Bellapianta Orthopedics Elbow

You know the feeling; you go to twist your grip and pang! A sharp pain in your elbow. It can happen to anyone at any age or activity level. Elbow pain may be caused by a number of different issues, ranging from overuse to acute injury to a chronic condition. These issues may involve any of the individual parts that make up your elbow joint, including tendons and ligaments, the radius and ulna bones, cartilage, and joint fluid sacs called bursae.

Some common elbow injuries and conditions can be treated with the classics: rest, ice and over-the-counter anti-inflammatory medications. However, if not properly treated, many elbow conditions may become chronic problems. The pain may hang on for several weeks at a time, or fade away and then come back just when you thought it was gone for good.

Conditions of the Elbow

Medial Epicondylitus

This affects the inner tendon in the elbow and is commonly called “golfer’s elbow” and “little leaguer’s elbow.” The repetitive throwing motion used in baseball or the downward swing of a golf club is a common cause.

Medial epicondylitis can also be the result of repetitive hand motion, such as swinging a hammer every day at work. This disorder can cause pain along the inside of the elbow. Wrist movements can especially trigger pain. This condition usually improves with rest and conventional treatment methods, such as icing or over-the-counter, anti-inflammatory drugs (ex. ibuprofen).

Lateral Epicondylitis

Another name for lateral epicondylitis is “tennis elbow.” It affects the tendon on the outside of the elbow. Playing racquet sports or working in certain professions that use the same sort of motion can cause this condition. Professionals who commonly experience lateral epicondylitis include:

cooks
painters
carpenters
autoworkers
plumbers

Symptoms such as pain or burning occur along the outside of the elbow. You also may experience problems with gripping. These symptoms usually improve with rest, physical therapy, or the use of a brace (tennis elbow strap).

Olecranon Bursitis

Common names for olecranon bursitis are “student’s elbow,” “miner’s elbow,” and “draftman’s elbow.” Bursitis affects bursae, small sacs of fluid that help protect and lubricate the joints. Olecranon bursitis affects the bursae protecting the pointy bone of the elbow. It may be caused by a blow to the elbow, leaning on the elbow for a prolonged period of time, infection, or medical conditions like arthritis.

Symptoms include swelling, pain, and difficulty moving the elbow. Redness and warmth may occur in the case of an infection. Medication and wearing elbow pads treat this condition. Surgery may be necessary in severe and chronic cases.

Osteoartritis

Osteoarthritis is a condition that affects the cartilage, a type of connective tissue found in joints. Osteoarthritis causes this tissue to wear down and become damaged. An elbow injury or wear and tear on the joints may cause osteoarthritis.

Symptoms include:

pain
difficulty bending the elbow
a locking sensation in the elbow
a grating sound with movement
swelling

Medication and physical therapy usually treat osteoarthritis. Surgery, including joint replacement, is an option in more severe cases.

Dislocation or Fracture of the Elbow

An injury to the elbow, such as a fall on an outstretched arm or elbow, can cause dislocation or a fracture. Dislocation occurs when a bone moves from its usual position, and a fracture happens when a bone cracks or breaks.

Symptoms include:

visual changes to the elbow, such as swelling and discoloration
inability to move the joint
pain

A doctor can move the dislocated bone back into place. They’ll place the dislocated or fractured elbow in a splint or cast, and give you medication for pain and swelling. Physical therapy will help restore the range of motion after the splint or cast is removed.

Ligament Strains and Sprains

Ligament problems can occur in any of the ligaments located in the elbow joint. Ligament sprains and strains can occur due to trauma or as a result of repeated stress. The ligament may be stretched, partially torn, or completely torn. Sometimes you’ll hear a popping noise upon injury.

Symptoms include:

pain
joint instability
swelling
problems with range of motion

Treatment may include rest, pain relief methods like icing, bracing, and physical therapy.

Osteochondritis Dissecans

Also called Panner’s disease, this condition occurs when small pieces of cartilage and bone become dislodged in the elbow joint. It’s often the result of a sports injury to the elbow and occurs most often in young men.

Pain and tenderness on the outside of the elbow, trouble extending the arm, and a feeling that the joint is locking could indicate this condition. You can treat this injury by immobilizing the elbow joint and going to physical therapy.

Biceps Tendon Tear at the Elbow

The biceps muscle is located in the front of your upper arm. It is attached to the bones of the shoulder and elbow by tendons — strong cords of fibrous tissue that attach muscles to bones.

Tears of the biceps tendon at the elbow are uncommon. They are most often caused by a sudden injury and tend to result in greater arm weakness than injuries to the biceps tendon at the shoulder.

Once torn, the biceps tendon at the elbow will not grow back to the bone and heal. Other arm muscles make it possible to bend the elbow fairly well without the biceps tendon. However, they cannot fulfill all the functions of the elbow, especially the motion of rotating the forearm from palm down to palm up. This motion is called supination.

To return arm strength to near normal levels, surgery to repair the torn tendon is usually recommended. However, nonsurgical treatment is a reasonable option for patients who may not require full arm function.

Anatomy

The biceps muscle has two tendons that attach the muscle to the shoulder and one tendon that attaches at the elbow. The tendon at the elbow is called the distal biceps tendon. It attaches to a part of the radius bone called the radial tuberosity, a small bump on the bone near your elbow joint.

Description

Biceps tendon tears can be either partial or complete.

Partial tears. These tears damage the soft tissue but do not completely sever the tendon.

Complete tears. A complete tear will detach the tendon completely from its attachment point at the bone.

In most cases, tears of the distal biceps tendon are complete. This means that the entire muscle is detached from the bone and pulled toward the shoulder.

Other arm muscles can substitute for the injured tendon, usually resulting in full motion and reasonable function. Left without surgical repair, however, the injured arm will have a 30% to 40% decrease in strength, mainly in twisting the forearm (supination).

Rupture of the biceps tendon at the elbow is uncommon. It occurs in only three to five people per 100,000 each year, and rarely in women.

Cause

The main cause of a distal biceps tendon tear is a sudden injury. These tears are rarely associated with other medical conditions.

