to focus on better diagnostic testing for this problem. With earlier identification, it may be possible to prevent stretching and tearing of the UCL in more athletes affected by this problem. And it isn’t just baseball pitchers anymore but a wide range of athletes (as described) who can be affected. For any athlete with an ulnar collateral ligament injury, the future may also bring improved surgical techniques with greater success rates and fewer complications.

If you have ever had tennis or golf elbow, you may know the frustration of not being able to use that arm without pain. And you have probably experienced the poor results of any treatment tried — whether that was steroid injections, antiinflammatories, stretching, or strengthening exercises. In many cases, patients feel they get better on their own regardless of the treatment applied.

What’s the answer to this problem? In this article, Dr. J.E. Kazanjian from the Philadelphia College of Osteopathic Medicine reviews all aspects of elbow tendinopathy from anatomy to pathology including diagnosis and treatment. Tendinopathy refers to the fact that tissue samples taken of tendons on the affected side of the elbow show no inflammation at all. Scarring and fibrosis can be seen on microscopic exam but there are no signs of acute tendon damage or healing.

Surgeons aren’t sure what the true pathology is that causes tendinopathies. There is some evidence that cell death is going on. The tenocytes (tendon cells) almost seem to commit suicide. But what turns that mechanism on and why it gets started in the first place remain a mystery. Without a clear understanding of the underlying problem, it’s difficult to find a specific treatment that is effective.

That’s one reason nonoperative care is the first line of treatment for elbow tendinopathies. Even though the “best” plan of conservative care is also unknown, until studies reveal the true pathoanatomy, treatment may remain a virtual hit-and-miss proposition.

Physical therapists have joined the search for some answers. From the clinical side, they are trying different approaches to see what might work best. Using bracing, proprioceptive (joint sense of position) techniques, and heat treatments such as ultrasound and laser therapy, they give the treatment and then measure results and observe who gets better. Examining characteristics of patients who improve and those who don’t might shed some light on the problem.

Other nonoperative approaches used with some success have included manual therapy and extracorporeal shock wave therapy (ESWT). Manual therapy is a hands on technique of moving soft tissue and bone to restore normal alignment and tissue tension. Shock wave therapy is thought to work by causing microtrauma to the tissue that is affected. The body responds to the microtrauma with a healing response. The result is blood vessel formation and increased delivery of nutrients to the affected area. The final outcome is pain relief from the tendinopathy.

When conservative measures fail to provide relief from painful symptoms or to improve function, then the surgeon starts to consider a surgical solution. As with nonoperative care, there are many choices available to the surgeon. Deciding on the approach (arthroscopic, percutaneous, open incision) is one consideration. Studies done to date have been unable to show that one of these three techniques is better than the others. In fact, no one (single) surgical technique has been shown to be superior to the others either.

Surgeons have tried muscle resection, debridement (shaving away frayed edges), reattachment of torn tendons to the bone, repair with tendon grafts, release of tendons, and combinations of these treatments. The author reports there isn’t enough good scientific evidence to support one treatment over another. All methods have worked to some extent but many patients still have painful symptoms. Return to daily activities and work remain an unfulfilled goal for many people.

As you might expect, the conclusion to this review of elbow tendinopathies and summary of treatment is that more high-quality studies are needed. Surgeons need to compare the results of the various treatment approaches (operative and nonoperative) to this condition. Until a definitive pathology is discovered, it looks like treatment will remain palliative (treat the symptoms) rather than curative.

From anatomy to the post-operative rehab process, the authors of this article provide us with a complete review of injuries to the biceps tendon. The specific focus is on the distal insertion of the tendon. That’s where it attaches to the radius (bone in the forearm).

The reason this topic is of interest to orthopedic surgeons is because rupture of the distal biceps tendon doesn’t happen very often. With injuries that are rare or infrequent, it’s difficult to know what’s the best treatment available. Having a topic like this reviewed from all angles based on current research evidence is helpful.

Let’s start with a quick review of the anatomy. The biceps muscle is the one most visible in the upper arm when you hold your arm up and make a fist. For those of you who remember the cartoon character Popeye, the biceps muscle is the one he always showed drooping down without his spinach and strong and large with his spinach. Much of the strength of elbow flexion (bending the elbow) comes from the biceps muscle.

