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Arthritis of the Elbow

How many times a day do you bend your elbow? Every time you eat or drink, sit at a desk to type or write, point the remote at the TV to change the channel—hundreds of times a day, you bend your elbow without even thinking about it. Now imagine if every time you bent your elbow, you felt the pain of arthritis.

For many Americans, this scenario is all too true. Arthritis of the elbow can cause pain not only when they bend their elbow, but when they straighten it, such as to carry a briefcase. The most common cause of arthritis of the elbow is rheumatoid arthritis (RA). Osteoarthritis (OA or "wear-and-tear" arthritis) and trauma can also cause arthritis in the elbow joint.

• RA is a disease of the joint linings, or synovia. As the joint lining swells, the joint space narrows. The disease gradually destroys the bones and soft tissues. Usually, RA affects both elbows, as well other joints such as the hand, wrist and shoulder.
• OA affects the cushioning cartilage on the ends of the bones that enables them to move smoothly in the joint. As the cartilage is destroyed, the bones begin to rub against each other. Loose fragments within the joint may accelerate degeneration.
• Trauma or injury to the elbow can also damage the articular cartilage. This eventually leads to the development of posttraumatic arthritis. Usually, this form of arthritis is confined to the injured joint.

Signs and symptoms

• Pain. In the early stages of RA, pain may be primarily on the outer (lateral) side of the joint. Pain generally worsens as you turn (rotate) your forearm. The pain of OA may intensify as you extend your arm. Pain that continues during the night or when you are at rest indicates a more advanced stage of OA.
• Swelling, particularly with RA.
• An inability to perform daily activities because the elbow is unstable and gives way.
• Inability to straighten (extend) or bend (flex) the elbow.
• "Catching" or locking of the elbow, particularly with OA.
• Stiffness, particularly with posttraumatic arthritis.
• Involvement of both elbows, or pain at the wrists and/or shoulders as well as the elbows, indicates RA.

Diagnosis and tests

During the physical examination, your physician will look for signs of tenderness and swelling. He or she will also assess your range of motion. The physician may try to recreate the pain by moving the joint. X-rays will show the joint narrowing as well as the presence of any loose bodies. If your pain is due to posttraumatic arthritis, the X-rays may show a malunion or nonunion of bones.

Nonsurgical Treatments

The initial treatment is nonsurgical and depends on the type of arthritis. Your physician will discuss the options with you and develop an individualized program of medical and physical activities. Among the therapies that can be used are:

• Activity modification. OA may be linked to repetitive overuse of the joint, so modifying job or sports activities can be helpful. Intermittent periods of rest can relieve stress on the elbow
• Medical management. Acetaminophen or ibuprofen can provide short-term pain relief. More potent agents can be prescribed to treat RA. These include antimalarial agents, gold salts, immunosuppressive drugs, and corticosteroids. An injection of a corticosteroid into the joint can often help.
• Physical therapies. Heat or cold applications and gentle exercises may be prescribed. A splint worn at night, or one that permits movement as it protects the elbow from stresses, may also be helpful. Other assistive devices, such as handle extensions, can be used to maintain daily activities.

Surgical options

If your arthritis does not respond to the above treatments, you and your physician may discuss surgical options. Because several nerves are near the elbow, a skilled orthopaedic surgeon should be consulted. Surgery usually results in improved pain control and increased range of motion.

The exact procedure will depend on the type of arthritis you have, the stage of the disease, and your own age, expectations, and activity requirements. Some of the options include:

• Arthroscopy. Using pencil-sized instruments and two or three small incisions, the surgeon can remove bone spurs, loose fragments, or a portion of the diseased synovium. This procedure can be used with both RA and OA.
• Synovectomy. The surgeon removes the diseased synovium. Sometimes, a portion of bone is also removed to provide a greater range of motion. This procedure is often used in the early stages of RA.
• Osteotomy. The surgeon removes part of the bone to relieve pressure on the joint. This procedure is often used to treat OA.
• Arthroplasty: The surgeon creates an artificial joint using either an internal prosthesis or an external fixation device. A total joint replacement is usually reserved for patients over 60 years old or patients with RA in advanced stages.

Biceps Tendinitis

The biceps muscle, in the front of the upper arm, helps stabilize the upper arm bone (humerus) in the shoulder socket. It also helps accelerate and decelerate the arm during overhead movement in activities like tennis or pitching. Strong, cord-like structures called tendons connect one end of the biceps muscle to the shoulder in two places. At the other end of the muscle, tendons connect the biceps muscle to the smaller bone (radius) in the lower arm. If the tendons become inflamed or irritated, the condition is called tendinitis.

Signs and symptoms

Injuries to the biceps tendons are commonly caused by repetitive overhead activity. Symptoms include:

• Pain when the arm is overhead or bent.
• Localized tenderness as the tendon passes over the groove in the upper arm bone.
• Occasionally, a snapping sound or sensation in the shoulder area.