Injury

Injuries to the biceps tendon at the elbow usually occur when the elbow is forced straight against resistance. It is less common to injure this tendon when the elbow is forcibly bent against a heavy load.

Lifting a heavy box is a good example. Perhaps you grab it without realizing how much it weighs. You strain your biceps muscles and tendons trying to keep your arms bent, but the weight is too much and forces your arms straight. As you struggle, the stress on your biceps increases and the tendon tears away from the bone.

Risk Factors

Men, age 30 years or older, are most likely to tear the distal biceps tendon.
Additional risk factors for distal biceps tendon tear include:
Smoking. Nicotine use can affect tendon strength and quality.
Corticosteroid medications. Using corticosteroids has been linked to increased muscle and tendon weakness.

Symptoms

There is often a "pop" at the elbow when the tendon ruptures. Pain is severe at first, but may subside after a week or two. Other symptoms include:

Swelling in the front of the elbow
Visible bruising in the elbow and forearm
Weakness in bending of the elbow
Weakness in twisting the forearm (supination)
A bulge in the upper part of the arm created by the recoiled, shortened biceps muscle
A gap in the front of the elbow created by the absence of the tendon

Elbow (Olecranon) Fractures

An olecranon (oh-LEK-rah-nun) fracture is a break in the bony "tip" of the elbow. This pointy segment of bone is part of the ulna, one of the three bones that come together to form the elbow joint.

The olecranon is positioned directly under the skin of the elbow, without much protection from muscles or other soft tissues. It can break easily if you experience a direct blow to the elbow or fall on an outstretched arm. A fracture can be very painful and make elbow motion difficult or impossible.

Treatment for an olecranon fracture depends upon the severity of the injury. Some simple fractures can be treated by wearing a splint until the bone heals. In most olecranon fractures, however, the pieces of bone move out of place when the injury occurs. For these fractures, surgery is required to restore both the normal anatomy of the elbow and motion in the joint.

Anatomy

Your elbow is a joint made up of three bones:

The humerus (upper arm bone)
The radius (forearm bone on the thumb side)
The ulna (forearm bone on the pinky side)

The elbow joint bends and straightens like a hinge. It is also important for rotation of the forearm; that is, the ability to turn your hand palm up (like accepting change from a cashier) or palm down (like typing or playing the piano).

The elbow consists of portions of all three bones:

The distal humerus is the lower end of humerus. It forms the upper part of the elbow and is the spool around which the forearm bends and straightens.
The radial head is the knobby end of the radius where it meets the elbow. It glides up and down the front of the distal humerus when you bend your arm and rotates around the ulna when you turn your wrist up or down.
The olecranon is the part of the ulna that "cups" the lower end of the humerus, creating a hinge for elbow movement. The bony "point" of the olecranon can be easily felt beneath the skin because it is covered by just a thin layer of tissue.

The elbow is held together by its bony architecture, as well as ligaments, tendons, and muscles. Three major nerves cross the elbow joint.

Description

Olecranon fractures are fairly common. Although they usually occur on their own, with no other injuries, they can also be part of a more complex elbow injury.

In an olecranon fracture, the bone can crack just slightly or break into many pieces. The broken pieces of bone may line up straight or may be far out of place (displaced fracture).

In some cases, the bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the bone. This is called an open fracture. Open fractures are particularly serious because, once the skin is broken, infection in both the wound and the bone are more likely to occur. Immediate treatment is required to prevent infection.

Cause

Olecranon fractures are most often caused by:

Falling directly on the elbow
Receiving a direct blow to the elbow from something hard, like a baseball bat or a dashboard or car door during a vehicle collision.

Falling on an outstretched arm with the elbow held tightly to brace against the fall. In this situation, the triceps muscle, which attaches to the olecranon, can pull a piece of the bone off of the ulna. Injuries to the ligaments around the elbow may occur with this type of injury, as well.

Symptoms

An olecranon fracture usually causes sudden, intense pain and can prevent you from moving your elbow. Other signs and symptoms of a fracture may include:

Swelling over the "tip" or back of the elbow
Bruising around the elbow. Sometimes, this bruising travels up the arm towards the shoulder or down the forearm towards the wrist.
Tenderness to the touch
Numbness in one or more fingers
Pain with movement of the elbow or with rotation of the forearm
A feeling of instability in the joint, as if your elbow is going to "pop out."

Tennis Elbow (Lateral Epicondylitis)

Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse. Not surprisingly, playing tennis or other racquet sports can cause this condition. However, several other sports and activities besides sports can also put you at risk.

Tennis elbow is inflammation or, in some cases, microtearing of the tendons that join the forearm muscles on the outside of the elbow. The forearm muscles and tendons become damaged from overuse — repeating the same motions again and again. This leads to pain and tenderness on the outside of the elbow.

There are many treatment options for tennis elbow. In most cases, treatment involves a team approach. Primary doctors, physical therapists and, in some cases, surgeons work together to provide the most effective care.

Anatomy

Your elbow joint is a joint made up of three bones: your upper arm bone (humerus) and the two bones in your forearm (radius and ulna). There are bony bumps at the bottom of the humerus called epicondyles, where several muscles of the forearm begin their course. The bony bump on the outside (lateral side) of the elbow is called the lateral epicondyle.

Muscles, ligaments, and tendons hold the elbow joint together.

Lateral epicondylitis, or tennis elbow, involves the muscles and tendons of your forearm that are responsible for the extension of your wrist and fingers. Your forearm muscles extend your wrist and fingers. Your forearm tendons — often called extensors — attach the muscles to bone. The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

Cause

Overuse

Recent studies show that tennis elbow is often due to damage to a specific forearm muscle. The extensor carpi radialis brevis (ECRB) muscle helps stabilize the wrist when the elbow is straight. This occurs during a tennis groundstroke, for example. When the ECRB is weakened from overuse, microscopic tears form in the tendon where it attaches to the lateral epicondyle. This leads to inflammation and pain.

The ECRB may also be at increased risk for damage because of its position. As the elbow bends and straightens, the muscle rubs against bony bumps. This can cause gradual wear and tear of the muscle over time.

