News Category: Elbow

Tennis elbow, also known as lateral elbow tendinopathy can be very hard to predict. Physical therapy often helps reduce painful symptoms, improve motion, and restore function. But after months of therapy, some patients may still need surgery. On the other hand, some people heal up nicely on their own and don’t need rehab or surgery.

Is there some way to predict in advance who needs what? In this study, orthopedic surgeons and radiologists team up to explore the usefulness of ultrasound studies in tennis elbow.

They started out with a hypothesis that there are sonographic predictors of prognosis for tennis elbow. Their approach was to test patients using the Patient-Rated Tennis Elbow Evaluation (PRTEE) to assess pain, function, and disability. At the same time, each patient had an ultrasound study done of the elbow.

Six months later, the same tests were given. Treatment with a physical therapist was provided during the six months between tests. The focus of conservative (nonoperative) care was stretching and eccentric loading (a specific type of exercise shown in other studies to be effective). No one had surgery or any steroid injections during that time.

The researchers compared the before and after results. They analyzed the data with respect to age, sex, and side (right or left elbow) as possible predictive factors of outcomes. Duration of symptoms, thickness of tendon, and amount of blood supply to the area were also studied as possible predictors of prognosis.

Previous studies of this type have been able to show that ultrasound is an excellent test tool to see what’s going on inside that painful elbow. It shows structural changes like tendon thickening, tendon tears, and blood flow (increased or decreased). Ultrasound also provides the physician with some idea of how much collagen fiber degeneration is present and whether or not there is any inflammation going on.

So many studies showed that chronic tennis elbow doesn’t have any inflammation that the condition was renamed from tendinitis to tendinosis. There aren’t any immune blood cells present but plenty of scar tissue called fibrosis and necrotic (dead) cells.

So which factors have a significant affect on outcomes? And can these be used to predict what how the patient will respond (i.e., what will happen)? Over the six months’ period of time, symptoms improved for three-fourths of the group. The remaining one-fourth of the group responded poorly to treatment.

What was the difference between the two groups? It boiled down to two things: partial or complete tear of the lateral collateral ligament (LCL) and size of the tear (more than four millimeters). There wasn’t a significant link to the rest of the factors (age, sex, right or left elbow).

The results of this study confirm the benefit of ultrasound as an imaging tool for the diagnosis and assessment of tennis elbow. Failed tendon healing after conservative care may be explained by size of tendon tears. Lateral collateral ligament tears are a good indication that surgery is needed.

The authors conclude that it is still acceptable to try a course of nonoperative care for tennis elbow. But for patients with large tears, stimulating tendon repair rather than focusing on pain relief may be the best approach. For this reason, steroid injections are not advised. Instead, the surgeon should consider some of the newer treatment methods such as blood injection, platelet-rich plasma, or cell therapy.

Ultrasound assessment early in the diagnostic process may help triage (sort) patients into the best treatment approach based on severity of findings, not severity of pain. Failed tendon healing may be avoided with this type of approach.

It might seem funny but tennis elbow (also known as lateral epicondylitis) could be caused by a problem in the neck. In other words, it may not be coming directly from the elbow. True lateral epicondylitis occurs as a result of local trauma and tissue inflammation. Overuse of the extensor carpi radialis brevis tendon causes microtrauma where the tendon attaches to the elbow.

That same spot along the outside of the elbow is where pain can be referred when pressure is placed on the C67 nerve root. This condition is referred to as cervical radiculopathy. The C67 nerve root leaves the spinal cord in the lower cervical spine and travels from the neck down the arm. When this nerve gets pinched or compressed, neck and arm pain can develop with pain traveling down to the elbow and below.

This may be the first study to show that elbow pain occurs as a result of muscle weakness because the C67 spinal nerve is compromised. The elbow pain and dysfunction aren’t caused by local microtrauma of the tendon at all but from altered muscle function as a result of the cervical radiculopathy. When nerve innervation of the muscles is interrupted, then weakness can make even everyday activities seem like overuse resulting in what looks like traditional lateral epicondylitis.

Making the differential diagnosis is important because the treatment differs from trauma-induced (overuse) tennis elbow and cervical radiculopathy. Instead of just treating painful elbow symptoms locally (at the elbow), efforts are directed toward the neck as well. Unnecessary surgery can even be avoided.

Out of 102 patients involved in this study, all had a confirmed diagnosis of cervical radiculopathy. Two-thirds also had tennis elbow. The tip-off that it was linked with the cervical radiculopathy (neck) was the fact that the symptoms of elbow pain, weakness, numbness and tingling were present in both arms. MRIs confirmed pathology in the cervical spine. EMGs and nerve conduction studies ruled out local nerve entrapment at the elbow.

The authors concluded that lateral epicondylitis is more common with cervical radiculopathy than was previously recognized. Anyone with tennis elbow should be evaluated carefully to look for underlying cervical radiculopathy. Women are affected more often than men. When cervical radiculopathy is present, symptoms of tennis elbow can be present on just one side but it’s more often the case that symptoms are bilateral (present in both elbows).

When lateral epicondylitis occurs as a result of cervical epicondylitis, treating it with traditional tennis elbow therapy won’t resolve the symptoms. That’ another clue that something more than tennis elbow is the problem. A comprehensive treatment program for both the cervical radiculopathy and the lateral epicondylitis is needed to resolve all symptoms.

A physical therapist will evaluate the individual and design a program specific for that person. Most likely the plan of care will include postural and strengthening exercises and manual therapy to restore normal neck alignment and movement. If needed, nerve mobilization techniques can be applied to help the affected nerves slide and glide smoothly. Neuromuscular training during daily activities and while performing work duties are incorporated until the individual can return to normal function.

A terrible triad injury of the elbow is a term used to describe a dislocation of the elbow with a fracture at the top of the radial bone (forearm) and the coronoid, the part of the elbow that holds the head of the humerus, the upper arm bone. Because of the extent of the injury, the usual treatment is open surgery. However, there are sometimes patients who cannot or do not want surgery, so nonsurgical treatment must be done instead. The authors of this article reviewed the cases of four patients who refused or preferred not to have surgery to treat the terrible triad injury.

The first patient, a 32-year-old male, fell from standing height and sustained the elbow injury. X-rays showed there was a posterior dislocation of the elbow and fractures of the radial head and coronoid. Both bones had been displaced (moved out of place), although the radial head had a more severe displacement. Because the patient refused surgery, he was fit with a sling and was told to avoid shoulder abduction, or moving the arm away from the body, for one month.

After three months, the elbow had stabilized but the patient had developed a problem with the nerves running through the elbow, which caused numbness and limited motion of the lower arm. New x-rays showed the bone had healed but joined together in areas where it should not have: at the front of the radial neck. The bone formation also caused a misshapen radial head, the top of the bone. At this point, surgery was done to help release the elbow contracture (bending inward of the elbow). Seven months after the surgery, the patient was able to extend his arm to 140 degrees and was no longer contracted, although one month later, he did report numbness and weakness because of pressure on the nerves extending from the elbow, which was corrected by another surgeon.

The second patient, a 60-year-old woman, also fell from standing height. Her dislocated elbow was reduced (put back into place) and splinted. After removing her splint 10 days later, she returned to the doctor, able to extend her arm to 135 degrees and that her elbow could contract to 25 degrees, and she did not complain of significant pain.

X-rays of the patient’s elbow showed that although the fractures for the terrible triad were present, there was not much bone movement. Because the patient had good range of motion and little pain, the decision was made not to operate. She was also told to avoid shoulder abduction, as was the first patient. Fifty-five months after the initial injury, follow up showed that she had 140 degrees movement on contraction and full movement on extension.

The third patient was a 40-year-old male who did manual labor who also injured himself from a standing height. After the elbow was reduced and splinted, x-rays showed that the fractures were not badly displaced. Since the patient had decent motion (flexion of 125 degrees and contraction of 40 degrees) and he did not want surgery, the doctors treated him with a sling, advice to avoid shoulder abduction for one month, and active, assisted range-of-motion exercises for the elbow. Two months later, the patients had returned to his pre-injury level of work. The x-rays did show some deformity and less flexion (only 125 degrees compared to 145 in the non-injured elbow) and some deformity on the radial head. However, the patient did not complain of pain or any nerve issues.

Finally, the fourth patient was a 48-year-old who fell from a mountain bike, dislocating his elbow and sustaining the two fractures. The initial hospital visit resulted in reducing the elbow and splinting. After two days, x-rays showed the fractures and movement of the bone. Although the doctors recommended surgery, the patient refused so treatment involved using a sling, avoiding shoulder abduction for one month, and active assisted elbow range-of-motion exercises.

Seven months after the initial injury, x-rays showed that the bones had aligned and healed and the patient had full range of motion. However, he did complain of mild pain.

In general, the authors found that certain patients with the terrible triad elbow injury can be managed without surgery. They pointed out that the cause of the injury could play a role in how effective nonsurgical treatment may be. The types of fractures the patients had were single, transverse, the type of bone that breaks straight through. Mot unstable fractures are those that are larger and not transverse.

Although one of the case study patients, the first one, did have surgery in the long-run, the cause of the bone build up may not have had anything to do with the nonsurgical and may have occurred anyway.

Sports fans watch the clock closely that records how fast baseball pitchers throw the ball. The fastest pitch ever recorded in the Guinness Book of World Records is 100.9 miles per hour. Unofficially, some pitchers have been clocked at 103 to 104 miles per hours. But even in lower league play, those fastballs are moving 80 to 90 miles per hour and that puts a tremendous strain on the elbow.

The throwing motion repeated over and over can cause tiny tears in the soft tissues around the elbow — especially the medial (inside edge of the) elbow. The first ligament to go is the ulnar collateral ligament (UCL). When that happens, the ability to throw becomes compromised by chronic, disabling elbow pain.

Older pitchers (30 years old or older) are at risk for damage to both the ulnar collateral ligament (UCL) and the flexor-pronator muscles. The flexor-pronator muscles bend the elbow and turn the palm down. The palm down motion needed to deliver the ball over the plate is called pronation is really a forearm motion that takes place at the elbow. In this study, hand surgeons from Harvard Medical School report on older baseball players with combined flexor-pronator and ulnar collateral ligament injuries.