Diagnosis and treatment

During the physical examination, the doctor will assess the shoulder area for range of motion, tenderness and signs of shoulder instability. He or she may ask you to raise or rotate the arm. X-rays may be requested to uncover associated conditions that might cause irritation. The doctor may also request an MRI that can show any damage to the tendons. Overuse, aging and stress can cause the tendon to deteriorate, even if there is no inflammation present.

Initial treatment is conservative. The first step is to rest the arm and shoulder. Switch to another sport or activity for awhile. Ice applications and nonsteroidal anti-inflammatory medications such as ibuprofen can help reduce inflammation. Your physician can also recommend stretching and progressive strengthening exercises to build muscle endurance and restore range of motion. Then you can gradually return to overhead activity.

Surgical options

If the pain results from shoulder instability or from pressure on the tendon from the shoulder bones, your orthopaedist may recommend arthroscopic surgery. Using fiber optic technology and miniature instruments inserted through a small incision, the surgeon can examine the shoulder joint and anchor the tendon properly.

After surgery, your orthopaedist will prescribe a rehabilitation program that includes stretching and strengthening exercises. Early movement is important, but you should wait for your physician’s approval before doing any heavy lifting or returning to sports.

Broken Arm

A broken arm is a common injury. Counting all fractures, about one in every 20 involve the upper arm bone (humerus). Children are more likely to break the lower arm bones (radius and ulna). Falling on an outstretched hand or being in a car crash or some other type of accident is usually the cause of a broken arm. Most people know right away if their arm broke, because there may be a snap or a loud cracking sound. The broken arm may appear deformed and be swollen, bruised and bleeding. A person with a broken arm usually has:

• Extreme pain at the site of the injury.
• Pain increased by any movement.
• Loss of normal use of the arm.

First aid

First make sure the injured person is out of the way of further harm. Is he or she breathing normally? Is there a good pulse? Call 911 if there is serious bleeding, reason to suspect multiple broken bones or other injuries. To slow bleeding and reduce swelling, elevate the injured arm above the level of the person’s heart. If a broken bone sticks out from the skin (open fracture), do not try to push it back in. Use a clean, dry cloth or bandage to cover it until medical help arrives.

It is important that the injured person not try to use the broken arm. Moving a broken arm would also cause more damage to blood vessels, nerves and other tissues. To immobilize a broken arm:

• Make a temporary splint. Immobilize the joints above and below the site of the injury. You can use wood or rolled up magazines, making sure both ends of the splint extend far beyond the injured region. You can use cloth, belts or tape to fasten the splint. Avoid any constriction of the arm with the supporting strap.
• Make a sling. This stabilizes the injury and supports the splint. A broken arm sling can be as simple as a loop of cloth supported from the neck.

Take the injured person to a doctor right away.

Doctor’s treatment

Exam: Tell the doctor exactly what happened. He or she will physically examine the broken arm and check for other injuries, such as nerve damage. The doctor may want to see if the patient can flex and extend the wrist and fingers. Sometimes the doctor may use X-rays or other diagnostic imaging tools to see the bones of both the injured and uninjured arms. If the patient is a child, the long bones of the arm are probably still growing. So the doctor will look carefully for any damage to growth plates.

Reduction: The doctor may need to move pieces of bone back into their correct positions (a process called reduction). Depending upon the severity of injury, the patient may or may not need anesthesia. Those with more serious fractures may require surgery.

Immobilization: With the broken bone back in place, the doctor immobilizes the arm. Most patients get a cast or splint. The doctor tells the patient how long to wear the cast or splint, and removes it at the right time.

Rehabilitation

It may take from several weeks to several months for the broken arm to heal completely. Rehabilitation involves gradually increasing activities to restore muscle strength, joint motion and flexibility. The patient’s cooperation is essential to the rehabilitation process. The patient must complete range of motion, strengthening and other exercises prescribed by the doctor. Rehabilitation lasts until tissues perform their functions normally. After rehabilitation, the doctor may want to see the arm again to make sure healing is complete.

Colles Fracture

When someone begins to fall, they almost always extend their hand to reduce the force of hitting the ground. When they fall on the outstretched hand, the sudden impact of their body weight on the hand may cause the end of the lower arm bone (radius) to fracture just above the wrist. This is known as a Colles fracture.

Colles fractures are very common injury among adults. Particularly at risk are middle-aged to elderly women who suffer from the bone weakening disease, osteoporosis.

Signs of a Colles fracture include pain and swelling just above the wrist, and inability to hold or lift objects of any significant weight. The wrist may be pushed back over the broken bone resulting in a "forked" appearance of the hand. X-rays of an injured wrist will reveal the extent of injury.

Treatment may include repositioning bones and immobilization such as a splint or cast. Fractures with three or more pieces of broken bone, known as a comminuted fracture, may require pins or other devices to hold the bones in proper position while they heal.

Many patients heal from a Colles fracture without any complications, but some people may not regain full mobility of their wrist joints. Chronic pain may result from ligament injury. Other possible complications include post-traumatic arthritis and median nerve damage/compression leading to carpal tunnel syndrome.