Activities

Athletes are not the only people who get tennis elbow. Many people with tennis elbow participate in work or recreational activities that require repetitive and vigorous use of the forearm muscle or repetitive extension of the wrist and hand.

Painters, plumbers, and carpenters are particularly prone to developing tennis elbow. Studies have shown that auto workers, cooks, and even butchers get tennis elbow more often than the rest of the population. It is thought that the repetition and weight lifting required in these occupations leads to injury.

Age

Most people who get tennis elbow are between the ages of 30 and 50, although anyone can get tennis elbow if they have the risk factors. In racquet sports like tennis, improper stroke technique and improper equipment may be risk factors.

Unknown

Lateral epicondylitis can occur without any recognized repetitive injury. This occurence is called "idiopathic" or of an unknown cause.

Symptoms

The symptoms of tennis elbow develop gradually. In most cases, the pain begins as mild and slowly worsens over weeks and months. There is usually no specific injury associated with the start of symptoms.

Common signs and symptoms of tennis elbow include:

Pain or burning on the outer part of your elbow
Weak grip strength
Sometimes, pain at night
The symptoms are often worsened with forearm activity, such as holding a racquet, turning a wrench, or shaking hands. Your dominant arm is most often affected; however, both arms can be affected.

Golfer's Elbow (Medial Epicondylitis)

Golfer's elbow is a condition that causes pain where the tendons of your forearm muscles attach to the bony bump on the inside of your elbow. The pain might spread into your forearm and wrist.

Golfer's elbow is similar to tennis elbow, which occurs on the outside of the elbow. It's not limited to golfers. Tennis players and others who repeatedly use their wrists or clench their fingers also can develop golfer's elbow.

The pain of golfer's elbow doesn't have to keep you off the course or away from your favorite activities. Rest and appropriate treatment can get you back into the swing of things.

Symptoms

Golfer's elbow is characterized by:

Pain and tenderness. Usually felt on the inner side of your elbow, the pain sometimes extends along the inner side of your forearm. Pain typically worsens with certain movements.
Stiffness. Your elbow may feel stiff, and making a fist might hurt.
Weakness. You may have weakness in your hands and wrists.
Numbness or tingling. These sensations might radiate into one or more fingers — usually the ring and little fingers.
The pain of golfer's elbow can come on suddenly or gradually. The pain might worsen with certain movements, such as swinging a golf club.

Causes

Golfer's elbow, also known as medial epicondylitis, is caused by damage to the muscles and tendons that control your wrist and fingers. The damage is typically related to excess or repeated stress — especially forceful wrist and finger motions. Improper lifting, throwing or hitting, as well as too little warmup or poor conditioning, also can contribute to golfer's elbow.

Besides golf, many activities and occupations can lead to golfer's elbow, including:

Racket sports. Improper technique with tennis strokes, especially the backhand, can cause injury to the tendon. Excessive use of topspin and using a racket that's too small or heavy also can lead to injury.
Throwing sports. Improper pitching technique in baseball or softball can be another culprit. Football, archery and javelin throwing also can cause golfer's elbow.
Weight training. Lifting weights using improper technique, such as curling the wrists during a biceps exercise, can overload the elbow muscles and tendons.
Forceful, repetitive occupational movements. These occur in fields such as construction, plumbing and carpentry

To cause golfer's elbow, the activity generally needs to be done for more than an hour a day on many days.

Risk factors

You could be at higher risk of developing golfer's elbow if you're:

Age 40 or older
Performing repetitive activity at least two hours a day
Obese
A smoker

Prevention

You can take steps to prevent golfer's elbow:

Strengthen your forearm muscles. Use light weights or squeeze a tennis ball. Even simple exercises can help your muscles absorb the energy of sudden physical stress.
Stretch before your activity. Walk or jog for a few minutes to warm up your muscles. Then do gentle stretches before you begin your game.
Fix your form. Whatever your sport, ask an instructor to check your form to avoid overload on muscles.
Use the right equipment. If you're using older golfing irons, consider upgrading to lighter graphite clubs. If you play tennis, make sure your racket fits you. A racket with a small grip or a heavy head may increase the risk of elbow problems.
Lift properly. When lifting anything — including free weights — keep your wrist rigid and stable to reduce the force to your elbow.
Know when to rest. Try not to overuse your elbow. At the first sign of elbow pain, take a break.

Osteoarthritis of the Elbow

Osteoarthritis of the elbow occurs when the cartilage surface of the elbow is worn out or is damaged. This can happen because of a previous injury such as elbow dislocation or fracture. Most commonly, however, it is the result of a normal wearing away of the joint cartilage from age and activity.

Osteoarthritis usually affects the weight-bearing joints, such as the hip and knee. The elbow is one of the least affected joints because of its well matched joint surfaces and strong stabilizing ligaments. As a result, the elbow joint can tolerate large forces across it without becoming unstable.

Cause

Some patients who are diagnosed with elbow osteoarthritis have a history of injury to the elbow, such as a fracture that involved the surface of the joint, or an elbow dislocation. Risk for elbow arthritis increases if:

The patient needed surgery to repair the injury or reconstruct the joint
There is loss of joint cartilage
The joint surface cannot be repaired or reconstructed to its preinjury level
Injury to the ligaments resulting in an unstable elbow can also lead to osteoarthritis, even if the elbow surface is not damaged, because the normal forces across the elbow are altered, causing the joint to wear out more rapidly.

In some patients, no single injury to the elbow occurs. Work or outside activities can lead to osteoarthritis of the elbow if the patient places more demands on the joint than it can bear. For example, professional baseball pitchers place unusually high demands on their throwing elbows, which can lead to failure of the stabilizing ligaments. When this occurs, surgical reconstruction may be needed. High-shear forces placed across the joint can lead to cartilage breakdown over a period of years.

The best way to prevent elbow arthritis is to avoid injury to the joint. When injury does occur, it is important to recognize it right away and get treatment. Individuals involved in heavy work or sports activities should maintain muscular strength around the elbow. Proper conditioning and technique should always be used.

