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.
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.
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 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.
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.
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.
When the joint surfaces of an elbow are separated, the elbow is dislocated. Elbow dislocations can be complete or partial. In a complete dislocation, the joint surfaces are completely separated . In a partial dislocation, the joint surfaces are only partly separated. A partial dislocation is also called a subluxation.
The elbow is stable due to bone surfaces, ligaments (which connect bones) and muscles. When an elbow dislocates, all of these can be injured to different degrees. A simple dislocation does not have any major bone injury. A complex dislocation can have severe bone and ligament injuries . In the most severe dislocations, there is injury to the blood vessels and nerves that travel across the elbow. If this happens, there is a risk of losing the arm.
Three bones come together to make up the elbow joint . The humerus bone is in the upper part of the arm and attaches to the two bones of the forearm (ulna and radius). Each of these bones has a very distinct shape. Ligaments connect all three bones together. As muscles contract and relax, two unique motions can occur at the elbow:
- Bending occurs through a hinge joint that allows you to bend and straighten the elbow.
- Rotation occurs though a ball and socket joint that allows the hand to be rotated palm up and palm down.
Injuries and elbow dislocations can affect either of these motions.
Elbow dislocations are uncommon. The most common age for an elbow dislocation is 30 years old.
Mechanism of injury
Elbow dislocations typically occur when a person falls onto an outstretched hand. When the hand hits the ground, the force is sent to the elbow. Usually there is a turning motion in this force. This can drive and rotate the elbow out of its socket. Elbow dislocations can also happen in car accidents. When the crash happens, the passengers often reach forward to cushion the impact. The force sent through the arm can dislocate the elbow, just as in a fall.
When the elbow is dislocated, the deformity of the arm is obvious. X-rays are the best way to confirm that the elbow is dislocated. If the bone detail is difficult to evaluate on an X-ray, sometimes a computer tomography (CT) scan will be done. If it is important to evaluate the ligaments, a magnetic resonance imaging (MRI) can be helpful. However, the doctor will set the elbow first, without waiting for the CT scan or MRI. These studies are usually taken after the dislocated elbow has been put back in place.
Some people are born with greater laxity or looseness in their ligaments. These people are at greater risk for dislocating their elbows. Some people are born with an ulna bone that has a shallow groove for the elbow hinge joint. They have a slightly higher risk for dislocation. Nothing can be done to alter these risk factors.
A complete elbow dislocation is extremely painful and very obvious. The arm will look deformed and may have an odd twist at the elbow. Get emergency treatment. It is important to evaluate the circulation of the arm and to check pulses at the wrist after an elbow dislocation. If the artery is injured at the time of dislocation, the hand will be cool to touch and may have a white or purple hue. This is due to the lack of warm blood getting to the hand. It is also important to check the nerve supply to the hand. If nerves have been injured during the dislocation, some or all of the hand may be numb and not able to move. Further testing such as an X-ray is necessary to determine if there is a bone injury. X-rays can also help show the direction of the dislocation.
A partial elbow dislocation or subluxation can be harder to detect. Typically it happens after an accident, but because the elbow is only partially dislocated, the bones can spontaneously relocate and the joint may appear fairly normal. There may be pain, however. The elbow will usually move fairly well. There may be bruising on the inside and outside of the elbow where ligaments may have been stretched or torn. Partial dislocations can recur on a chronic basis if the ligaments never heal.
Treatment Options: Nonsurgical
The goal of immediate treatment of a dislocated elbow is to put the elbow back in joint. The long term goal is to restore function to the arm. First the alignment of the elbow must be restored. This can usually be done in an emergency department. The patient will receive sedation and pain medications. The act of restoring alignment at the elbow is called a reduction maneuver. This should be done gently and slowly and usually takes two people to perform.
Simple elbow dislocations are treated with early motion after a short period in a splint or sling. Keeping the elbow immobile for a long time usually results in poor range of motion for the recovered elbow. Physical therapy can be helpful during this period of recovery. Some people will never recover full elbow extension even after a course of therapy. Fortunately the elbow can work very well even without full motion. Once the elbow's range of motion improves, the doctor or physical therapist may add a strengthening program. Interval X-rays may be necessary while the elbow recovers. This helps to ensure that the elbow joint remains well aligned.