Osteoporosis is a factor in as many as 250,000 wrist fractures. It has been suggested that people who suffer a wrist fracture may need to be screened for osteoporosis, especially if they have other risk factors.

Dislocated Elbow

A dislocated elbow is one of the most common injuries that occur when you fall. It happens when you fall on your outstretched hand and the bones in your elbow are knocked out of position. In adults, it's second only to a dislocated shoulder. But dislocated elbows are common among children and adolescents, too. In fact, in children, the elbow is the most commonly dislocated joint.

You'll know when it happens. You'll feel immediate intense pain, your elbow won't bend and it swells.

Treatment

If you think your elbow is dislocated, try to immobilize it and go to a doctor immediately for evaluation and treatment. Your doctor or emergency room physician will put your dislocated elbow back into place right away. You may need a local anesthetic. If your injury is more than several hours old, you may need general anesthesia because of swelling and muscle spasm.

Once your elbow joint is back in place, your doctor may flex, extend and rotate your arm to make sure it is stable and capable of all its motions. Your doctor may also take X-rays to check for other injuries such as fractures and nerve damage. In some cases, these injuries may require additional treatments, including surgery.

Assuming your elbow was stable after your doctor put it back in place and you have no other major injuries such as a fractured bone in the elbow, you will wear a splint for only a few weeks. You may take nonsteroidal anti-inflammatory medications such as ibuprofen to ease any pain. Your doctor will tell you when you’re ready to begin exercises to work your elbow back to full function. Depending on the severity of the injury, it may take many months of physical therapy for your elbow to return to normal function.

 

Elbow Bursitis

When you rub your elbow, you can feel the hard bones of your forearm. What you can’t feel is the olecranon (oh-LEK-ra-non) bursa, a slippery sac between the loose skin of the elbow and the bones of your forearm.

Normally, the bursa acts as a cushion between the skin and the bone. But if the elbow is hit, or if you put constant pressure against the tip of the elbow (as when you lean on a desk or other hard surface), the bursa can become inflamed and irritated, a condition called bursitis. The bursa begins to swell, and may create a lump over the tip of the elbow.

Signs and symptoms

• Gradual swelling indicates a chronic or long-lasting condition.
• Sudden swelling indicates a traumatic injury or an infection in the elbow.
• If the elbow was injured, the skin may be scraped or cut.
• Red, hot skin may indicate an infection.
• Pain and tenderness is variable.
• Motion may be limited if there was a traumatic injury to the elbow.

Treatment

Generally, RICE is the first line of treatment for bursitis. If you notice that your elbow is sore or gradually beginning to swell, follow these guidelines:

• Rest: Take a break from whatever activity is causing the elbow to swell or become painful.
• Ice: Apply ice packs for short periods of time (15 to 20 minutes, three or four times a day).
• Compression: Wrap an elastic bandage around the elbow to keep swelling down.
• Elevation: Elevate the elbow above the level of your heart.

However, if the bursitis swelling comes on suddenly or if you experienced a direct blow to the elbow, see your orthopaedist. You may need X-rays to rule out the possibility of a fracture.

Your doctor may recommend aspirating, or draining, the bursa. This is an outpatient procedure that can be done in the doctor’s office. The fluid from the bursa is removed with a syringe. An anti-inflammatory medication such as ibuprofen can help reduce pain and swelling. An elbow protector or padding can help reduce the risk of further injury.

Another treatment that may be used is an injection of a corticosteroid, a powerful anti-inflammatory drug. A final option is surgery to remove the bursa.

 

Elbow Fractures in Children

If your child is an active athlete, there’s a good possibility that he or she will take a spill on the field or court at some time. These falls are usually harmless; but when a young athlete falls on an outstretched arm, the velocity of the fall combined with the pressure of hitting the ground could be enough to break a bone. That’s how most fractures around the elbow joint occur. These fractures account for about 10 percent of all fractures in children.

Types of fractures

A child can experience a fracture in several places about the elbow, including:

• Above the elbow (supracondylar): The upper arm bone (humerus) breaks, slightly above the elbow. These fractures usually occur in children younger than 8 years of age. This is the most common elbow fracture, and one of the more serious because it can result in nerve damage and impaired circulation.
• At the elbow knob (condylar): This type of fracture occurs through one of the bony knobs (condyles) at the end of the upper arm bone. Most occur through the outer (lateral) knob. These fractures require careful treatment, because they can disrupt both the growth plate (physeal) and the joint surface.
• At the inside of the elbow tip (epicondylar): At the top of each bony knob is a projection called the epicondyle. Fractures at this point usually occur on the inside (medial) epicondyle in children between 9 and 14 years of age.
• Growth plate: The upper arm bone and both lower arm bones have growth plates located near the end of the bone. A fracture that disrupts the growth plate can result in arrested growth and/or deformity if not treated promptly.
• Forearm: An elbow dislocation can break off the head of the thumb-side lower arm bone (radius), and excessive force can cause a compression fracture to the bone as well. Fractures of the tip (olecranon) of the other lower arm bone (ulna) are rare.

