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Elbows

Normal Anatomy of the Elbow

The arm in the human body is made up of three bones that join together to form a hinge joint called the elbow. The upper arm bone or humerus connects from the shoulder to the elbow forming the top of the hinge joint. The lower arm or forearm consists of two bones, the radius and the ulna. These bones connect the wrist to the elbow forming the bottom portion of the hinge joint.

The elbow joint is actually three separate joints surrounded by a watertight sac called a joint capsule. This capsule surrounds the elbow joint and contains lubricating fluid called synovial fluid.

  • Humerus
  • Ulna
  • Radius

The three joints of the elbow include:

  • Ulnohumeral joint is where movement between the ulna and humerus occurs.
  • Radiohumeral joint is where movement between the radius and humerus occurs.
  • Proximal radioulnar joint is where movement between the radius and ulna occurs.

Our elbow is held in place and supported by various soft tissues.

Cartilage
Shiny and smooth, cartilage allows smooth movement where two bones come in contact with each other.

Tendons
Tendons are soft tissue that connects muscles to bones to provide support.

  1. 1. Biceps Tendon
    This tendon attaches the biceps muscle on the front of the arm to the radius allowing supination, rotation of the elbow.

  2. 2. Triceps Tendon
    This tendon attaches the triceps muscle on the back of the arm to the ulna bone allowing the elbow to straighten.

  3. 3. Lateral Epicondyle
    This bony prominence located just above the elbow on the outside is where the forearm muscles that straighten the fingers and wrist come together in one tendon to attach to the humerus.

  4. 4. Medial Epicondyle
    This bony prominence located just above the elbow on the inside is where the muscles that bend the fingers and wrist come together in one tendon to attach to the humerus.

Ligaments
Ligaments are strong rope like tissue that connects bones to other bones and help hold tendons in place providing stability to joints. Ligaments around the elbow join to form a watertight sac called a joint capsule. This capsule surrounds the elbow joint and contains lubricating fluid called synovial fluid.

There are four main ligaments in the elbow.

  1. 1. Medial collateral ligament
    Located on the inside of the elbow this ligament connects the ulna to the humerus.

  2. 2. Lateral collateral ligament
    Located on the outside of the elbow this ligament connects the radius to the humerus.

  3. 3. Annular ligament
    This ligament forms a ring around the head of the radius bone, holding it tight against the ulna.

  4. 4. Quadrate ligament
    This ligament also connects the radius to the ulna.

Muscles
Muscles are fibrous tissue capable of contracting to cause body movement.

  1. 1. Biceps
    This is the large muscle on the front of the arm above the elbow that allows elbow supination, rotation of the elbow.

  2. 2. Triceps
    This is the large muscle on the back of the arm above the elbow enabling elbow extension, straightening of the elbow.

  3. 3. Brachialis
    This muscle is the primary elbow flexor enabling bending of the elbow. It is located at the distal end of the humerus.

  4. 4. Wrist extensors
    These muscles of the forearm attach to the lateral epicondyle enabling extension of the hand and wrist.

  5. 5. Wrist flexors
    These muscles of the forearm attach to the medial epicondyle enabling flexion of the hand and wrist.

Nerves
Nerves are responsible for carrying signals back and forth from the brain to muscles in our body, enabling movement and sensation such as touch, pain, and hot or cold.

The three main nerves of the arm are:

  1. 1. Radial nerve
  2. 2. Ulnar nerve
  3. 3. Median nerve

All three nerves begin at the shoulder and travel down the arm across the elbow.

Blood Vessels
The main vessel of the arm is the brachial artery. This artery travels across the inside of the elbow at the bend and then splits into two branches below the elbow.

These branches are:

Radial Artery: The radial artery is the largest artery supplying the hand and wrist area. Traveling across the front of the wrist, nearest the thumb, it is this artery that is palpated when a pulse is counted at the wrist.

Ulnar Artery: The ulnar artery travels next to the ulnar nerve through Guyon’s canal in the wrist. It supplies blood flow to the front of the hand, fingers and thumb.