These combined soft tissue injuries are rare but can keep a player out of the game — permanently. Out of 187 male baseball players operated on by the author, only eight had the more extreme combined injury. All were major league baseball players (seven pitchers, one catcher). Of those eight, five had a poor result after surgery. Only one player reported an excellent outcome. The remaining two rated their results ss fair. Fair meant they were demoted from the major to minor league.

The likelihood of returning to sports play at the player’s preinjury level after a combined flexor-pronator and ulnar collateral ligament injury is poor. Older age and chronic, degenerative changes affect soft tissue integrity and elbow joint stability. The authors suggest warning players with this type of injury that surgery may or may not help and the result may not be full return to the game.

Is age the only predictive factor in cases like these? That’s one thing the surgeons wanted to find out because severity of injury (partial versus complete tear) could also make a difference. But then again, maybe age has something to do with how severely the soft tissues tear. And then there’s also the chance that the type of surgery done could make a difference in the final results.

With these questions in mind, the data was analyzed. Type and extent of surgery was first assessed based on the patient’s history, the surgeon’s examination, and MRI results. The final diagnosis was made during the operation when the surgeon could get a first-hand look at the soft tissues in question.

Only one of the eight player was younger than 30 and he was 29 years old. The rest ranged from 30 to 42, so age was a big determining factor. Most of the injuries or tears were severe. One-third of the group ended up having at least one more surgery for re-tears of the repaired damage.

The authors concluded that older baseball players who already have damage to the ulnar collateral ligament from chronic repetitive throwing have a poor prognosis even with surgery. As long as the throwing speed is greater than the tensile strength of the soft tissues around the elbow, there’s going to be a problem. Pain from tears and instability changes the way a player throws the ball.

Without full and unrestricted use of both the ulnar collateral ligament and the flexor-pronator muscle, successful return to play may be impossible for older pitchers. But there is good news in all this. Thanks to advanced imaging with MRIs, elbow injuries are recognized earlier now than they used to be — early enough to prevent the more severe type of injuries suffered by the older players in this study.

The hope is that these combined injuries will be eliminated in today’s young pitchers and catchers. Newer surgical and rehab techniques may also help improve final results. There’s some indication that repeated cortisone injections may also be a risk factor for the combined injury. Since the combined injury is rare, it may take a while to see if these changes (early diagnosis and improved treatment) will eliminate this type of injury.

Most people know someone with or has heard of carpal tunnel syndrome, a repetitive stress injury involving the nerve that goes through the wrist (the carpal tunnel) and into the hand. While this is the most common entrapment neuropathy (nerve problem due to a nerve being trapped or pressed on), the second most common entrapment neuropathy that involves the arm has to do with the elbow and how the nerve passes through the cubital tunnel. This is called ulnar neuropathy.

When a person has entrapment neuropathy from compression of the nerve in the cubital tunnel, this can leave them with weakness in the fourth and fifth fingers (the ring and little fingers). They may also experience problems with the forearm muscles that are fed by the ulnar nerve, the one affected by this problem. The neuropathy is diagnosed by doctors using electrodiagnosis, tests that use electricity to assess how the muscles respond. Usually, the sensitivity of diagnosing an elbow problem is lower than that of testing for the wrist. In fact, there are reports of patients who have supposedly normal results from the electrodiagnostic tests but they still have the signs and symptoms of ulnar neuropathy.

There are some theories that suggest why some patients’ neuropathy isn’t diagnosed with electrodiagnosis. These theories include issues such as improper positioning of the elbow during testing or the problem being too mild still to be detected. Some doctors have begun using high-resolution ultrasound to determine if there are nerve conduction issues in some neuromuscular disorders and some studies have looked into the usefulness of this type of ultrasound to look for entrapment problems. The authors of this study evaluated ultrasound and nerve abnormalities in four patients who had undergone typical electrodiagnosis that didn’t find any problems, yet the patients still had the signs and symptoms of an entrapment.

After the patients underwent the initial testing, they underwent ultrasound testing that checked all along the ulnar nerve from the wrist up to the underarm. In the first case, a 50-year-old woman who had experienced numbness for several months, as well as decreased feeling in the fourth and fifth fingers, the ultrasounds showed a marked enlargement of the ulnar nerve about 1 centimeter away from the nerve, next to the top of the forearm.

The second case involved a 56-year-old manual laborer who also had numbness in the fourth and fifth finger, but it had been present for several years. the ultrasound findings showed an enlargement of the ulnar nerve, also near the top of the forearm. The third patient, a 28-year-old woman complained of similar finger numbness, which began two months earlier after a marathon session of playing video games while resting her elbow on a hard surface. Once again, the ultrasound showed an area above the forearm, as it also did for the fourth patient, a 30-year-old man who has a high level of computer use and who had experienced similar numbness for three months.

The authors wrote that this was the first study done to determine suspected ulnar neuropathy, despite supposedly normal electrodiagnostic findings, although there has been an earlier study that investigated nerve changes in ulnar neuropathy in patients who appeared to have the problem but were not diagnosed by electrodiagnosis. They concluded that more research should be done into using ultrasounds to help diagnosis of patients who appear to have ulnar neuropathy but do not have electrodiagnostic proof of it.

Of the two most common nerve entrapment conditions affecting the arm, the cubital tunnel syndrome is less well-known than the compression neuropathy known as carpal tunnel syndrome. In this article, patients, orthopedic surgeons, and physical therapists will all find valuable information on the cubital tunnel syndrome.

The authors present a detailed review of the surgery done to release the nerve from its confinement in the cubital tunnel. Cubital tunnel syndrome is a lot like carpal tunnel syndrome. Instead of the median nerve being pinched or compressed (the median nerve is affected in carpal tunnel syndrome), it’s the ulnar nerve that’s affected. Both nerves come down from the cervical spine (neck) to the elbow. The median nerve takes more of a middle of the forearm approach to the wrist, whereas the ulnar nerve travels along the inside of the elbow down to the little finger side of the wrist.

Pressure on the ulnar nerve anywhere along its path from the elbow to the hand can cause numbness and tingling of the last two fingers (ring and little). Ulnar nerve entrapment can also result in hand weakness. Pain is not usually a main symptom with cubital tunnel syndrome. When pain does occur, the patient often reports it occurs along the medial (inside) of the elbow and sometimes down into the forearm.

The condition is called cubital tunnel syndrome because one of the most common places where the ulnar nerve gets pinched is the cubital (elbow) tunnel. This tunnel is just a space made by ligaments, connective tissue, tendons, joint capsule, and bone at the elbow through which the ulnar nerve passes.

The authors place quite an emphasis on understanding the anatomy of the elbow and how it can compress the nerve in one of five places (the cubital tunnel plus four other locations). When treatment is surgical to release restrictions on the nerve, all areas of limitations must be addressed. If the nerve is compressed in more than one area but the surgeon only releases one area, then the symptoms will not be gone — or they might come back quickly after surgery once the nerve gets irritated again.

How does the physician know you have cubital tunnel syndrome instead of carpal tunnel syndrome? The symptoms affect different parts of the hand and fingers since each nerve supplies different muscles, skin, and tendons. But there are also different clinical tests that can be done to identify which nerve is affected. In the case of cubital tunnel syndrome, tapping, scratching, and pressure tests can be done to provoke the nerve and reproduce the same symptoms.

The physician will carefully examine and test all areas of the elbow looking for the specific cause of the symptoms. The joint will be assessed for any instability and the bones checked for fractures. The condition will be labeled mild, moderate, or severe depending on whether the symptoms are transient (come and go), the severity of weakness, and loss of hand function for activities such as buttoning, typing, or opening doors, bottles, and other containers.

When compression on the nerve has been present a long time, muscle weakness gets worse and deformities of the fingers can start to develop. One of the most recognizable hand deformities from ulnar nerve palsy is a claw hand (also referred to as Duchenne’s sign.

Loss of motor control of the muscles to the ring and little fingers results in those fingers getting stuck in a bent position. It’s tough to get your hand in pants pockets with the fingers in this position. The longer the paralysis goes on, the more muscles are affected until the patient can no longer grip a key or move the thumb toward the ring and small fingers. This progression of symptoms tells the doctor that the intrinsic (inner) muscles of the fingers have been affected, too.

To confirm the diagnosis and pinpoint the exact area of nerve compression, electrodiagnostic testing can be done. These tests consist of nerve conduction velocity (NCV) and electromyography (EMG). X-rays may be ordered to rule out fractures. A newer test called high-resolution ultrasound is being studied to see if it is a more reliable way to diagnose cubital tunnel syndrome.

Once the diagnosis has been made and confirmed, then it’s a matter of identifying the best treatment approach. Sometimes what doctors refer to as benign neglect works for mild cases — in other words, don’t do anything and the problem may eventually correct itself. But most patients aren’t willing to test that approach out. They want relief from the annoying symptoms now.

Mild cases of cubital tunnel with symptoms that come and go caused by excessive elbow flexion (usually while curled up sleeping) can be successfully treated using splints to keep the elbows out of bent postures. Physical therapists can help mobilize (move, slide, glide) the nerve within its protective outer covering or sheath. Such neural mobilization techniques can be very successful in alleviating the unpleasant symptoms without surgery.

But when patient education about position and use of the elbow doesn’t make a difference, then surgery may be needed. The surgeon has several tools in his/her bag of tricks so-to-speak. Decompression is the first option. The surgeon makes an incision along the nerve near the elbow and releases any tissue holding the nerve down or entangled around the nerve.

Sometimes a simple decompression isn’t enough and the surgeon has to transpose or move the nerve away from its original location. In other cases, a muscle is pressing against the nerve every time the muscle contracts. The surgeon moves the muscle instead of moving the nerve. That’s called a submuscular or intramuscular transposition. The transposition procedures are much more complex than simple decompression. With muscular transpositions, there is a greater potential for post-operative complications like bleeding, nerve damage with loss of motor function and/or sensation, scar tissue formation, and pain.

If the nerve is being pressed against the bone or the indentation in the bone for the nerve is too shallow, it may be necessary to cut away some of the bone. This procedure is called a medial epicondylectomy. Medial tells us the surgeon is working on the bone along the inside of the elbow. In fact, the surgeon is removing what we often refer to as the funny bone.

