Information about Elbow related conditions
Treatment of this is fairly complex and usually requires significant investigation and examination under anaesthetic to be absolutely certain of the instability pattern. Treatment is always surgical if it needs to be corrected with a fairly complex reconstruction while using tendons and using ligament reconstruction techniques.
When one develops an acute dislocation of the elbow it can lead to a weakness of the ligaments, on either the medial or lateral side. This is a complex problem where the ligaments do not function well and lead to discomfort and lack of strength in the elbow, in the form of instability
The risks with any operation on the elbow is injury to the ulnar nerve which leads to tingling and numbness and perhaps muscle deficit to its distributed territory. Other risks are fairly standard with elbow replacements including infection, stiffness, loosening and life span of approximately 10 years or so.
Elbow arthritis is most commonly seen in patients suffering with rheumatoid arthritis and in people who receive regular trauma to the elbow, for instance rugby players who are prone to, aswell as injury and trauma that has been previously sustained.
The elbow joint is usually composed of three joints; the radius head, the ulna and the distal part of the humerus. It is a complex joint, and once the articular surface starts wearing down or developing a lot of new bone formation around it, it can cause pain and limitation of movement.
Investigations for elbow arthritis are fairly standard in the form of x-rays and also perhaps CT scans with or without an MRI scan. These investigations provide a good insight into the structural damage that has been caused to the joint.
Treatment recommendations are initially conservative to allow pain relief with physiotherapy and mobility exercises. However if pain becomes a major feature and functional deficit is significant where the hand cannot reach the mouth to perform normal activities of daily living, one would have to consider surgical intervention.
Surgery performed for the elbow is of two types initially:
An arthroscopic surgery (keyhole) which is essentially to allow improved movement and to a certain extent by trimming osteophytes and new bone formation around it to give it a better range of motion and also attempt pain relief as a result.
A more consistent, as far as results are concerned, is a total elbow replacement. This is a fairly complex operation needing a replacement of the entire elbow joint with a new artificial joint. This operation is usually fairly successful but is a complex operation.
Fractures of the elbow are a fairly complex clinical entity. It usually occurs on the tip of the elbow. Fractures can involve several aspects including a fracture of the distal humerus, fracture of the olecranon, fracture of the radius or a combined fracture of them all. We as clinicians use a significant classification systems to aid us in management protocols of these fractures.
The important management protocol of a fracture is to ensure that there is no associated dislocation, the articular or the joint surface is well aligned and to make a decision whether the fracture needs to be fixed or can be treated conservatively. Usually the fractures need some form of fixation due to the complexity of the various articular surfaces and joint surfaces in the elbow.
Most of the fractures are fixed with an incision on either the back or the side of the elbow. Fracture fixation involves screws, wires and specially pre-contoured plated to enable a secure fixation. Once the elbow fracture is fixed securely then a regular physiotherapy protocol is organised.
Outcomes of elbow fractures are usually good if they are fixed timely and are well aligned. However elbows do not always extend out fully and may remain bent in approximately 15-20 ̊ of flexion. However full flexion can be achieved.
The risks of operations for such fractures is elbow stiffness, infection, nerve injury to the ulnar nerve, median nerve and the radial nerve which would in turn affect or significantly alter hand function.
Sometimes these fractures, even though they are fixed, can lead to new bone formation, stiffness and even arthritis. They do need further treatment at a later stage if such a condition occurs.
It is a safe and simple operation that has instant benefits.
This is a situation which takes place in fairly young people. The presentation is when the elbow gets stuck in a certain position when using it whilst performing normal activities.
The main cause is when loose bony parts are floating around in the elbow joint. The genesis of this problem can be a previous injury or very early development of arthritis.
Management usually involves an x-ray, sometimes a CT scan or MRI scan, to find out what is causing the problem. If there are loose bodies then this can be easily treated with the removal of the loose bodies through an arthroscopy (keyhole surgery). The relief is instant and the recovery fully takes place in a matter of two weeks.
Tennis Elbow
Tennis elbow is a common problem associated with pain on the outer aspect of the elbow joint. The pain usually presents when attempting to grip an object or lift something. The main cause is either an injury due to pulling on something very hard or hurting the outer aspect of the elbow when one would do either a reverse or backhand return in tennis.