Bursae

Bursae are small fluid filled sacs that decrease friction between tendons and bone or skin. Bursae contain special cells called synovial cells that secrete a lubricating fluid. When this fluid becomes infected, a common painful condition known as Bursitis can develop.


Elbow Arthroscopy

Elbow is the joint that connects the upper arm bone and the forearm bones. Elbow joint helps in moving of the arms forward, backward, as well as to twist the arms inside and outside. Elbow joint may get affected by inflammation, injury, or other disease conditions causing severe pain and requiring surgical treatment. Arthroscopy is a minimally invasive surgery performed using a tiny device called arthroscope.

Conditions of the elbow that can be treated by arthroscopy include fractures, tennis elbow, stiffness, arthritis, and tear in the ligaments, and cartilage.

Your surgeon performs medical physical examination and seeks your medical history before arthroscopy is performed.

Elbow arthroscopy is a minimally invasive surgery or keyhole procedure that allows your surgeon to look inside the elbow using small incisions and instruments to evaluate and treat elbow conditions. It is performed under anesthesia. At first, your surgeon makes 2-3 incisions near your elbow one for insertion of an arthroscope, a small device with a camera and lens fixed to the end of a narrow fiber-optic tube and other for insertion of operating instruments. The camera-lens setting magnifies and projects images of the elbow on a large screen monitor. Through the other incisions surgical instruments are inserted to treat the condition. Your surgeon injects a sterile solution into the elbow to expand the joint that allows giving an extra room to work. After the surgery the stitches are closed and dressing is applied.

After the surgery, your surgeon will place a cast or a splint that prevents the movement of the elbow until it is healed completely. You should elevate the elbow to avoid swelling and minimize pain. Ice (wrapped over a cloth) can be applied over the operated area which helps to reduce swelling. Medications are prescribed to reduce pain. Always keep the operated area dry and clean.

Some of the advantages of arthroscopy are it requires smaller incisions, minimal soft tissue trauma, less pain, faster recovery time, low infection rate, less scarring, earlier mobilization, and allows patient to restore to normal activities faster.

Some of the risks observed after elbow arthroscopy include infection, damage to the nearby nerves or tissues during surgery, and stiffness which can be treated through occupational therapy. Exercises are performed to strengthen and rebuild elbow strength.

Elbow arthroscopy may not be performed in individuals with ulnar nerve transposition and in those who had surgery earlier that had changed the normal elbow anatomy.

For more information about Elbow Arthroscopy, click on below tabs.

Elbow Arthroscopy

Lateral Epicondylitis

Lateral epicondylitis, commonly referred as tennis elbow, is an overuse injury that causes inflammation of the tendons that attach to the bony prominence on the outside of the elbow. It is a painful condition occurring from repeated muscle contractions in the forearm that leads to inflammation and micro-tears in the tendons that attach to the lateral epicondyle. The lateral epicondyle is the bony prominence that is felt on the outside of the elbow.

Patients with tennis elbow experience certain symptoms and they include:

  • Elbow pain that gradually worsens
  • Pain to the outside of the elbow that radiates to the forearm and wrist with grasping objects
  • Weak grip
  • Painful grip
  • Pain is exacerbated in the elbow when the wrist is bent back

Tennis Elbow is usually caused by overuse of the forearm muscles but may also be caused by direct trauma such as with a fall, car accident, or work injury.

Tennis elbow is commonly seen in tennis players, hence the name, especially when poor technique is used when hitting the ball with a backhand stroke. Other common causes include any activity that requires repetitive motion of the forearm such as:

  • Painting
  • Hammering
  • Typing
  • Raking
  • Weaving
  • Gardening
  • Lifting heavy objects
  • Playing musical instruments

Your physician will evaluate tennis elbow by,

  • Medical History
  • Physical Examination
  • Diagnostic procedures such as X-rays

