News Category: Elbow

Complex elbow fractures with dislocation need careful surgical management. In this report, surgeons review hinged external fixators for complex elbow injuries. Four of these devices are currently on the market. They can be helpful in the treatment of elbow instability.

Hinged external fixators protect the joint and allow motion until the bones have healed. Features of each fixator are presented along with advantages and disadvantages.

The authors describe the frame construction for each of the four fixators. Location and direction of pins and type of motion allowed are discussed. Some fixators have more adjustment than others. In some cases the patient or therapist can adjust the amount of motion allowed.

Problems with the fixators are common. Infection around the pin or inside the joint can occur. The pins can break or come loose. Improper placement of the pins can cause a loss of bone reduction needed to heal the fracture. Ways to avoid nerve damage are offered. Precise pin insertion by the surgeon is an important key to preventing nerve injury.

Finally the authors review when to use external fixators for elbow fractures. Some examples include chronic dislocation or when a patient can’t handle a long operation. Fracture along with ligament tear or major joint instability are two other reasons to consider using an external fixator.

Surgeons rely on research to know which operation or implant for joint replacement has the best results. There aren’t very many studies on elbow replacement. Doctors in England reviewed the literature and found only five articles comparing elbow implants. Two of those devices aren’t even used any more.

So they set out to compare three of the current implants on the market. Three groups of patients with rheumatoid arthritis were studied. Each group of 33 subjects had a different implant. The names of the implants used are 1) Souter-Strathclyde, 2) Kudo, and 3) Coonrad-Morrey.

Pain levels and range of motion (elbow flexion) were the measures used to compare success. X-rays were used to look for any loosening or sinking into the bone of the new joint. All implants were done by or under the supervision of one surgeon. The patients were followed for at least five years.

All three implants were equally good at giving patients pain relief. Range of motion was also the same among the groups. The clear difference was how long the implant lasted without coming loose. The Coonrad-Morrey implant had the best results. The authors say this implant prevents dislocation without increasing the risk of coming loose.

Cubital tunnel syndrome from pressure on the ulnar nerve at the elbow is a common problem in baseball. Professionals on down to Little League pitchers, catchers, and infielders are affected most often. This study shows that repeated strain on the ulnar nerve when throwing the ball puts the nerve at the limits of what it can handle.

Researchers from Sapporo Medical University in Japan conducted a study of the movement and strain on the ulnar nerve during the throwing motion. They used cadavers to measure how much the nerve stretches with each phase of throwing. They also used a gauge to record strain on the nerve. All measurements were taken at the cubital tunnel where the ulnar nerve passes through the elbow.

The results showed the ulnar nerve was stretched to capacity when the elbow was flexed 45 degrees or more. Most of the nerve movement took place during the wind-up phase of the pitch or throw. Most of the strain on the nerve occurred up until the early acceleration phase of the throw.

The scientists also found that the maximum strain on the ulnar nerve at the elbow was about 13 per cent. This is close to the 15 per cent elastic or circulatory limits. At 15 per cent damage to the structure of the nerve can occur.

The authors point out that their results may not mimic live, healthy, young baseball players. The measurements were all taken on older cadavers. The cadavers may not have the same mobility as young athletes. Future studies are needed to look at this more closely.

Does splinting help with tennis elbow? Studies so far say, “No.” Forearm bands increase muscle fatigue. Splints prevent activity and may lead to deconditioning. This study looked at the effects of splinting for injured workers with epicondylitis or tennis elbow.”

All patients with tennis elbow going to any one of 253 occupational medical centers were included. A total of 4,614 patients were studied. Each patient was identified as being treated with “splints” or “no splints.” Splints included any restraint to the elbow, forearm, or wrist. Braces, splints, straps, and wrap bandages all counted as splints.

The results of this study were able to show who is more likely to get splints. The splint group was women with moderate to severe pain on the outside of the elbow (lateral epicondylitis). This information suggests that the decision to use splinting isn’t random. There are certain patients more likely to get a splint.

This study also showed patients with splints had more visits to the doctor or physical therapist with higher overall costs. The splinting group had higher rates of limited duty at work. The authors conclude that patients with tennis elbow who remain active do better than those who rest using splints.

In this study researchers at the San Diego Sports Medicine Center used
radiofrequency (RF) to treat tendinosis of the elbow. Tendinosis is damage and degeneration of the tissue without inflammation. It’s different from tendonitis, which has active inflammation.