Symptoms

The most common symptoms of elbow arthritis are:

Pain
Loss of range of motion

Both of these symptoms may not occur at the same time. Patients usually report a "grating" or "locking" sensation in the elbow. The "grating" is due to loss of the normal smooth joint surface. This is caused by cartilage damage or wear. The "locking" is caused by loose pieces of cartilage or bone that dislodge from the joint and become trapped between the moving joint surfaces, blocking motion.

Joint swelling may also occur, but this does not usually happen at first. Swelling occurs later, as the disease progresses.

In the later stages of osteoarthritis of the elbow, patients may notice numbness in their ring finger and small finger. This can be caused by elbow swelling or limited range of motion in the joint. The "funny bone" (ulnar nerve) is located in a tight tunnel behind the inner (medial) side of the elbow. Swelling in the elbow joint can put increased pressure on the nerve, causing tingling. If the elbow cannot be moved through its normal range of motion, it may stiffen into a position where it is bent (flexion). This can also cause pressure around the nerve to increase.

Elbow (Olecranon) Bursitis

Elbow bursitis occurs in the olecranon bursa, a thin, fluid-filled sac that is located at the boney tip of the elbow (the olecranon).

There are many bursae located throughout the body that act as cushions between bones and soft tissues, such as skin. They contain a small amount of lubricating fluid that allows the soft tissues to move freely over the underlying bone.

Normally, the olecranon bursa is flat. If it becomes irritated or inflamed, more fluid will accumulate in the bursa and bursitis will develop.

Cause

Elbow bursitis can occur for a number of reasons.

Trauma. A hard blow to the tip of the elbow can cause the bursa to produce excess fluid and swell.
Prolonged pressure. Leaning on the tip of the elbow for long periods of time on hard surfaces, such as a tabletop, may cause the bursa to swell. Typically, this type of bursitis develops over several months.
People in certain occupations are especially vulnerable, particularly plumbers or heating and air conditioning technicians who have to crawl on their knees in tight spaces and lean on their elbows. Certain athletic activities may also prompt the development of olecranon bursitis, such as long holds of the plank position.
Infection. If an injury at the tip of the elbow breaks the skin, such as an insect bite, scrape, or puncture wound, bacteria may get inside the bursa sac and cause an infection. The infected bursa produces fluid, redness, swelling, and pain. If the infection goes untreated, the fluid may turn to pus. Occasionally, the bursa sac may become infected without an obvious injury to the skin.
Medical conditions. Certain conditions, such as rheumatoid arthritis and gout, are associated with elbow bursitis.

Symptoms

Swelling. The first symptom of elbow bursitis is often swelling. The skin on the back of the elbow is loose, which means that a small amount of swelling may not be noticed right away.

Pain. As the swelling continues, the bursa begins to stretch, which causes pain. The pain often worsens with direct pressure on the elbow or with bending the elbow. The swelling may grow large enough to restrict elbow motion.

Redness and warm to the touch. If the bursa is infected, the skin becomes red and warm. If the infection is not treated right away, it may spread to other parts of the arm or move into the bloodstream. This can cause serious illness. Occasionally, an infected bursa will open spontaneously and drain pus.

Elbow Bursitis Treatment Options

Nonsurgical Treatment

If your doctor suspects that bursitis is due to an infection, he or she may recommend aspirating (removing the fluid from) the bursa with a needle. This is commonly performed as an office procedure. Fluid removal helps relieve symptoms and gives your doctor a sample that can be looked at in a laboratory to identify if any bacteria are present. This also lets your doctor know if a specific antibiotic is needed to fight the infection.

Your doctor may prescribe antibiotics before the exact type of infection is identified. This is done to prevent the infection from progressing. The antibiotic that your doctor prescribes at this point will treat a number of possible infections.

If the bursitis is not from an infection, there are several management options:

Elbow pads. An elbow pad may be used to cushion your elbow.
Activity changes. Avoid activities that cause direct pressure to your swollen elbow.
Medications. Oral medications such as ibuprofen or other anti-inflammatories may be used to reduce swelling and relieve your symptoms.

If swelling and pain do not respond to these measures after 3 to 6 weeks, your doctor may recommend removing fluid from the bursa and injecting a corticosteroid medication into the bursa. The steroid medication is an anti-inflammatory drug that is stronger than the medication that can be taken by mouth. In some patients, corticosteroid injections work well to relieve pain and swelling. However, some patients do not have any relief of symptoms with corticosteroid injections.

Surgical Treatment

Surgery for an infected bursa. If the bursa is infected and it does not improve with antibiotics or by removing fluid from the elbow, surgery to remove the entire bursa may be needed. This surgery may be combined with further use of oral or intravenous antibiotics. The bursa usually grows back as a non-inflamed, normally functioning bursa over a period of several months.

Surgery for the noninfected bursa. If elbow bursitis is not a result of infection, surgery may still be recommended if nonsurgical treatments do not work. In this case, surgery to remove the bursa is usually performed as an outpatient procedure. The surgery does not disturb any muscle, ligament, or joint structures.

Recovery. Your doctor will apply a splint to your arm after the procedure to protect your skin. In most cases, casts or prolonged immobilization are not necessary.

Although formal physical therapy after surgery is not usually needed, your doctor will recommend specific exercises to improve your range of motion. These are typically permitted within a few days of the surgery.

Your skin should be well healed within 12 to 16 days after the surgery, and after 3 to 4 weeks, your doctor may allow you to fully use your elbow. Your elbow may need to be padded or protected for several months to prevent reinjury.

Cubital Tunnel Syndrome Treatment Options

Unless your nerve compression has caused a lot of muscle wasting, your doctor will most likely first recommend nonsurgical treatment.

Nonsurgical Treatment

Nonsteroidal anti-inflammatory medicines. If your symptoms have just started, your doctor may recommend an anti-inflammatory medicine, such as ibuprofen, to help reduce swelling around the nerve.

Although steroids, such as cortisone, are very effective anti-inflammatory medicines, steroid injections are generally not used because there is a risk of damage to the nerve.

