Arm and Elbow Treatment
Chondral Injuries
These are joint cartilage injuries which can sometimes also be accompanied by bone injury. It is less common in the elbow than in the ankle, knee and hip, usually producing pain, inflammation and functional limitation.
Treatment
There are several treatment options aimed at preventing the early onset of osteoarthritis:
- Microperforations are bone perforations to increase the vascularization of the area and help with the possible regeneration of the cartilage.
- Mosaicplasty is a technique where a piece from another joint of lesser load is transplanted into the injured area.
- Autologous Chondrocyte implantation is a two-part procedure where a culture of the patient’s cells are processed in the laboratory, and the resulting collagen matrix is implanted into the injured area. This procedure has the best results.
Posterointernal and Posteroexternal Impingement
Impingement is caused by tissue becoming pinched between the joint and its neighboring structures. This produces pain and functional limitation in elbow flexion and extension. It is common for pitchers and golfers and may be confused with epicondylitis and epitrocleitis.
Treatment
Initial treatment is conservative with ice, anti-inflammatories, physiotherapy and rest.
Intra-articular treatments as corticosteroid infiltrations and Platelet-Rich-Plasma (PRP) can also be used.
Surgical treatment consists of arthroscopy for a definitive diagnosis and treatment to repair the synovium.
Elbow Arthrolysis
Chondral, osteochondral and cartilage injuries are the result of tissue degeneration or a traumatic injury. If the injury is extensive and affects all of the cartilage, it is called osteoarthritis (or arthrosis).
Treatment
This is a form of arthroscopic surgery also known as elbow release surgery. Its purpose is to unlock the elbow and give back mobility to the stiff joint by eliminating adhesions present in the joint. The stiffening affects the range of flexion and extension. Following surgery, self-assisted passive mobilization will be started as part of physiotherapy. Elbow joint stiffness can be caused by trauma, injuries, fractures or elbow surgery.
Epicondylitis – Tennis Elbow
This is a frequent overuse injury affecting the tendons on the outside of the elbow and the extensor carpi radialis brevis muscle. It causes pain in the upper third of the forearm, radiating to the back of the hand and the third and fourth finger. It is a type of tendinitis and a typical injury of tennis players although it can affect anyone.
Treatment
- Conservative - consisting of modification of daily activities and avoiding movements that cause pain. Treating the area with ice, anti-inflammatories, wrist splint and physiotherapy.
- Corticoid infiltrations and Platelet-Rich-Plasma (PRP) can also be used.
- Arthroscopic surgery if there is no improvement after one to two years consisting of resectioning the muscle or a synovectomy.
Medial Epicondylitis – Golfer’s Elbow
This is a form of tendinitis where the damage is to the tendons on the inside of the elbow. Pain occurs at the level of the inner side of the forearm, in the area of the epitrochlear which usually worsens with flexion and pronation of the wrist. It is much less frequent than tennis elbow.
Treatment
- Conservative - usually involves modifying daily activity, treating area with ice, anti-inflammatories, corticoid injections and platelet-rich plasma (PRP).
- Surgery - If recovery is not achieved within 1-2 years.
Fröhse Syndrome - Posterior Interosseous Nerve
This injury is caused by a neuropathic compression of the posterior interosseous nerve that is a deep branch of the radial nerve at the level of the elbow.
The most frequent place of compression is inside the radial tunnel at the Arc of Fröhse. It is usually due to repetitive movements with the elbow in extension and produces pain in the epicondyle muscle that radiates through the arm. It produces weakness of the extensor muscles in the fingers.
Treatment
- Conservador: Conservative - consisting of immobilization along with wrist or elbow splints and physiotherapy. It usually improves after six weeks.
- Surgery - is considered if conservative treatment is not helpful and if the compression is progressive. This involves an exploration of the entire nerve path and release of the area of compression.
Dynamic Compartment Syndrome
The body’s muscles are grouped into compartments and between them there is connective tissue called fascia. When exercising, blood increases in the muscles and the fascia lacks the distention capacity for this increased volume of blood. This causes pain due to the increase of pressure when you exercise which will then subside when exercise ceases. This is a typical chronic condition in athletes.
Treatment
- Conservative - consisting of ice, physiotherapy, stretching and relative rest of that muscle group.
- Surgery - A fasciotomy is required in most cases, to open the fascia and decompress the affected muscle.
Ulnar Nerve Neuropathy
This is the second most frequent neuropathy of the upper limb after carpal tunnel. The ulnar nerve supplies innervation to muscles in the forearm and hand. Most compression occurs at the level of the elbow near the cubital tunnel. It usually produces pain in the anterior and medial part of the elbow and forearm, numbness and tingling in the hand and fingers and a decrease in sensitivity of the dorso-ulnar area of the hand.
It can be caused by compression when the nerve becomes entrapped, by repeated activity such as golf or by metabolic diseases like diabetes, an old elbow fracture, or by working with the elbow in flexion.