RF energy is a type of heat treatment used to break molecular bonds. The particles have enough energy to dissolve soft tissue when heated to between 100 and 160 degrees. The treatment was used on 13 patients who didn’t get better with conservative care after six months or more of pain.

All of the patients got better with this treatment. Most had pain relief on the first or second day after the RF treatment. Grip strength improved as much as possible after four to six weeks. Arm and hand function improved steadily for up to a year after the treatment.

Arthroscopically applied RF is less invasive than open surgery. It’s a safe and effective treatment for tendinosis. Rehab begins early, and patients get rapid relief of symptoms.

Does Worker’s Compensation (WC) status affect results of surgery for tennis elbow? Does it take longer for the WC group to return to work? Does WC status make any difference in how much pain the patient has? That’s the topic of this study comparing two groups of patients with tennis elbow.

Group one received WC; group two didn’t. Everyone in both groups had pain bad enough to prevent them from doing their daily chores and activities. Both groups were treated with surgery to release the wrist extensor tendon along the outside of the elbow. A small bit of joint capsule is also cut where the tendon attaches. The tendon isn’t reattached
anywhere.

Patients were followed for at least four years. Relief from pain was about the same in both groups. The symptoms came back now and then for patients in both groups. Patient satisfaction was the same for WC patients as for non-WC patients. Most patients went back to work, but WC patients changed jobs more often.

In general there is data from many studies to show WC patients don’t do as well after surgery as non-WC patients. Researchers were surprised at the good outcomes after surgery for tennis elbow in this study. Results of this study show surgical treatment (lateral release) for tennis elbow has equal results regardless of employment status.

Pain, weak grip strength, and decreased quality of life (QOL). These are the challenges patients with chronic tennis elbow face everyday. Researchers trying to find a way to treat this problem compared two groups of patients. One group got a local injection of botulinum toxin type A. The second (placebo) group received an injection of saline. Based on pain, strength, and QOL, they found no difference between the two groups. Measurements were taken before and three months after treatment.

Studies of tissue at the painful site show no actual inflammation involved with tennis elbow. Some reports have shown botulinum A works for tennis elbow that hasn’t responded to other treatment. Botulinum A paralyzes the painful elbow muscle. The goal is to allow the muscle to heal. The injection works for about three to four months.

The authors conclude that botulinum A is not an effective treatment for chronic tennis elbow. They suggest a second study with a larger number of patients since there were only 20 patients in each group. Grip strength would be a better measure of change than the subjective measure of pain.

Physical therapists can help patients with tennis elbow manage their symptoms at home and at work. This report gives the second batch of results after a physical therapy (PT) program for tennis elbow. The first study reported on short-term results after eight weeks. This report offers details after six months.

Sixty (60) patients from nine sports clinics and two physical therapy clinics were included in the study. All patients had lateral tennis elbow with pain along the outside of the elbow. Pain was made worse by gripping or extending the wrist.

Before the study was started each patient was asked questions about pain and function. A careful exam was done by the physical therapist. The first study reported on results after eight weeks. Patients were contacted again by mail or phone at the end of six months.

They found some risk factors that might predict who will get better and who won’t. Repetitive work tasks was one. Female gender was another. Nerve symptoms with neck motion and neck pain added two more risk factors. Women who had both neck signs and a repetitive job were more likely to have a poor outcome.

Work was often the cause of the injury, but very few patients saw the link between the two. None of the men reported work as part of the problem. Only 18 percent of the women reported a work-related injury. A key factor linked to long-term prognosis was the amount of time spent using the forearm. Patients working 25 hours or more per week at the computer were at increased risk for poor outcome after treatment for tennis elbow.

The authors make several suggestions for PTs treating patients with tennis elbow. First, the therapist must be aware of the patient’s work tasks. This is true even if the patient hurt the elbow while playing sports or some activity outside the work setting. Treatment should include a visit to the patient’s work place. If that can’t be done, the patient should be shown on a computer station at the PT clinic how to reduce risk of injury at work.

More study is needed to find out if changing work place activities can speed up recovery in patients with tennis elbow.

This is the first study to look at the use of extracorporeal shock wave therapy (ESWT) as the only treatment for lateral epicondylitis. Lateral epicondylitis is the technical name for tennis elbow when it involves the outside of the elbow. ESWT is a fairly new treatment for this problem.