As part of the research for this article, the authors reviewed studies published on the outcomes of the different surgical procedures. There really wasn’t a difference in results from one procedure to the next. Without evidence of a clear winner, surgeons are advised to do whatever is the simplest and least invasive to correct the problem.

The surgeon must weigh all factors when making a decision about the best surgical approach to take. Sometimes the final decision about what to do and how to do it isn’t made until the surgeon can take a look inside at what’s going on with the nerve. This decision-making method is called intraoperative assessment. The surgeon checks the nerve’s movement; stability; and presence, amount, and location of scar tissue. Every effort is made to avoid complications, problems, and recurrent symptoms requiring additional surgery.

Fractures of the elbow can involve the upper bone (humerus) or the two lower bones in the forearm (radius and ulna). In this review article, surgeons from Columbia University Medical Center in New York City discuss current ways to treat bicolumnar distal humerus fractures. Evaluation of the injury as well as nonsurgical management and surgical treatment are discussed in detail. Results of treatment and potential complications are included.

A distal humeral fracture is just another way of saying it’s the elbow that’s involved. The humerus (upper arm bone) obviously can be broken at the top near the shoulder, in the middle along the shaft of the bone, or at the bottom where it joins the elbow. Bicolumnar is a more complex fracture pattern affecting both sides of the elbow. The two sides are medial or inside next to the body and lateral or outside away from the body.

When the humerus breaks across or through both sides, different soft tissues (skin, ligaments, tendons, muscles), nerves, and blood vessels are affected. For example, the radial nerve travels down the lateral (outside) of the elbow and forearm, whereas the ulnar nerve takes the medial (inside) track.

Two groups of patients seem to make up the majority of bicolumnar distal humeral fractures: young athletes involved in high-energy trauma and older adults (mostly women) with osteoporosis (brittle bones). Older folks who lose their balance and fall on an outstretched hand/arm or directly onto the elbow are at risk for elbow fractures of all kinds, especially bicolumnar.

Although this injury doesn’t happen very often, those individuals affected by it need careful evaluation and an effective management plan. A visual and hands-on examination is followed by X-rays, CT scans, and any other tests indicated by the results of the clinical evaluation. Once an accurate and complete diagnosis has been made (with all injured parts accounted for), then a management plan can be determined.

So what are the patient’s options here? Well — there aren’t many: mostly surgery. The goal of treatment is to restore full function while avoiding long-term problems and complications like nonunion, joint stiffness, nerve injury, or infection. That means each fragment of bone must be dealt with. Conservative (nonoperative) care with bracing or other means of immobilization is only used when it’s an older, fragile adult who can’t handle surgery. Bracing can be the first choice to avoid surgery when the patient is paralyzed and won’t be able to use that arm anyway.

That leads us right down the path to surgery as the main means of managing these fractures. It’s a complicated fracture pattern so open-incision rather than arthroscopic surgery is the way to go. Now the surgeon must decide how to open the elbow. The usual approach is from the back (posterior) side of the elbow.

But whether to make the incision from side to side or split it up the middle depends on several factors. For example, has the fracture affected the inside of the joint (intraarticular or is it confined to the outside of the joint (extraarticular)? Having to gain access to the joint changes everything. Making a cut along the back of the elbow usually requires cutting through the triceps muscle. Some surgeons try to spare the triceps by cutting off the end of the bone and going into the joint that way. The muscle isn’t cut and the tip of the bone can be reattached once the joint has been repaired.

You can see the surgeon has many decisions to juggle in the process of treating these complex fractures. Next there are considerations around fixation techniques. Fixation refers to how the surgeon holds the bone fragments together once they are all lined up again. Fixation techniques include plates, pins, screws, and wires. When a bicolumnar fracture is present, both columns (medial and lateral) must be stabilized.

Okay, that seems easy enough but guess what? Plates come in a variety of shapes and types. They can be precontoured to fit the curve of the bone or locking in order to increase stability at the site of the fixation. Oh, did we mention the possibility of the hardware being bioabsorbable? That means as the bone knits itself together, the fixation implant slowly dissolves and gets reabsorbed by the body. If a bioabsorbable type isn’t used, it may be necessary to complete a second surgery later to remove the hardware when it is no longer needed.

Studies are ongoing looking at how much strength and stiffness each type of plate provides and how much strain each one can take during elbow motion and with load placed on the joint. At the same time, researchers are reporting on the outcomes or results for each type of implant based on final measurements of elbow range-of-motion, strength, and function. Complication rates are also reported to help surgeons decide which one is best for their patients.

Opening the elbow and using fixation to hold and stabilize the bone is referred to as open reduction and internal fixation or ORIF. That takes us through the first wave of surgical decisions. But if the type of fracture can’t be managed with ORIF, then the other options include total elbow arthroplasty (TEA) or elbow replacement, arthrodesis or fusion, and hemiarthroplasty or partial elbow replacement.

Older adults with severe fractures of osteoporotic bones may not be able to benefit from ORIF. The brittle, weak bone structure just can’t support the weight of the hardware. That’s when a partial or complete elbow replacement is considered. This is a nice option for those patients who already have a painful, limited elbow joint due to arthritis. It’s best if these patients have low activity demands because they will be restricted to lifting nothing that weighs more than five pounds. Most grandchildren, dogs, cats, and groceries weigh more than that, so it can be a real issue.

When is an elbow fusion the best choice? Well, this is really a last choice effort to save the joint. Once the joint is fused, there’s no elbow motion and that can be very nonfunctional when trying to wipe after toileting, lift a cup of coffee to the lips, or perform any number of self-care activities (e.g., brushing the teeth, combing the hair, putting on a pair of eyeglasses, or adjusting a hearing aid). Fusion is only considered when the joint is severely painful and arthritic, there’s been considerable loss of bone or soft tissue, and/or an elbow replacement has been tried and failed. Fusion is really the end of the line, so-to-speak.

Finally, no matter what kind of surgical procedure is carried out, the patient now faces a long period of healing, recovery, and rehabilitation. There’s a fine line between resting and immobilizing this particular joint in order to foster healing and waiting too long to move it and finding out it stiffened up too much.

A hand therapist (usually a physical or occupational therapist) will consult with the surgeon to set up the right postoperative program for each patient. The patient should expect a minimum of three to four months in rehab. Then the program continues at home with a daily program of exercises to regain elbow motion, strength, and function. Many patients simply don’t get full elbow extension. In other words, they cannot straighten the elbow all the way. But the loss of the last five to 10 degrees of elbow extension doesn’t usually affect function in any way.

Surgeons can expect to see more of these kinds of complex elbow fractures in the near future. As the graying of America continues, the epidemic of osteoporosis is expected to get worse, not better. Staying abreast of treatment options, when to use each one, and other considerations such as presented in this article will be necessary.

When Popeye, the cartoon sailor man wanted to show off his muscles, he lifted his arm and flexed his biceps muscle. Every child who ever wanted to show off his or her strength has imitated this posture ever since. But when Arnold Schwarzenegger, a well-known actor in Terminator movies posed, it was always with the hands pressed together in front of his body. This body builder pose shows off the chest and triceps muscles. The triceps is located along the back of the upper arm. It’s the triceps muscle that catches our attention in this article.

The triceps muscle doesn’t tear or rupture very often. In fact, of all the tendons in the body that do get injured, injuries affecting this one are reported the least often. When it does happen, it’s usually in a professional-level football player or weight lifter. Of course, the nature of these sports with potentially violent contact or powerful lifts increases the risk of this type of injury. But the illegal use of steroids to build up the muscles can lead to rupture of the triceps tendon, too. Anyone who falls on an outstretched hand is at risk for a triceps injury. Getting cut with a knife or other sharp object such as a piece of glass can also disrupt the muscle and/or its tendon at its attachment.

The triceps tendon is a broad three-sectioned muscle that comes down along the back of the upper arm from the shoulder and inserts into the back of the elbow. The place where these three sections meet into one tendon and attaches to the bone is called the triceps footprint. When the muscle is completely torn, the tendon usually pulls away from its footprint. Sometimes the traumatic event is so powerful that the tendon pulls away still attached to the footprint, taking a piece of the underlying bone with it. Because the muscle functions to straighten the elbow, when it is ruptured, arm extension is compromised.

What does a torn triceps look and feel like? First, there’s pain reported along the back of the elbow and visible swelling there. It is very tender to touch in this same area. Often, there’s a large indentation in the skin called a defect just above the olecranon (point of the elbow). The defect can be seen and felt.

There may be weakness with elbow extension against resistance. The patient may not be able to extend (straighten) the elbow at all or only through part of the normal range-of-motion. But surprisingly, a completely ruptured triceps doesn’t mean the patient won’t always be unable to extend the elbow against resistance. There is another muscle that helps the triceps (the anconeus) and it may compensate for the loss of the main muscle.

The examining physician can do a clinical test to look for a triceps rupture. It’s modified from a test for ruptures of the Achilles tendon at the back of the foot/heel. A squeezing pressure is applied by the examiner to the triceps muscle. The test is done with the patient lying face down on an examining table. The elbow is bent and the forearm is dangling over the edge of the table. When the triceps is intact or only partially torn, squeezing the muscle belly causes the elbow to extend (just as if the muscle contracted on its own). No movement of the elbow with this test is a sign that the tendon is fully ruptured.

Further testing is needed to confirm the diagnosis. X-rays will show if the bone has been avulsed or pulled away with the tendon. X-rays also show if there are any fractures of the bones of the elbow. MRIs and ultrasound studies help identify the full extent of the lesion (location and severity). All this information is needed when planning the most appropriate treatment. The surgeon also takes into consideration the patient’s age, physical condition, and how long the injury has been present (acute versus chronic). Both the current level of function and the desired level of function are factored into the decision. It makes a difference whether the patient is a young athlete, eager to get back on the playing field versus an older adult struggling to push up out of a chair or off the toilet.

Current treatment guidelines for triceps tears include: conservative care for anyone with less than half the tendon torn and for older adults with more than half the tendon thickness torn who are inactive. Surgery is always advised when the triceps has ruptured completely away from the tendon footprint. When surgery is indicated, it should be done as soon as possible (within the first two weeks of injury). A delay in diagnosis and/or in treatment can result in significant loss of muscle strength and other complications.

