News Category: Elbow

This article is the second in a 12-part series on aspiration (removing fluid) and injection of corticosteroid into various joints. The focus of this report is the elbow.

Elbow pain from bursitis can be treated effectively with aspiration and steroid injection. Specific how tos are included. A diagram of the anatomy and where to place the needle is provided. The authors show specific points to place the needle.

Finding the joint space is often easier when it is inflamed. But asking the patient to turn the palm up and down can also help. The bursa (gel cushion over the joint) can be injected directly or via a zig zag approach.

In the zig zag method, the needle does not enter the bursa directly. Instead it is inserted at an angle. Once the tip of the needle has passed through the skin and first layer of tissue, it is turned toward the bursa. Then the needle is placed into the bursa. This approach reduces the chances of cortisone leaking.

The authors describe the supplies needed and review the elbow surface anatomy. Patient position and exact steps of the procedure are also included. They suggest giving the patient a sling to wear for 24-hours after the injection. This may help keep the steroid in the elbow and keep it from spreading.

Elbow dislocations are often accompanied by injuries to the ligaments. These ligaments support the joint so an injury can leave the elbow unstable. Sometimes an external fixator (frame with pins) is used to maintain joint stability while still allowing motion. The goal is to give the ligaments a chance to heal but prevent joint stiffness.

Fixators commonly used are large and rigid. They keep the elbow joint from sliding from side-to-side during motion. This is called varus and valgus motion. Normally the intact ligament would prevent this motion. But until the ligament heals, the joint is at risk. The unstable joint can’t handle varus or valgus stresses.

In this study, six cadaver elbows are used to test a small, unilateral, articulated external fixator. Articulated means it has moving parts that allow joint motion. Patient using the larger, rigid frames often end up with a stiff elbow that doesn’t move normally. The smaller fixator may work better.

The elbows were damaged to simulate a ligament injury on either side of the joint. Each elbow was tested for side-to-side motion under three loading conditions. The first test was with just the weight of the hand. The second was with a weight equal to a 12-oz drink. The third test doubled the load to 24 oz.

An electromagnetic tracking system recorded the elbow motion. Then the fixator was applied. Motion was tested again. Testing was done under the same three loading conditions.

The authors report the smaller, moveable fixator does protect the soft-tissue injury from both varus and valgus displacement loads. The fixator did give enough rigidity to decrease the force on healing tissue. The amount of load acceptable was still limited to 12 ounces. This restriction is the same as for the larger, bulkier fixators.

Tennis elbow is the second most diagnosed injury of the neck and upper body in the United States. It occurs in between four and seven people out of every 1,000 who are seen in a general physician’s office. It is caused by repetition of the elbow or wrist, flexibility problems, poor circulation, and psychological factors, among others.

Because this is such a common injury, the researchers in this study wanted to compare the levels of pain and functional disability, and the relationship between anxiety and depression, with tennis elbow. The researchers studied eight men and eight women who ranged in age from 40 to 66 years, with most being around 49 years. Fourteen were still working; two were retired. All had been treated for their tennis elbow with corticosteroid injections to the painful site, medications to treat the inflammation (non-steroidal anti-inflammatory drugs), and even acupuncture. None of the patients were taking anti-anxiety medications or antidepressants. The tennis elbow group was compared with a control group of 16 healthy students and university staff.

All subject, those with tennis elbow and controls, completed questionnaires measuring their functional ability and their levels of anxiety and depression. At the end of the study, the researchers found that the DASH (Disabilities of the Arm, Shoulder, and Hand) scores were significantly higher among the patients with tennis elbow than the controls. The TE group scored and average of 54 while the control group scored an average of 2. There were similar findings with the PRFEQ (Patient-Related Forearm Evaluation Questionnaire) and the PRWEQ (Patient-Related Wrist Evaluation Questionnaire). For the PRFEQ, the TE group reported an average score of 31 on the pain subscale, the control group, 1. The TE group reported an average of 29. On the function scale, the control group, 0. With the PRWEQ, the TE reported an average of 30 on the pain scale, the control group, 1. On the function scale, the TE group reported an average score of 26, the control group, 0.

