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common injuries - elbow

Loose Bodies

Description
Occasionally, small pieces of cartilage or bone chips may break off in the elbow joint, and catch or get stuck in the joint.
Common Causes
Elbow trauma, such as a direct blow to the elbow, or a fall on the outstretched arm. Sometimes a long period of time elapses between the initial injury and the development of loose bodies.
Symptoms
Pain in the elbow. A sense of catching, or getting 'stuck'. There may be loss of motion, or actual locking of the elbow.
Physical Findings
There may be areas of tenderness on physical examination, loss of joint motion, or swelling in the elbow. Often the exam is surprisingly unremarkable.
Workup
History and physical examination. X-rays may show bony loose bodies (cartilage is invisible on x-ray). Rarely, an MR scan or CT scan may be ordered to assist in locating loose bodies.
Non-Operative Treatment
Generally not too helpful. Anti-inflammatory medication, and corticosteroid injections my reduce symptoms.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
Arthroscopy, with removal of the loose body, is the treatment of choice.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments
Arthroscopy is usually curative for this problem, and leaves minimal scars while allowing rapid return to work and sports. Even after successful removal of loose bodies, new loose bodies may occur later on.

Tendonitis/ Medial and Lateral Epicondylitis/ Tennis Elbow/ Golfer's Elbow

Description
The forearm muscles that are involved in gripping, squeezing, and lifting are attached both to the wrist and to the elbow. If those muscles are overloaded, or overstressed, they can partially tear at either end. Frequently the muscle attachment (tendon) becomes injured at its insertion on either the inside or outside of the elbow (epicondylitis).
Tendons(hide)

Tendons are the strong whitish tissues that attach muscles to bones. All muscles cross a joint, and when the muscle contracts, the joint moves. If the muscle is overloaded beyond its normal strength, the tendon may begin to tear, causing a strain. These may range from a mild strain, which heals quickly, to a complete tendon rupture. Since the normal elasticity of the muscle causes the torn tendon to pull away from the bone, the tendon end does not remain near its normal attachment. This means that most complete tendon ruptures will not heal normally, and thus many complete tendon ruptures require surgical repair.

Common Causes
Excessive gripping or squeezing; too much tennis, golf, weightlifting, gardening, hammering, etc. Chronic overuse of the wrist extensor muscles; excessive keyboarding.
Symptoms
Pain in the outside (lateral) or inside (medial) aspect of the elbow, exacerbated with gripping or squeezing. Usually pain free at rest.
Physical Findings
Tender at either the medial or lateral epicondyle of the elbow.
Workup
Diagnosis is almost entirely made by history and physical examination. Occasionally x-rays are helpful.
Non-Operative Treatment
Rest and anti-inflammatory medication will reduce symptoms. The use of forearm bands and wrist splints allows the injured tendon to rest. Corticosteroid injections are often very helpful in speeding recovery. Physical therapy too early can actually aggravate symptoms; Gentle strengthening is helpful once the pain has resolved.
Surgical Treatment
Fasciotomy, or the release/removal of injured tissue.
Comments

Surgery is rarely required, as non-operative treatment is successful in the majority of cases. Recovery is usually slow, however, and may take many months.

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Cubital Tunnel Syndrome/ Ulnar Nerve Neuritis

Description
Cubital tunnel syndrome is due to excessive pressure on one of the major nerves to the arm and hand (the ulnar nerve), as it crosses around the back of the inside of the elbow.
Common Causes
Repeated activities with a flexed elbow, including driving, sleeping, keyboarding, weightlifting etc.
Symptoms
Earliest symptoms are numbness, tingling, or pain in the ring and small fingers, at night or with the aggravating activity. Later on, weakness and coordination difficulties develop.
Physical Findings
History and physical examination, with a positive 'Tinel's sign', and 'Elbow Flexion Test'. Impaired function of the muscles innervated by the Ulnar nerve are found late.
Workup
Occasionally, electrodiagnostic studies (nerve conduction tests and electromyography) will be required to confirm the diagnosis, and its severity.
Electrodiagnostic Studies(hide)

Key words: electrodiagnostic, NCV, EMG, nerve conduction, electromyography

Electrodiagnostic studies refer to two different tests that examine the health of muscles and nerves.

Nerve Conduction Velocities (NCV) test how well a nerve can conduct an electrical signal, much like a wire conducts electricity. By giving a nerve a small stimulation, and then measuring how long it takes to conduct that signal to another point, the physician can calculate the speed of nerve conduction. If a nerve is injured or compressed, the speed of conduction may be impaired. NCVs can also help localize where a nerve is injured or compressed.