When surgery is not the first-line of treatment, the patient is instructed to keep the arm in a splint (or cast) for 30-days. The arm will be immobilized in a position of 30 degrees of elbow flexion. This position helps protect the triceps tendon from tearing more by avoiding muscle contraction needed to get the last bit of elbow extension. If the conservative (nonoperative) approach doesn’t work, then surgery is the next option considered.

The authors discuss the various surgical techniques used to reattach the torn tendon depending on how close the muscle is torn to its footprint. Slightly different methods might be used when there is complete rupture with avulsion (tendon still attached to bone). Step-by-step color photos of the surgeons’ preferred technique are provided with a detailed description. Angle of drill holes, type of sutures used, and placement of suture anchors are also described.

Basically, they try to restore the tendon attachment as close to the preinjury anatomy as possible. This procedure is called an anatomic triceps tendon footprint repair. It is thought to be the best way to get tendon-to-bone healing and the best results possible in terms of function. Care is taken with the incision in order to see clearly what’s going on while avoiding delays in wound healing and other potential problems with wound healing.

Postoperative care and management are just as important as the actual surgical procedure. The arm doesn’t have to be put in a splint or cast. A simple sling works just fine. The patient is allowed to take it off or stop wearing it whenever he or she feels comfortable doing so. In the early days after surgery, a physical or occupational therapist will work with the patient to maintain elbow and forearm movement. Strengthening exercises will begin when full (or near normal) elbow motion is present. Lifting weights isn’t allowed for the first four to six months after surgery.

You can see a complete rupture requiring surgery can really put an athlete behind in terms of training and competition. And it’s no picnic for the older adult either. Struggling just to do daily tasks and activities can become a real burden. In all patients, there’s a risk of re-rupture. This is especially true for those patients who waited to have surgery done or who weren’t diagnosed quickly.

The quality of the tissue that needs repairing changes as time goes by. It can become filled with and surrounded by fibrotic (scar) tissue that is weak and tears easily. Sometimes the tendon retracts (pulls back) so far, it can’t be pulled back down to reach the footprint for repair. Then the procedure becomes a reconstruction rather than a simple repair.

Now we’re talking graft material to lengthen the tendon and that raises all sorts of other complications — where should the graft be taken from? Can the patient donate tendon tissue from his or her own body or is tendon from a donor bank needed? Each of these sources of tendon graft material has plusses and minuses.

When it’s all said and done, patients with a complete and full rupture of the triceps tendon can recover nicely. Studies that have been done showed a return of motion and strength even in patients who had a delayed surgery. There can be a loss of full elbow extension that never fully returns but this doesn’t always mean the individual can’t get back to a preinjury level of function.

Peripheral nerves to the arms and legs can get compressed, pinched, or entrapped in soft tissue causing sensory symptoms of pain, numbness, and tingling. This condition is called a peripheral neuropathy. If the motor portion of the nerve is affected, muscle weakness and paralysis called palsy can occur.

Carpal tunnel syndrome and sciatica are probably the two most common peripheral neuropathies. But any of the peripheral nerves can be affected and any place along the nerve as it leaves the spinal cord and travels down the arm or leg. In this first part of a two-part review on compression neuropathies, three more unusual compression neuropathies are presented. All three conditions are the result of one particular nerve being affected: the radial nerve in the forearm.

Compression of the radial nerve is fairly uncommon and can present as posterior interosseous nerve syndrome, radial tunnel syndrome, or superficial radial nerve compression. To help us understand these syndromes, the authors provided a detailed review of the radial nerve anatomy as it travels down the arm. The nerve gets started up near the neck as part of a group of nerves called the brachial plexus. Once it leaves the brachial plexus, the radial nerve travels down from the neck through the shoulder area to the upper arm and then down the forearm to the wrist and hand.

Loss of blood supply for any reason, direct injury to the nerve, or compression from swelling, scar tissue, or tumors can lead to changes in the nerve causing a peripheral neuropathy. Any local change of this sort can affect the tiny nerve fibers that raise an alarm sending pain messages along the nerve to the spinal cord and then up to the brain. Mild pressure can be treated conservatively without surgery.

The patient may begin with a trial of rest and antiinflammatory medications. Sometimes the treatment is as simple as removing a wristwatch or bracelet that is pressing on the nerve. The surgeon may follow up with steroid injections to confirm the diagnosis and/or help treat any of these problems that persist after the initial period of conservative care.

A hand therapist will advise the patient in ways to modify activities and positions of the arm to protect the nerve. The therapist may provide a splint for the patient to wear to accomplish the same thing. Sometimes special neural mobilization techniques can be used by the therapist to release tension from around the nerve and restore a more natural sliding and gliding of the nerve in its sheath (lining around the nerves) needed during arm motion.

More severe conditions can lead to deterioration of the nerve and may require surgical intervention. Surgery to release pressure from around the nerve is called nerve decompression. If there is a cyst, tumor, or scar tissue pressing on the nerve, the surgeon will remove it. The basic decompressive surgical procedure doesn’t change much with these syndromes.

What is different about these syndromes is the way each one manifests itself. In other words, the patient’s symptoms differ depending on where the nerve is affected. In the case of posterior interosseous nerve syndrome, benign tumors and swelling around the elbow from rheumatoid arthritis are the major causes of nerve palsy. The fingers and thumb drop and can no longer be extended or lifted up.

Patients with radial tunnel syndrome don’t have weakness as much as they experience forearm and elbow pain that looks like tennis elbow. The pain gets worse with use of the elbow. But the physician can tell the difference between radial tunnel syndrome and tennis elbow by the location of tenderness when palpating (pressing on) the soft tissues around the elbow.

It’s the superficial radial nerve compression syndrome that can be improved by removing tight or constricting objects from around the wrist. Because the nerve is close to the back of the wrist here, tight sleeves, a wrist watch, or even handcuffs can compress the nerve causing pain and loss of sensation along the back of the forearm, wrist, thumb, and index (first) finger. The nerve can also get stretched here when someone has a wrist fracture that is put back in place by manually applying traction to the wrist in a procedure called a closed reduction. Symptoms from compression of the superficial radial nerve are present even when the wrist is at rest and not moving. That helps differentiate it from other problems like de Quervain tenosynovitis.

What’s not clear is the best way to treat each of these problems. Conservative care is always advised first but for how long? Weeks? Months? How many weeks or months should we wait to see improvement? When does the patient become a surgical candidate? Are there some problems and/or some patients that require surgery right away? What’s the natural course (what happens over time) for each of these conditions?

The authors report there just isn’t enough research available to answer these questions yet. There are some arguments over the use of peripheral nerve stimulation to treat these problems. Such stimulation is attempted using pulsed low-intensity infrared laser or direct electrical stimulation. No matter what kind of nonoperative treatment methods are used, anyone who does not get better during the first 12 weeks should at least be evaluated for surgery. The optimal timing for surgery remains another area where future research is needed.

Many people have heard of the median nerve because when it is compressed or injured, carpal tunnel syndrome (CTS) occurs. But the median nerve that’s involved with carpal tunnel syndrome actually starts way up in the upper arm. It travels all the way down to the wrist and continues on to the hand. Compression or irritation of the median nerve causing pain, numbness, tingling and other symptoms of peripheral neuropathies can occur anywhere along its path.

Carpal tunnel syndrome just happens to be one of the most common median nerve entrapments. It occurs when the nerve is compressed in the wrist. Less often, compression of the median nerve occurs in the forearm. The result can be one of two other median nerve entrapments: pronator syndrome and anterior interosseous nerve syndrome. These peripheral neuropathies are the focus of this review article.

To help us understand these two peripheral neuropathies, the authors provide a mini-anatomy lesson. The pathway of the median nerve from upper arm to hand is described in detail with drawings to illustrate its location along the way.

To appreciate how these syndromes develop, it’s helpful to know that midway down the forearm, the median nerve divides to form a branch called the anterior interosseous nerve (AIN). The anterior interosseous nerve has no sensory branch. It only controls movement of the flexor muscles on the inside of the forearm. It’s this nerve that makes it possible for you to make the OK sign with your thumb and index finger or hold a piece of paper between the thumb and index finger.

The median nerve divides again at the wrist crease just past the carpal tunnel. Here it forms the palmar cutaneous sensory nerve. This nerve gives the palm of your thumb and first two fingers sensation. The hows and whys of median nerve compression in the forearm aren’t fully understood. For example, why do some people develop one type of neuropathy but not the other? Why do some people have either problem when others have no trouble with compression?

One explanation for the anterior interosseous nerve syndrome rests again with the anatomy. There may be differences in the bone, muscle, and tendon structures that can put pressure on the median nerve in various locations.

Nerve entrapment from some type of odd anatomical variation is a common cause of peripheral neuropathies. For example, a larger or wider bony bump along the inside of the elbow might be a factor. If the nerve passes close to this bump and gets trapped between the unusual shaped-bone and the ligament of Struthers, nerve entrapment occurs. The ligament of Struthers is a fibrous band that isn’t part of everyone’s anatomy.

In the case of pronator syndrome, the median nerve gets the pinch when it passes through two sides of the pronator teres muscle, which helps explain the name. Tumors, bone spurs, or other space-occupying lesions can also contribute to the development of either of these neuropathies.

What can be done about these problems? Well, truly, the first step is to make sure the diagnosis is correct. And that can take some time and a bit of sleuthing along with additional studies. There’s a lot of overlap in symptoms among the many neuropathies. Getting to the bottom of the problem and making sure the correct location of compression has been found can be a challenge.

The hand surgeon has a variety of clinical tests at his or her disposal to use when sorting out what’s going on. MRIs, nerve conduction studies, and electromyography (EMGs) can help pinpoint the problem. Management depends on the cause. Whenever possible, rest, immobilization, and hand therapy are used to avoid surgery. But sometimes surgery is the only treatment that can change the anatomical features at fault in order to relieve painful symptoms.

The surgeon will perform the least invasive procedure but it may be necessary to release the connective or scar tissue around the nerve. Sometimes, soft tissue structures around the nerve (e.g., tendon, muscle) must also be cut in order to remove the compressive forces exerted by those moving parts. This procedure is called a nerve decompression.