Sixty patients with tennis elbow were divided into two groups. One group got ESWT. Pulses of low energy were applied to the painful areas once a week for three weeks for this group. The second group thought they were getting ESWT, but the treatment was a sham. This control group had an air buffer pad next to the elbow to prevent the ESWT from getting through. Patients were told that two different treatments were being compared. This was so patients didn’t know which treatment they were getting. Results were measured by the amount of pain relief. Patients were followed for eight weeks after treatment.

The authors report no difference in results between the two groups. Night pain, activity pain, resting pain, and grip strength were all the same. It’s possible that long-term results would show a difference. But more study is needed to show what happens months (instead of weeks) later.

Doctors tracked patients with tennis elbow to compare the results of open and closed surgical methods. The study was done over five years and included 87 patients.

Open release is done through an incision in skin. Open release was used for 54 patients. Closed release using an arthroscope was used in 33 cases. An arthroscope is a tool that allows the doctor to enter the joint without a large opening. One or two small puncture holes are all that are needed. A tiny TV camera on the end of the scope allows the doctor to see inside.

In both methods the tendon was cut, and scar tissue was removed. The bone was shaved, and then the tendon was repaired. After the operation, the open group had to wait about six weeks before starting exercise. The arthroscopic group started strengthening exercises as soon as they felt ready.

Patients were followed after the operation for up to two years. The long-term results show no difference between the two methods of operating on the elbow. In the short run, patients with arthroscopic release went back to work sooner. They also needed less therapy after the operation.

Physical therapists often treat patients with tennis elbow, known as lateral epicondylitis. Finding the best treatment for this problem is a goal among therapists. In this study, physical therapy researchers report on the use of two treatments for patients with tennis elbow.

In one group, just the elbow was treated with ultrasound, massage, stretching, or joint mobilization. In a second group, patients received treatment of the elbow and manual therapy for the neck. Manual therapy of the neck included passive joint motion and muscle energy techniques.

The therapists report equal results for both groups. The added manual therapy of the neck did not seem to make a difference in patients’ final outcomes. However, patients getting treatment to the neck and elbow had fewer visits.

This is the first long-term study of its kind. This type of study looks at current treatment practices and finds the most effective treatment method. Physical therapy helps tennis elbow in about 80 percent of all cases. Treatment with manual therapy to the neck may be more efficient.

How well do young, active patients recover from elbow surgery to release the ulnar nerve? This is the first study to ask and answer this question.

Twenty active duty members with cubital tunnel syndrome (CuTS) were treated with an operation called the SMUNT. CuTS causes pressure on the ulnar nerve as it passes along the inside edge of the elbow. The result is elbow pain and numbness of the inner arm and hand. Weakness of the hand is also common with CuTS.

SMUNT stands for submuscular ulnar nerve transposition. It involves a long incision to open the side of the elbow closest to the body. Pressure on the ulnar nerve from nearby soft tissues is removed. The nerve is then moved over to the middle on the front side of the elbow.

Each patient was followed for at least 12 months. All patients were given a physical exam and test of function to measure results. Return to work and patient satisfaction were also used to report outcomes.

The authors report that 19 of the 20 soldiers returned to active, strenuous military duty. Everyone had a good result. Grip and pinch strength were better for all soldiers.

Open elbow surgery always has risks. The researchers say that using the SMUNT works well in young, active patients. It’s possible after this operation for patients to return to work with high physical demands.

This case report features a 34-year old woman with a history of right elbow and forearm pain. Her diagnosis was radial tunnel syndrome (RTS). With RTS, there’s pressure on a branch of the radial nerve as it passes through the elbow.

Most of the time RTS gets better with conservative treatment. Sometimes surgery is needed. The standard operation is with an open incision. But since arthroscopy has been used to treat similar problems in other joints, these surgeons tried it in this case. The results are reported in this study.

The surgeons looked inside the elbow using an arthroscope, a slender tool with a tiny TV camera on the end. They were able to see a ganglion cyst pressing on the nerve causing the patient’s pain. There was a small hole in the joint capsule leaking fluid into the sac forming the cyst. The front half of the joint capsule was removed along with the cyst. This took the pressure off the nerve.

The patient was able to get full motion back in her elbow after the operation. She was also pain free for the first time in three years. The authors conclude that arthroscopy can be used to operate on the elbow. A surgeon with good skills and a lot of practice can avoid damaging the nerves in this area. This is an important step in the treatment of elbow problems. More research is needed to study this problem.

The best way to treat tennis elbow (epicondylitis) is still a mystery. Studies have shown that acupuncture, cortisone injections, and splints or other aids don’t work for everyone all the time. There’s still debate whether or not a special type of shock wave treatment has any effect on tennis elbow. The treatment is called extracorporeal shock wave treatment (ESWT).