Signs and symptoms

Regardless of where the break is, the symptoms of a broken elbow are similar:

• Acute pain
• Tenderness
• Swelling (may be severe or mild)
• Limited movement

Diagnosis and treatment

If your child complains of elbow pain after a fall and refuses to straighten his or her arm, see a doctor immediately. The doctor will first check to see whether there is any damage to the nerves or blood vessels. X-rays will help determine what kind of fracture occurred and whether the bones moved out of place. Because a child’s bones are still forming, the doctor may request X-rays of both arms for comparison.

Treatment depends on the type of fracture and the degree of displacement. If there is little or no displacement, the doctor may immobilize the arm in a cast or splint for 3 to 5 weeks. During this time, another set of X-rays may be needed to determine whether the bones are staying properly aligned.

If the fracture forced the bones out of alignment, the doctor will have to manipulate them back into place. Sometimes, this can be done without surgery, but more often, surgery will be needed. Pins, screws or wires are used to hold the bones in place. The child will have to wear a cast for several weeks before the pins are removed. Range of motion exercises can usually begin about a month after surgery.

Preventing injuries

If your child is an active athlete, make sure that he or she wears the proper protective equipment. Elbow guards and pads can help reduce the risk of a fracture about the elbow.

 

Erb's Palsy (Brachial Plexus Injury)

If your newborn can move one arm but not the other, he or she may have a condition called Erb’s palsy. The inability to move the arm is a symptom of an injury to the brachial plexus (BRAY-key-el PLEK-sis), a network of nerves that provides movement and sensation to the arm, hand and fingers. One or two of every 1,000 babies have this condition. Most infants with Erb’s palsy will recover both movement and sensation in the affected arm without surgery. But parents must be watchful and active participants in the treatment process to ensure maximum functional recovery.

How it happens

The nerves to the arm, hand and fingers exit the spinal cord between the bones (vertebrae) of the neck and travel into the arm below the collarbone (clavicle). The nerves to the arm exit high in the neck; those that go to the hand and fingers exit lower in the neck, just above the chest. These nerves branch and join together near where the neck joins the shoulder, in an area called the brachial plexus.

Brachial plexus injuries in newborns usually occur during a difficult delivery, such as with a large baby, a breech presentation, or a prolonged labor, when the person assisting the delivery must exert some force to pull the baby from the birth canal. One side of the baby’s neck is stretched, which can damage the nerves by stretching or tearing them. If the upper nerves are affected, the condition is called Erb’s palsy. The infant may not be able to move the arm, but may be able to move the fingers. Injuries that involve both the upper and lower nerves are more severe and result in a condition called global palsy.

There are four types of nerve injuries to the brachial plexus.

• Avulsion injuries. The nerve is torn from its attachment to the spinal cord. This is the most serious type of injury.
• Rupture injuries. The nerve is torn, but not at the spinal cord.
• Neuroma injuries. These injuries result from scar tissue that forms and puts pressure on the nerve.
• Stretch injuries. These injuries, known as neurapraxia (new-rah-PRAK-see-ah) are the most common. The nerve is damaged but not torn. Normally, these injuries heal on their own, usually within three months.

The symptoms of a nerve injury (paralysis and loss of feeling) are the same, regardless of the type of injury. However, the severity of the injury does affect both treatment decisions and the extent of recovery possible.Diagnosis A newborn with Erb’s palsy will have the arm straight down at the side and will not move it. Sometimes, the arm may be slightly turned, with a bent wrist and straight fingers. A droopy eyelid on the affected side may indicate a more severe injury. The doctor may order an X-ray or magnetic resonance image (MRI) to see if there is any damage to the bones and joints of the neck and shoulder. The doctor may also use an electromyogram (EMG) or nerve conduction studies (NCS) to see if any nerve signals are present in the upper arm muscle.

Because most newborns with Erb’s palsy recover without surgery, your baby will be examined again at one month and at three months to see if the nerves are recovering by themselves. It may take up to two years for complete recovery. During this time, range of motion exercises are very important to keep the baby’s joints from getting stiff.

Treatment

If there is no change over the first three months, nerve surgery may be helpful. However, nerve surgery will not restore normal function or help infants over one year old. After surgery, the infant will wear a splint for approximately three weeks. Because nerves grow at a rate of one inch per month, it may take several months, or even years, for nerves repaired at the neck to reach the muscles of the lower arm and hand.

Some children with brachial plexus injuries will continue to have weakness in the shoulder, arm or hand. They may find it difficult to raise the hand over the head, to turn the hand palm up, or to extend the wrist. In some of these cases, a surgical procedure called tendon transfer may be helpful. Tendons are the connective tissues between muscle and bone. The surgeon will separate the tendon from its normal attachment and reattach it in a different place. This is often helpful in improving shoulder and wrist motions as well as elbow position and hand grip.