Who should have surgery and when remain two points of debate among hand surgeons. There just isn’t enough evidence to provide specific guidelines. Some experts say 12 weeks of hand therapy with no change is the signal to schedule surgery. Others report recovery is possible as much as 12-months after the symptoms started. And there are even observations that patients get better with no treatment of any kind, including conservative (nonoperative) care.

Without treatment, there is a risk that patients with either of these neuropathies may develop permanent paralysis and loss of function. That’s not an acceptable outcome. The authors suggest that the final results may be an indication of what was causing the problem in the first place. For example, viruses affecting the nerve can cause symptoms very much like compression. It’s possible that the folks who get better over time really had an inflammatory, not a compressive, cause of the problem.

The authors conclude that more studies are needed to determine what type of treatment is best for patients with anterior interosseous or pronator syndrome. The results of these studies could help determine who should have surgery, how soon to do the surgery, and the ideal length of time to try nonsurgical approaches before turning to decompressive surgeries.

You’ve heard it over and over from us: doctors, physical therapists, and other individuals dedicated to research are seeking evidence to show what treatment works best for each orthopedic condition or problem. Today, we report on the results of information gathered about cubital tunnel syndrome. Are patients happy with the results? Does their satisfaction match the surgeon’s view of the results?

Cubital tunnel syndrome is a condition that affects the ulnar nerve where it crosses the inside edge of the elbow. Another way to describe this problem is ulnar nerve entrapment. 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.

In this systematic review results from studies around the world were gathered, analyzed, and reported on. The authors intended to compare patients’ level of satisfaction after surgery for cubital tunnel syndrome with surgeons’ satisfaction. But they found there was too much variation in how the results were reported to do so. So, instead, they ended up looking at the measures used to report patient satisfaction after surgery for this condition.

The hope was to find one instrument, tool, or method that is reliable and valid and could be used over a range of studies. Then the results could be compared across all studies. That, in turn, would make it possible to compare the results of each type of surgery done to treat this problem. And in the end, surgeons might be able to identify one surgical technique that works best for cubital tunnel syndrome.

The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel. There are different kinds of surgery for cubital tunnel syndrome. A simple nerve decompression involves removing any adhesions from around the nerve or cutting any soft tissues that might be pressing on the nerve. A second procedure is called an ulnar nerve transposition. In this procedure, the surgeon forms a completely new tunnel from the flexor muscles of the forearm. The ulnar nerve is then transposed (moved) out of the cubital tunnel and placed in the new tunnel.

The third approach is to remove the medial epicondyle (bony bump) on the inside edge of the elbow, a procedure called medial epicondylectomy. By getting the medial epicondyle out of the way, the ulnar nerve can then slide through the cubital tunnel without pressure from the bony bump. It is not clear whether one operation is better than the other.

Using several electronic databases, the authors selected articles that pertained to surgery for cubital tunnel syndrome in adults. Small studies with fewer than 20 patients were not included. Out of a possible 141 studies, 42 met the final criteria for inclusion. These studies were published over a span of 10 years between 1997 and 2007.

Most of them were Level 4 evidence, which means they were mostly case series, not the higher quality randomly controlled trials or blinded studies. They came from all over the world including Turkey, Greece, Australia, Korea, the Netherlands, France, Japan, Germany, England, Sweden, Canada, and the United States. They were published in peer reviewed high quality medical journals.

Data collected was classified as patient satisfaction, activities of daily living (ADLs), symptom scales, and non-disease-specific measures. Symptom scales included pain, weakness, numbness, ability to work, and sensation. Non-disease-specific measures included sports or performing arts (e.g., dance) as well as self-reported ratings of physical and mental health.

The authors were unable to complete the task they set out to do: they could not find one method that was consistently used to measure before and after patient satisfaction for patients having surgery for cubital tunnel syndrome. Right now, there is not one standardized test available that could be used to assess results of surgical treatment for ulnar neuropathy.

Not only that, there’s some question of whether the evidence already reported can really be considered evidence. That’s because the way most results were measured was simply on the basis of a scale rating outcomes as poor, fair, good, or excellent. From a statistical research point-of-view, if this scale hasn’t been tested and proven reliable and valid, then the reported evidence may not be a real measure of results.

The authors suggest what is really needed is a validated instrument sensitive to changes made in symptoms and satisfaction from before treatment to after treatment. It should be easy to use, reliable, and responsive to small changes while still showing a trend in the patient’s overall progress. Data collected should also include patient’s perception of symptom severity, ability to work and perform daily activities, strength, and satisfaction.

In summary, this systematic review set out to accomplish one thing and ended up with a different final result. Instead of being able to compare patient satisfaction with surgeon satisfaction for patients who had surgery for cubital tunnel syndrome, they made a recommendation for the development of an instrument that could allow for such an assessment on the part of patients and/or surgeons. This would require a series of steps involving focus groups, expert review and consensus, testing of the tool, and reporting results. With such a tool, new evidence could be generated around this topic that could be relied upon for future patient management.

People who have ulnar neuropathy, compression of the nerve that passes through the elbow to the lower arm, must be diagnosed as quickly as possible in order to prevent long-term complications from the injury. Currently, there are seven independent tests used by doctors to diagnose ulnar neuropathy. It is known that just using one of these tests isn’t enough for an accurate diagnosis, because patient history and other types of testing are also important parts of the puzzle. Wrongly diagnosing the problem as ulnar neuropathy could result in the doctor missing other issues that could be the true problem. The authors of this article wanted to see how these tests compared in determining the problem and the severity of the problem, and how accurate they were.

When ulnar neuropathy first begins, patients may experience hand weakness and some changes in sensation. Testing the changes in sensation may be done by checking light moving touch, vibration thresholds, pressure and pain. However, in the early stages, these changes may not be easily identifiable. As the injury progresses, it is possible that muscle atrophy (wasting away) begins, along with loss of dexterity and muscle strength. Both would affect the strength of pinch and grip.

Researchers studied 26 patients (19 men) who were diagnosed with ulnar neuropathy of the elbow, also called cubital tunnel syndrome. The patients were, on average, 47.6 years old. Testing on the patients was performed by a hand surgeon or an occupational therapist who specialized in this field. The seven tests, in addition to elbow flexion (bending) were:

1- Froment’s sign (making a circle with thumb and index finger)
2- Jeanne’s sign (similar to Froment’s sign)
3- crossed finger test
4- Egawa’s sign (bending the middle finger and moving it up and down)
5- finger flexion sign
6- Wartenberg’s sign (movement of the little finger)
7- observable signs of fasciculations (muscle twitches)

The researchers found that two of the motor signs (muscle twitches and positive finger flexion) were found more often among the patients than the other tests. They were present in 11 of the patients. The one that was found the least was the Jeanne’s sign (not found in any patient) and the Wartenberg’s sign (found in four patients).

The authors of this article concluded that the effectiveness of detecting muscle twitches and a positive finger flexion sign could provide useful information for the doctors. They suggest that more testing be done to analyze effectiveness more thoroughly, with a larger group, to ensure the results are repeated.

Many people have heard of carpal tunnel syndrome, where a nerve going through the wrist to the hand is compressed, causing pain and numbness. But, although ulnar neuropathy, pressure on the nerve in the elbow, is the second most common nerve entrapment problems after carpal tunnel, not many people know about it.

The most common cause of ulnar neuropathy in older people is degeneration in the elbow. In younger patients, it’s often caused by repetitive motions, much like carpal tunnel syndrome is. It can also be caused by a trauma, such as an elbow dislocation and if it shows up after an injury, doctors may call it tardy ulnar palsy.

The problem usually begins as pain over the middle part of the elbow and down into the forearm. After the pain has been present for a while, it progresses to weakness in the hand, including the grip and pinch. Treatment may be with surgery or without, depending on the patient, the severity, and the cause. Usually, the more severe the problem, the more likely surgery would be needed. To see if severely affected patients could sometimes be treated without surgery, the authors of this article looked into if education would be helpful.

Researchers investigated 77 patients, with 80 ulnar nerve problems among them. Five had tardy ulnar palsy while the rest of the group had cubital tunnel syndrome, or ulnar neuropathy. Two men and one woman had both arms affected.

The patients were taught the pathophysiology (make up) of the elbow and how to modify their activity to avoid injuring the elbow. They were taught to avoid:
– pressure on the elbow
– repetitive activities using the elbow
– bending the elbow more than 90 degrees except for essential daily activities (such as brushing teeth)

The researchers also explained to the patients that if they kept their elbows at 45 degrees bend, this would relieve much of the pressure in the elbow. They were then taught how to maintain this position as they went through their day at home and at work. They were instructed to keep following these suggestions and activities for at least three months. Every three to four weeks, the patients were examined. As some patients improved, their follow-up period was made longer. If the patients showed signs of worsening or no change at all, the treatment was stopped.

To determine patient progress, the researchers looked at x-rays taken before and after the treatment, and nerve conduction studies. These studies allowed the researchers to see how well nerve impulses were sent through the ulnar nerve. The patients were also asked to rate their progress.

The results showed that 66 percent of the patients had excellent or good outcomes from the treatment, despite their severe nerve compression. Interestingly, age, sex, elbow side, diabetes, severity of the problem, and elbow dislocation didn’t play a role in how well the patients responded to this treatment. How much the elbow had degenerated, most often with the older patients, did play a role, however.

The authors of this study concluded that patient education is a good option for treatment of ulnar neuropathy, even if the situation is severe. The doctors do, however, have to look at if there is degeneration in the elbow as this will give an indication of how successful the treatment may be.

In this case report, orthopedic surgeons who specialize in the treatment of traumatic upper extremity injuries ask the question, What’s the best way to treat a badly broken elbow? It’s dislocated and fractured into bits. Should it be wired together? Would it just be better to replace the elbow with an artificial replacement? What to do — what to do!

These are some of the questions surgeons face, especially when dealing with a broken and often dislocated radial head. The radius is one of two forearm bones that meet the humerus (upper arm bone) to form the elbow. The radial head is the top of the radial bone. It sits up under one side of the humerus and articulates (moves) against the other bone of the forearm (the ulna).

Today’s current approach with a radial head fracture is to take all the individual patient-factors into consideration. Then look at current opinion of the experts and combine that information with any evidence available from published studies. The result is a set of guidelines to help with the decision. There isn’t always a clear treatment path. In other words, one approach doesn’t work for everyone.