The HADS (Hospital Anxiety and Depression Scale) scored anxiety and depression. Among the TE group, the anxiety score was between 3 and 16, and the depression score between 2 and 15. For the control group, the anxiety score was between 1 and 9, the depression between 0 and 6.

The researchers pointed out that the results were not surprising, that both depression and anxiety are related to pain. They noted, though, that their only real measurement for anxiety and depression was the HADS and that there are no other appropriate questionnaires available for patients with upper body injuries. There has also been a recent interest in “fear avoidance” among patients with chronic pain. In an earlier study, a researcher used a questionnaire called the Fear-Avoidance Beliefs Questionnaire (FABQ) and found that fear of pain does play a role in anxiety as well.

The authors conclude that it is important to use tools (questionnaires) that are specific to this type of injury to be able to adequately assess a patient. They say that their findings show that there is a connection between anxiety and depression, and tennis elbow.

One well-known complication from surgery is a pulmonary embolism, a clot that travels in the bloodstream until it reaches the lungs. This complication does happen between 1.79 percent and 2.27 percent of the time after hip or knee replacement surgery, but until now, there have been no statistics for elbow replacement surgeries. The authors of this study wanted to determine the prevalence of pulmonary embolism after elbow replacements.

Researchers found the records of 1,076 patients with total elbow replacements, 816 with a first-time replacement (primary replacement) and 260 with revisions. All patients had received standard prophylactic, or preventive, anti-blood clotting medication and all used compression devises to minimize clot risk, after surgery. Walking after surgery was also encouraged.

The researchers found that among the replacements, there was a 0.25 percent incidence of pulmonary embolism among patients with primary replacements and a 0.1 percent among patients with revisions. None of the patients had a history of blood clots in the veins. Diagnosis was made between the day of surgery and day 3 after.

The patients were 43-year-old (woman), 39 years (woman), and 57 years (man). The 43-year-old had a primary replacement because of juvenile rheumatoid arthritis. After developing shortness of breath on the day after surgery, she went into respiratory arrest and died. The 39-year-old had a primary replacement because of rheumatoid arthritis. She recovered from the embolism and was able to stop blood thinning medication after 6 months. The man had a revision and also recovered from the embolism, stopping the blood thinners after 3 months.

The authors say that although there has been a lot of research on pulmonary embolism and knee and hip replacement, up to now, there has been nothing on elbow replacement. They were concerned about this because their findings showed that pulmonary embolisms do occur in patients who have upper body surgeries.

They conclude that this is a rare but fatal complication and that this should be kept in mind by surgeons if their patients complain of shortness of breath following surgery of the upper body.

There is much debate among surgeons about the treatment of elbow fractures. In particular, fractures of the radial head can be difficult to manage. This article addresses those issues and tries to shed some light on the subject.

There are two bones in the forearm that meet at the elbow: the ulna and the radius. The ulna fits into the elbow socket while the radius swivels back and forth against the bottom of the humerus (upper arm).

The top of the radius is called the radial head. The head has a flat top to allow it to glide back and forth as the hand turns palm up and palm down. One-third of all elbow fractures occur at the radial head and neck. In many cases, the injury is caused by a fall on the outstretched hand and arm. The elbow dislocates, and the ligaments around the elbow are torn.

The big question is: should the elbow be repaired or replaced? Elbow joint replacement is called an arthroplasty. Repair is done with an operation called open reduction and internal fixation (ORIF). The authors describe both procedures in detail and discuss when to use each one.

Part of the problem in making this decision is the lack of studies comparing the two operations. And changes in the type of implants and methods used are occurring so fast that results of recent studies reported are already outdated.

The authors suggest that the surgeon must be prepared to make the final decision in the operating room. Fracture pattern and amount of soft tissue damage must be assessed before choosing the best way to stabilize the elbow and restore motion. They prefer the new precontoured implants for ORIF when it can be done easily. Complex injuries require radial head arthroplasty.