The biceps muscle goes from the shoulder to the elbow on the front of the upper arm. It is attached to the bone by tendons at the top and bottom. Two separate tendons connect the upper part of the biceps muscle to the shoulder. One tendon connects the lower (distal) end of the biceps to the elbow.

A distal biceps rupture occurs when the tendon attaching the biceps muscle to the elbow is torn from the bone. A distal biceps rupture is rare compared to ruptures where the top of the biceps connects at the shoulder. This injury occurs mainly in middle-aged men during heavy work or lifting. Similar injuries in women are extremely rare. Smokers are more 7.5 times more likely to rupture the distal biceps tendon than nonsmokers.

If this is such a strong muscle, why does the distal biceps tear at all? The answer to that question is still a bit of a mystery. Studies of cadavers (bodies preserved for study after death) and X-rays of live humans point to two possible causes. One idea is that there is a decreased blood supply to the area. Degeneration of the tissue occurs when there isn’t enough blood delivered to the area to keep it healthy.

The other is more of a mechanical problem: the tendon gets pinched or impinged with certain movements. Over time, impingement leads to damage to the tendon and wearing through the tendon and then over time, rupture. With color drawings, CT scans, and photos taken of the tissues during open surgery, the authors are able to illustrate how both causes might explain this type of injury.

The diagnosis is made using a combination of patient history, visual inspection, palpation, clinical tests, and imaging studies. The history is often an important clue because patients usually describe a sudden force applied to the arm followed by a tearing sensation on the inside of the elbow. There is immediate pain and then weakness when trying to bend the elbow.

Two clinical tests that are very useful are the squeeze test and the hook test. You can actually do these tests on yourself to try them out. The squeeze test is done by using one hand to squeeze the upper portion of the biceps muscle of the other arm. You’ll see and feel the hand of the arm being squeezed turn slightly toward a palms up position. This happens automatically when the muscle is squeezed.

The hook test is done with the elbow slightly bent. Use your fingers of the opposite hand and feel the tendon as it attaches to the front of the elbow. You can actually use your index finger to grab or “hook” that tendon and pull it up. If the tendon is ruptured, you won’t be able to see the hand turn when you squeeze the biceps muscle and you won’t be able to find the tendon to hook a finger under it.

To confirm the diagnosis, the surgeon can order MRIs, which will show exactly what’s happening in the soft tissues around the elbow. Of course, the diagnosis is confirmed if/when surgery is done. But sometimes, operative repair isn’t needed.

Older adults or people who are fairly inactive may regain enough strength and motion to remain functional without surgery. The arm is placed in a sling for a few days up to a few weeks. Medications may be used to control pain and make the patient comfortable.

Physical therapy is a key part of conservative (nonoperative) care. The therapist helps the patient learn how to regain motion, strength, and proper motor control. The therapist will also use manual (hands on) techniques to help the healing tissue fibers line up correctly during the healing process.

Surgical repair is really the most common treatment approach and recommended for those who want to regain full strength, motion, and return to work at their preinjury level. The method of operative care isn’t as straight forward as nonoperative care. Surgeons have a wide range of methods they can use to complete this repair.

The first decision is whether to try and reattach the tendon to its proper (native) location or stitch it to a muscle nearby (the brachioradialis muscle). Reattaching it where it belongs is called an anatomic repair. Suturing the tendon to the brachioradialis muscle instead is referred to as a nonanatomic repair.

The surgeon can choose between using one versus two incisions to make the repair. There are advantage and disadvantages with each one. With one incision, there is less scar tissue formation and fewer cosmetic changes. But access to the area is limited and nerve injury is a greater risk factor. Two-incisions opens up the area more completely but puts the patient at increased risk of pain, heterotopic ossification, wound infection, and loss of motion.

No matter what type of technique the surgeon uses, the right amount of tension must be applied to get the correct muscle pull and direction. Different type of sutures (stitches, buttons, anchors, screws) apply varying amounts of tension and can hold up under different levels of load. The goal is to restore the natural alignment, tension, pull, and function.

Once the operation has been completed, the work of rehab and recovery begins. Studies have shown that it is acceptable to follow a more aggressive postoperative plan than was used in previous years.

Immobilizing the arm is still done in the early days but motion is started much earlier than before. Different surgeons use different approaches. Some put the patient in a splint right after surgery (limiting all motion), while others use a hinged elbow brace (set to allow certain movements).