Tendon transfers are generally performed when the child is old enough to follow instructions. After surgery, the child will have to wear a cast for about six weeks and a splint at night for up to six months. Physical therapy may continue for up to one year after surgery.

Your doctor will discuss the various treatment options with you and make a specific recommendation based on your child’s individual situation. Do not hesitate to ask questions; there is much that parents can do to help ensure a good functional outcome.

Special considerations

Because your baby cannot move the affected arm alone, it is important that you take an active part in keeping the joints limber and the functioning muscles fit. Your doctor will recommend physical therapy and range of motion exercises. Do these exercises with your baby every day, two or three times a day, beginning when your baby is about three weeks old. The exercises will maintain a range of motion in the shoulder, elbow, wrist and hand and prevent the joint from becoming permanently stiff, a condition called a joint contracture.

Sometimes, the affected arm is noticeably smaller than the unaffected arm. This occurs because the arm is not used as much. Although the size difference is permanent, it will not increase with age. You should also remember that your child is very adaptable. Be supportive and encouraging; focus on what your child can do. This will help your child develop a healthy sense of self-esteem and adjust to any functional limitations.

 

Forearm Fractures in Children

Children love to run, hop, skip, jump and tumble. But if they fall onto an outstretched arm, they could break one or both of the bones in the lower arm. Forearm fractures account for 40 to 50 percent of all childhood fractures. Fractures can occur near the wrist at the farthest (distal) end of the bone, in the middle of the forearm, or near the elbow at the top (proximal) end of the bone.

The bones of the forearm are the radius and the ulna. If you hold your arm naturally by your side, the ulna is the bone closer to you, and the radius is further away. About three out of four forearm fractures in children involve the wrist-end of the radius.

Signs and symptoms

• Any type of deformity about the elbow, forearm or wrist
• Acute pain
• Tenderness
• Swelling
• An inability to rotate or turn the forearm

A child’s bones begin to heal much more quickly than an adult’s bones. If you suspect a fracture, you should obtain prompt medical attention for the child so that the bones can be set for proper healing.

Types of fractures

• Torus fracture: Also called a "buckle" fracture. The topmost layer of bone on one side of the bone is compressed, causing the other side to bend away from the growth plate. This is a stable, nondisplaced fracture.
• Metaphyseal fracture: The break is across the shaft of the bone and does not affect the growth plate.
• Greenstick fracture: The break extends through a portion of the bone, causing it to bend on the other side.
• Galeazzi fracture: Affects both lower arm bones; there is usually a displaced fracture in the radius, and a dislocation at the wrist where the radius and ulna come together.
• Monteggia fracture: Affects both lower arm bones; there is usually a fracture in the ulna, and the head of the radius is dislocated. This is a very severe injury and requires urgent care.
• Growth plate fracture: Also called a physeal fracture. The break occurs at or across the growth plate. Usually these fractures affect the growth plate near the wrist on the radius.

Diagnosis and treatment

The hand, wrist, arm and elbow can all be injured during a fall on an outstretched arm. To determine exactly what injuries occurred, the doctor will probably want to see X-rays of the elbow and wrist as well as the forearm. The doctor will also test to make sure that the nerves and circulation in the hand and fingers are not affected.

Treatment depends on the type of fracture and the degree of displacement. If the bones do not break through the skin, the physician may be able to push (manipulate) them into proper alignment without surgery. However, surgery to align the bones and secure them in place may be required if:

• The skin is broken
• The break is unstable
• Bone segments have been displaced
• The bones cannot be aligned properly through manipulation alone
• The bones have already begun to heal at an angle or in an improper position

After the bones are aligned, the physician may use pins or a cast to hold them in place until they have healed. A stable fracture such as a buckle fracture may require three to four weeks in a cast; a more serious injury such as a Monteggia fracture-dislocation may need to be immobilized for six to ten weeks. If the fracture disrupts the growth plate at the end of the bone, the physician will probably want to watch it carefully for several years to ensure that growth proceeds normally.

 

Olecranon (Elbow) Fractures

When you bend your elbow, you can easily feel its "tip," a bony prominence that extends from one of the lower arm bones (the ulna). That tip is called the olecranon (oh-lek’-rah-nun). It is positioned directly under the skin of the elbow, without much protection from muscles or other soft tissues. So it can easily break if you experience a direct blow to the elbow or fall on a bent elbow.

Signs and symptoms

• Sudden, intense pain.
• Bruising around the elbow.
• Rupture or abrasion of the overlying skin.
• Possible deformity, if there is also a dislocation of the bone.
• Tenderness and swelling over the bone site.
• Numbness in one or more fingers.
• Pain with movement of the joint.

Evaluation and classification

It is important to see a physician and verify that there is no associated damage to nerves or blood vessels. Your physician will use X-rays to confirm the diagnosis and classify the type of fracture. Fractures are generally divided into three types, depending on the stability of the joint and the amount of separation among the broken pieces of bone. (Note: Some fractures can have characteristics of more than one category.)