ESWT is a form of energy used to enhance healing of soft tissues. It’s applied to the painful or damaged area from outside the body. The body’s natural healing process begins by bringing more blood to the area after ESWT.

In this study, researchers put 78 tennis players with lateral epicondylitis in one of two groups. The first group got ESWT to the painful or tender area. Three treatment sessions were given. Each session lasted 30 minutes. The patients waited one week between sessions.

The second (placebo) group thought they were getting ESWT. They were set up exactly as the first group. However, in this group, the shock waves were reflected away from the patient. All patients in both groups were asked to stop playing tennis until seven days after the last treatment.

The authors report good results with ESWT. Three months after the treatment, the ESWT group had much better pain relief. The treatment group could do more physical tasks, such as opening jars, carrying heavy objects, or picking up a dime.

Sixty-five percent of the active treatment group went back to playing tennis. This compares to 35 percent in the placebo group. The authors conclude that there was some improvement in the placebo group, but the treatment group clearly did better. Thus, the authors support the use of ESWT for lateral epicondylitis.

Four doctors from three orthopedic and sports medicine clinics present a safe and simple operation for tendonitis and rupture of the biceps muscle. The method has been used for over 10 years. This is the first report on it.

Twenty-five patients had the operation. An arthroscope was used to get a close look at the damage. This operation is done when the doctor can see a partial or complete tear of the tendon. The authors describe in detail the steps in this operation. They advise other surgeons to look at other parts of the shoulder affected by a frayed or torn tendon.

During an arthroscopic operation, a long, thin tool goes through the skin directly into the joint. There’s a tiny TV camera on the end to guide the surgeon. In this study the doctors combined arthroscopy with a small incision as well. This is called an arthroscopic assisted mini-open tendon repair.

Guidelines for post-operative rehab are also provided. The specific program depends on whether or not the rotator cuff was repaired along with the biceps. Sometimes a piece of bone from the end of the collarbone is also removed. This is another factor that guides the steps in rehab.

The authors conclude that their method of biceps tendon repair has good results. The patient ends up with a tiny scar along the line of a natural skin fold, and there is good shoulder and arm function. With this technique the surgeon can find the torn tendon quickly and easily. Mini-open arthroscopy is needed when the tendon is torn completely and has pulled away from the bone.

A whole bunch of Little League baseball players teamed up for this study. All 343 ball players had taken part in the regional and national championships in Taiwan. Most were pitchers, but catchers and fielders were also included. They ranged in age from 9.5 to 12 years. The goal was to find rates of elbow injury and see what shows up on an X-ray.

Players were asked about hand dominance, years of playing, number of throws, and hours of practice each day and week. They also reported any painful or sore symptoms during or after pitching or throwing practice. A doctor examined each player’s elbows. The angle of each elbow was measured and compared. X-rays of each elbow were taken. Thickness of the bone was recorded for both arms (throwing and nonthrowing arms).

Almost all the players had increased bone density at the elbow of the throwing arm. Pitchers had the greatest amount of change in this area compared to fielders and catchers. Catchers were more likely to have soreness and elbow deformity than pitchers or fielders. More than half of all the boys had a space greater than 1 mm between the growing bone and the main bone on the inside of the arm. Only half of these players had any pain or soreness.

The authors think changes seen on X-ray are caused by chronic traction stress on the inside of the elbow. The changes in the bone may not have anything to do with the player’s symptoms. This finding needs more study before any links are known for sure.

Most malls in America offer at least one arcade to entertain those who aren’t shopping. There’s an arcade in your body, too, but it’s not for fun. It’s a canal that gives the ulnar nerve safe passage along the inside edge of the elbow. It’s called the Arcade of Struthers, named after Sir John Struthers, a whale anatomist from Scotland.

Until recently doctors and anatomists thought the Arcade of Struthers was a thin band of tissue near the elbow. Two doctors from the University of Toronto Hand Program have shown it’s not what we’d always thought. They dissected 11 arms and mapped out the arcade one layer at a time. They measured, sketched, and photographed every section above and beside the arcade.

They found the same anatomy in all 11 specimens. The ulnar nerve was followed from the armpit down past the elbow, into the inside edge of the forearm. Instead of a thin band, the arcade is actually a canal with muscle, fascia, and ligament on all sides. The ulnar nerve actually takes a turn and changes direction at the opening of the canal.

