Common Injuries of The Elbow

Biceps Tendon Tear at Elbow

Cause
Injury to the biceps tendon can happen when the arm, bent at the elbow, is forced to straighten. With this injury, the tendon is typically pulled from its attachment point on the forearm near the elbow joint. This is an unusual injury, affecting only 1 to 2 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 to bend the elbow and twist the forearm. However, strength is reduced. Tests have compared the strength of people with a normal healthy arm and those who have injured their biceps tendons. Results show that the injured arm has a loss of 30% to 40% of its strength, mainly in twisting the forearm.

Diagnosis
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
• A gap created by shortening of the biceps tendon on the front of the elbow

Although X-rays do not typically show biceps tendon rupture abnormalities, they are obtained to make sure there are no other problems. Other tests may include ultrasound or an MRI (magnetic resonance imaging) of the elbow to get an image of the disruption.

Symptoms

• Snap or popping sound as the tendon disconnects
• Swelling in front of the elbow and upper arm
• Weakness of bending the elbow
• Tangible gap
• Not usually pain at rest, but in movement

Surgical Treatment
Goal - The aim of surgical treatment is to return the patient to normal function by reattaching the tendon to where it normally connects on the forearm near the elbow joint.

Timing - Outcome and recovery is improved when there is little delay in receiving treatment. Surgery should occur within the first two weeks after injury. A longer delay can cause scarring of the contracted muscle and tendon, which in turn can make surgery more difficult to perform. With long treatment delays, it may be impossible to stretch the tendon back to its normal attachment site. Biceps tendon rupture repair is easier to perform before scar tissue has started to form.

Procedure - No one method is considered the best overall for repairing a ruptured biceps tendon; therefore, the selection of the surgical procedure to use is typically left to the surgeon. One method involves placing suture material in the tendon to grab it, and then attaching the tendon to the bone through drill holes. Another method requires tying the tendon down to man-made devices that are left in place permanently.

Rehabilitation - The orthopaedic surgeon may recommend physical therapy, splints, or slings, depending on the individual patient. Physical therapy may help patients to regain range of motion and strength. Splints or slings can be used for initial rest and for guiding and protecting the injury after motion is resumed. The period of complete rest after surgery should not be too long because some decrease in elbow motion from scarring can occur.

Recovery - Because it takes months for the tendon to reform a strong attachment to the bone, the recovery phase is quite 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.

Distal Biceps Tendon Rupture

Rupture of the distal biceps tendon at the elbow joint is much less common and accounts for less than 5% of biceps tendon ruptures. This injury is also usually found in middle-aged patients, although not always. There is usually some degree of tendinosus, or degenerative changes within the tendon, that predisposes the patient to rupture of the tendon.

The significance of a distal biceps tendon rupture is that without surgical repair, patients who experience complete rupture of the distal biceps tendon will notice loss of strength at the elbow. The strength will affect both the ability to bend the elbow against resistance, and the ability to turn the forearm to the palm-up position against resistance (for example, turning a doorknob or screwdriver).

Symptoms

• Sudden pain over the front of the elbow
• Snap and pain when the rupture occurs
• Swelling
• Bruising

Treatment - Most patients will experience benefit if the biceps tendon is repaired surgically. If the tear is incomplete, or if the patient is very low-demand (not active), then surgery may not be needed. However, most patients who want more normal use of their arm will benefit from surgery to repair the ruptured tendon to the bone.

Elbow (Olecranon) Bursitis

Description - The bursa is a slippery sac between the loose skin and the bones of the elbow. It is located at the tip of the elbow. The bursa allows the skin to move freely over the underlying bone. Normally, the bursa is flat. If it becomes irritated or inflamed, a condition known as bursitis develops.

Cause
Elbow bursitis can occur for a number of reasons.

Symptoms

• Swelling that may restrict movement of the elbow
• Pain
• Skin may become red and warm

Note:
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.

Surgical Treatment
If the bursa is infected and it does not improve with antibiotics or by removing fluid from the elbow, surgery may be needed. This is an inpatient procedure.

If elbow bursitis is not a result of infection, surgery may still be needed if nonsurgical 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.

Elbow Fractures in Children

If a 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 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 (Physis) - The upper arm bone and both forearm 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 radius bone, and excessive force can cause a compression fracture to that bone as well. Fractures of the tip of the other forearm bone are rare.

Fracture dislocation - The ulna and the radius make up the bones of the forearm and meet the bones of the hand at the wrist. A fracture of the ulna associated with a dislocation of the top of the radius at the elbow 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.

Elbow (Olecranon) Fractures

The tip of your elbow 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. It can easily break if you experience a direct blow to the elbow or fall on a bent elbow.

When the elbow structure is altered, either by breaking a bone or by tearing ligaments, muscles, or tendons, or a combination of those problems, then the elbow will not function normally. It can become very painful and stiff, and can cause a feeling of instability.

Cause
There are many types of elbow fractures. Olcranon fractures are common. Although they usually occur without any other injuries, they can be a part of a more complex elbow injury.

Elbow fractures can occur in a number of ways:

• A direct blow – By landing directly on the elbow or being struck by a blunt object.
• An indirect fracture – By landing on an outstretched arm.

Treatment - While in the emergency room, the doctor will treat an olecranon fracture with ice, pain medicine, a splint (like a cast), and a sling to keep the elbow in position.

Whether or not the fracture requires surgery will be determined. Not all olecranon fractures require surgery.

Tennis Elbow (Lateral Epicondylitis)

Tennis elbow is a degenerative condition of the tendon fibers that attach on the bony prominence (epicondyle) on the outside of the elbow. These tendons anchor the muscles that extend or lift the wrist and hand.

Cause
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 muscle. Some common activities that lead to epicondylitis include:

• Recreational: Tennis, racquetball, squash, fencing
• Occupational: Meat cutting, plumbing, painting, raking, weaving

Some patients develop tennis elbow without any specific recognizable activity leading to symptoms. Common activities that lead to epicondylitis are both recreational and occupational.

Symptoms
Severe, burning pain on the outside of the elbow, possibly radiating to the forearm

Osteoarthritis of the Elbow

Diagnosis
A doctor can usually diagnose osteoarthritis of the elbow based on symptoms and standard X-rays. X-rays show the arthritic changes. Advanced diagnostic imaging is typically not needed to diagnose osteoarthritis of the elbow.

Treatment
There are many ways to treat the pain caused by arthritis. One way is total elbow replacement surgery. The decision to have total elbow replacement surgery should be made very carefully after consulting your doctor and learning as much as you can about the elbow joint, arthritis, and the surgery.

In total elbow replacement surgery, an artificial hinge made of metal and a very durable plastic material is inserted into the joint so that the elbow can move without allowing the two forearm bones to contact the humerus. We call this artificial hinge an "implant.

Ulnar Nerve Entrapment

Anatomy
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 of tissue behind the inside of the elbow. Here you can feel the nerve through the skin. It is commonly referred to as the " funny bone. "

Beyond the elbow, the nerve travels under muscles on the inside of the arm and into the hand on the side of the palm with the little finger. As the nerve enters the hand, it travels through another tunnel.

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.

Cause
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.

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
• 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.

Symptoms

• Tingling sensations in the ring finger and little finger
• Weakening of the grip
• Difficulty with finger coordination
• Muscle wasting

Note: 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 any of the symptoms are noticed.

Diagnosis
Always see an orthopedist if there 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 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 an 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 computed tomographic (CT) scan or a magnetic resonance image (MRI) may be recommended to see if a cyst or other structure is the cause of the compression.

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.