• Type I fractures are generally stable with little displacement. These fractures can generally be treated nonsurgically.
• Type II fractures are the most common. They are relatively stable, although there is displacement of the bone pieces.
• Type III fractures are displaced and involve more than 50 percent of the joint surface, resulting in joint instability.

Treatment

Treatment depends on the type of fracture.

• A type I fracture can usually be treated with a splint or sling to hold the elbow at a 90 degree angle. The physician will request a second set of X-rays after 10 days to make sure that the broken pieces have not become displaced. Gentle motion is permitted, and hand and wrist exercises should be done daily.
• A type II fracture is best treated surgically. The orthopaedic surgeon will use a plate or a combination of wires and pins or screws to hold the bones in place. Physical therapy to maintain range of motion will start a day or two after the operation, and continue for at least six weeks.
• Type III fractures are also treated surgically, usually with a plate that fits under the ulna and around the tip of the elbow. Screws hold the plate in place. You will have to wear a splint for a couple of days, then physical therapy to maintain range of motion will begin.

Fractures of the tip of the olecranon that do not involve the joint are may be treated by removing the small fragment and repairing the tendon that has pulled off. Elderly people who experience a type II or type III fracture may be treated with a sling and early range of motion instead of surgery. Athletes who have stress fractures of the olecranon are treated with activity restriction, stretching and range of motion exercises, and substitution activities for 8 to 12 weeks, although complete recovery may take three to six months.

Radial Head Fractures

Trying to break a fall by putting your hand out in front of you seems almost instinctive. But the force of the fall could travel up your lower forearm bones and dislocate your elbow. It also could break the smaller bone (radius) in the forearm. The breaks can occur at the wrist (Colles fracture), or near the elbow at the radial "head."

Radial head fractures are common injuries, occurring in about 20 percent of all acute elbow injuries. They are more frequent in women than in men and occur most often between 30 and 40 years of age. Approximately 10 percent of all elbow dislocations involve a fracture of the radial head. As the upper arm bone slides back into its appropriate place after the dislocation, it can chip off a piece of the radial head, resulting in a fracture.

Signs and symptoms

If you have any of these signs or symptoms after a fall, see your doctor:

• Pain on the outside of the elbow.
• Swelling in the elbow joint.
• Difficulty in bending or straightening the elbow accompanied by pain.
• Inability or difficulty in turning the forearm (palm up to palm down or vice versa).

Fracture types and treatments

Radial head fractures are classified according to the degree of displacement (movement from the normal position).

Type I fractures are generally small, like cracks, and the bone pieces remain fitted together.

• The fracture may not be visible on initial X-rays, but can usually be seen if the X-ray is taken three weeks after the injury.
• Nonsurgical treatment involves using a splint or sling for a few days, followed by early motion.
• If too much motion is attempted too quickly, the bones may shift and become displaced.

Type II fractures are slightly displaced and involve a larger piece of bone.

• If displacement is minimal, splinting for one to two weeks, followed by range of motion exercises, is usually successful.
• Small fragments may be surgically removed.
• If the fragment is large and can be fitted back to the bone, the orthopaedic surgeon will first attempt to fix it with pins or screws. If this is not possible, however, the surgeon will remove the broken pieces or the radial head.
• For older, less active individuals, the surgeon may simply remove the broken piece, or perhaps the entire radial head.
• The surgeon will also correct any other soft-tissue injury, such as a torn ligament.

Type III fractures have more than three broken pieces of bone, which cannot be fitted back together for healing.

• Usually, there is also significant damage to the joint and ligaments.
• Surgery is always required to remove the broken bits of bone, including the radial head, and repair the soft-tissue damage.
• Early movement to stretch and bend the elbow is necessary to avoid stiffness.
• A prosthesis can be used to prevent deformity if elbow instability is severe.

Even the simplest of fractures will probably result in some loss of extension in the elbow. Also, regardless of the type of fracture or the treatment used, physical therapy will be needed before resuming full activities.

Rupture of the Biceps Tendon

A pro football player attempts an arm tackle and hears a pop in his upper arm. A weightlifter doing curls suddenly feels his shoulder "bubble." A woman rearranging the living room furniture gets a sharp pain in her shoulder. Each of these individuals just ruptured their biceps tendon.

Tendons attach muscle to bone. The biceps muscle in the upper arm splits near the shoulder into a long head and a short head. Both attach to the shoulder in different places. At the other end of the muscle, the distal biceps tendon connects to the smaller bone (radius) in the lower arm. These connections help the muscle stabilize the shoulder, rotate the lower arm and accelerate or decelerate the arm during overhead motions such as pitching.

The long head of the biceps tendon is vulnerable to injury because it travels through the shoulder joint to its attachment point. If it tears, you may lose some strength in your arms and be unable to turn your arm from palm down to palm up. Because the torn tendon can no longer keep the muscle taut, you may also notice a bulge in the upper arm (Popeye muscle). If the distal tendon tears, you may be unable to lift items or bend your elbow.