Future studies are needed comparing these two treatment options with long-term follow-up before best practice can be determined. Until this information is available, the surgeon must weigh all the factors and make the best decision possible. Keeping up with all the latest changes and techniques is an important part of that process.

Elbow injuries can cause nerve damage to the ulnar nerve. The ulnar nerve is located on the inside of the elbow. The ulnar nerve can be injured easily.
This is because it rests in a shallow groove close to the surface of the skin,

In this report, surgeons from Massachusetts General Hospital (MGH) in Boston review current concepts in the treatment of the ulnar nerve in elbow injuries. Forearm muscle atrophy and elbow weakness can occur as a result of acute injury or nerve palsy. Numbness, tingling, and other sensory changes are also commonly reported. This condition is called ulnar nerve neuropathy.

The authors review the ulnar nerve anatomy and discuss what happens when the nerve is injured. Swelling, scarring, and thickening of the fibrous tunnel around the nerve can occur right away after injury or much later. Pulling or traction on the nerve can happen during surgery to treat an elbow injury.

Even the most gentle handling of the nerve can result in problems. Sometimes symptoms don’t occur for many months after the injury. Causes of delayed nerve palsy include the development of bone spurs in the elbow area and poor healing of a bone fracture.

Recovery from ulnar nerve injury is often a long process. Return to normal doesn’t always happen. Patients with diabetes are even more likely to have delayed or incomplete healing. Left alone, these injuries often get worse.

Surgery may be the only way to relieve symptoms. The nerve may be transposed (moved) away from the pressure area. Or bone around the nerve may be shaved off or removed.

Prevention is the key to ulnar nerve neuropathies. Surgeons are advised to identify and protect the nerve whenever surgery is done to the elbow. Certain conditions are more likely than others to cause ulnar nerve damage. Surgeons are advised to be cautious when treating elbow dislocation with fracture.

Both men and women in overhead throwing sports are at risk for ulnar
collateral ligament (UCL) injuries of the elbow. Finding ways to return
them to their previous level of play is the subject of many studies.

This review article summarizes the information from recent articles on UCL
injuries. Anatomy, diagnosis, and treatment of this problem are presented. The goal of treatment is to restore stability to the elbow. It must be pain free and able to hold up under the stresses of repetitive, overhead throwing activities.

When conservative care is unable to restore elbow function, then surgery may
be needed. Twenty years ago, surgery was done to repair or reattach the torn ligament. Poor results from this treatment led to improved surgical methods.

Modifications to the operation included using a tendon graft to reconstruct
the ligament. Success improved but the results remained inferior. The athletes
were unable to get the same motion and strength that is possible with a
normal, uninjured ligament. Surgeons have continued to look for better ways to attach the graft.

The authors review the current methods of graft fixation. The docking
technique tucks the ends of the tendon graft into a tiny tunnel made in
the bone. Screw fixation is another popular method of securing the
tendon graft.

With any surgical method currently available, it can take up to a year or
longer for the athlete to get back to competitive sports. Finding treatment
strategies to allow earlier return to previous level of play is the goal of
future studies.

In this review article, orthopedic surgeons give up-to-date information on the exam and treatment of elbow problems in throwing athletes. The advice offered is based on work they have done with professional football players.

Elbow anatomy is reviewed first. The ulnar collateral ligament (UCL) on the inside of the elbow is affected most often with throwing sports. The UCL is also called the medial ligament complex. It has three separate parts. Each one resists force on the elbow at different times in the throwing sequence.

Bone, ligaments, and muscles all work together to prevent too much force on the elbow during overhead throwing activities. Injury occurs when the stress on a ligament is greater than the strength of the ligament.

Symptoms of pain, weakness, and numbness bring the patient to the doctor’s office. Sometimes the player reports a pop or sharp pain on the inside of the elbow during a pitch. They may not be able to keep pitching after that.

The surgeon examines the elbow looking for specific patterns of tenderness to identify the problem. The authors review specific tests used to detect UCL instability. Photos and a description are provided for the milking sign, the moving valgus stress test, and the valgus impingement overload test.