It is usually the inflammation of the common extensor tendons that arise from the lateral epicondyle. This inflammation starts due to either over use or a sudden jerk on the muscle tendon and bone unit.
The best initial treatment is rest, ice, ultrasound massage with physiotherapy and anti-inflammatories. Early treatment recommendation is a steroid injection into the region. All efforts to reduce inflammation help to treat the condition successfully early on.
However some of these problems become chronic and long standing. This becomes fairly difficult to get a good result with any conservative management and surgery is often necessary. Surgery can be performed in the form of an arthroscopic (keyhole) operation which usually cleans up the area of degenerative tendon tissue. This allows fresh healing and hence getting rid of the pain. Open surgery can be done if arthroscopic is not possible or successful. This type of surgical procedure is not always successful and success rates vary between 50-70%, hence is not always undertaken at the initial stages.
Once surgery is performed recovery usually takes place in approximately 4-6 weeks time. Rest and regular physiotherapy is advised and the patient can return to work and normal activity in the time mentioned above.
Golfer’s Elbow
The golfer’s elbow is a similar condition to tennis elbow but on the inner aspect of the elbow. It is the inflammation of the common flexor tendons arising from the medial epicondyle of the elbow.
The cause is similar and the treatment is also similar. However surgical intervention and injections are to be exercised with extreme caution due to a very important nerve, the ulnar nerve going in close proximity. Hence surgical intervention is fairly uncommon and not usually recommended due to the high possibility of a complication injury to the ulnar nerve.
Recovery is usually fairly swift with arthroscopic procedures in 2-3 weeks time but open procedures need at least 4-6 weeks to recover fully. Regular physiotherapy is essential in maintaining a good range of motion in the elbow.
There are several causes for a stiff elbow. The most common is peri-arthritis which is the development of new bone formation or thickening of the capsule around the elbow joint. The main articular joint surface of the elbow is usually normal, it is the edges that develop a lot of stiffness due to new bone formation and thickening and scarring of the capsule.
One of the main causes of stiffness is either a gradual onset of arthritis or an injury or trauma that has led to thickening of the capsule and contraction. Sometimes new bone formation can be seen on x-rays aswell.
Treatment essentially depends on trying to improve the range of motion, by either arthroscopic or open techniques.
The principal of the arthroscopic techniques is essentially to debride the capsule and remove bone. This doesn’t always succeed in the first instance and may take several attempts if necessary. the main aim is to get full flexion and extension is always limited and is difficult to achieve to full extension. Usually the patient ends up with 15-20 IS of extensor lack.
If arthroscopic techniques do not succeed then an open operative procedure is done in order to excise all of the contracture, capsule and new bone. This surgery is fraught with significant risks in the form of nerve injury, infection, recurrence or stiffness.
One of the most common dislocations is the radial head subluxation in a child which is also known as a ‘Pulled Elbow’. This is a condition which takes place when the child starts shrieking when someone has tried to pull on the arm and it can easily be reduced with some sedation and the pain suddenly disappears.
The other dislocation situation is seen in the elbow when someone falls heavily and the elbow slips out of the joint. The treatment is obviously an emergency reduction under general anaesthetic. Sometimes these dislocations are associated with fractures.
Depending on the presentation all of the dislocations need to be treated appropriately.
The risks from an elbow dislocation are nerve injury, a blood vessel getting pinched which leads to circulation problems and post reduction stiffness due to the amount of trauma which is caused by stripping off the ligament and capsule. The recovery following a dislocation being reduced in an adult is approximately 4-6 weeks.
Olecranon bursitis is an inflammation of the olecranon bursa which is present at the tip of the elbow.
It is usually caused by either leaning on the tip of the elbow or knocking it. It can also originate from an insect bite or a superficial infection.
An olecranon bursa can be presented as a red, hot, angry elbow swelling on the tip. The initial treatment is to treat it with antibiotics, rest and anti-inflammatories. Sometimes this problem can become chronic and develop a small ulcer or fistula leading to chronic drainage.
Such a situation requires a surgical excision of the olecranon bursa.
All surgical attempts to treat the olecranon bursa are not very successful. The biggest problem is usually a persistence of drainage from the olecranon bursa and usually takes several weeks for this to settle down. Hence surgery is not always advised as an initial stage of the procedure.