Possible causes

Ruptures of the distal tendon near the elbow are rare. They usually occur when an unexpected force is applied to a bent arm. For example, a snowboarder can rupture the distal biceps tendon if he or she uses the arm to try to break a fall during a turn.

The proximal biceps tendons near the shoulder tear more easily. Tears can be either partial or complete. Often, these tendons are already frayed, particularly if you are over 40 years of age, have a history of shoulder pain, and participate in activities that involve overhead motions. Among the elderly, biceps tendon ruptures near the shoulder are often associated with rotator cuff tears.

Signs and symptoms

• Sudden, sharp pain in the upper arm.
• Sometimes, an audible snap.
• A bulge in the upper arm above the elbow, and a dent closer to the shoulder.
• Bruising from the middle of the upper arm down toward the elbow.
• Pain or tenderness at the shoulder.

Diagnosis and treatment

Your physician will examine your arm and ask you to bend the arm and tighten the biceps muscle. The doctor may apply pressure to the top of the arm to see if there is any pain. If you have a history of shoulder pain, your doctor may request an MRI or a special X-ray called an arthrogram to see if you have also torn the rotator cuff muscle.

Conservative treatment is usually all that is needed for tears in the proximal biceps tendons.

• Ice applications keep down the swelling.
• Nonsteroidal anti-inflammatory medications such as ibuprofen reduce pain.
• You should also rest the muscle, limiting your activity when you feel pain or weakness.
• To keep the shoulder mobile and strengthen the surrounding muscles, your doctor may prescribe some flexibility and strengthening exercises.
• Surgical repair of a complete tendon tear can be done for younger individuals whose work involves heavy labor or lifting.

Complete tears of the distal biceps tendon require surgery to reattach the tendon to the bone. Range of motion exercises can begin as early as two weeks after surgery, although forceful biceps activity is often restricted for four to six months. Partial tears of the distal biceps tendon may be treated either conservatively or surgically. You and your orthopaedic surgeon should discuss the options for your specific case.

 

Tennis Elbow

Tennis players and golfers are familiar with elbow pain. But baseball players, home fix-it enthusiasts and gardeners also may experience the symptoms of "tennis elbow" or "golfer’s elbow."

Tennis elbow is a painful condition on and around the bony prominence (epicondyle) on the outside (lateral side) of the elbow. This location gives tennis elbow its technical name: lateral epicondylitis. Pain may radiate down your arm. Gripping or extending your wrist may intensify the pain.

Golfer’s elbow describes a similar condition. The pain focus is the knobby bump on the inside of the elbow closest to the body (the medial side), so it is technically known as medial epicondylitis.

Both tennis elbow and golfer’s elbow typically result from repetitive arm movement. Over-using the muscles in your arm can lead to tiny tears in the tendons that attach the muscles in your forearms to the epicondyles. If you continue to do the activity without allowing the tears to heal, the tendons can become inflamed. This condition can be caused by excessive use of your arm in long sessions practicing your golf swing or tennis stroke and in many other activities, including painting, raking, pitching, rowing, hammering and using a screwdriver.

If you’ve increased your activity in one of these areas and feel tenderness in the elbow or pain that radiates down the arm, take some time off. Stop doing whatever is causing the symptoms. Rest allows the microtears to heal. If the symptoms are sports-related, you might examine your technique and equipment.

Conservative treatment usually works. Applying ice helps reduce swelling. An anti-inflammatory medication, such as aspirin or ibuprofen, can also help. If symptoms don’t subside in two or three weeks, call your doctor. You may have to wear an arm brace for some time. Occasionally, injections of cortisone-based steroidal medication may be used.

Flexibility and strengthening exercises are effective and will eventually allow you to return to the activity. You can find more information on overuse injuries and sprains and strains on this web site.

Throwing Injuries in the Elbow

With the start of the baseball season each spring, doctors frequently see an increase in elbow problems in young baseball players. A common elbow problem is Little Leaguer’s Elbow.

Little Leaguer’s Elbow affects pitchers and other players who throw repetitively. This condition may cause pain on the inside of the elbow.

The elbow is the joint where the upper arm bone (humerus) meets the two bones of the lower arm (ulna and radius). The elbow is a combination hinge and pivot joint. The hinge part of the joint lets the arm bend like the hinge of a door; the pivot part lets the lower arm twist and rotate. The rounded ends of the upper arm bone give the elbow its two "knobs" or bumps (epicondyle). Several muscles, nerves and tendons (connective tissues between muscles and bones) cross at the elbow.

Injury occurs when the repetitive throwing creates an excessively strong pull on elbow tendons and ligaments. The young player feels pain at the knobby bump on the inside of the elbow.

Little Leaguer’s Elbow can be serious if it becomes aggravated. Repeated pulling can tear the ligament and tendon away from the bone. The tearing may pull tiny bone fragments with it in the same way a plant takes soil with it when it is uprooted. This can disrupt normal bone growth, resulting in to a deformity.