X-rays, CT scans, or MRI may be ordered. Each test has its own specific purpose. CT scans will show bone spurs that don’t show up on X-rays. MRIs reveal deep tears under the surface.

Treatment is discussed with the emphasis on conservative or nonsurgical care. Rest and strengthening exercises are the first approach. The program is gradually progressed from absolute rest to return to sports.

Patients with UCL sprains or tears must rest at least one full month to start. Splinting or bracing may be needed at night to protect the elbow during the healing phase. The authors provide a sample throwing program based on distances from 30 feet up to 90 feet.

Even with a proper rehab program, there’s no promise that the athlete will always get back to competitive play. It’s still not clear which athletes won’t benefit from rehab and who should just have surgery done right away. More studies are needed to help guide the diagnosis and treatment of this complex problem.

In this study, electromyographic (EMG) studies of the triceps muscle were compared in two groups of men. The triceps muscle has three parts (tendons) and is located on the back of the upper arm. When it contracts, the elbow straightens. The first group had a condition called snapping triceps syndrome (STS). The second (control) group) included normal, healthy male adults with no elbow problems.

STS is an actual dislocation of the medial triceps tendon and ulnar nerve over the medial epicondyle of the humerus (upper arm bone). The medial epicondyle is the bump on the inside of the elbow sometimes referred to as the funny bone.

The researchers suspected that the firing pattern of the dislocating triceps muscle was different from the firing pattern of a normal elbow. Fine wire electrodes were used to record the electrical activity of the muscle in both groups.

EMG activity was recorded for each elbow in five different positions from zero (full extension) to full elbow flexion. Data was recorded for all three tendons of the triceps muscle. Electrical signals were recorded and analyzed by a computer program.

The authors found no difference in the firing patterns of the triceps muscle between the two groups. These results suggest that abnormal muscle activity isn’t the reason the triceps muscle dislocates.

Since the problem occurs in men who lift weights, it may be the excess bulk of the muscle displaces the muscle causing the dislocation. An ultrasound study may be the next step to measure and compare muscle bulk between the two groups.

Elbow replacements called elbow arthroplasties are used most often for patients with rheumatoid arthritis, fractures that don’t heal, and for elbow problems after trauma or injury. In a small number of cases, the implant, also called a prosthesis, can fracture.

In this study, doctors from the Mayo Clinic report on the results of treatment for 23 elbow implants that fractured. Two-thirds of the patients had a fractured ulnar component. One-third had a broken humeral component. The ulna is the larger of two bones in the forearm. The humerus is the upper arm bone. The stem of the elbow implant fits down into each of these bones to anchor it in place.

Two methods were used to repair the broken prosthetic. In some cases, the implant was cemented back together. This is called a cement-within-cement technique. Other patients were treated by removing the cement and replacing the broken piece.

Results were measured in terms of pain relief and function. X-rays were used to look for bone loss and placement of the implant. Everyone was followed for an average of five years after revision for the fracture. There was a wide range of outcomes from excellent to poor.

Infection, bone loss, and cancer metastases were factors for patients with poor results. Two other patients had ongoing moderate pain with no known cause. Problems after the revision operation were common. These included nerve damage, tendon avulsion, elbow stiffness, bone fracture, and loosening of the prosthetic.

The authors conclude that fatigue fracture from high stress is the most likely cause of elbow prosthetics. Some of these problems have been corrected with a new implant that came out in the year 2000. There have been no reported ulnar fractures since then. Revision techniques and ways to avoid fatigue fractures are included in this study for surgeons treating patients with elbow arthroplasties.

In this study cadavers are dissected to find out why small ulnar coronoid process fractures lead to an unstable elbow joint.

The elbow is a hinge joint made up of three bones. These include: 1) the humerus (the upper arm bone), 2) the ulna (the larger bone of the forearm, on the opposite side of the thumb), and 3) the radius (the smaller bone of the forearm on the same side as the thumb).

The end of the ulna at the elbow is called the coronoid process. It is shaped like a hook that fits around or hooks over the spool-shaped end of the humerus. Fractures of the tip of the coronoid process are called coronoid tip fractures.