Bracing or splinting.Your doctor may prescribe a padded brace or splint to wear at night to keep your elbow in a straight position.

Nerve gliding exercises. Some doctors think that exercises to help the ulnar nerve slide through the cubital tunnel at the elbow and the Guyon's canal at the wrist can improve symptoms. These exercises may also help prevent stiffness in the arm and wrist.

Surgical Treatment

Your doctor may recommend surgery to take pressure off of the nerve if:

Nonsurgical methods have not improved your condition
The ulnar nerve is very compressed
Nerve compression has caused muscle weakness or damage

There are a few surgical procedures that will relieve pressure on the ulnar nerve at the elbow. Your orthopaedic surgeon will talk with you about the option that would be best for you.

These procedures are most often done on an outpatient basis, but some patients do best with an overnight stay at the hospital.

Cubital tunnel release. In this operation, the ligament "roof" of the cubital tunnel is cut and divided. This increases the size of the tunnel and decreases pressure on the nerve.

After the procedure, the ligament begins to heal and new tissue grows across the division. The new growth heals the ligament, and allows more space for the ulnar nerve to slide through.

Cubital tunnel release tends to work best when the nerve compression is mild or moderate and the nerve does not slide out from behind the bony ridge of the medial epicondyle when the elbow is bent.

Ulnar nerve anterior transposition. In many cases, the nerve is moved from its place behind the medial epicondyle to a new place in front of it. Moving the nerve to the front of the medial epicondyle prevents it from getting caught on the bony ridge and stretching when you bend your elbow. This procedure is called an anterior transposition of the ulnar nerve.

The nerve can be moved to lie under the skin and fat but on top of the muscle (subcutaneous transposition), or within the muscle (intermuscular transposition), or under the muscle (submuscular transposition).

Medial epicondylectomy. Another option to release the nerve is to remove part of the medial epicondyle. Like ulnar nerve transposition, this technique also prevents the nerve from getting caught on the boney ridge and stretching when your elbow is bent.

Surgical Recovery

Depending on the type of surgery you have, you may need to wear a splint for a few weeks after the operation. A submuscular transposition usually requires a longer time (3 to 6 weeks) in a splint.

Your surgeon may recommend physical therapy exercises to help you regain strength and motion in your arm. He or she will also talk with you about when it will be safe to return to all your normal activities.

Surgical Outcome

The results of surgery are generally good. Each method of surgery has a similar success rate for routine cases of nerve compression. If the nerve is very badly compressed or if there is muscle wasting, the nerve may not be able to return to normal and some symptoms may remain even after the surgery. Nerves recover slowly, and it may take a long time to know how well the nerve will do after surgery.

Carpal Tunnel Syndrome Treatment Options

Although it is a gradual process, for most people carpal tunnel syndrome will worsen over time without some form of treatment. For this reason, it is important to be evaluated and diagnosed by your doctor early on. In the early stages, it may be possible to slow or stop the progression of the disease.

Nonsurgical Treatment

If diagnosed and treated early, the symptoms of carpal tunnel syndrome can often be relieved without surgery. If your diagnosis is uncertain or if your symptoms are mild, your doctor will recommend nonsurgical treatment first.

Nonsurgical treatments may include:

Bracing or splinting. Wearing a brace or splint at night will keep you from bending your wrist while you sleep. Keeping your wrist in a straight or neutral position reduces pressure on the nerve in the carpal tunnel. It may also help to wear a splint during the day when doing activities that aggravate your symptoms.
Nonsteroidal anti-inflammatory drugs (NSAIDs). Medications such as ibuprofen and naproxen can help relieve pain and inflammation.
Activity changes. Symptoms often occur when your hand and wrist are in the same position for too long—particularly when your wrist is flexed or extended.
If your job or recreational activities aggravate your symptoms, changing or modifying these activities can help slow or stop progression of the disease. In some cases, this may involve making changes to your work site or work station.
Nerve gliding exercises. Some patients may benefit from exercises that help the median nerve move more freely within the confines of the carpal tunnel. Specific exercises may be recommended by your doctor or therapist.
Steroid injections. Corticosteroid, or cortisone, is a powerful anti-inflammatory agent that can be injected into the carpal tunnel. Although these injections often relieve painful symptoms or help to calm a flare up of symptoms, their effect is sometimes only temporary. A cortisone injection may also be used by your doctor to help diagnose your carpal tunnel syndrome.

Surgical Treatment

If nonsurgical treatment does not relieve your symptoms after a period of time, your doctor may recommend surgery.

The decision whether to have surgery is based on the severity of your symptoms—how much pain and numbness you are having in your hand. In long-standing cases with constant numbness and wasting of your thumb muscles, surgery may be recommended to prevent irreversible damage.

Surgical Procedure

The surgical procedure performed for carpal tunnel syndrome is called a "carpal tunnel release." There are two different surgical techniques for doing this, but the goal of both is to relieve pressure on your median nerve by cutting the ligament that forms the roof of the tunnel. This increases the size of the tunnel and decreases pressure on the median nerve.

In most cases, carpal tunnel surgery is done on an outpatient basis. The surgery can be done under general anesthesia, which puts you to sleep, or under local anesthesia, which numbs just your hand and arm. In some cases, you will also be given a light sedative through an intravenous (IV) line inserted into a vein in your arm.

Open carpal tunnel release. In open surgery, your doctor makes a small incision in the palm of your hand and views the inside of your hand and wrist through this incision. During the procedure, your doctor will divide the transverse carpal ligament (the roof of the carpal tunnel). This increases the size of the tunnel and decreases pressure on the median nerve.

After surgery, the ligament may gradually grow back together—but there will be more space in the carpal tunnel and pressure on the median nerve will be relieved.

Endoscopic carpal tunnel release. In endoscopic surgery, your doctor makes one or two smaller skin incisions—called portals—and uses a miniature camera—an endoscope—to see inside your hand and wrist.

A special knife is used to divide the transverse carpal ligament, similar to the open carpal tunnel release procedure.