Let’s see what is the reported current opinion of-the-day. Well, it looks like there is a 50-50 split over what to do. Some surgeons say they must save the elbow at all costs. Others debate the point that complex elbow fractures respond better with a prosthetic. Usually just the radial head needs replacing, but sometimes the entire elbow is replaced.

No matter what decision is made, the goal is to restore forearm and elbow stability and motion. In order to accomplish this, it is important that both bones of the forearm (radius and ulna) must be kept equal in length. The surgeon must assess the entire arm for injuries in case there are other bones broken or torn soft tissues.

The next consideration is for current evidence available through published studies. Since complex fractures of this type are uncommon, the number of patients in each study are fairly limited (sometimes only one as in this case study). But each study brings to light different things to consider. For example, the surgeon must evaluate the blood vessels and nerves to the area and see if there has been any damage there. Does the patient have strong enough bones to hold pins, miniplates, screws, or wires necessary to hold the bone fragments together while it is healing?

There are many ways to evaluate the treatment choices available. Some surgeons try to repair the damage with a procedure called open reduction and internal fixation (ORIF). Open reduction involves an open incision to get to the elbow. Fixation refers to the different ways of holding the bones together. If that procedure fails, then the elbow can be converted to a prosthetic (replacement) joint. Studies show that ORIF is an acceptable choice IF it is possible to realign the bones closely enough to get good enough fixation and union. If not, then it’s best to go right to the replacement option.

The more the bone is fragmented into pieces, the greater the chances that the patient will lose motion and function with any attempts at fixation. If the radial head is involved, forearm rotation is often compromised. And without the ability to rotate the forearm, the patient cannot turn the palm up, a movement called supination and palm down (pronation). The loss of forearm supination and pronation can be very limiting. Imagine trying to turn a key in the door, wipe yourself after going to the bathroom, or even carry a bowl of cereal without these motions.

Over the years, bone grafting and improved fixation devices like the miniplates has made it possible to preserve more elbows than ever before. And that’s good because implants cannot successfully replace a natural radial head. It’s just such a unique and unusual bone in shape, form, and function. One advantage the prosthetic head does offer is stability when torn elbow ligaments cannot be repaired.

Studies presenting outcomes of radial prostheses report a mix of results from poor to excellent, with equally varying levels of patient satisfaction. The implants are expensive and don’t always fit the patient well. Overstuffing the joint is a real concern. This means the implant is too large for the joint space available and too long. Over time, the joint cartilage gets worn down and the elbow can start to dislocate.

There is still room for research in this area. What kind of materials (e.g., metal, pyrocarbon, plastic) and types of devices would work best for fixation and/or implants? Studies are needed to compare the results of open reduction and internal fixation against the different types of implants. Studies that follow patients for 10, 15, and 20 years to give long-term results are needed. Surgeons who are familiar with the different types of prostheses (e.g., loose monoblock, fixed monoblock, fixed bipolar) need to know how the results of each of these compare. Studies comparing the various prosthetic implants would help surgeons choose the best one for each patient.

The authors conclude by sharing their own preferences. First, they say that they make every effort to repair complex, fragmented fractures of the radial head. This decision is based on personal experience as well as published results of a limited number of studies. The bottom-line is that it’s impossible to mimic the natural anatomy, movement, and function with an implant because there’s a slight valgus angle of the normal forearm/elbow complex. As you hold your arm out straight, you’ll see how the inside of the elbow angles inward slightly. Disruption of the medial ligament along the inside of the elbow makes it difficult to reproduce this angle. Surgery to repair or replace any part of the elbow just doesn’t restore the normal dynamics of mechanical motion provided by the angle.

Fractures of the humerus (upper arm bone) just above the elbow are difficult to treat. Surgery is the standard way to treat these fractures. But the optimal approach isn’t always clear at the out set. The surgeon must take into consideration many factors. How did it happen? What kind of break is involved? Are the soft tissues around the bone damaged in any way? Did the elbow joint surface crack in the process? How strong is the bone (i.e., does the patient have osteoporosis or brittle bones)?

The orthopedic surgeons who wrote this article are from the University of Maryland in Baltimore. They offer a review of the latest research in the area of distal humeral fractures. Distal is just another way of saying the break occurred at the bottom end of the bone.

Surgeons are seeing more of these injuries with the aging adult population in America. Most of these fractures occur in older adults with poor bone quality. That’s one of the things that really makes surgery so difficult. Conservative (nonoperative) care is possible but only when the fracture is stable and can be immobilized in a cast or splint. That type of fracture isn’t as common as the displaced (bones separate), comminuted (many tiny bone fragments) fractures that require surgery.

The surgical choices are usually: 1) internal fixation, 2) external fixation, and 3) total elbow replacement. Each of these choices has its own indications (when to use them), advantages, and disadvantages.

One of the ways surgeons have of evaluating which approach to use is to examine the results from other patients who were treated with one approach versus another. Outcome measures include elbow range-of-motion, return of normal muscle strength, function, bone healing, and quality of life. The joint should be stable yet move freely. Length of time in the hospital and in rehab along with the associated costs might also be factored in. Complications such as infection, poor wound healing, and nonunion (failure of the bone to heal) are recorded. Implant failure (usually from loosening) and revision surgery are two other possible problems that researchers keep track of as a way to evaluate the final results.

By reviewing all of the available research data, the authors were able to summarize what is known about each of these three surgical treatment approaches. Let’s take a look at each one separately.

Internal Fixation. Internal fixation refers to an open procedure where the surgeon puts the bones back together and holds them in place with wires, metal plates, and/or screws. This is the most commonly used operation. Many decisions come into play with this approach. The surgeon sizes up the injury and decides how best to get into the joint: from the back of the elbow (posterior or from the sides? If it seems best to make the incision from the side, then which side: medial (side closest to the body) or lateral (side away from the body)?

Studies show that the posterior approach gives the surgeon a full view of both sides of the elbow but in order to get to the joint, it’s necessary to cut through the triceps muscle and take a chunk of bone out. Removing a wedge-shaped piece of bone for this approach is called an osteotomy. Anytime an osteotomy is done, there is an increased risk that the bone won’t knit back together nicely. The result would be a nonunion of the bone where the osteotomy was done.

As technology and surgical technique improve, new contoured plating with different shapes to choose from and locking screw techniques have become available. Researchers are just beginning to study and report on the results using these various options. Measurements of the healing site strength and stiffness as well as bending forces are under investigation when the various plating systems are placed in different locations and angles (called the configuration). For example, the surgeon may use a Y-shaped plate or the orthogonal plate and place them perpendicular (at a right angle to each other) or in parallel (one on each side of the joint).

Most of these studies are being done on cadavers. The bone strength can be tested until it breaks to determine the upper limit of force each configuration can withstand. Using cadavers with osteoporosis makes it possible to also study the results of fixation on patients with poor bone quality. Results using different length of screws and strength of the bone-to-screw interface are also being compared.

What they’ve found so far is that locking plates may work better than standard plates. And failure is more likely as a result of the bone-implant interface, not because the hardware itself breaks. There isn’t enough data yet to say at what bone mineral density results will be successful. More study is needed before this information will be available.

External Fixation. Like internal fixation, some type of rigid support is needed to hold the bones together during the healing. But instead of being inside the body and unseen, external fixation consists of pins placed through the skin and soft tissues into the bones with metal rods between them. The rods remain outside of the arm. External fixation is used when the fracture is displaced (separated) and poking out through the skin. The surgeon must get the bones lined back up and keep them there until healing takes place but is unable to do so from the inside. That’s where the external support can be helpful.

Only one small study (eight patients) treated for open fractures with open incision and external fixation was reviewed. The patients were seen at a large trauma center right after the injury. Different surgical approaches were used. Of the three who had a posterior approach with an osteotomy, all ended up with a second surgery to wire the bone together to foster healing. Eventually everyone had healing of the fracture but two of the eight people ended up with poor results as measured by overall elbow range-of-motion and function.

Elbow Replacement. If the patient doesn’t have strong enough bones to hold the hardware needed for fixation, then a joint replacement may be needed. The same is true if the joint surface has been too damaged to fix or repair. Older adults and/or patients who have had a failed internal fixation procedure may also qualify for a total elbow replacement.

Results from studies of elbow replacement for distal humeral fractures that were reviewed showed good-to-excellent results for the majority of patients (85 per cent). Outcomes were better when the surgery was done right away as opposed to being delayed for a time. Complications such as nerve injuries, infection, implant loosening, and chronic pain were reported in 22 per cent. The use of elbow replacements may expand as surgeons are able to reduce the complication rates. Improved surgical techniques, better implant designs, and improved ways of cementing the implant in place may help move this along.

Finding the optimal way to treat distal humeral fractures will take some time. There are just too many things that can go wrong and factors to consider when choosing the right procedure, the best approach, and the necessary fixation or implant for the patient’s injury. The authors conclude that this orthopedic injury is complex, multifactorial, and definitely challenging.

Elbow replacements are available for younger adults (less than 40 years old) but results have not been great. Studies show that success rates are getting better but may not be good enough yet. At the Mayo Clinic, less than 10 per cent of the patients who received a total elbow replacement over a 20-year period were 40 years old or younger. The surgery was done to save the elbow.

All of the 55 patients in this Mayo study had severe osteoarthritis, nonunion of bone fracture at the elbow, or severe joint instability. They either had severe inflammatory or posttraumatic arthritis. Most of the patients had at least one previous elbow surgery. Some had several (up to six) prior surgeries. They were considered good candidates for a salvage procedure such as total elbow arthroplasty (TEA).

And despite 92 per cent of the group scoring good-to-excellent on the Mayo Elbow Performance Score (MEPS), there was still a 22 per cent revision rate. The surgeons consider this unacceptable and suggest pursuing non-replacement options for as long as possible.

The MEPS measures motion, joint stability, and ability to perform daily activities. Other measures used to assess outcome included X-rays of the implant and pain. X-rays show areas of radiolucency around the implant indicating greater transparency and less bone density. A small number of patients had a complete radiolucent line around one side of the elbow replacement. This is a sign of implant loosening.

MEPS scores improved after the elbow replacement. Before surgery, patients in both groups had great difficulty just doing simple things like combing their hair, feeding themselves, and getting dressed in the morning. The posttraumatic group had the greatest motion restrictions both before and after surgery (compared with the inflammatory group).