This type of injury is fairly uncommon. Coronoid tip fractures can result in elbow instability. This occurs when the anterior joint capsule is disrupted and the elbow dislocates. Dislocation is more likely when a large portion of the tip breaks off.

The authors of this study explore why smaller fractures can become unstable. They looked at the anterior elbow capsule and tendons and ligaments that attach to the ulnar coronoid process. They wanted to see what happens to these structures when there’s an unstable elbow from a small coronoid fracture.

They found that the location of the capsule as it inserts at the coronoid tip is the key factor in elbow instability after small coronoid fractures. It appears that the capsule inserts close to the tip of the coronoid process. So, even when only a small portion of the tip is fractured and dislocates, the capsule goes with it, leaving the joint loose and unstable.

The findings of this study point out why even small ulnar coronoid process fractures should be repaired surgically. The goal is to prevent elbow dislocation and instability. The larger the fragment size, the greater the need for surgical repair of this injury.

Injury to the elbow from a fall, car accident, or direct trauma often results in fractures or dislocations. Dislocation with fracture or one or more bones can create an unstable elbow, a condition called complex elbow instability. Usually the ligaments around the elbow are also torn or damaged.

In this article, types of complex elbow injuries and their management are reviewed. The goal of treatment is to prevent recurrent dislocations and trauma-related arthritis. Patients need painless motion that allows them to complete daily tasks.

Surgery is often needed to manage difficult cases. For example, when the elbow won’t stay in a reduced position (in the socket) then it may have to be pinned. Elbow joint replacement is used when fixation fails. The authors say that surgeons need a good understanding of elbow anatomy and treatment options to treat complex elbow problems. This article reviews both in detail.

Results of surgical management have improved over the years. Silicone implants have been replaced by titanium. Silicone joint replacements were better than removing the joint but there was a high failure rate. Studies show good long-term results with titanium. However, most patients aren’t pain free and almost half develop signs of arthritis.

There’s still a lot of debate about the best way to treat complex elbow fractures especially when combined with dislocations. Treatment within two weeks of the injury and early motion seem to give the best results. Recognizing when bony fragments need fixation to stabilize the joint is important.

Doctors often poke and prod patients to find out exactly what’s causing their pain or symptoms. In the case of nerve entrapment at the elbow, two tests are often used to diagnose cubital tunnel syndrome (CuTS). A false positive test may result in unnecessary nerve testing and even surgery. False positive occurs when the test is positive but there’s nothing really wrong with the elbow.

In this study, the Tinel and elbow flexion tests are checked for reliability. The Tinel test for the ulnar nerve applies tapping pressure on the inside of the elbow where the nerve is close to the surface. A positive test is if two taps causes numbness or tingling at the elbow, down the arm, or into the hand.

In the second test (elbow flexion) the patient bends the elbow fully with the upper arms at the side. Again, numbness and tingling from the ulnar nerve after one. two, or three minutes is a positive test.

These two tests were given to 100 healthy college students who had no previous history or signs of ulnar nerve entrapment. A total of 200 elbows were tested. One doctor did all the testing.

The Tinel test was positive in 36 percent of the elbows. The elbow flexion test was positive 20 percent of the time. The authors believe these are false positive responses in this group of subjects. Neither test is useful to evaluate for possible CuTS.

At the present time no single test can be used to diagnose CuTS. These two tests can still be used but the result must be viewed with caution. History, physical exam, and other tests such as nerve conduction velocity (NCV) tests are needed to confirm or rule out CuTS as the problem.

In this study surgeons measure the pressure inside the cubital tunnel alongside the elbow. The ulnar nerve runs through this tunnel. Pressure on the nerve can cause cubital tunnel syndrome (CTS). Patients with CTS have pain, numbness, tingling, and weakness of the hand. The goal was to find out if increased pressure on the nerve is the cause of CTS or a result of CTS.