Treatment Options: Surgical
In a complex elbow dislocation, surgery may be necessary to restore bone alignment and repair ligaments. It can be difficult to reduce the joint and to keep it in line. There is an increased risk for arthritis in the joint if:
- The alignment of the bones is not good.
- The elbow does not track well.
- The elbow continues to dislocate.
After the surgery, the elbow may be protected with an external hinge. This device guards against re-dislocation. If there are associated blood vessel or nerve injuries with the elbow dislocation, multiple surgeries may be necessary. These surgeries repair the blood vessels and nerves in addition to reducing the joint. They also fix the bone and ligament injuries.
Research on the Horizon/What's New?
Treatment for simple dislocations is usually straightforward and the results are usually good. However, many people with complex dislocations still end up with permanent disability at the elbow. Treatment is evolving to improve results for these people. The best time to schedule surgery is being evaluated for treatment of complex dislocations. For some patients with complex dislocations, it seems that a slight delay for definitive surgery may improve results by allowing swelling to decrease. The dislocation still needs to be reduced right away, but then a brace, splint or external fixation frame may rest the elbow for about a week before a specialist surgeon attempts major reconstructive surgery.
Moving the elbow early appears to be good for recovery for both kinds of dislocations. However, early movement with complex dislocations can be difficult. Pain management techniques encourage early movement. Improved therapy and rehabilitation techniques such as continuous motion machines, dynamic splinting (spring-loaded assist devices) and progressive static splinting can improve results.
Late reconstructive surgery can successfully restore motion to some stiff elbows. This surgery removes scar tissue and extra bone growth. It also removes obstacles to movement.
Severe arthritis can develop in the elbow. For this condition, newly designed elbow replacement prosthesis can be implanted. The arthritic elbow joint can be replaced with an artificial elbow, similar to joint replacements in the hip or knee. This decreases pain and improves motion.
Elbow (Olecranon) Bursitis
The bursa is a slippery sac between the loose skin and the bones of your elbow. The bursa allows the skin to move freely over the underlying bone. It is located at the tip of the elbow. Normally, the bursa is flat and it's hard to tell it is even there. If the bursa becomes irritated or inflamed, a condition known as elbow bursitis develops.
Common causes of elbow bursitis include:
- Trauma: A hard blow to the tip of the elbow could 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 would develop over several months.
- Infection: If the tip of the elbow has an injury that breaks the skin, such as an insect bite or a scrape, bacteria may get inside the bursa and cause an infection. The infected bursa produces fluid, redness and swelling. If the infection goes untreated, the fluid may turn to pus.
- Medical conditions: Certain conditions such as rheumatoid arthritis and gout are associated with development of elbow bursitis.
Swelling is often the first symptom. The skin on the back of the elbow is loose, so you may not notice small amounts of swelling right away. As the swelling continues, the bursa gets larger. This causes pain as the bursa is stretched, since the bursa contains nerve endings. The swelling may get large enough to restrict motion in the elbow.
If the bursitis 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.
See your doctor to diagnose elbow bursitis. You may need an X-ray so the doctor can look for a foreign body or a bone spur. Bone spurs are often found on the tip of the bone in the elbow in patients who have recurrent problems with elbow bursitis.
Treatment Options: Nonsurgical
First, the doctor must determine whether the bursitis is due to an infection. If the doctor suspects this, fluid removal (aspiration) of the swollen area may be recommended. This is commonly performed as an office procedure. Fluid removal helps relieve symptoms and gives the doctor a sample that can be looked at in a laboratory to identify if any bacteria are growing. This also lets the doctor know if a specific antibiotic is needed to fight the infection. Often, the doctor may start you on antibiotics before the exact bacteria can be identified. This is done to prevent the infection from progressing. The antibiotic that the doctor recommends in this case will cover a number of possible infections.
If the bursitis is not from an infection, it is treated with elevation, ice and other nonoperative treatments such as an elbow pad and avoidance of direct pressure on the swollen elbow. Oral medications such as ibuprofen or other anti-inflammatories may also be used. If the swelling and pain do not respond to these measures, your doctor may recommend removing fluid from the bursa and injecting a corticosteroid medication into the bursa. The steroid medication is an anti-inflammatory that is stronger than the medication that can be taken by mouth.
Treatment Options: Surgical
Infected bursa that do not improve with antibiotics and/or removing fluid from the elbow may require surgery. Patients who have surgery for elbow bursitis may need to stay in the hospital for a period of time.