Treatment
- Conservative - recommended for mild symptoms consisting of modifying what caused the symptoms, anti-inflammatories, stretching exercises, soft elbow braces and night splints.
- Surgery - for when the symptoms do not improve. This involves simple decompression by opening the canal, or by means of anterior transposition of the nerve to reduce the tension.
ELBOW AND FOREARM FRACTURES
Proximal Ulna Fractures
Olecranon Fracture
A fairly common fracture to the end of the ulna, the bony part of the elbow which is often caused by direct trauma to the elbow coming from a fall. It can be non-displaced, displaced but stable, and displaced but unstable. Each type requiring a different treatment.
Treatment
- For non-displaced fractures immobilization with a sling and progressive mobilization.
- For displaced fractures, both stable and unstable, surgery will be required. surgery.
Coronoid Apophysis
This is a very important part of the humeroulnar joint where collateral ligaments insert and resist the posterior displacement of the biceps and triceps. It is a fairly uncommon fracture indicative of elbow instability due to the collateral ligamentous structures involved. The fracture is classified according to the degree the coronoid apophysis has been affected.
Treatment
Surgical treatment will depend on the associated injuries, the head of the radius, ligaments and the stability of the joint. The most important cause of treatment failure is not to identify the associated injuries and therefore the instability of the elbow.
Proximal Radius Fractures in Adults
The head of the radius is an intra-articular structure, which articulates with the humeral condyle, allowing movements of flexion and extension and pronosupination of the elbow. It is joined to the ulna by the interosseous ligament. This is a frequent elbow fracture and in 30% of cases is associated with other injuries.
Treatment
Treatment depends on the type of fracture, whether displaced, compelled or non-reconstructible and if associated with other lesions such as injury to the triangular fibrocartilage. Treatment can be both conservative and surgical and may potentially require a prosthesis.
Diaphyseal Fractures of the Ulna and Radius
The ulna and radius form a ring together with the proximal and distal radioulnar joints. Fractures in this area, called double-bone fractures, are common and if not treated correctly can cause loss of function. It is also important to look for other associated injuries. These fractures are typically caused by direct trauma or indirectly due to hyperextension.
Treatment
Treatment aims to obtain the length, rotation, axis and shape of the radius. These fractures are treated as joint fractures, consisting of open reduction and stable osteosynthesis or for non-displaced fractures with brachial plaster, consolidating in eight to twelve weeks.
Isolated Ulnar Fractures
These are common forearm injuries affecting the middle third or distal forearm. They usually occur due to direct trauma and are classified according to stability and displacement.
Treatment
Treatment for non-displaced fractures will be a brachial plaster for ten to fifteen days and then an orthosis for up to twelve weeks.
Treatment for displaced fractures consists of surgery with open reduction and internal fixation.
Monteggia Fracture Dislocation
This is a relatively uncommon injury consisting of a fracture to the head of the ulna with radial head dislocation. The most frequent are Type 1: ulnar fracture with anterior angulation and anterior dislocation of the radial head. These injuries are most often the result of a fall on an outstretched hand.
Treatment
Surgical treatment consists of osteosynthesis and closed reduction of the head of the radius.
Isolated Radius Fractures
These fractures are most frequent in the middle third and proximal part of the radius without injury of the distal radioulnar joint. They are typically caused by a fall on the hand with the elbow in extension.
Treatment
Treatment for non-displaced fractures is with brachial plaster and for displaced fractures either closed reduction and plaster, intramedullary needles or DCP.
Galeazzi Fracture-Dislocation
This is a fracture of the distal third of the radius with distal radioulnar dislocation. The more distal the fracture the more instability it causes. Other signs of instability are fracture of the base of the ulnar styloid, widening of the joint, shortening of the radius and persistent incongruence of the distal ulna. It is caused by a direct blow to the forearm or indirectly with a fall where the forearm is in pronation.
Treatment
These fractures are very unstable by definition and will therefore require surgical reduction with osteosynthesis, and closed reduction of the dislocation.
Elbow Dislocation
It is the second most frequently dislocated joint after the shoulder and typically produces injuries of capsuloligamentous structures.
The dislocation can be referred to as the Terrible Triad Injury TTI when associated with fractures of the radial head and ulnar coronoid process. This is a very serious and unstable injury requiring surgical intervention.
Possible injuries of the ulnar or median nerve must also be assessed, in addition to possible vascular affectations.
Treatment
- Conservative - requires mobilization as early as possible, almost from the first day, to reduce loss of extension and post-traumatic stiffness.
- Surgery - consisting of closed reduction for dislocation. Unstable dislocations and those with associated bone fractures will require reconstructing the stabilizing elements of the elbow, osteosynthesis or radius head prostheses, coronoid osteosynthesis and ligament reconstruction.