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Lateral epicondylitis

 

  • Often referred to as tennis elbow

     

  • Due to inflammation at the origin of the wrist and finger extensors

     

  • Its is an enthesopathy of the lateral epicondyle

     

Clinical features

 

  • Occurs between 30 and 50 years of age

     

  • Men and women are equally affected

     

  • 75% experience symptoms in their dominant arm

     

  • Causes pain over the lateral epicondyle radiating to the forearm

     

  • Tenderness is usually maximum 5 mm distal to the insertion of the tendon

     

  • Resisted wrist extension increases the pain

     

Plain x-ray may show calcification in the soft tissue.

Management

 

  • Non surgical management involves

     

    • Rest

       

    • Non-steroidal anti-inflammatory medication

       

    • Steroid injection

Surgical treatment if no improvement with 6 months conservative treatment

 

  • Involves division and reattachment of the tendon

     

  • 85% notice a dramatic improvement in symptoms

     

  • I now do these arthroscopic with excellent post op rehab and recovery.

     

Medial epicondylitis

  • Often referred to as golfers elbow

  • It is less common than lateral epicondylitis

     

  • Occurs in same age group

     

  • is is an enthesopathy of the pronator teres and flexor carpi radialis tendon

     

  • Characterised by pain over the medial aspect of the elbow

     

  • Pain is exacerbated by wrist flexion

     

  • Tenderness is distal to medial epicondyle

     

  • Management is similar to lateral epicondylitis

     

  • Very resistant to any form of surgery.

OLECRANON BURSITIS

 

 A bursa is a fluid filled sack between skin and bone which allows the skin to move easily over the bone.

 

There is a bursa outside the elbow called the olecranon bursa which can be felt around the hard bone of the point of the elbow only with the elbow straight. With the elbow fully bent a normal bursa cannot be felt. The bursa sometimes becomes enlarged as a result of pressure or friction.

 

The commonest cause of swelling within the bursa, not related to trauma, is gout. There may be a sizeable lump with calcium seen on x-ray. This can also happen in rheumatoid arthritis. Unfortunately it can be difficult to differentiate between an infected and a non infected olecranon bursa and about one in five cases of acute bursitis are, in fact, infected.

 

 

 

 

 

Infected bursae are almost always painful whereas non infected bursitis is painful in less than 25% of cases.

 

A swollen olecranon bursa is usually not painful unless it is associated with infection or a specific inflammatory process such as gout or rheumatoid arthritis. In most patients there is no problem with the arm straight, however, symptoms become evident when attempting to bend the elbow beyond 90° or when leaning on the elbow.

Treatment depends on whether the bursa is infected or not.

 

In non infected bursitis the simplest treatment is to stop the elbow moving and allow the fluid filled sac to rest.

 

This often involves a resting splint, a compression bandage and ice packs.

 

In addition to these measures an infected bursitis will require antibiotic treatment (this may require admission to hospital or simply be in tablet form).  

 

 

 

For the great majority of patients, simple symptomatic treatment such as using a padded elbow brace or resting the arm on a pillow will be sufficient. Some patients will require repeated periods of immobilization and some patients will eventually come to surgical removal of the bursa. This procedure is usually extremely effective, however, in a small number of patients the wound does not heal properly for up to three months. A period of immobilisation of the elbow following surgery is necessary and does not guarantee that the bursa will not recur.

 

In most patients, the swelling is simply a nuisance and as long as the bursa is not infected should not be interfered with.

I now debride the bursa arthroscopically with minimal scar and good long term results.

Ulnar nerve entrapment at the elbow

 

  • Ulnar nerve runs behind medial epicondyle at the elbow

     

  • Runs in a tunnel formed by aponeurosis between tow head of flexor carpi ulnaris

     

  • Aponeurosis is slack in elbow extension

     

  • Becomes tight in elbow flexion

     

  • Disorders of the elbow joint can result in nerve compression

     

  • Symptoms are often worse when elbow is flexed

Clinical features

 

  • Pain and paraesthesia in the ring and little finger

     

  • Weakness of grasp and grip

     

  • Loss of manual dexterity

     

  • Wasting of the intrinsic muscles of the hand

 

Management

  • Night splints to reduce elbow flexion may improve symptoms

     

Surgical options include

 

  • Ulnar nerve decompression

     

  • Medial epicondylectomy

Elbow Stiffness

The most common complication following any elbow surgery or injury is stiffness. It is also possible for excess bone to form in the soft tissues around the elbow, called heterotopic ossification. It is best to prevent a stiff elbow by moving the elbow as soon as practical.