When to start motion and how much to allow also varies from surgeon to surgeon. Some of this is determined by the type of surgery that was done. Some decisions are made based on reports from other studies. And, of course, surgeon training, experience, and preferences play a part in the plan of care.

The authors conclude there isn’t one method of operative repair for distal biceps tendon ruptures that works best for everyone. The operative technique used over the years has certainly improved with a more aggressive rehab protocol. Treatment will continue to evolve over time as more and more studies are able to offer helpful information about best practice for best results.

For the most part, patients can expect to get back to normal daily activity four to six weeks after surgery. Full strength and return-to-work (especially manual labor or activities requiring lifting) may take longer.

Hip and knee replacements are so common now, no one questions them. But elbow joint replacement is a newcomer on the scene. There are still many questions left unanswered. Who should have one put in? When? How well do they work? Do they hold up over time?

Studies reporting results are slowly being published. In this report, Dr. J. D. Keener from Washington University in St. Louis summarizes what we know about total elbow arthroplasty or TEA as it is referred to in its shortened form.

There is more than one kind of artificial elbow joint (also called a prosthesis or implant). The most common types are like a hinge. Each prosthesis has two parts. The humeral component replaces the lower end of the humerus in the upper arm. The humeral component has a long stem that anchors it into the hollow center of the humerus. The ulnar component replaces the upper end of the ulna in the lower arm. The ulnar component has a shorter metal stem that anchors it into the hollow center of the ulna.

The hinge between the two components is made of metal and plastic. The plastic part of the hinge is tough and slick. It allows the two pieces of the new joint to glide easily against each other as you move your elbow. The hinge allows the elbow to bend and straighten smoothly.

So far, it looks like people of all ages with inflammatory arthritis like rheumatoid arthritis (RA) have the best results with elbow joint replacements. The implant holds up well over time. Elbow function is improved and patients are satisfied with the results.

But younger patients who either have osteoarthritis, arthritis from an injury, or a severe acute injury of the elbow seem to have a high rate of complications. This group is also more likely to need a second (revision) surgery.

Researchers are trying to get to the bottom of this problem. They are looking at all patient, implant, and surgical factors. For example, is younger age (with a higher activity level) the reason why TEAs come loose? Is there a specific feature (flaw?) in the implants that just doesn’t work well with joint damage from trauma or the degenerative effects of osteoarthritis?

Trying to sort out effects of the implant itself has been a challenge. These prosthetic devices come in a wide assortment. They can be linked, unlinked, convertible from linked to unlinked, constrained, unconstrained, semi-constrained, cemented or uncemented, and so on. Each one of these design features addresses a specific problem such as torn ligaments or other soft tissue damage, bone loss, and elbow deformities.

What about complications? How do these compare between patients with rheumatoid arthritis versus osteoarthritis? In general, patients with rheumatoid arthritis (RA) have other health issues that result in complications. That’s because RA is a systemic disease, not just a joint problem. Systemic means the disease affects many other systems in the body including heart, kidney, and lungs.

Comparing joint infections, poor or delayed wound healing, and the death rate, reported outcomes are fairly equal between the two groups. Older patients who fall and fracture the humeral part of the elbow are at greatest risk for death from pulmonary embolism (PE). Pulmonary embolism is a blood clot to the lungs. This complication doesn’t have anything to do with which implant is used — it’s more of a patient factor.

As far as which TEA are the most durable (last the longest and have fewer mechanical problems), there is a national registry with data to help take a look back at success versus failure rates. Another word for durability of these implants is survivorship. Survivorship data comes from patients treated at many different clinics and hospitals.

The National Registry Data shows a fairly consistent 15 per cent failure rate. As mentioned, results are better in patients with rheumatoid arthritis. And there is a higher rate of revision surgeries when the implant was done outside of a joint replacement specialty hospital or center.

Loosening of the implant without infection (called aseptic loosening) is the number one complication across the board. But there have been other problems reported that require a second surgery (e.g., implant breaks, bushings wear out, mechanical failure of linkage pins.

With a large number of revision surgeries, surgeons also collect data on outcomes following those procedures. Surgeons face many additional challenges in revision TEAs. Once the first implant is removed, there may not be enough bone to anchor the second one. Damage to the soft tissues or nerves can also present some interesting problems. Deep infections in the first implant may be hard to get rid of and cause failure of the second implant.