Eight patients with CTS had surgery to remove the pressure from the nerve. During the operation, a microtransducer was gently placed inside the cubital tunnel. Pressures were measured at three different places. The measurements were taken first with the elbow fully flexed. The same measures were taken again with the elbow fully extended.

Pressures were the highest closest to the elbow and during elbow flexion. Patients with the highest pressures had the worst disease. As the disease progressed pressures increased in both flexion and extension.

>From the results of this study the authors believe that pressure from outside the nerve is linked with CTS. They also say that pressure inside the nerve adds to the problem. They recommend a two-part surgery to take pressure off the nerve and to move the nerve out of the tunnel. A simple decompression is not enough.

Ulnar and median nerve impulses across the elbow are difficult to test. The nerves don’t always run straight. They curve and sometimes slip out of the shallow groove designed for them. In this study scientists try a different way of measuring the function of these two nerves.

They used a simple and fast method called mixed latency difference (MLD). MLD is the difference between the peak action potential of the median nerve compared to the ulnar nerve. The action potential is a wave of electrical discharge that travels along the nerve. It measures latency or how fast the nerve carries messages.

In this study the nerves were stimulated at the wrist, below the elbow, and above the elbow. MLD was measured in 57 normal, healthy adults who had no signs or symptoms of nerve problems. They tested another group of 100 patients who had positive symptoms of ulnar nerve problems. This second group was divided into two groups.

One group included patients who had a test positive for ulnar nerve neuropathy of the elbow (UNE). The second group had “suspected” UNE. They called it suspected because the standard test (motor conduction velocity) wasn’t positive to prove change in the nerve function.

Results showed that MLD seems to be linked with height. This is a new finding never reported before. The authors aren’t sure how to explain this correlation. They say it could be greater height means a longer nerve length and longer nerve conduction time. Or maybe with increased height, there’s less difference between the two nerves.

Overall this study showed that MLD is a good way to test for mild cases of UNE. The test avoids measuring nerve function across the elbow where problems develop. It’s less accurate with severe cases of ulnar nerve injury.

In this study treatment of elbow pain caused by a thickened synovium is reported. Twelve athletes (golfers, baseball players, or baseball pitchers) had arthroscopic surgery to remove the extra tissue. All patients were followed for at least two years.

Lateral elbow pain (along the outside of the elbow) isn’t as common as medial elbow pain along the inside of the elbow. When it occurs, the patient must be evaluated for an inflamed or thickened synovial plica. Synovium is the thin layer of membrane that lines joints. The plica is an extra piece or fold of synovium where the separate parts of the synovium join together.

Repetitive elbow motion like throwing a ball or swinging a golf club seem to put competitive athletes at increased risk for this problem. Elbow pain and snapping, clicking, or catching are common symptoms when the plica gets caught in the elbow joint. This condition is called elbow impingement.

Arthroscopic surgery can be done to shave away the plica. The athletes in this study all had at least three months of nonoperative treatment first. This included antiinflammatory drugs, physical therapy, and change in activity level. More than half also had a steroid injection. There was only temporary relief from the painful symptoms.

After surgery eight of the 12 had complete pain relief. The rest had only mild discomfort or occasional pain during their sports activity. Clicking, snapping, or catching but without pain persisted for two patients. All but one patient went back to their previous level of competitive play.

The authors conclude careful diagnosis is needed to identify synovial plica as the cause of elbow impingement. Arthroscopic treatment can help return athletes to the playing field.

Professional baseball players have a preseason physical every year. From these exams, doctors know that elbow range of motion (ROM) is different for the pitcher than for other players. In this study pitchers from the Chicago Cubs and St. Louis Cardinals baseball teams were examined. All testing was done during the spring training preseason. The researchers hoped to find a way to explain the ROM differences.

All elbow motions were measured for both the dominant and nondominant sides of 33 pitchers. The baseball records for these players were also reviewed. Age, years pitching, and history of any elbow surgeries were collected. After careful analysis the authors concluded none of these factors could be linked with the changes in elbow motion for these pitchers.