Diagnostic procedures such as X-rays

  • Limit use and rest the arm from activities that worsen symptoms
  • Splints or braces may be ordered to decrease stress on the injured tissues
  • Ice packs to the elbow for swelling
  • Avoid activities that tend to bring on the symptoms and increase stress on the tendons
  • Anti-inflammatory medications and/or steroid injections to treat pain and swelling may be ordered
  • Occupational Therapy may be ordered for strengthening and stretching exercises to the forearm once your symptoms have decreased
  • Pulsed Ultrasound may be utilized to increase blood flow and healing to the injured tendons

If conservative treatment options fail to resolve the condition and symptoms persist for 6 -12 months, your surgeon may recommend you undergo a surgical procedure to treat Tennis Elbow called lateral epicondyle release surgery. Your surgeon will decide whether to perform your surgery in the traditional manner or endoscopically. Traditional surgery involves up to a 2″ incision in the elbow area, whereas arthroscopic surgery involves one or two smaller incisions and the use of an arthroscope with a camera for viewing internal structures.

The television camera attached to the endoscope displays the image of the joint on a television screen, allowing the surgeon to look throughout the elbow joint at cartilage, ligaments, nerves and bone.

The benefits of endoscopic surgery compared to the alternative, open elbow surgery, include:

  • Smaller incisions
  • Minimal soft tissue trauma
  • Less pain
  • Faster healing time
  • Lower infection rate
  • Less scarring
  • Earlier mobilization
  • Usually performed as outpatient day surgery

Your surgeon will decide which options are best for you depending on your specific circumstances.


Cubital Tunnel Syndrome

Cubital tunnel release surgery is a surgery to correct the cubital tunnel syndrome. Cubital tunnel syndrome, also called ulnar nerve entrapment, is a condition caused by the compression of ulnar nerve in the elbow. The ulnar nerve travels down back to the elbow behind the bony bump called the medial epicondyle and through a passageway called the cubital tunnel. The cubital tunnel is a narrow passageway on the inside of the elbow formed by bone, muscle, and ligaments with the ulnar nerve passing through its center. The roof of the cubital tunnel is covered with soft tissue called fascia. When the elbow is bent, the ulnar nerve can stretch and catch on the bony bump. When the ulnar nerve is compressed or entrapped, the nerve can tear and become inflamed leading to various symptoms.

Signs and symptoms of cubital tunnel syndrome usually occur gradually, progressing to the point where the patient seeks medical attention. Left untreated, cubital tunnel syndrome can lead to permanent nerve damage in the hand. Commonly reported symptoms associated with cubital tunnel syndrome include intermittent numbness, tingling, and pain to the little finger, ring finger, and the inside of the hand. These symptoms occur more frequently at night, and with elbow bending or prolonged resting on the elbow.

Injury to the elbow such as fractures, dislocations, or a direct blow can cause tissue swelling which can compress the ulnar nerve within the cubital tunnel. Individuals who perform repetitive elbow flexion movements at work or play are believed to be at high risk for developing cubital tunnel syndrome. Repeatedly bending and straightening the elbow can irritate and inflame the ulnar nerve. Leaning on the elbow for extended periods of time such as when working at a desk can also cause ulnar nerve irritation. Bone spurs, ganglion cysts, or tumors can form in the cubital tunnel leading to pressure and irritation of the ulnar nerve.

Your physician will recommend conservative treatment options initially to treat the cubital tunnel syndrome symptoms unless muscle wasting or nerve damage is present. Conservative treatment options may include wearing a brace or splint at night while sleeping to keep the elbow in a straight position. You can also wrap the arm loosely with a towel and apply tape to hold in place. If conservative treatment options fail to resolve the condition or if muscle wasting or severe nerve compression is present, your surgeon may recommend you undergo a surgical procedure to treat Cubital Tunnel Syndrome.

Different surgeries are performed to treat your condition.

  • Medial Epicondylectomy: This surgery involves removing the medial epicondyle, the bony bump on the inside of the elbow, enabling the ulnar nerve to glide smoothly when the elbow is flexed and straightened
  • Ulnar Nerve Transposition: This surgery involves creating a new tunnel in front of the medial epicondyle and transposing (moving) the ulnar nerve to the new tunnel

Your surgeon will decide which surgery would be best for you depending on your conditions.