The surgeon will balance soft tissue considerations, fracture stability and other patient factors when deciding whether to move the elbow early or not. If the elbow becomes stiff it can sometimes be splinted back to a functional range of motion. This is most effective in the first six months following injury or surgery. Typically this involves soft tissue stiffness only and will not overcome joint deformity. 

If all non operative measures have failed, a surgical stiff elbow release can be performed. This is typically performed when patients are no longer able to put their hand to their mouth, or lose more than half of their straightening ability. 

Stiffness can be:

 

1.           Within the joint,

 

2.           Because of the joint, or,

 

3.           Outside the joint.

 


I will discuss your particular problem and its treatment with you. 

There are many different methods of performing a stiff elbow release.

Nowadays, a significant portion of the surgery is usually done arthroscopically (with keyhole surgery) but often an open incision is required. If the elbow does not bend beyond a right angle you will almost certainly require release of the nerve at the inside of the elbow (the ulnar nerve) to prevent problems with the nerve following the surgery. While the risk of complication is quite low with this type of surgery, the consequences of a complication can be significant. This is particularly true with regard to hand function if one of the nerves which supplies the muscles in the hand and/or skin sensation is damaged.

 

There is a significant post operative rehabilitation period required following the surgery. This may involve up to 5 days in hospital on a machine which moves the elbow for you and, depending on the type of operation, either a splint or movement machine at home for a period of weeks as well. 

While there are risks involved with this type of surgery, the results are quite gratifying. At least 80 percent of patients achieve a fully functional elbow and 90 percent of patients are within 10 degrees of this. 

The pre-operative range of movement does not necessarily dictate the final motion gained, although it does determine the complexity of the operation which is required.

Distal Biceps Rupture.

 

Distal biceps rupture occurs when the tendon attaching the biceps muscle to the elbow is torn from the bone. This injury occurs mainly in middle-aged men during heavy work or lifting. A distal biceps rupture is rare compared to ruptures where the top of the biceps connects at the shoulder. Distal biceps ruptures make up only three percent of all biceps tendon ruptures.

The most common cause of a distal biceps rupture happens when a middle-aged man lifts a box or other heavy item with his elbows bent. Often the load is heavier than expected, or the load may shift unexpectedly during the lift. This forces the elbow to straighten, even though the biceps muscle is working hard to keep the elbow bent. The biceps muscle contracts extra hard to help handle the load. As tension on the muscle and tendon increases, the distal biceps tendon snaps or tears where it connects to the radius.

Surgery

People who need normal arm strength get best results with surgery to reconnect the tendon right away. Surgery is needed to avoid tendon retraction. When the tendon has been completely ruptured, contraction of the biceps muscle pulls the tendon further up the arm. When the tendon recoils from its original attachment and remains there for a very long time, the surgery becomes harder, and the results of surgery are not as good.

 

Direct Repair

Direct repair surgery is commonly done soon after the rupture. Doing a direct repair soon after the injury lessens the risk of tendon retraction.

In a direct repair, the surgeon begins by making a small incision across the arm, just above the elbow. Forceps are inserted up into this incision to grasp the free end of the ruptured biceps tendon. The surgeon pulls on the forceps to slide the tendon through the incision.

Attention is given to the free end of the tendon. A scalpel is used to slice off the damaged and degenerated end. Sutures are then crisscrossed through the bottom inch of the distal biceps tendon.

I use the Arthrex Tight Rope Repair for my biceps distal rupture.

Elbow Replacement

 

Elbow joint replacement (also called elbow arthroplasty) can effectively treat the problems caused by arthritis of the elbow. The procedure is also becoming more widely used in aging adults to replace joints damaged by fractures. The artificial elbow is considered successful by more than 90 percent of patients who have elbow joint replacement.

Replacement surgery is usually not considered until it has become impossible to control your

symptoms without surgery. If replacement becomes necessary, it can be a very effective way to take away the pain of arthritis and to regain use of your elbow.