The outcomes of open surgery and endoscopic surgery are similar. There are benefits and potential risks associated with both techniques. Your doctor will talk with you about which surgical technique is best for you.

Recovery

Immediately following surgery, you will be encouraged to elevate your hand above your heart and move your fingers to reduce swelling and prevent stiffness.

You should expect some pain, swelling, and stiffness after your procedure. Minor soreness in your palm may last for several weeks to several months.

Grip and pinch strength usually return by about 2 to 3 months after surgery. If the condition of your median nerve was poor before surgery, however, grip and pinch strength may not improve for about 6 to 12 months.

You may have to wear a splint or wrist brace for several weeks. You will, however, be allowed to use your hand for light activities, taking care to avoid significant discomfort. Driving, self-care activities, and light lifting and gripping may be permitted soon after surgery.

Your doctor will talk with you about when you will be able to return to work and whether you will have any restrictions on your work activities.

Outcomes

For most patients, surgery will improve the symptoms of carpal tunnel syndrome. Recovery, however, may be gradual and complete recovery may take up to a year.

If you have significant pain and weakness for more than 2 months, your doctor may refer you to a hand therapist who can help you maximize your recovery.

If you have another condition that causes pain or stiffness in your hand or wrist, such as arthritis or tendonitis, it may slow your overall recovery. In long-standing cases of carpal tunnel syndrome with severe loss of feeling and/or muscle wasting around the base of the thumb, recovery will also be slower. For these patients, a complete recovery may not be possible.

Occasionally, carpal tunnel syndrome can recur, although this is rare. If this happens, you may need additional treatment or surgery.

Elbow Arthroscopy Surgery

Arthroscopy is a procedure that orthopaedic surgeons use to visualize and treat problems inside a joint.

The word arthroscopy comes from two Greek words, "arthro" (joint) and "skopein" (to look). The term literally means "to look within the joint." During elbow arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your elbow joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts), rather than the larger incision needed for open surgery. This results in less pain for patients, less joint stiffness, and often shortens the time it takes to recover and return to favorite activities.

Elbow arthroscopy has been performed since the 1980s. It has made diagnosis, treatment, and recovery from surgery easier and faster than was once thought possible. Improvements to elbow arthroscopy occur every year as new instruments and techniques are developed.

Anatomy

The elbow is a complex joint formed by the joining of three bones:

The humerus (upper arm bone)
The ulna (forearm bone on the pinky finger side)
The radius (forearm bone on the thumb side)

The surfaces of the bones where they meet to form the elbow joint are covered with articular cartilage, a smooth substance that protects the bones and acts as a natural cushion to absorb forces across the joint. A thin, smooth tissue called synovial membrane covers all remaining surfaces inside the elbow joint. In a healthy elbow, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost any friction as you bend and rotate your arm.

On the inner and outer sides of the elbow, ligaments (collateral ligaments) hold the elbow joint together and prevent dislocation.

The elbow joint is surrounded by muscles on the front and back sides. In addition, the three major nerves that cross the elbow joint are located close to the joint surfaces and capsule and must be protected during arthroscopic surgery.

The elbow joint allows two basic movements: bending and straightening (flexion and extension) and forearm rotation (pronation — palm down, and supination — palm up).

Normal bending and straightening motions occur at the joining of the humerus and ulna bones. Forearm rotation occurs at the joining of the ulna and radius and is also influenced by muscles and ligaments further down the forearm and at the wrist joint.

When Is Elbow Arthroscopy Recommended?

Your doctor may recommend elbow arthroscopy if you have a painful condition that does not respond to nonsurgical treatment. Nonsurgical treatment includes rest, physical therapy, and medications or injections that can reduce inflammation. Inflammation is one of your body's normal reactions to injury or disease. In an injured or diseased elbow joint, inflammation causes swelling, pain, and stiffness.

Injury, overuse, and age-related wear and tear are responsible for most elbow problems. Elbow arthroscopy may relieve painful symptoms of many problems that damage the cartilage surfaces and other soft tissues surrounding the joint. Elbow arthroscopy may also be recommended to remove loose pieces of bone and cartilage, or release scar tissue that is blocking motion.

Common arthroscopic procedures include:

Treatment of tennis elbow (lateral epicondylitis)
Removal of loose bodies (loose cartilage and bone fragments)
Release of scar tissue to improve range of motion
Treatment of osteoarthritis (wear and tear arthritis)
Treatment of rheumatoid arthritis (inflammatory arthritis)
Treatment of osteochondritis dissecans (activity related damage to the capitellum portion of the humerus seen in throwers or gymnasts)
Treatment of fractures
This x-ray of an elbow taken from the side shows severe osteoarthritis. Note the large bone spurs that have formed around the joint. During an arthroscopic procedure, these bone spurs can be removed, along with any loose fragments of cartilage.
There are several elbow surgical treatments that are currently most effective when done as an open, traditional procedure. These include surgeries to:
Treat golfer's elbow (medial epicondylitis)
Repair the collateral ligaments
Fix some types of fractures
Perform elbow joint replacement (arthroplasty)
Decompress the ulnar nerve (funny bone nerve)

Some advanced surgeries combine arthroscopic and open procedures in the same setting. For example, in a severe case of osteochondritis dissecans, a loose piece of bone may be removed arthroscopically, and the damaged area of the humerus may be treated with a bone graft using an open surgical technique.

Planning For Surgery

Evaluations and Tests

Your orthopaedic surgeon may ask you to see your primary doctor to make sure that you do not have any medical problems that need to be addressed before your surgery. Blood tests, an electrocardiogram, or chest x-ray may be needed to safely perform your surgery.

If you have certain health risks, a more extensive evaluation may be necessary before your surgery. Be sure to inform your orthopaedic surgeon of any medications or supplements that you take. You may need to stop taking some of these prior to surgery.

If you are generally healthy, your arthroscopy will most likely be performed as an outpatient. This means you will not need to stay overnight at the hospital.

Admissions Instructions

The hospital or surgery center will contact you ahead of time to provide specific details about your procedure. Make sure to follow the instructions on when to arrive and especially on when to stop eating or drinking prior to your surgery.