Electromyography (EMG) involves testing the health of individual muscles. By giving a specific muscle a small electrical stimulation, the physician can measure how the muscle behaves electrically. This is useful to detect any damage to a muscle, or to determine if there is long-term nerve damage to that muscle.

Both of these types of studies are generally performed by a specialist, either a Neurologist or Physiatrist. There is occasionally some discomfort with these tests, although they are not excruciating! As with any test, there are several limitations with these studies; they often give helpful information, but need to be interpreted only with a good clinical examination.

Non-Operative Treatment
Splinting, including nighttime elbow splints. Avoidance of specific activities. Anti-inflammatory medication. A single trial of a corticosteroid injection in the cubital tunnel may by quite helpful.
Corticosteroids ("cortisone")(hide)

Key words: cortisone, corticosteroid, Medrol

Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.

Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.

This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.

Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.

Surgical Treatment
Several surgical procedures are available, depending on the anatomy of the arm, severity of the disease, specific source of nerve entrapment, and surgeon preference. All work by taking the pressure off of the ulnar nerve, and moving it to a safer, and less compressed location.
Comments

All nerve decompression surgeries work by taking the pressure off of the nerve, and allowing it to heal on its own.

This is much like taking a 'pot-bound' plant, and repotting it in a larger pot. The goal of surgery is to prevent progression, and allow for the nerve to recover. Prolonged compression of a nerve may cause permanent damage. Think of a garden hose after your car has parked on it for a very long time. Even after a nerve is successfully decompressed, it may not fully recover.

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Radial Tunnel Syndrome

Description
The Radial nerve controls the muscles that extend, or straighten the wrist and fingers. Radial tunnel syndrome is a painful condition that occurs when the nerve is compressed just beyond the elbow, as it runs under the muscles down the back of the forearm to the wrist.
Common Causes
Often seen with weightlifting, or other exercises that cause increased forearm muscle bulk. May occur with repetitive upper arm activities, especially gripping and squeezing.
Symptoms
A deep aching running down the back of the forearm, sometimes to the wrist. Usually aggravated with lifting and gripping. Occasionally there is tingling, or a 'funny feeling' on the back of the arm or hand.
Physical Findings
Tenderness over the radial tunnel, where the radial nerve passes under some of the forearm muscles. The discomfort may be worsened by certain physical exam tests.
Workup
The diagnosis is primarily based on history and physical examination. Electrodiagnostic studies may be helpful, although are often interpreted as 'normal' in patients with this condition.
Electrodiagnostic Studies(hide)

Key words: electrodiagnostic, NCV, EMG, nerve conduction, electromyography

Electrodiagnostic studies refer to two different tests that examine the health of muscles and nerves.

Nerve Conduction Velocities (NCV) test how well a nerve can conduct an electrical signal, much like a wire conducts electricity. By giving a nerve a small stimulation, and then measuring how long it takes to conduct that signal to another point, the physician can calculate the speed of nerve conduction. If a nerve is injured or compressed, the speed of conduction may be impaired. NCVs can also help localize where a nerve is injured or compressed.

Electromyography (EMG) involves testing the health of individual muscles. By giving a specific muscle a small electrical stimulation, the physician can measure how the muscle behaves electrically. This is useful to detect any damage to a muscle, or to determine if there is long-term nerve damage to that muscle.

Both of these types of studies are generally performed by a specialist, either a Neurologist or Physiatrist. There is occasionally some discomfort with these tests, although they are not excruciating! As with any test, there are several limitations with these studies; they often give helpful information, but need to be interpreted only with a good clinical examination.

Non-Operative Treatment
Rest, avoidance of aggravating activities, and anti-inflammatory medication will generally resolve most cases. A well placed corticosteroid injection is often curative.
Surgical Treatment
Decompression of the nerve by releasing all of the constricting structures on top of the nerve.
Comments

Surgery is rarely indicated with this condition. All nerve decompression surgeries work by taking the pressure off of the nerve, and allowing it to heal on its own. This is much like taking a 'pot-bound' plant, and repotting it in a larger pot. The goal of surgery is to prevent progression, and allow for the nerve to recover. Prolonged compression of a nerve may cause permanent damage. Think of a garden hose after your car has parked on it for a very long time. Even after you decompress a nerve, it may not recover completely.

For more detailed information: Click here!