In conclusion, there’s more unknown than known about outcomes with total elbow arthroplasty (TEA). Much more study is needed to provide surgeons with evidence-based guidelines.

Patient selection, implant design, and reasons for failure are all areas of interest for surgeons providing elbow replacement for patients of all ages. Implant designs will continue to change and evolve requiring careful data collection to see what works and what doesn’t.

Straighten your arm and let the forearm drop down to your sides. Now turn your hands so the palms are facing forward. Look at your elbow and notice the angle formed from the shoulder to the wrist with the center at the elbow. This is called the carrying angle of the elbow.

You don’t think much about your elbow angle until something happens to disrupt it. In the case of elbow fractures (especially supracondylar fractures), posttraumatic deformities can cause changes in the carrying angle of the elbow. The most common late complication of a supracondylar fracture is called a cubitus varus deformity.

A supracondylar fracture occurs in the lower portion of the humerus (upper arm bone) just above the elbow. In the normal arm, the bottom end of the humerus flares out on each side forming a part of the bone called the condyles. A fracture just above the condyle is a supracondylar fracture.

A cubitus varus deformity gives the elbow an unnatural outward curved angle — like a bowed leg only affecting the elbow instead. Cubitus refers to the inner soft side of the elbow. Varus is the outwardly bowed angle. When the person with cubitus varus looks down at the carrying angle of the elbow, it’s curved in the opposite direction from normal.

Why does this varus deformity occur in the first place? The elbow is a very complex joint when viewed in three-dimensional (3-D) space. Getting the broken bone lined back up in all three dimensions isn’t always easy. Viewed from the side on X-ray, the fracture might look fine. But viewed from the front, back, or from above, the malalignment remains and is much easier to see.

Deformities affecting the carrying angle are equally difficult to correct. Surgery is required and in particular, a supracondylar osteotomy procedure is usually the preferred treatment.

What is a supracondylar osteotomy? Supracondylar tells you where the osteotomy is performed (above the condyle). An osteotomy refers to a wedge-shaped piece of bone that is removed from one side of the bone. The two remaining edges of bone (now separated by a space that looks like a piece of pie taken out of the bone) is then allowed to collapse. The result is a correction of the deformity.

In some cases, a triangular-shaped piece of bone (instead of a pie-shaped piece) is removed. This is done in order to get maximum correction of the varus deformity. The result is a correction of the bone and carrying angle of the elbow. An alternate technique to correct the carrying angle is the step-cut osteotomy.

But that’s only two of the three dimensions. Now the surgeon considers what the elbow looks like from above. That view gives an idea of what kind of rotational forces have affected the elbow. To correct a situation of too much internal (inward) rotation, the surgeon might use a procedure called the rotational dome osteotomy.

In the rotational dome osteotomy, a cut is made in the shaft of the humerus just above the condyles. The upper portion of the humerus is then shifted (rotated and/or tipped forward) to create a more natural elbow carrying angle. Using this type of osteotomy, the surgeon can correct for deformities in all three planes. The result is to correct the carrying angle, reduce the excess elbow extension, and realign the internal rotation malunion.

In this study from Japan, orthopedic surgeons investigated the various osteotomies used to correct elbow varus deformities. The goal was to find which one worked best for supracondylar fractures with this varus deformity. They had a total of 86 patients ranging in ages from three to 31 years old who had this type of problem after a traumatic elbow fracture.

One group had the three-dimensional type of osteotomy. A second group had the standard simple osteotomy with correction only when viewed from the side. The question was: is a three-dimensional correction even necessary? Does the simple correction work just as well?

The answer was determined by looking at the carrying angle and passive elbow motion from before to after surgery. They also calculated the loss of correction as a means of deciding which surgical technique yields the best results.

They found no difference between the groups in terms of carrying angle or elbow motion from before to after surgery. The only significant finding was that the three-dimensional group lost more of their correction than the one-dimensional group. Complications such as infection, nerve palsies, refracture, or elbow instability were nearly equal between the two groups.

The loss of correction in the three-dimensional group was explained as the result of an unstable osteotomy from the way the bones were cut and arranged. Pins were used to hold everything together until complete bone union took place. But the decrease in contact area between the bones made it difficult to stabilize the osteotomy site.