If elbow bursitis is not a result of infection, surgery may be needed if nonoperative treatments don't work. Surgery to remove the bursa is usually performed as an outpatient procedure. The surgery does not disturb any muscle, ligament or joint structure. Physical therapy after surgery is not always needed. Postoperative casting or prolonged immobilization is not typically required.
Elbow Fractures in Children
Whether your child is an active athlete or just a toddler jumping on the bed, there's a good possibility that he or she will take a spill at home or on the field or court at some time. These falls are usually harmless; but when a child 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.
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.
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.
- Fracture dislocation: A fracture of the inside bone (ulna) can be combined with the top of the thumb-side bone (radius) coming out of the socket at the elbow. This is called a Monteggia fracture. If the dislocation is not seen, and only the fracture is treated, this can lead to permanent impairment of elbow joint function.
Risk Factors / Prevention
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.Symptoms
Regardless of where the break is, the symptoms of a broken elbow are similar:
- Acute pain
- Swelling (may be severe or mild)
- Limited movement
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.
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 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.
Osteoarthritis of the Elbow
Osteoarthritis occurs when the cartilage surface of the elbow is damaged or becomes worn. This can happen because of a previous injury such as elbow dislocation or fracture. It may occur due to degeneration of the joint cartilage from age. Osteoarthritis usually affects the weightbearing joints, such as the hip and knee. The elbow is one of the least affected joints due to its well matched joint surfaces and strong stabilizing ligaments. This makes the joint able to tolerate large forces across it without becoming unstable.
A doctor can usually diagnose elbow arthritis based upon a patient's symptoms and standard X-rays. X-rays show the arthritic changes. Most of the time, advanced imaging studies such as CT (computed tomography) or MRI (magnetic resonance imaging) scans are not needed. Elbow osteoarthritis that occurs without previous injury is more common in men than women. It usually begins after age 50, although some patients can have symptoms earlier.
Most 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. The 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 pre-injury level
Injury to the ligaments resulting in an unstable elbow can also lead to arthritis, even if the elbow surface is not damaged. That's because the normal forces across the elbow are altered, causing the joint to wear out more rapidly.
Sometimes there is no single injury. Work or outside activities may also lead to elbow arthritis 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. This can lead to failure of the stabilizing ligaments. It usually needs surgical reconstruction. 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 happen, 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. Always use proper conditioning and technique.
The most common symptoms of elbow arthritis are:
- Loss of range of motion
You might not have both symptoms at once. Patients usually complain of 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. These can 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 later stages, patients might also 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. This causes 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.
Treatment options depend on the stage of the disease, prior history, what the patient desires, overall medical condition, and the results of X-rays.
For the early stages, the most common treatment is non-surgical. This includes oral medications such as TylenolŪ or AdvilŪ, physical therapy, activity modification and joint injections.
Sometimes corticosteroid injections are used to treat arthritis symptoms. Steroid medication has typically been used with good results. The affects are temporary. But injections may give significant relief until symptoms progress enough to need additional treatment. An alternative to steroids has been the injection of hyaluronic acid in various forms. This attempts to increase the fluid in a joint, a process called viscosupplementation. It surrounds the diseased cartilage with a thicker and more "cushioned" environment. This treatment has been recently studied in people with osteoarthritis of the knee. While there was enthusiasm for this treatment, research has not shown it to be better than traditional steroid injections. Additionally, the hyaluronic injections were significantly more expensive. The results of these "viscosupplementation" injections in the elbow or other joints have not been investigated.
When nonsurgical interventions are not enough to control symptoms, surgery may be needed.
Treatment Options: Surgical
By the time arthritis can be seen on X-rays, there has been significant wear or damage to the joint surfaces. If the wear or damage is limited, arthroscopy can offer a minimally invasive surgical treatment. It may be an option for patients with earlier stages of arthritis. Arthroscopy has been shown to provide symptom improvement at least in the short term. It involves removing any loose bodies or inflammatory/degenerative tissue in the joint. It also attempts to smooth out irregular surfaces. Multiple small incisions are used to complete the surgery. It can be performed as an outpatient procedure. The recovery is reasonably rapid.
If the joint surface has worn away completely it is unlikely that anything other than a joint replacement would bring about relief. There are several different types of joint replacement available.