Complications requiring revision surgery included deep infection, implant loosening, triceps weakness, and implant wear. Again, the group with posttraumatic arthritis was more likely to develop problems leading to a second surgery. In other words, they had a much higher complication rate.

The authors conclude by saying the surgical treatment of elbow arthritis is very difficult. There really aren’t very many good options. But before replacing the elbow, they suggest trying a synovectomy or interposition arthroplasty whenever possible. Synovectomy is the partial removal of the synovial membrane that lines the non-cartilaginous surfaces within joints like the elbow. Usually the head of the radius (top of the forearm bone at the elbow) is removed at the same time.

Interpositional arthroplasty is the removal of the damaged joint and placement of a rolled up tendon (or other soft tissue) in the empty joint space. The main goal of interposition surgery is to ease pain where the surfaces of the elbow joint are rubbing together. The piece of tendon forms a “spacer” that separates the surfaces of the joint. This procedure is not recommended if the patient has significant bone loss, gross joint instability, or a severe elbow deformity.

Even with the high complication and revision rates, there is still a place for elbow replacement in younger patients. Those with advanced arthritic disease who have already failed nonreplacement options may still be aided by a joint replacement. It is certainly preferred over an elbow fusion since the fusion eliminates elbow motion and creates a functionally disabling condition.

Imagine throwing a baseball so fast your elbow moves 2300 degrees per second. Now do that over and over and imagine the shear force placed on the medial (side closest to the body) structures of the elbow. For throwing athletes, microtrauma to the ulnar collateral ligament (UCL) from repetitive throwing causes pain, loss of throwing speed, decreased accuracy, and weakness. Ultimately, when the forces placed on the UCL are greater than its tensile strength, something’s got to give. And that something is usually the ligament itself.

These injuries can be prevented with proper training and strengthening of the muscles around the elbow to help assist with the load and transfer some of the energy up the kinetic chain of the arm. But when injury occurs and surgery is the necessary treatment, then the athlete starts the long road to recovery with a special rehab program.

In this article, two well-known physical therapists outline the current standard of care in the rehabilitation of UCL reconstruction. Treatment goals, precautions, and strategies are presented week by week through various phases of rehab. Those phases include: immediate post-op, intermediate (weeks one through three), and advanced (weeks nine through 12). There’s actually a fourth phase and that is the return-to activity, which takes place from week 13 through the first nine months post-op.

Programs vary slightly depending on the type of surgery done. Two orthopedic surgeons join the discussion by describing the two most commonly used reconstruction procedures. These include the figure of eight (also known as the modified Jobe procedure) and the docking procedure.

The basic method of either approach is to take a piece of tendon from another muscle (usually the palmaris longus or gracilis) and use it to replace the damaged ulnar collateral ligament. The main difference between the two procedures is the way in which the tendon graft is anchored to the elbow. In either operation, the surgeon assesses the damage and performs a few extra steps when needed, like shaving off any bone spurs or moving the ulnar nerve if it’s rubbing against the bone.

Reconstructive surgery is meant to stabilize the elbow while rehab restores motion, strength, and function. But the rehab portion must go slowly and according to the load the healing tissue can handle. Studies on cadavers show that without the proper length of time needed for healing and without the necessary strength, the graft will fail with very low number of loads placed on the elbow. For example, a native (healthy, strong) UCL can withstand over 2500 pitches. The figure-of-eight graft gives out after only 300 cycles. And the docking procedure fails after 700 cycles.

Using tables, drawings, and photos, the authors show each exercise and outline number of repetitions, range-of-motion, and how to advance to the next level. The therapist must know which type of surgery was done in order to guide the patient through the safest and most effective rehab program. The main differences between the postop programs following a figure-of-eight versus modified Jobe procedure is in the timing of the motion allowed. Rehab can be a bit more aggressive after the modified Jobe reconstruction.

After either procedure, a posterior splint is used at first to hold the elbow in 90-degrees of flexion. A posterior splint is placed along the back of the arm/elbow, specifically preventing extension. The patient is allowed to move the wrist and fingers but not the elbow. The authors provide the rationale, precautions, and criteria for advancing the program from one step to the next, and from one phase to the next. Acute injuries heal faster and progress more rapidly through the rehab protocol than chronic injuries. In all cases, the goals are to promote healing, reduce pain, limit inflammation, and return to normal motion, strength, and function.

Therapists will find this article helpful in describing what to do if the patient does not respond as expected. Not getting full elbow extension using range-of-motion and mobilization techniques? Use a low-load, long-lasting stretch. Frequency, intensity, and duration of exercises are described to help avoid a stiff elbow. Pain before even getting to the end of the available elbow motion? Low, gentle stretches are in order.

Even though a small area of the body was operated on (the elbow), the throwing athlete needs a complete head-to-toe conditioning, strengthening, and endurance training program. Restoring joint proprioception(sense of position) and kinesthesia (sense of movement through space) involves the entire upper quadrant (neck, shoulder, arm), not just the elbow. Stabilization of the shoulder through strengthening of the rotator cuff and scapular (shoulder blade) muscles surrounding the shoulder joint reduces stress across the elbow.

Eventually, the athlete will need to progress through training to restore control through various throwing speeds. Advanced training incorporates plyometrics, a type of exercise training designed to produce fast, powerful movements. With plyometric training, muscles are loaded and then contracted in rapid sequence. Plyometrics is used with the throwing athlete to increase the speed or force of muscular contractions.

The authors summarize current concepts in rehab following reconstructive surgery of the ulnar collateral ligament in throwing athletes by pointing out that changes have been made in the surgical procedure that also affect postoperative treatment. Surgery involves less disruption of the nearby soft tissues, making it possible to move the rehab along faster than ever before. But there’s a fine balance between protecting the healing tissue and progressing forward. The authors provide plenty of details in the rehab protocol to help guide any physical therapist with this type of patient.

Tennis elbow has been around for a long time — and not just in tennis players. The typical patient with chronic tennis elbow is between 30 and 60 (most often around 50 years old) and involved in heavy lifting or repetitive work. The dominant arm is usually the painful one and it’s been going on for months without relief. That’s true even for the folks who get some kind of treatment for the problem.

In this study, a group of surgeons from Canada show how measurable results can be obtained with surgery for chronic lateral epicondylitis (the medical term for tennis elbow along the outside of the elbow). They performed an arthroscopic release of thecarpi radialis brevis (ECRB) tendon to reduce pain and improve elbow motion, function, and strength.

The extensor carpi radialis muscle and tendon unit extend the wrist (move the hand toward the face) when the palm is facing down. It inserts along the lateral (outside) epicondyle of the humerus (lower part of the upper arm bone). It travels down the middle of the forearm as a flat tendon and then connects at the wrist.

Other studies have reported on case series of patients treated surgically for tennis elbow. But this study is different because a group of 36 patients were included (not just isolated cases or half a dozen cases). Data on each patient was collected. Before and after valid and standardized functional tests were performed to measure outcomes.

The patients all had lateral tennis elbow that lasted more than a year despite conservative (nonoperative) care. Most of them (but not all) were workers involved in jobs with high occupational demands (repeated actions) and/or on worker’s compensation.

Several assessment tools were used to measure results. These included the Patient-Rated Tennis Elbow Evaluation (PRTEE), the American Shoulder and Elbow Surgeons Elbow (ASIS-e), the Short Form-12 (SF-12), and the Work Limitations Questionnaire (WL-26).

The PRTEE and ASIS both measure pain and function. The SF-12 measures general health (physical and mental) for a sense of the patient’s well-being. The Work Limitations Questionnaire assesses five areas of function including mental, physical, social, scheduling, and work demands. This test helps show if the patient has trouble doing the job and gives some idea of how much of the day they are compromised (all day, half-day, one-third of the day).

Other tests measured grip and forearm strength, motion, and the patient’s sense of their own prognosis (expect to get better, much better, be cured completely, get worse, or stay the same). Computer analysis was used to evaluate the patients in a variety of ways and look for subgroups that might respond differently from other patients.

The surgeon reported on what was found at the time of the procedure. The presence of inflammation, fraying of the tendon, and tendon tears or ruptures were recorded and described. The patients weren’t restricted in any way after surgery. They could move the hand, wrist, and forearm as tolerated (within a comfortable range of motion). Daily activities were gradually added over the next few days to weeks. No heavy lifting or repetitive motions were allowed for six weeks.

The results were pretty good. Thirty of the 36 patients were improved with the surgery. Pain was less, grip strength was stronger, and function was improved. One-third of the group was completely better with no symptoms at all after recovery. It was clear that the patients with high workplace demands involving heavy lifting or repetitive motion had the poorest results. The same was true for those who had active worker’s compensation claims.

They also found that patients who got temporary relief from their pain before surgery with cortisone shots seemed to do better after surgery when compared with those who got the injections but no relief. Some things didn’t seem to make a difference, like age, how long the symptoms had been present before surgery, or what the lesion looked like.

Returning to full-time work at the level required by the job wasn’t in the cards for some patients. Only two of the patients required to engage in heavy labor could do it. Most of the patients who made it back to work either changed their workload or changed their jobs. Several patients ended up retiring after surgery.

Workers on worker’s compensation benefits took twice as long to return to work as those who were not on any benefits. And their final results weren’t as good as the other workers. With all workers they found that those who didn’t think they would make it back to work were less likely to have a successful return to work. They had more physical and mental limitations all around.

The authors conclude that their study shows the benefit of arthroscopic release of the extensor carpi radialis brevis tendon for cases of work-related chronic tennis elbow. The patients selected for this procedure made up a challenging subgroup of workers who were engaged in heavy work demands and who had not gotten relief from their symptoms with prior treatment.

The two ways this study was different from other studies was in the fact that a specific surgical technique was studied and specific outcomes were assessed before and after using valid tools of measure.

Patients most likely to respond to this type of surgery include those who had a favorable response to steroid injections, patients with less physically demanding jobs, and those who were not involved in a worker’s compensation claim. Limitations in work performance can be expected for those involved in heavy labor or jobs requiring repetitive motions.