Osteochondrosis dissecans is a less common condition that is also caused by excessive throwing and may be the source of the pain on the outside of the elbow.

Muscles work in pairs. In the elbow, if there is pulling on one side, there is pushing on the other side. As the elbow is compressed, the joint smashes immature bones together. This can loosen or fragment the bone and cartilage. The resulting condition is called osteochondrosis dissecans.

If left untreated, osteochondrosis dissecans can become a complicated condition. Surgery may be necessary, especially in girls over 12 years old and boys over 14 years old. Younger children, however, tend to respond better to nonsurgical treatments.

What to do

A child should stop throwing if any of the following symptoms appear: elbow pain, restricted range of elbow motion, or locking of the elbow joint. Continuing to throw may lead to major complications, and jeopardize a youngster's ability to remain active in a sport that requires throwing.

• Rest the affected area.
• Apply ice packs to bring down any swelling.
• If pain persists after a few days of complete rest of the affected area or if pain recurs when throwing is resumed, stop the activity again until the youngster gets treatment.

Ulnar Nerve Entrapment

If you’ve ever bumped your elbow and felt a tingling sensation down your arm into your hand (hitting your "funny bone"), you’ve bumped the ulnar nerve. But the ulnar nerve also can be the cause of more serious and permanent problems in the fingers and hand.

The ulnar nerve extends down the arm, across the elbow, and into the hand. It provides sensation to the little and ring fingers and activates many of the small muscles in the hand. You can actually feel this nerve as it passes behind the elbow and through a tight tunnel (the cubital tunnel) at the inside of the elbow.

The problem An injury to the elbow such as a dislocation or fracture can tear or inflame the ulnar nerve. The inflamed nerve can swell and become trapped in the cubital tunnel. This gives the condition its name, ulnar nerve entrapment. It is often also called cubital tunnel syndrome.

Prolonged pressure on the nerve also can be a problem. Bending the elbow stretches the ulnar nerve and puts pressure on it as it passes through the cubital tunnel, pressing it against the bone. This constant rubbing can damage the nerve’s protective covering (myelin sheath) or the nerve itself and disrupt the nerve’s ability to conduct messages from the brain. Gradually, the muscles of the hand start to weaken, so that it becomes difficult to open a jar or grasp a tool.

Signs of a problem

Although the problem is in the elbow area, most symptoms occur in the hand and fingers because the ulnar nerve controls movement and sensation there. Both sensory and motor skills are affected. Symptoms include:

• Tenderness along the inside of the elbow.
• Tingling and numbness in little and ring fingers (especially at night).
• Numbness in your hand when the elbow is bent, such as when you drive or hold a telephone.
• Difficulty with hand coordination (such as when typing or playing a musical instrument).
• Decreased grip and pinch strength; muscle weakness.
• Pain along the inside border of the shoulder blade.

If you experience any of these symptoms, contact a physician. Early diagnosis and treatment is essential to controlling symptoms.

Diagnosing the problem

A physician can use several methods to diagnose ulnar nerve entrapment. Your own description of the symptoms is a primary source of information. If you’ve experienced a fall, blow or other injury to the elbow, the physician may request an X-ray. The physician may also apply pressure around the nerve to see if pain or tingling results, check to see if the hand muscles are atrophying, or do an electrical stimulation test to see how well the nerve conducts sensory information.

Who’s at risk

• Anyone who falls on or injures their elbow
• People whose jobs involve excessive bending of the elbow (typists or data entry operators, drivers)
• Diabetics
• People with arthritis or thyroid problems
• Alcoholics

Nonoperative (conservative) treatment

• Keep the elbow as straight as possible. A straight elbow puts less pressure on the ulnar nerve.
• Avoid crossing your arms across your chest.
• If you frequently use the telephone, consider using a headset or cradle attachment, so you don’t have to hold the telephone to your ear with a bent elbow.
• Adjust your workspace so that you don’t have to bend your elbow more than 30 degrees and you can keep your wrist in a neutral position.
• Consider wearing a splint at night. Something as simple as a towel wrapped around the elbow can help keep it straight.
• Use elbow protectors if you play sports to avoid bumping the elbow.
• If muscle atrophy and numbness continues, corticosteroids may be used to reduce swelling and pressure.

Operative treatment

If conservative treatment is not effective and muscle strength continues to weaken, further evaluation and surgery may be needed. There are several surgical options; the most frequent type of surgery (anterior submuscular transposition) moves the nerve from behind the bone to the front of the elbow. After the surgery, treatment must focus on maximizing the use of the hand and arm through physical therapy. This process can take several months.

 

Source: American Academy of Orthopaedic Surgeons

Disclaimer

The material on SLOC.org is for informational purposes only and is not a substitute for medical advice or treatment for any medical conditions. You should promptly seek professional medical care if you have any concern about your health, and you should always consult your physician before starting a fitness regimen.