In appropriately selected patients, the improvement in pain and function can be dramatic. With an experienced surgeon, the results of elbow replacement are the same as the results of hip replacement and knee replacement. For patients who are too young or who are too active to have prosthetic joint replacement, there are other reasonably good options. If loss of motion is the primary symptom, the surgeon can release the contracture and smooth out the joint surface. At times, a new surface made from the patient's own body tissues can be made. These procedures can give years of symptom improvement.
Research on the Horizon/What's New?
Recently, joint supplementation has been used as an alternative to traditional oral and injectable medication. For oral medication, this involves a glucosamine/chondroitin supplement. These "nutraceuticals" attempt to give the body more of the basic elements that make up cartilage. Then the body may attempt to maintain or "build back" cartilage. There have been few well-controlled research studies on glucosamine/chondroitin. They have not included patients with elbow arthritis. So the short and long term effects are not yet known. Anecdotal reports have been favorable.
In cases where there has been loss or damage to areas of the joint, a cartilage/bone graft can be considered. This procedure attempts to return the joint to its prior smooth appearance and form in an attempt to prevent further deterioration of the joint. As our understanding of cartilage growth and regeneration improves, this may allow replacement of larger areas of joint damage or degeneration. Newer elbow replacements have also been designed with the goals of greater longevity and easier insertion compared with prior designs.
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 at the Elbow
The biceps muscle attaches to the radial tuberosity, which is a small hump on the side of one of the two bones of the forearm (the radius) near the elbow joint. The biceps muscle bends the elbow bringing the hand in toward the body. This muscle also helps to twist the forearm, turning the hand palm up, the motion you use to tighten a screw with a screwdriver. Injury to the biceps usually happens when the arm, bent at the elbow, is forced to straighten. With this injury, the tendon is typically pulled off from its attachment point on the forearm near the elbow joint. This is an unusual injury, affecting only one to two people per 100,000 each year.
The biceps works in conjunction with other muscles that cross the elbow joint. If the biceps tendon ruptures or detaches from the bone, these other muscles make it possible for you to bend the elbow and twist the forearm. However, strength is reduced. Tests have compared the strength of people with a normal healthy arm with those who have injured their biceps tendon. Results show that the injured arm has a loss of 30 percent to 40 percent of its strength, mainly in twisting the forearm.
Diagnosis begins by reviewing the events of the injury to determine how the injury occurred. During examination the doctor looks for:
- Swelling in the front of the elbow
- Weakness bending the elbow
- Weakness twisting the forearm against resistance (screwdriver motion)
- Visible bruising
- Gap created by shortening of the biceps tendon on the front of the elbow
X-rays don't usually show biceps tendon rupture abnormalities. They are taken to make sure there are no other problems. Other tests might include ultrasound or an MRI (magnetic resonance imaging) of the elbow to get an image of the disruption.
The usual person with this injury is a male in his 30s to middle-aged. Females very rarely get this injury. The injury is equally likely to occur in the dominant arm or the non-dominant arm. It is usually related to lifting a heavy weight. Smoking and corticosteroid use increase the risk of getting this injury. It is believed that smoking alters nutrition to the tendon. This injury is not usually associated with other medical conditions.
As the tendon disconnects, there is often a feeling or the sound of a pop in the elbow. Some swelling in the front of the elbow is likely. There is weakness when bending the elbow. The biceps muscle and tendon can recoil and shorten, creating a firm swelling in the upper arm and a gap that can often be felt. Following injury, there may not be much pain at rest. Pain is usually felt when using the arm forcefully.
Treatment Options: Non-surgical
Nonsurgical treatment may be considered, especially if there are reasons not to perform surgery and there is less need to restore full strength in the arm. Nonsurgical treatment consists of short-term rest followed by gradually and gently resuming activities. Although other muscles make it possible to bend the elbow fairly well without the biceps, the biceps provides most of the power for turning the forearm. Nonsurgical treatment results in a significant reduction of power (about a 30 percent to 40 percent loss).
Treatment Options: Surgical
Surgical treatment is an appropriate option if a better outcome in terms of strength is required, and surgical risks have been taken into account. The aim of surgical treatment is to return the patient to normal function by reattaching the tendon to the spot where it normally connects.