For patients who were experiencing palsy of the ulnar nerve, the nerve was moved away from the bone where it was getting pinched. This procedure called a nerve transposition can be done at the time of the osteotomy surgery. Older children (10 years old and older) are more likely to develop hyperextension of the elbow as a result of the varus deformity. This occurs because there is less bone remodeling at this age to self-correct the problem.

The authors concluded that the most important deformity to correct in cubital varus elbows following traumatic supracondylar fractures is the carrying angle. If the joint is off its normal alignment because the bone has rotated, the shoulder can compensate and function is not lost. A three-dimensional correction is not needed for children under the age of 10. And a one-dimensional osteotomy may not be enough for older children.

The elbow is normally a very stable, solid joint. It doesn’t dislocate easily. But when a traumatic injury occurs and enough force is placed on it, fracture and dislocation can be the result. In this continuing medical education (CME) article, orthopedic surgeons from the Hand and Upper Extremity Service at Massachusetts General Hospital in Boston present an update on the surgical repair of traumatic elbow instability.

The key anatomical feature of elbow dislocations is the lateral collateral ligament (LCL). When this important stabilizing structure is torn or damaged as a result of injury, elbow instability is often the result. Instability means the joint keeps slipping out of place. There can be a partial dislocation called subluxation or a full, recurrent (repeated) dislocation.

Other important anatomical features of the elbow needed for joint stability include the capsule and surrounding ligaments, tendons, and muscles. The joint capsule is a fibrous covering much like the gristle at the end of a chicken bone. Injuries from a sudden fall that result in a simple dislocation can damage any of these soft tissue structure. “Simple” means there is no bone fracture.

More complex elbow dislocations involve fractures of any of the bones that make up the joint. This can include either of the bones in the forearm (radius, ulna) or the bottom of the humerus (upper arm bone) where it joins the forearm bones to form the elbow. The exact type of elbow dislocation and which soft tissues or bones are affected depends on the force(s) placed on the elbow at the time of the injury.

Simple elbow dislocations can often be reduced (put back in place) without surgery. More complex dislocations require a surgical procedure to reduce the joint and repair the damage. Nonsurgical relocation is followed by wearing a splint for a few weeks (two to three weeks) while the soft tissues are healing. Patients are advised to avoid moving the arm away from the body as this puts too much force on the healing elbow.

Dislocations that involve fracture of the radius where it connects to the elbow and the coronoid process are called the terrible triad. The coronoid process is the bottom lip of the ulna at the elbow. The “triad” (meaning three) refers to the dislocation itself plus fractures of the two forearm bones.

Modern treatment of this injury involves repairing (or replacing) the broken radial head, wiring the broken pieces of the coronoid together, and reattaching the torn lateral collateral ligament (LCL). Sometimes a long plate is attached (with screws) to the broken bones to hold them together until bone union takes place. The authors provide specific details about the type and location of the surgical incision and sutures for this procedure.

The decision about just what type of surgery to do depends on the extent of the damage. The surgeon may not know in advance what will be done exactly. Once the arm is opened up and the area can be examined, then the choices for repair and reconstruction become much clearer. If the radial head is broken into too many pieces (especially many small pieces), then repair isn’t possible and that portion of the radius is replaced with a prosthesis (implant).

After reduction or after surgery, the patient with a repaired elbow dislocation is watched closely for elbow instability. Surveillance (observation) is especially important during the recovery period for those who have had surgery and throughout the rehab process for everyone. Failure to maintain a stable joint may be a sign that further surgery is needed.

Long-term problems that can occur after a traumatic elbow injury include chronic, recurrent elbow dislocations, joint stiffness, and/or eventually degenerative changes in and around the joint. The goal of treatment is to restore joint stability and prevent these kinds of problems. According to the authors, the bottom is that a stiff but located (in place) joint is easier to save than one that is so damaged that the joint surface has been disrupted.

In summary, the surgeon who understands elbow anatomy and the patterns of elbow instability that occur from trauma will know how to manage these injuries. Patients who are throwing athletes are especially susceptible to traumatic elbow injuries and also in great need of proper counsel and advice. Regaining stability and motion require time for adequate healing before returning to sports activity. Avoiding lateral (side-to-side) stress on the joint is a key element to recovery.