Anesthesia

Before the operation, a member of the anesthesia staff will talk with you about anesthesia options. Elbow arthroscopy is usually performed using general anesthesia, meaning you are put to sleep.

Regional nerve block injections that numb just your elbow area are rarely used in elbow arthroscopy because the numbing effect can last for a few hours after the procedure is completed. Although the numbing effect can help with managing pain, it prevents your surgeon from completing a careful nerve examination in the recovery room to make sure that the nerves that travel down your arm are functioning well.

If necessary for pain control, a regional anesthetic may be provided in the recovery room after your surgeon completes the nerve examination.

Surgical Procedure

Positioning

Once in the operating room, you will most likely be given general anesthesia, as well as intravenous antibiotics. Antibiotics are typically given before surgery to lessen the risk of infection after surgery.

You will then be positioned so that your surgeon can easily adjust the arthroscope to have a clear view of the inside of your elbow. The two most common positions for elbow arthroscopy are lateral decubitus (side lying) and prone (lying on your stomach). Care is taken to ensure that your spine and other pressure points in your arms and legs are protected and padded after positioning.

Next, a tourniquet is applied to your upper arm which is then placed in an arm holder to keep it in position during the procedure. A compressive dressing may be applied to your lower arm and hand to limit swelling. The surgical team will clean your skin with antiseptic and cover your shoulder and upper body with sterile surgical drapes.

Surgeons typically draw lines on the elbow to indicate specific structures (such as the ulnar nerve and olecranon bone), as well as incision placements and portals for the arthroscope.

The small lines drawn on the skin are common incisions made during arthroscopic surgery.

Procedure

Your surgeon will first fill the elbow joint with fluid. The fluid helps your surgeon more clearly see the structures of your elbow through the camera on the arthroscope. This lessens the risk of injury to the blood vessels and nerves surrounding your elbow joint. Your surgeon will make several small incisions to introduce the arthroscope and small instruments into the joint.

Fluid flows through the arthroscope to keep the view clear and control any bleeding. Images from the arthroscope are projected on the video screen showing your surgeon the inside of your elbow and any problems. Your surgeon will evaluate the joint before beginning any specific treatments. If indicated, the entire joint will be evaluated, which may require a total of five or seven very small arthroscopy incisions. The surgeon will insert other small instruments through separate incisions to assist with the procedure. Specialized instruments are used for tasks like shaving, cutting, grasping, suture passing, and knot tying. In many cases, special devices are used to anchor stitches into bone.

The arthroscopy incisions are usually stitched or covered with skin tapes at the end of the surgery. An absorbent dressing is applied to the elbow. Depending upon the procedure, your surgeon will place either an additional soft dressing that will allow movement or a plaster splint that will restrict movement and better protect the elbow.

Recovery

Postoperative

After surgery, you will stay in the recovery room for 1 to 2 hours before being discharged home. For some complex arthroscopic procedures, patients may be admitted to the hospital overnight. Nurses will monitor your responsiveness and provide pain medication, if needed. You will be provided discharge instructions that cover medications, need for ice and elevation, as well dressing care. You will need someone to drive you home and stay with you for at least the first night.

At Home

Although recovery from arthroscopy is often faster than recovery from open surgery, it may still take from weeks to months for your elbow joint to completely recover.

You can expect some pain and discomfort for several weeks after surgery. If you have had a more extensive surgery, however, it may take longer before your pain subsides. Your doctor will likely prescribe pain medicine to be taken regularly for the first few days after surgery. In addition, other medicines such as stool softeners or anti-inflammatory medicines may be prescribed.

It is important to ice and elevate your elbow regularly for 48 hours after surgery. This will reduce the risk of severe swelling and help to relieve pain. When elevating your arm, whether you lie flat or recline, make sure your elbow is resting higher than your heart and your hand is positioned higher than your elbow. Depending on the type of surgery performed, your doctor may have specific instructions for longer periods of ice and elevation.

You will most likely be encouraged to move your fingers and wrist frequently to help stimulate circulation and minimize swelling. Your doctor may recommend early range-of-motion exercises to prevent joint stiffness. When you can start these gentle exercises, as well as return to daily activities, will depend on the type of surgery performed.

Dressing care will depend on the type of surgery performed and the preferences of your doctor. In most cases, the operative dressing and/or splint is removed 2 to 3 days after surgery. During this time, your dressing must be left intact and kept dry. In some instances, you may be instructed to keep the dressing in place until your first postoperative clinic visit with your doctor.

Rehabilitation

Rehabilitation plays an important role in getting you back to your daily activities. An exercise program will help you regain elbow and forearm motion and strength. Your surgeon will develop a rehabilitation plan based on the surgical procedures you required.

In some cases, your doctor will instruct you or a family member with basic exercises to begin at home a few days following surgery. In more advanced surgeries, physical therapy is often prescribed after the first postoperative visit to facilitate motion, strength, and return of function of the elbow. The type and duration of therapy will depend on the type of problem you have and the type of surgery you required.

Return to driving, basic activities of daily living, and return to work will depend on the type of surgery you required and should be discussed with your doctor prior to surgery.

Long-Term Outcomes

Because patients have varied elbow conditions, complete recovery time is different for everyone.

If you have had a minor repair, you may not need a splint and your range of motion and function may return after a short period of rehabilitation. You may be able to return to work or school within a few days of your procedure.

It takes longer to recover from more complicated procedures. Although the incisions are small in arthroscopy, extensive damage within the joint can be repaired with the procedure. Full recovery may take several months. Although it can be a slow process, following your surgeon's guidelines and rehabilitation plan is vital to a successful outcome.

Total Elbow Replacement Surgery

Although elbow joint replacement is much less common than knee or hip replacement, it is just as successful in relieving joint pain and returning people to activities they enjoy.

Whether you have just begun exploring treatment options or have already decided to have elbow replacement surgery, this article will help you understand more about this valuable procedure.

Anatomy

The main structures of the elbow when viewed from the side.