The authors point out that mental and social aspects of the job should be taken into consideration. Patients seem fairly accurate in predicting their own outcomes. Whether that’s because they really know themselves well or it’s just a self-fulfilling prophecy remains the subject of future studies. It does suggest the importance of selecting patients carefully for surgery.

When it works well, no one thinks much about the elbow. It bends and straightens. But a stiff elbow after injury or associated with arthritis or other condition can be a real detriment to function. And even though it seems like a simple joint with two major movements, it’s really made up of three separate articulations (places where the bones join and move).

In this article, hand surgeons from the Cleveland Clinic provide us with an in-depth review of elbow anatomy, injuries, and treatment of the stiff elbow. The focus and goal of treatment is actually prevention of elbow stiffness. Several strategies are presented based on the underlying problem.

For example, when inflammation from arthritis is present, the rheumatologist prescribes medications such as antiinflammatory drugs and disease modifying antirheumatic drugs (DMARDs). The design of these medications is to limit joint destruction. In the case of patients with hemophilia (a blood disorder), bleeding into the joints can be prevented by giving patients missing blood factors.

When surgery is needed for an elbow injury (dislocations, fractures, crush or soft tissue injuries), bleeding, swelling, and scar tissue must be limited. Continuous passive motion (a device used to slowly and repetitively move the elbow) is effective in keeping fluid from building up in and around the joint.

The role of the hand therapist is very important in the prevention of complications before and after surgery. Sometimes splinting the elbow is needed. The type of splint depends on the problem. There are two basic types of splints: static and dynamic.

Static splinting puts the elbow in a position and holds it there. The idea is to prevent the soft tissues from tightening up and forming contractures (loss of motion). Dynamic splinting has some give to it using adjustable springs or elastic. With dynamic splinting, it is possible to increase the tension over time in order to increase motion.

There are problems with splints that have led to the development of adjustable splints. They are more comfortable with less stress on the soft tissues. That makes it more likely that the patient will wear the splint. Patient compliance with splinting is extremely important in regaining elbow motion. In some cases, surgeons resort to serial casting. The elbow is placed in a position at the end range-of-motion and cast in place. As the soft tissues stretch and the elbow motion increases, the cast is removed and a new cast put on. This process is repeated several times until motion is restored.

If none of these methods works, then surgery is considered. It could be as simple as a manipulation where the surgeon gently moves the elbow through all of its motions while the patient is anesthetized. Or it may be necessary to perform a surgical release of the contracted soft tissues. The goal is to restore motion without losing joint stability. That sounds simple but it’s much more complex than that.

The surgeon must take into consideration many factors when planning the type of surgery. First, where is the loss of motion coming from? Is it muscle or bone? Are the ligaments involved? Is it flexion or extension that’s affected? Can the surgery be done arthroscopically or is an open incision needed to gain access to the area? Will it be possible to perform the procedure while avoiding damage to the nearby nerves and blood vessels?

Some patients have more than one problem going on. For example, there may be contractures of both the flexor and extensor muscles. There may be bone particles in the muscles, a condition called heterotropic ossification. There may be a nerve trapped in scar tissue. The combination of problems requires multiple steps in the surgical procedure. The surgeon may use both an open and an arthroscopic method for completing all of the repairs needed.

The authors provide surgeons with advice about surgical approaches and techniques to use. They discuss and provide drawings of the column procedure and the medial over-the-top approach to the stiff elbow. They offer ways to avoid damaging the neurovascular (nerves and blood vessels) structures when working within the elbow area. Techniques differ depending on whether the procedure can be done arthroscopically versus with an open incision.

A new technique in preventing elbow stiffness after traumatic injury is with the injection of Botulinum Toxin A (BOTOX). The BOTOX is injected into the muscles that are contracted. It acts as a paralyzing agent to prevent muscle contraction of the muscles injected. The muscles can no longer contract to hold the elbow. As they relax, joint motion is increased.

Another unique problem is the loss of forearm rotation (palm up or palm down motion). Because of the small area within the three elbow articulation, it isn’t always possible to restore normal motion without damaging nerves. Sometimes, the surgeon must resect or remove portions of the bone that have gotten stuck and no longer move, thus limiting elbow motion.

Destruction of the elbow joint from arthritis can affect both young and old. The treatment varies depending on activity level and age of the patient. For younger, high-demand patients, a procedure called interposition arthroplasty may help save the joint.

The surgeon smoothes the joint surfaces and then uses a soft tissue graft to resurface the joint. Usually, it’s necessary to release the joint capsule. This makes the joint unstable. The patient is placed in an external fixation device that allows joint motion but protects stability until healing occurs.

For older adults (60 years old and older) with significant joint damage (more than 50 per cent of the joint), a total elbow joint replacement is advised. This can work well in the patient who is not overly active.

Postoperative care is very important in preventing stiffness after any elbow surgery. Swelling is limited through the use of cold, compression, and motion during the first 72 hours. Static, progressive splinting is used starting six weeks after surgery. The hand therapist provides exercises and uses mobilization techniques to keep the soft tissues moving. A home program is necessary for up to six months to ensure continued success.

A smooth moving elbow is essential to hand and arm function. The authors hope for a better approach to preventing elbow stiffness in the future. Research to understand how and why soft tissues contract and stiffen up may help us step in earlier with better prevention techniques. Improved methods of prevention may help patients avoid surgery with all of its complications and disruption to the elbow.

How do you know if that elbow stiffness, pain, and loss of motion you are having is arthritis? What causes elbow arthritis? What can be done about it? In this article, experts in the area of hand and upper extremity surgery review studies from the past five years and attempt to answer these questions.

The diagnosis of elbow symptoms begins with a patient history followed by a physical exam. The symptoms could be from rheumatoid arthritis, osteoarthritis, infection, or some other problem. By identifying the location of pain and the aggravating/relieving factors, doctors can help narrow down the underlying cause.

For example, rheumatoid arthritis usually causes pain throughout the entire range-of-motion. The pain is more likely to be located along the outside edge of the joint. Osteoarthritis is more common among males involved in heavy lifting (e.g., manual laborers, weight lifters, throwing athletes). Osteoarthritic pain is more likely to be present at the beginning and ending of motion, rather than throughout the entire arc of motion.

Examination by the physician takes into account any skin changes, joint motion (quantity and quality), and blood work. Lab studies examining the blood can identify the presence of infection as a possible source of pain and stiffness.

Sometimes the clinical exam is said to be unremarkable. That means there weren’t enough findings to point to anything specific. Then X-rays or other more advanced imaging studies can be ordered. X-ray findings do help identify the difference between rheumatoid and osteoarthritis. The X-rays may show the presence of bone spurs, narrowing of the joint margins, and the presence of any fractures, subluxations, or dislocations.

Once the diagnosis has been made, the doctor turns his or her attention to developing a plan of care that will prevent further complications or problems. If it looks like surgery might be necessary, CT scan and/or MRIs may be ordered.

Treatment is divided into two types: conservative (nonoperative) and surgery. Nonsurgical treatment usually begins with medications to control symptoms and prevent damage to the joint. For some patients, the use of antiinflammatory drugs and disease modifying anti-rheumatic drugs (DMARDs) can completely eliminate all signs and symptoms of rheumatoid arthritis.

No matter what the cause of the problem is, activity modification, rest, and physical therapy are often recommended. Sometimes splinting is advised to help protect, support, and mobilize (move) the joint. If after three to six months of conservative care, there is no improvement (or the symptoms are worse), then surgery may be an option.

There are various types of surgical procedures to consider. Which one is selected depends on the patient’s age, diagnosis, job demands, or sports participation. The selection of surgical procedures also takes into account the areas of the joint affected most (e.g., joint surface, capsule, synovium). The surgeon does everything possible to preserve the dynamic nature of the joint — both stability and mobility needed for upper extremity function.

Sometimes, the surgeon can go into the joint using an arthroscope and thus avoid a more invasive open incision approach. It may be possible to remove bone spurs, loose fragments of bone or cartilage, or even release the joint capsule to reduce pain and improve elbow motion. This procedure is called arthroscopic débridement.

Studies show that this approach can be quite successful for patients who have not had major elbow trauma. A history of previous elbow injury would be a contraindication to arthroscopic surgery. In those cases, the surgeon must use an open incision approach. The reason for this is to avoid damaging nerves or blood vessels that have shifted from their normal anatomic position as a result of the previous injury.

Besides débridement, removing a portion of the bone called resection may be helpful. The head (top) of the radius (forearm bone) is resected when there is damage or disease of the radiocapitellar joint. This is where the radius joins the bottom of the humerus (upper arm bone) to form part of the elbow joint. This procedure is done when there is pain with forearm rotation.

More extensive surgery such as interposition arthroplasty or a total elbow replacement may be needed. Younger, more active patients with severe inflammatory arthritis benefit from the interposition arthroplasty.

This surgical technique shaves away the joint surface, removing any bone spurs and loose fragments of bone or cartilage in the joint. A piece of tendon used as a graft is placed where the surfaces of the elbow joint are rubbing together. The main goal of interposition surgery is to ease pain by using the soft tissue graft to form a spacer separating the surfaces of the joint. The patient can still lift more than the 10-pound lifting limit imposed on total elbow replacements.

Total elbow arthroplasty (replacement) is used for the older adult (65 years or older) who has severe pain and loss of motion and function. Conservative care has not been able to help. Patients with rheumatoid arthritis of the elbow seem to have the best results with this approach. They have to be willing to restrict activities that involve lifting more than 10 pounds.

Today’s improved elbow implants do a better job of reproducing normal elbow motion than earlier designs. The newer prostheses allow for side-to-side and rotational motions needed for full elbow motion. Various implant systems are available now (e.g., constrained, unconstrained, convertible, fixed).

Each new generation of implant designs try to improve elbow stability while still allowing mobility at the same time preserving bone and soft tissue structures. Patients who have arthritis compounded by fractures and/or loss of bone mineral density may need one of these newer implants. Older adults seem to do better with elbow implants than younger patients. They have far fewer problems and are much less likely to need a second (or third) surgery.

Companies designing and making elbow implants continue to look for better materials that won’t wear loosen, or break. Preventing mechanical failure of the implant will improve long-term results for patients with various kinds of elbow problems. There is still a need to find an implant that will hold up with active use for younger patients who have debilitating elbow arthritis.