There’s no match for the design of the elbow as nature intended it to be. When the ulnar collateral ligament (UCL) is ruptured, reconstructing it with the same fine tuning of the intact (natural or “native”) ligament is a bit of a challenge. Injuries to the UCL are most common in athletes who are involved in high-level sports activities such as overhead throwing, weight-lifting, and gymnastics.

The ulnar collateral ligament (UCL) is a thick triangular-shaped band of fibrous tissue. It connects between the bottom portion of the humerus (upper arm bone) and the upper portion of the ulna (one of the two bones in the forearm). The UCL is on the medial side of the elbow (side closest to the body).

Orthopedic surgeons have been trying for years to find a technique that can stabilize an elbow joint disrupted by a UCL rupture while still allowing for a normal arc of motion. The most commonly used procedure was developed 25 years ago by Frank Jobe,MD, a well-known surgeon. Holes are drilled through the bone and graft material is used to form a figure-of-eight loop around the bones to hold them in place.

But the Jobe technique for ulnar collateral ligament (UCL) isn’t easy to do and has a few potential problems such as bone fracture and too loose or too tight graft tension. Three other methods of UCL reconstruction include the use of an interference screw, a docking procedure, and a modified docking technique that uses a device called an EndoButton</i to hold the graft in place.

Various studies have been done using these four techniques. Loading strength has been tested for each one and compared with the intact (uninjured) ligament. None have the holding power of the normal UCL but some (e.g., docking and EndoButton) have tested out to be superior to the other two (Jobe technique, interference screws).

In an effort to find a better technique, surgeons from several clinics joined together to test out a new technique for ulnar-sided fixation. The new method combined a ZipLoop, the docking technique, and an interference screw. The ZipLoop device makes it easier to tighten or loosen the graft once it's in place.

The first set of tests was done on cadaver elbows (humans donated for study after death). The docking ZipLoop technique with fixation screw was compared with the traditional Jobe technique and against the normal, intact ligament. All graft material used to reconstruct the UCL came from allograft (donated) gracilis tendons.

The researchers were able to use a special electromagnetic tracking system to test the elbows’ arc of motion under loaded and unloaded conditions. Each elbow was tested first in its intact, natural (uninjured) condition.

Then the UCL was cut to simulate an injury and testing was repeated. The surgically ruptured elbows were treated with one of the two treatment techniques being investigated (Jobe technique and ZipLoop technique). The authors provided a detailed description of all surgical techniques used in this study.

The elbows were put through their paces and data collected for both techniques. Various valgus loads (against the ligament) were applied in different positions of elbow flexion. The last test applied was to the failure point — in other words, how much load does it take before the ligament snaps and ruptures. This final measure gives an accurate measure of stability under all conditions.

In the end, they had information on valgus load limits for natural ulnar collateral ligaments (UCLs), transected (surgically cut) UCLs, and reconstructed ligaments through the full arc of motion while loaded and unloaded. What were they able to glean from this experiment?

As was stated at the beginning: nothing works as well as the original (native) ligament. Having said that, what’s the second best option when the native ligament is torn? And, in this case, how does the ZipLoop technique (with its ability to adjust the graft tension) compare with the Jobe technique?

The results showed equal results between the new combined docking/screw/ZipLoop technique and the so-called gold standard Jobe technique for this ligament. And the new technique had two distinct advantages over the Jobe technique: the new method allows for slight changes in the tension of the graft and eliminates the risk of fractures.

With this knowledge, surgeons can test out the new, novel technique to repair (reconstruct) the ulnar collateral ligament at the elbow in live patients. Patient satisfaction can be measured in terms of restored motion, reduced pain, improved function, and abilithy to return-to-sport at the preinjury level of participation. For athletes with UCL injuries, surgery that can restore ligament strength to normal and provide a stable yet flexible elbow is an important discovery!

Pain, numbness, and tingling in the wrist and hand are common features of compression neuropathies like carpal tunnel syndrome (CTS). But there are two other nerves in the forearm that (when pinched or pressed) can cause similar symptoms: the radial nerve and the ulnar nerve. Radial nerve compression is called radial tunnel syndrome. Problems with the ulnar nerve result in cubital tunnel syndrome.

Radial tunnel syndrome is the focus of this patient report. Because there are no definite tests that prove the patient has radial nerve compression, the surgeon must rely on patient report and clinical findings to make the diagnosis. Knowing this, physicians then ask, What evidence can I rely on? What tests are valid and reliable?