The elbow is a hinge joint which is made up of three bones:
The humerus (upper arm bone)
The ulna (forearm bone on the pinky finger side)
The radius (forearm bone on the thumb side)

The surfaces of the bones where they meet to form the elbow joint are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily. A thin, smooth tissue called synovial membrane covers all remaining surfaces inside the elbow joint. In a healthy elbow, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost any friction as you bend and rotate your arm.

Muscles, ligaments, and tendons hold the elbow joint together.

Description

In total elbow replacement surgery, the damaged parts of the humerus and ulna are replaced with artificial components. The artificial elbow joint is made up of a metal and plastic hinge with two metal stems. The stems fit inside the hollow part of the bone called the canal.

There are different types of elbow replacements, and components come in different sizes. There are also partial elbow replacements, which may be used in very specific situations. A discussion with your doctor will help to determine what type of elbow replacement is best for you.

Cause

Several conditions can cause elbow pain and disability, and lead patients and their doctors to consider elbow joint replacement surgery.

Rheumatoid Arthritis

This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness.

Osteoarthritis (Degenerative Joint Disease)

Osteoarthritis is an age-related, "wear and tear" type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones of the elbow softens and wears away. The bones then rub against one another. Over time, the elbow joint becomes stiff and painful.

Post-traumatic Arthritis

This type of arthritis can follow a serious elbow injury. Fractures of the bones that make up the elbow, or tears of the surrounding tendons and ligaments may cause damage to the articular cartilage over time. This causes pain and limits elbow function.

Severe Fractures

A severe fracture of one or more bones that make up the elbow is another common reason people have elbow replacements. If the elbow is shattered, it may be very difficult for a doctor to put the pieces of bone back in place. In addition, the blood supply to the bone pieces can be interrupted. In this type of case, a surgeon may recommend an elbow replacement. Older patients with osteoporosis (fragile bone) are most at risk for severe elbow fractures.

Instability

Instability occurs when the ligaments that hold the elbow joint together are damaged and do not work well. The elbow is prone to dislocation. Chronic instability is most often caused by an injury.

Preparing for Surgery

Medical Evaluation

If you decide to have elbow replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your family physician several weeks before surgery. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process.

Many patients with chronic medical conditions, like heart disease, must also be evaluated by a specialist, such a cardiologist, before the surgery.

Medications

Be sure to talk to your orthopaedic surgeon about the medications you take. Some medications may need to be stopped before surgery. For example, the following over-the-counter medicines may cause excessive bleeding and should be stopped 2 weeks before surgery:

Non-steroidal anti-inflammatory medications, such as aspirin, ibuprofen, and naproxen sodium
Most arthritis medications

If you take blood thinners, either your primary care doctor or cardiologist will advise you about stopping these medications before surgery.

Home Planning

Making simple changes in your home before surgery can make your recovery period easier.

For the first several weeks after your surgery, it will be hard to reach high shelves and cupboards. Before your surgery, be sure to go through your home and place any items you may need afterwards on low shelves.

When you come home from the hospital, you will need help for a few weeks with some daily tasks like dressing, bathing, cooking, and laundry. If you will not have any support at home immediately after surgery, you may need a short stay in a rehabilitation facility until you become more independent.

Your Surgery

Before Your Operation

You will most likely be admitted to the hospital on the day of your surgery. After admission, you will be taken to the preoperative preparation area and will meet a doctor from the anesthesia department.

You, your anesthesiologist, and your surgeon will discuss the type of anesthesia to be used. In most total elbow replacement surgeries, a general anesthetic that puts you to sleep for the entire operation is used.

Surgical Procedure

To reach the elbow joint, your surgeon will make an incision (cut), usually at the back of the elbow. After making the incision, your surgeon will gently move muscles aside to get access to the bone. After removing scar tissue and spurs around the joint, your surgeon will prepare the humerus to fit the metallic piece that will replace that side of the joint. The same preparation is done for the ulna.

The replacement stems are placed into the humerus and ulna bones, and kept in place with a bone cement. The two stems are connected by a hinge pin. After the wound is closed, a padded dressing is then placed to protect the incision while it heals.

Some surgeons will place a temporary tube in the joint to drain the surgical fluid. This tube can be easily removed in your hospital room within the first few days after surgery.

The metal replacement parts are made of chrome-cobalt alloy or titanium and there is a liner made of polyethylene (plastic). The bone cement is made of polymethylmethacrylate (acrylic, a type of plastic).

Recovery

Your medical team will give you several doses of antibiotics to prevent infection. Most patients are able to eat solid food and get out of bed the day after surgery. You will most likely stay at the hospital 2 to 4 days after your surgery.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Rehabilitation

A careful, well-planned rehabilitation program is critical to the success of an elbow replacement. You will be taught some exercises for your hand and wrist to avoid stiffness and help to control swelling. You will do gentle elbow range-of-motion exercises as the incision heals. Your doctor may prescribe therapy or may teach you how to do the exercises yourself.

You will most likely not be allowed to put any weight on your arm or push against resistance with your hand until about 6 weeks after your surgery.

Long-Term Outcomes

The majority of patients have experienced an improved quality of life after total elbow replacement surgery. They experience less pain, improved motion and strength, and better function.

You should expect to do all basic activities of daily living, such as getting a plate out of a cabinet, cooking dinner, lifting a milk jug, styling your hair, basic hygiene, and dressing. Talk to your doctor about activities you may want to avoid, such as contact sports and activities with a major risk of falling (such as horseback riding or climbing ladders), as well as heavy lifting. These things increase the risk of the metal parts loosening or breaking, or the bone breaking.

When traveling on airplanes, be prepared for extra security screening. There is a chance that your metal implant will set off the metal detector during the security check-in.

To make the check-in go more smoothly, tell the security officer beforehand that you have an elbow replacement and carry a medical identification card. Although this does not change the screening requirements, it will help the security officer confirm the nature of the alarm. Be prepared for the security officer to use a wand scanner, and perhaps examine your arm in a private area in order to see the scar. The new body scanners can identify joint replacements, making further individual screening unnecessary.