Surgical Treatment

If your nerve compression is mild your surgeon may recommend a medial epicondylectomy. In this procedure your surgeon will make an incision over the medial epicondyle, the bony bump on the inside of the elbow. The cubital tunnel is cut open through the soft tissue roof exposing the ulnar nerve. The forearm muscles or flexor muscles are cut and detached from the epicondyle. Using special instruments, your surgeon will shave away the bump, freeing the ulnar nerve to glide smoothly within the cubital tunnel without pressure from the bump. The flexor muscles are then reattached to the area of shaved bone with special sutures. The incision is then closed with sutures and covered with a dressing.

More commonly, your surgeon may recommend an ulnar nerve transposition. Your surgeon will make an incision over the medial epicondyle. The cubital tunnel is cut open through the soft tissue roof exposing the ulnar nerve. The forearm muscles or flexor muscles are cut and detached from the epicondyle. The ulnar nerve is transposed or moved from behind the elbow to a new location in front of the elbow. The ulnar nerve may be placed above the flexor muscle, within the muscle, or under the muscle. Your surgeon will decide which option is best for you. The flexor muscles are then sutured back together and reattached with special sutures to the Epicondyle. The incision is then closed with sutures and covered with a dressing.

The majority of patients suffer no complications following cubital tunnel surgery however complications can occur following elbow surgery and include:

  • Infection
  • Nerve damage causing permanent areas of numbness around the elbow or forearm
  • Elbow instability
  • Elbow flexion contracture
  • Pain at site of scar
  • Symptoms are not improved by the surgery
Hip ConditionsHip Surgery

Biceps Tendon Repair

The biceps muscle, located in the front of the upper arm allows you to bend the elbow and rotate the arm. Biceps tendons attach the biceps muscle to the bones in the shoulder and in the elbow.

Biceps tear can be complete or partial. Partial biceps tendon tears will not completely break the tendon. Complete tendon tears will break the tendon into two parts.

Biceps tendon tears at the shoulder: Two tendons that attach the biceps muscle to the bones in the shoulder, the long head tendon that attaches the muscle to the top of the shoulder’s socket (glenoid) and the short head that attaches it to the shoulder blade. Tears are more likely to occur in the long head of the biceps tendon. Tears of the short head of the biceps are very rare. But even in case of a complete tear of the long head, the short head of the biceps may allow you to continue using your biceps muscle.

Biceps tendon tears at the elbow: Although two tendons attach the biceps muscle to the bone at the shoulder, only one tendon attaches it to the elbow. This is known as the distal biceps tendon. Tears of the distal biceps tendon are usually complete and the muscle is separated from the bone. Tears of the distal biceps tendon most often result from a sudden injury or lifting a heavy object.

Biceps tendon tear can be caused by injury such as falling down with your arm outstretched or during the act of lifting heavy objects. In case of overuse, a tendon may fray and eventually tear. Other shoulder problems such as tendonitis, shoulder impingement, and rotator cuff injuries are more likely to weaken or tear the biceps tendon. Additional risk factors such as advancing age, heavy overhead activities, repetitive overhead sports, smoking, and use of corticosteroids can also result in a tendon tear.

The most common symptom is a sudden, severe pain in the upper arm or at the elbow, depending on where the tendon is injured. At times you may hear a “pop”. Other symptoms include swelling, visible bruising, weakness in the shoulder or elbow, and trouble turning your arm palm or palm down. A bulge referred to as a “Popeye Muscle,” may also appear in your arm, because the tendon is no longer holding the muscle in place properly.

Biceps tendon tear is usually diagnosed based on your symptoms, medical history, and physical examination. During the physical examination, your doctor will look for a gap in the front of the elbow. Your doctor will diagnose a partial tear by asking you to bend your arm and tighten the biceps muscle. You may have pain if there is a partial tear. X-rays may be taken to rule out other conditions causing shoulder and elbow pain. Using an MRI scan your doctor can know whether tear is partial or complete.