In this case, the patient was a middle-aged male who had a year and a half’s worth of elbow pain along the outside of the elbow. There was tenderness with palpation of the common extensor muscles just below the bump on the outside of the elbow. That bump is called the lateral epicondyle. That’s a common place for pain to develop with radial tunnel syndrome.

But patients with pain at this place don’t always have radial tunnel syndrome. And people with radial tunnel syndrome don’t always have pain or tenderness there. Okay — so, what else might help identify radial tunnel syndrome as the problem?

There’s the forearm and finger extension test. The patient attempts to turn the palm up with the elbow extended (straight), a motion called supination. At the same time, the examiner resists the movement. The test is considered positive if there is pain with resistance. Another resistive test involves asking the patient to extend the middle finger. Pain with resistance to this movement is another sign that the radial nerve is entrapped somehow.

With carpal tunnel syndrome, the orthopedic surgeon can order electrophysiologic tests to confirm the diagnosis. A delay in the speed or signal along the nerve to the muscles suggests the median nerve is compromised. But with the radial nerve, electrophysiologic tests are almost always normal even when there’s a problem.

Some experts claim that injecting the area around the nerve with a numbing agent is diagnostic. If the pain goes away, then the pain was caused by the nerve being compressed, pinched, or trapped inside scar tissue, muscle, or other layers of tissue. Still others use pressure over the supinator muscle (the one most often contracting around the nerve and compressing it) to reproduce the painful symptoms.

Unfortunately, no one has ever been able to get consisent enough results to consider these tests accurate. There simply aren’t reliable enough differences between painful and nonpainful arms to point to one test as the best to diagnose radial tunnel syndrome.

What about imaging studies such as X-rays or magnetic resonance imaging (MRIs)? X-rays have not proven helpful unless there is an obvious bone spur or abnormal anatomy causing nerve compression. The number of those cases is small compared to the total number of patients with radial tunnel syndrome.

So there must be something else to look for. MRIs give additional information that might show mechanical compression as the cause of the problem. But like electrophysiologic testing, imaging studies just don’t clearly verify this disease process in the majority of patients.

Where does that leave us? Mostly without an acceptable reference standard for diagnosis of this condition. There’s no consensus on reliable tests. And surgeons continue to debate about the availability of evidence and discuss the evidence that has been offered.

Right now, surgeons say they find out for sure after doing surgery to release the posterior interosseous nerve/i>. The posterior interosseous nerve is a part of the radial nerve in the forearm. After the radial nerve has crossed the supinator muscle, it continues on as the posterior interosseous nerve. If the painful symptoms go away after cutting this branch the surgeon can safely assume the diagnosis was radial tunnel syndrome. If not, well then, it must have been something else.

Understandably, patients would prefer to head into surgery knowing it will be successful. That brings us back to the diagnostic drawing board. If researchers can find better, more reliable ways to diagnose the problem before treatment, then patients can be selected for conservative (nonoperative) care or surgical intervention. And patients like the gentleman discussed in this report won’t have to suffer 18 months worth of elbow pain before having surgery.

There’s a new way to evaluate data pooled from many studies when comparing two different treatment techniques for the same problem. The statistical method is called number needed to harm (NNH).

Number Needed to Harm refers to the number of patients treated in a certain way before someone gets hurt or has a complication. It might seem like an odd way to look at something. But using the Number Needed to Harm is more meaningful to a surgeon than using mathematical ratios or odds.

Using the Number Needed to Harm gives the surgeon a better perspective of the benefits and risks of a procedure. Likewise, it gives patients a way to make an informed choice about surgery. This study gives an example of how this statistical method can be used.

Patients with a diagnosis of displaced supracondylar humeral fracture were included in the study. This type of elbow fracture is common in children who reach an arm out to brace themselves when falling. Children involved in this study were between the ages of three and 12.

The upper arm bone (humerus) is fractured above the elbow. The fracture affects the bone just above the natural flare that occurs at the bottom of the bone on both sides. The term displaced tells us the fractured piece of bone has shifted away from the rest of the humerus.

In cases of a displaced supracondylar fracture of the humerus, the displaced piece of bone must be reattached. A wire (called a K-wire) is used to tie the pieces of bone together. The wire can be inserted through the skin and into the bone in a procedure called percutaneous wire fixation. Percutaneous means through the skin.