The ulnar nerve slid easily through the canal in ten of the 11 cadavers. Even so, the shape of the canal wasn’t the same in all 11 arms. The length varied as much as two centimeters (just under an inch). In two cases there were extra bands of tissue crossing over the ulnar nerve at the end of the canal.

The authors report exact details of the anatomy for the Arcade of Struthers. They say this will help other doctors when doing surgery on the ulnar nerve in this area. The canal is one place where pressure on the nerve can occur.

Knowing where the nerve changes direction helps when tracing the nerve through the arm. Seeing the arcade as a canal instead of a thin band will guide the surgeon. Knowing there can be extra bands of tissue also helps the surgeon look for the cause of nerve compression. Treating ulnar nerve problems will be easier with this new detailed description of the Arcade of Struthers.

Tennis elbow isn’t life-threatening, but it can keep a person from going to work or enjoying other activities. The average episode of tendonitis lasts between six months and two years. The usual treatment for tendonitis is rest, splinting, and an exercise program.

Researchers in Australia are trying nitric oxide (NO) as another treatment option. NO is present throughout the body as a byproduct of protein metabolism. Scientists think NO increases collagen tissue needed for tendon healing and repair.

In this study, patients with lateral epicondylitis (tennis elbow along the outside of the elbow) were divided into two groups. Both groups followed the same exercise program. All patients received a patch to wear on or around the elbow. Patients in group one received patches with NO. The other group received placebo patches without NO. Patches were worn daily and replaced every 24 hours. Patients were followed for six months.

The NO patches seemed to help. The best results occurred in the first two weeks with decreased elbow pain and increased activity. Patients continued to show improvement through week 24 when the patches were taken off. After six months 80 percent of the patients were still symptom-free. This compares to 60 percent of the patients who didn’t get NO patches.

The authors conclude that NO can be used to treat tennis elbow. They don’t know why 80 percent got better while the other 20 percent didn’t improve. More studies are needed to find out why NO works and who can benefit from its use. How much is needed? How long should it be used? Researchers have more questions than answers. But this is the first step toward using NO therapy for tennis elbow.

“Put ‘er there, pardner!” With that phrase comes a hand-crushing handshake grip. For the patient with tennis elbow, it also comes with a jolt of elbow pain.

Relief may be close at hand. A study done by doctors and physical therapists compared two forms of treatment for tennis elbow. This condition is also called lateral epicondylitis. Lateral means outside, so all patients had pain along the outside of the elbow.

Group one received wrist manipulation twice a week for up to nine sessions over six weeks. The manipulation was stopped if the painful symptoms went away. Group two had a more traditional physical therapy program with ultrasound, massage, stretching, and strengthening. The same number of sessions was allowed. Both groups were treated by physical therapists.

Results were measured after six weeks using patients’ own view of their overall progress. Patients could rate their results on a scale from “complete recovery” to “much worse.” Pain, grip force, and activity level were also noted.

The group receiving the wrist manipulation had the better success rate (62 percent compared to 20 percent in the therapy group). Pain in the wrist manipulation group was also much less. All other measures were equal.

The small number of patients (28 total between the two groups) makes this a pilot study. This means they are testing out the idea to see if it’s worth studying in greater depth. The researchers think the results can be used now to guide treatment. They suggest the next step is a large-scale trial with a control group (an equal number of people who gets no treatment). The next study will have a longer follow-up as well.

Here’s the typical picture of a patient with a biceps tendon that is torn where it attaches to the elbow: a middle-aged man who injures the dominant arm while lifting with his elbow bent. Elbow strength and motion are reduced. However, pain is usually minimal to nonexistent.

How should this problem be treated? Doctors used to think that some cases would do well without surgery. The idea was that the tendon would reattach to the bone close to the place where it ended up after the tear. The patient could get along just fine after healing. Now we know strength is reduced by almost half if the biceps tendon is not reattached to its normal location.

This study compared two different surgical methods of repair. One operation uses one incision to reattach the biceps tendon to the bone using special fasteners, called suture anchors. The second approach uses two incisions to gain access to the bone.

The results showed very little difference between the groups after one year. Strength in both groups was near normal. However, short-term results were slightly different. The one-incision group could bend the elbow farther than the two-incision group. Although the one-incision group also had more complications, most of these problems went away given enough time. The two-incision group had a faster recovery early on, but the results were the same between groups by the end of one year.

The authors conclude that that there isn’t much difference in the results between these two surgical techniques for a biceps tendon rupture near the elbow.