Timing of surgical treatment is important. Outcome and recovery is improved when you don't delay. Surgery should occur in the first week or two after injury. Scarring of the contracted muscle and tendon can make the surgery more difficult the longer you delay. With long delays it may be impossible to stretch the tendon back to its normal attachment site. The surgery is easier to perform before scar tissue has started to form.
No one method is considered the best overall, so the decision is left to the surgeon. One method involves placing suture material in the tendon to grab it, then attaching the tendon to the bone through drill holes. Another method requires tying the tendon down to manmade devices that are left in place permanently.
After surgery, one can usually expect to have a very good range of motion and strength nearly equal to the uninjured arm. Long-term difficulties are rare, but it would not be unusual to lose some ability to fully straighten the elbow.
Complications of surgery can include sensory problems in the forearm, which usually go away. Abnormal bone formation might require another operation. At times, abnormal bone can severely limit the twisting motion of the forearm. The overall complication rate is about 9 percent.
The surgeon may recommend physical therapy, splints or slings, depending on the particular case. Physical therapy might help to regain range of motion and strength. Splints or slings might be used for initial rest and for guiding and protecting the injury after motion is resumed. The period of time for complete rest after surgery should not be too long, because some decrease in elbow motion from scarring can occur.
It takes months for the tendon to reform a strong attachment to the bone, so the recovery phase is long. During recovery, vigorous use of the arm, especially for pulling and lifting, should be avoided. A gradual increase in motion and strength training is required.
Activities with the arm are gradually increased, beginning with motion of the elbow while relying on the other hand for power. Another exercise involves light isometric contraction of the biceps muscle without added resistance, and then gradually adding resistance. After a couple of months, more freedom in strengthening can be added. You can return to work with light lifting at this time; however, vigorous use and heavy lifting should be delayed for several months.
Tennis Elbow (Lateral Epicondylitis)
Tennis elbow is a degenerative condition of the tendon fibers that attach on the bony prominence (epicondyle) on the outside (lateral side) of the elbow. The tendons involved are responsible for anchoring the muscles that extend or lift the wrist and hand.
Tennis elbow happens mostly in patients between the ages of 30 years to 50 years. It can occur in any age group. Tennis elbow can affect as many as half of athletes in racquet sports. However, most patients with tennis elbow are not active in racquet sports. Most of the time, there is not a specific traumatic injury before symptoms start. Many individuals with tennis elbow are involved in work or recreational activities that require repetitive and vigorous use of the forearm muscles. Some patients develop tennis elbow without any specific recognizable activity leading to symptoms.
Patients often complain of severe, burning pain on the outside part of the elbow. In most cases, the pain starts in a mild and slow fashion. It gradually worsens over weeks or months. The pain can be made worse by pressing on the outside part of the elbow or by gripping or lifting objects. Lifting even very light objects (such as a small book or a cup of coffee) can lead to significant discomfort. In more severe cases, pain can occur with simple motion of the elbow joint. Pain can radiate to the forearm.
To diagnose tennis elbow, tell the doctor your complete medical history. He or she will perform a physical examination.
- The doctor may press directly on the bony prominence on the outside part of the elbow to see if it causes pain.
- The doctor may also ask you to lift the wrist or fingers against pressure to see if that causes pain.
X-rays are not necessary. Rarely, MRI (magnetic resonance imaging) scans may be used to show changes in the tendon at the site of attachment onto the bone.
In most cases, nonoperative treatment should be tried before surgery. Pain relief is the main goal in the first phase of treatment. The doctor may tell you to stop any activities that cause symptoms. You may need to apply ice to the outside part of the elbow. You may need to take acetaminophen or an anti-inflammatory medication for pain relief.
Orthotics can help diminish symptoms of tennis elbow. The doctor may want you to use counterforce braces and wrist splints. These can reduce symptoms by resting the muscles and tendons.
Symptoms should improve significantly within four weeks to six weeks. If not, the next step is a corticosteroid injection around the outside of the elbow. This can be very helpful in reducing pain. Corticosteroids are relatively safe medications. Most of their side effects (i.e., further degeneration of the tendon and wasting of the fatty tissue below the skin) occur after multiple injections. Avoid repeated injections (more than two or three in a specific site).
After pain is relieved, the next phase of treatment starts. Modifying activities can help make sure that symptoms do not come back. The doctor may want you to do physical therapy. This may include stretching and range of motion exercises and gradual strengthening of the affected muscles and tendons. Physical therapy can help complete recovery and give you back a painless and normally functioning elbow. Nonoperative treatment is successful in approximately 85 percent to 90 percent of patients with tennis elbow.