A percutaneous procedure is considered a closed fixation technique since an incision isn’t needed. Two other ways to perform this operation are open (with an incision) and mini-open (using a small incision).

The surgeon can place one or more wires in one of two ways: straight or what’s referred to as a lateral or crossed pin configuration. As you might imagine, crossing the wire increases the risk of injuring the ulnar nerve, which runs down along the elbow in this area. The question in this study was: which wiring method has the greatest risk of nerve injury?

The authors searched all the published studies they could find for studies that compared crossed and lateral wiring techniques for this type of elbow fracture. They found 32 studies with a total of 2639 patients. Using the Number Needed to Harm, they calculated that the crossed pin method increased the risk of nerve injury. But by how much?

The results showed that for every 28 patients who were treated with the crossed pin fixation method, one would have an ulnar nerve injury. This was the number of patients who would have to be treated by crossed pinning to have one more nerve injury compared with the lateral pin method.

Using the Number Needed to Harm (NNH) as the only measure to show that one method is safer than another is not necessarily recommended. Together with other measuring methods, it provides some additional information for patients and surgeons.

The authors share at the end of their article that there were some challenges in the analysis that might affect the results. First, there were a low number of ulnar nerve injuries with either pinning fixation method. Second, the studies they included in the Systematic Review were retrospective (after the fact). This means there could have been patients who developed ulnar nerve problems later that weren’t included in the study.

Third, the studies included in the review were gathered from 1966 to the present. Many things have changed in surgical technique since the ’60s. It’s possible (even likely) that improved methods have changed the number of nerve injuries reported from study to study. And that could skew the results reported here.

And finally, there were studies that didn’t report the number of ulnar nerve injuries with these two pinning techniques. Patients in the studies had the surgery using the pinning methods but nerve injuries either didn’t occur or weren’t a focus of the study. In either case, that means there were studies on the subject (and a number of patients in those studies) that weren’t included in the total number used to calculate Number Needed to Harm.

The authors conclude that crossed pinning of supracondylar elbow fractures in children does increase the risk of ulnar nerve injury. Surgeons may still opt to use this method because it gives a more stable fixation needed in active children. They must weigh the pros and cons of each technique with each child when making the decision to choose one fixation method over another.

More than half the time, elbow pain along the inside of the elbow is caused by a pinched nerve in the neck. That was the reported result of examining 102 patients with elbow pain called medial epicondylitis, golfer’s elbow, or pitcher’s elbow.

Pressure on the spinal nerve roots as they exit the spinal column can cause neck and/or arm pain, and numbness and tingling down the arm. Weakness of the muscles supplied by the affected nerve root is another main symptom of a pinched nerve. The medical term for a pinched nerve in the neck is cervical radiculopathy.

In the case of medial epicondylitis linked with cervical radiculopathy, weakness of the muscles supplied by the pinched nerve leads to problems at the elbow. The spinal nerve roots affected and thus associated with golfer’s elbow are C6 and C7.

Weakness compounded by repetitive motion and overload of the muscle-tendon junction can then lead to microtearing and tendon damage. But as this study showed, weakness from cervical radiculopathy can be enough to put the elbow at risk for the development of medial epicondylitis. The 55 patients who developed golfer’s elbow didn’t golf or play ball.

Abnormal findings on MRIs taken as part of the diagnostic workup confirmed the diagnosis of cervical radiculopathy in 54 per cent of these patients. The levels affected most often were C5-6 and C6-7. Three-fourths of the patients had bilateral (both elbows) medial epicondylitis.

With epicondylitis, it is known that the damaged tendon doesn’t heal correctly. Degeneration occurs with fibrotic (scar) tissue forming instead of new, healthy tissue. The lack of tendon healing is possibly another end-result of the compromised (pinched) nerve tissue in the neck. The connection between poor tendon healing and the cervical radiculopathy has not been proven yet, so this is just a suggested theory for now.

The importance of this study was to remind physicians to consider cervical radiculopathy as the primary diagnosis when a patient presents with medial elbow pain. A history of repetitive elbow motion is not always present. If the diagnosis is missed at first, failure to resolve the symptoms with conservative (nonoperative) care is likely. This should point back to the need to look to the neck as the possible cause of the elbow symptoms.