Conservative treatment for a proximal biceps tendon tear includes ice application, limiting activity, non-steroidal anti-inflammatory medications to reduce the pain and keep down the swelling. To restore the mobility and strengthen of the surrounding muscles, your doctor may prescribe certain flexibility and strengthening exercises. Surgery to reattach the torn tendon back to the bone is rarely needed. However, for patients with partial tears who continue to experience symptoms after non-surgical treatments or who want all of their arm strength back, such as athletes or manual laborers, surgery may be the best option. Complications are rare and a re-tearing of the repaired tendon is rare. Following surgical repair, you will need to do flexibility and strengthening exercises to improve the range of motion in your shoulder.

Your surgeon may opt for several surgical procedures for distal bicep tendon tear where the distal biceps tendon is reattached to the forearm bone. Some doctors would instead use two incisions, while some use only 1 incision. Both procedures carry certain advantages and disadvantages. During the procedure, the tendon is attached with stitches through holes drilled inside the bone or small metal implants may be used to attach the tendon to the bone.

Complications are rare and may include numbness and weakness in the forearm, formation of new bone, limited movement, and re-tearing may occur.


Tennis Elbow

Tennis elbow is the common name for the elbow condition lateral epicondylitis. It is an overuse injury that causes inflammation of the tendons that attach to the bony prominence on the outside of the elbow. It is a painful condition occurring from repeated muscle contractions in the forearm that leads to inflammation and micro tears in the tendons that attach to the lateral epicondyle. The lateral epicondyle is the bony prominence that is felt on the outside of the elbow and the condition is more common in sports individuals playing tennis.

Patients with tennis elbow experience certain symptoms and they include:

  • Elbow pain that gradually worsens
  • Pain to the outside of the elbow that radiates to the forearm and wrist with grasping objects
  • Weak grip
  • Painful grip
  • Pain is exacerbated in the elbow when the wrist is bent back

Tennis Elbow is usually caused by overuse of the forearm muscles but may also be caused by direct trauma such as with a fall, car accident, or work injury.

Tennis elbow is commonly seen in tennis players, hence the name, especially when poor technique is used when hitting the ball with a backhand stroke. Other common causes include any activity that requires repetitive motion of the forearm such as:

  • Painting
  • Hammering
  • Typing
  • Raking
  • Weaving
  • Gardening
  • Lifting heavy objects
  • Playing musical instruments

Your physician will evaluate tennis elbow by,

  • Medical History
  • Physical Examination
  • Diagnostic procedures such as X-rays

Your physician will recommend conservative treatment options to treat the tennis elbow symptoms. These may include:

  • Limit use and rest the arm from activities that worsen symptoms.
  • Splints or braces may be ordered to decrease stress on the injured tissues
  • Ice packs to the elbow for swelling
  • Avoid activities that tend to bring on the symptoms and increase stress on the tendons
  • Anti-inflammatory medications and/or steroid injections to treat pain and swelling may be ordered.
  • Occupational Therapy may be ordered for strengthening and stretching exercises to the forearm once your symptoms have decreased
  • Pulsed Ultrasound may be utilized to increase blood flow and healing to the injured tendons.

If conservative treatment options fail to resolve the condition and symptoms persist for 6 -12 months, your surgeon may recommend you undergo a surgical procedure to treat Tennis Elbow called lateral epicondyle release surgery. Your surgeon will decide whether to perform your surgery in the traditional manner or endoscopically. Traditional surgery involves up to a 2″ incision in the elbow area, whereas arthroscopic surgery involves one or two smaller incisions and the use of an arthroscope with a camera for viewing internal structures.

The television camera attached to the endoscope displays the image of the joint on a television screen, allowing the surgeon to look throughout the elbow joint at cartilage, ligaments, nerves and bone.

The benefits of endoscopic surgery compared to the alternative, open elbow surgery, include:

  • Smaller incisions
  • Minimal soft tissue trauma
  • Less pain
  • Faster healing time
  • Lower infection rate
  • Less scarring
  • Earlier mobilization
  • Usually performed as outpatient day surgery

Your surgeon will decide which options are best for you depending on your specific circumstances.

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