Treatment Options: Surgical
Surgery is considered only in patients who have incapacitating pain that does not get better after at least six months of nonoperative treatment.
The surgical procedure involves removing diseased tendon tissue and reattaching normal tendon tissue to bone. The procedure is an outpatient surgery; you do not need to stay in the hospital overnight. It can be performed under regional or general anesthesia.
Technique for surgical treatment of lateral epicondylitis. A, Skin incision over the lateral epicondyle. B, Distal reflection of the extensor mechanism exposing the lateral compartment of the elbow. C, Excision of pathologic tissue from the underside of the extensor mechanism. D, Decortication of the lateral epicondyle. E, Drilling of two V-shaped tunnels within the lateral epicondyle. F, Reattachment of the extensor mechanism to the lateral epicondyle. G, Side-to-side repair of the extensor tendon mechanism.
Most commonly, the surgery is performed through a small incision over the bony prominence on the outside of the elbow.
Recently, an arthroscopic surgery method has been developed.
So far, no significant benefits have been found to using the arthroscopic method over the more traditional open incision.
After surgery, the elbow is placed in a small brace and the patient is sent home. About one week later, the sutures and splint are removed. Then exercises are started to stretch the elbow and restore range of motion. Light, gradual strengthening exercises are started two months after surgery. The doctor will tell you when you can return to athletic activity. This is usually approximately four months to six months after surgery. Tennis elbow surgery is considered successful in approximately 90 percent of patients.
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.
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 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.
Risk Factors / Prevention
Little Leaguer's Elbow affects pitchers and other players who throw repetitively. Continuing to throw may lead to major complications and jeopardize a youngster's ability to remain active in a sport that requires throwing.
Little Leaguer's Elbow may cause pain on the inside of the elbow. A child should stop throwing if any of the following symptoms appear:
- Elbow pain
- Restricted range of motion
- Locking of the elbow joint
If left untreated, osteochondrosis dissecans can become a complicated condition. Younger children tend to respond better to nonsurgical treatments.
- 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.
- Return to throwing.
Treatment Options: Surgical
Surgery may be necessary, especially in girls more than 12 years old and boys more than 14 years old.
Ulnar Nerve Entrapment
Ulnar nerve entrapment occurs when one of the nerves in the arm (the ulnar nerve) becomes compressed and can't function normally. This can give symptoms of "falling asleep" in the ring finger and little finger, especially when the elbow is bent. You may have aching pain on the inside of the elbow. In some cases, you may have trouble moving the fingers in and out, or manipulating objects. Carpal tunnel syndrome has similar symptoms but involves a different nerve (the median nerve). Carpal tunnel syndrome typically causes tingling in the thumb, index finger and long finger.
The ulnar nerve is one of the three main nerves in the arm. It travels from under the collarbone and along the inside of the upper arm. It passes through a tunnel (the cubital tunnel) behind the inside of the elbow. Here you can feel the nerve through the skin. It is commonly called the "funny bone." Beyond the elbow, the nerve travels under muscles on the inside of the arm, and into the hand on the pinky side of the palm. When the nerve goes into the hand, it travels through another tunnel (Guyon's canal). The most common place where the nerve gets compressed is behind the elbow. Sometimes it gets compressed at the wrist, beneath the collarbone, or as it comes out of the spinal cord in the neck.
The nerve functions to give sensation to the little finger and the half of the ring finger that is near the little finger. It also controls most of the little muscles in the hand that help with fine movements, and some of the bigger muscles in the forearm that help to make a strong grip.
It is not known exactly what causes compression of the ulnar nerve. Some factors can make it more likely that the nerve will be compressed. These include prior fractures of the elbow, bone spurs, swelling of the elbow joint, or cysts. A direct blow to the inside of the elbow, leaning on the elbow for prolonged periods, or repetitive activity that requires a bent elbow can irritate the nerve if it is already compressed. If the ulnar nerve is compressed at the wrist, the cause is more likely to be a cyst in Guyon's canal.