They did find that the pitching elbow was often unable to extend as far as the other (nondominant) elbow. The number of years of pitching didn’t seem to be a cause of this change. There was a slight trend for pitchers with eight or more years to have more elbow flexion compared to pitchers with less than eight years pitching.

Number of innings pitched was also looked at as a possible factor. ROM in the nondominant arm seemed more affected by the number of innings pitched. Nondominant elbows showed a decrease in elbow extension as the number of innings pitched increased. Increasing age had the same effect but again, just on the nondominant side.

The authors conclude that mild loss of elbow extension in baseball pitchers is common. This change in ROM doesn’t seem to affect their playing or the length of their careers.

Nerve problems at the elbow can cause pain and make work and daily activities difficult. In this study removing part of the bone on the inside of the elbow is reviewed as a surgical treatment for the problem. The operation is called a partial medial epicondylectomy.

Researchers tried to answer these questions: does a partial epicondylectomy improve function? Does it help patients with severe symptoms? Can the problems of elbow instability and pain (common after a total epicondylectomy) be avoided by doing a partial procedure instead?

Results of 80 partial epicondylectomies were compared with total epicondylectomies reported in other studies. Measures included pain, grip and pinch strength, elbow motion, and function.

The results showed 86 percent of the patients improved and returned to work five months later. One-third of the patients still had some loss of nerve function. Two-thirds of the patients with severe symptoms gained strength and function in the hand and forearm.

The authors conclude that partial epicondylectomy is a safe and reliable way to treat nerve problems at the elbow. Major problems are avoided although elbow pain persists for many patients.

In this article doctors from the Mayo Clinic provide an in-depth review of elbow anatomy. Color photos of cadavers are used to show specific nerves, tendons, and bony landmarks. The purpose of the review is to understand, diagnose, and treat nerve injuries of the elbow.

Nerve injuries are divided into five groups from mild to severe. Most elbow nerve injuries are mild and heal in six to eight weeks. Nerve injuries in children often heal faster than in adults. Fractures with nerve trauma usually need surgery to repair. This is especially true if the nerve has been cut or divided by the jagged edge of a broken bone.

The authors provide surgeons with strategies for when and how to diagnose and treat nerve injuries. For example they suggest waiting three weeks after injury to order EMG studies. Changes in nerve function from the point of injury and below may take this long to show up fully.

The management of every stage of nerve injury is discussed in detail. Signs of recovery can help the surgeon in planning treatment. Nerves recover at a rate of about one inch each month. Sweating returns before sensation. Repairing damaged nerves too late increases the risk of a poor result.

In the final section of this article, Drs. Adams and Steinmann note that nerve damage can occur with elbow arthroscopy. The needle used to enter the joint can puncture or cut a nerve by mistake. Trauma and muscle tightness from injuries can change the anatomic landmarks. The authors discuss specific ways the surgeon can avoid these types of injuries.

Dutch researchers report the Extensor Grip Test (EGT) can tell whether or not a patient with tennis elbow can be helped by a brace. The test was done by having the patient pull the hand and wrist back toward the face. Then the examiner gripped the patient’s forearm just below the elbow.

The patient rested for one minute. The reverse steps were taken. The forearm was gripped again and then the wrist was pulled back. Less pain the second time is a positive test meaning a brace would help. All patients had the EGT done before treatment.

The patients were divided into three treatment groups. Group one got a brace. They wore it all day but kept it off at night. Group two had physical therapy. Therapy included ultrasound, friction massage, strengthening, and stretching for six weeks. Everyone got a total of nine physical therapy sessions. Group three got both the brace and physical therapy.

Results were measured using three tools. First each patient assessed how he or she was doing on a six-point scale. The scale went from fully recovered (1) to much worse (6). Second, severity of pain was reported. And third, patient satisfaction was measured.

Patients with a positive test were compared to patients with a negative result. There was no difference between the physical therapy and the combination group. The test had the highest predictive value with the brace-only group.

The authors conclude the EGT can direct treatment for tennis elbow. Anyone with a positive EGT can start off with a brace to support the arm and limit pain. Anyone with a negative EGT should receive physical therapy.