Numbness and tingling in the ring finger and little finger are common symptoms of ulnar nerve entrapment. Often these symptoms come and go. They happen more often when the elbow is bent, such as when you are driving or talking on the phone. Some people wake up at night because their fingers are numb. You may also have weakness of grip and difficulty with finger coordination (such as typing or playing an instrument). If the nerve is very compressed or has been compressed for a long time, muscle wasting in the hand can occur. Once this happens, muscle wasting cannot be reversed. For this reason, it is important to see the doctor as soon as you experience any of the symptoms.
Always see an orthopaedist if you are having symptoms of ulnar nerve entrapment that interfere with normal activities or last more than a few weeks.
The doctor will examine the arm to check the nerve, and try to determine where the nerve is compressed. If the nerve is irritated, tapping over the nerve at the "funny bone" can cause a shock into the little finger and ring finger, although this can happen when the nerve is normal as well. The doctor will probably move the shoulder, elbow and wrist to see if any of these cause symptoms. The doctor will test the sensation in the fingers.
Although most causes of compression of the ulnar nerve cannot be seen on X-ray, the doctor may take an X-ray of the elbow or wrist to look for bone spurs, arthritis or other places that the bone may be compressing the nerve. If the doctor thinks that the nerve is compressed at the wrist, a CT scan (computed tomography) or MRI (magnetic resonance image) may be recommended to see if a cyst or other structure is the cause of the compression.
The doctor may recommend nerve conduction studies. These are special tests to determine how well the nerve is working and to help localize the area of compression. Nerves work like wires; when the nerve is not working well, it takes too long for the nerve to conduct. During this test, the nerve is stimulated in one place; the amount of time it takes for the response to be conducted to another place is determined. The area where the nerve conduction takes too long is likely to be the place where the nerve is compressed. Sometimes, a small needle is put into some of the muscles that the ulnar nerve controls. This can determine if there is any evidence of muscle wasting.
Unless you have a lot of muscle wasting, your doctor will probably recommend nonsurgical treatment initially. The following treatments may help to improve the symptoms. They may be all the treatment you need.
- Avoid frequent use of the arm with the elbow bent. If you use a computer frequently, make sure that your chair is not too low. Do not rest the elbow on the armrest.
- Avoid leaning on the elbow or putting pressure on the inside of the arm. For example, do not drive with the arm resting on the open window.
- Keep the elbow straight at night when you are sleeping. This can be done by wrapping a towel around the straight elbow, wearing an elbow pad backwards, or using a special brace.
If symptoms are acute, the doctor may recommend that you take an anti-inflammatory medicine such as ibuprofen to help reduce swelling around the nerve. Steroid (cortisone) injections around the ulnar nerve are not generally used because there is a risk of damage to the nerve.
Some doctors think that exercises to help the nerve slide through the tunnels can improve the symptoms. These exercises can help keep the arm and wrist from getting stiff.
Treatment Options: Surgical
If you are not improving with the strategies listed above, if the nerve is very compressed, or if you have muscle wasting, the doctor may recommend surgery to take pressure off of the nerve. Most often, the surgery is done around the elbow, but it can be done at the wrist if that is the place of the compression. Sometimes, the nerve is compressed in both places, so surgery is done at both the elbow and the wrist.
Surgeons use various ways to relieve compression from the nerve around the elbow. All of the operations involve making an incision around the elbow. In one operation, only the "roof" is taken off of the cubital tunnel. This tends to work best when the nerve compression is mild. More commonly, the nerve is moved from its place behind the elbow to a new place in front of the elbow. This 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), within the muscle (intermuscular transposition) or under the muscle (submuscular transposition). There are many factors that go into deciding where the nerve is moved. The doctor will recommend the best option for you.
If the nerve is compressed at the wrist, a zigzag incision will be made at the base of the palm on the pinky side. The surgeon will open the roof of Guyon's canal to take the pressure off the ulnar nerve. If there is a cyst or another reason for the compression, the surgeon will remove that at the same time.
The surgery is usually done on an outpatient basis or with an overnight stay in the hospital. Depending on the type of surgery, you may need to wear a splint for a few weeks after the operation. A submuscular transposition usually requires a longer time (3-6 weeks) in a splint. The surgeon may recommend physical therapy to help you regain strength and motion in the arm.
The results of the surgery are generally good. If the nerve is very badly compressed or if you have muscle wasting, the nerve may not be able to get back to normal and you may have some symptoms even after the surgery. Nerves recover slowly, and it can take a long time to know how well the nerve will do after the operation.