Fractures around the elbow
Adult Elbow injuries or fractures can range from undisplaced crack fractures, which he can definitely be treated in splints with a view to early movement of the elbow joint, to severely shattered fractures into the joint, which require meticulous reconstruction in order to prevent severe elbow stiffness. A fact that is often overlooked is that the elbow does not just flex and extend, it plays a major role in rotation of the forearm, which is required for almost all clerical activities such as writing, the use of a keyboard, painting and many others. The decision as to whether a fracture requires surgical intervention based on strict, often non-intuitive criteria and must be made by an orthopaedic surgeon and often requires imaging investigations above and beyond simple x-rays (CT scan or MRI scan). If the opportunity to treat these fractures early is missed, complications such as compartment syndrome from excessive swelling as well as elbow stiffness and early onset of osteoarthritis often become unavoidable.
Radial head fractures occur when people fall on an outstretched hand with side force. This is often associated with medial ligament injury. Minimally displaced fractures can be treated with early mobilization, but in the case of displaced fractures it is better to do surgery to restore the joint surface and function. Radial head fractures can sometimes be impossible to fix due to the fact that there are too many fragments and if the ligaments are injured either at the wrist or at the elbow the best option would be to do a radial head replacement. Physiotherapy after radial head fractures is important to achieve good results.
Avulsion fractures: Another group of fractures around the elbow which are often misdiagnosed are avulsion or pull-off fractures. These may be small on x-ray, but if they are not correctly managed, may result in elbow instability and recurrent dislocations. Again, many of these injuries may be treated non-surgically, however, they have to meet certain criteria in order for this to be successful and patients with such injuries should be reviewed by an orthopaedic surgeon. It is also common for more extensive soft tissue injuries to accompany such fractures and these require diagnosis and management also.
Pure soft tissue injuries of ligaments and tendons around the elbow are also common, and except for soft tissue swelling, they do not show up on x-ray. Commonly injured structures are the collateral ligaments as well as the biceps tendon. Collateral ligament injuries can only be diagnosed with difficulty in the early stages and often require further imaging investigations such as an ultrasound scan or an MRI scan in order to determine the extent of injury. Many of these injuries may be treated with bracing and early range of motion, however, if these are not managed properly, an unstable elbow joint may result with disastrous functional impairment. Biceps tendon injuries are often surgically treated and usually require reattachment of the tendon to the radius bone. A little-known fact is that the biceps is the main power-rotator of the forearm, rather than a flexor and its loss results in functional impairment as discussed above.
Non-traumatic elbow injuries which are commonly managed by our practice include tennis elbow, golfers elbow, olecranon bursitis, ulna nerve entrapment around the elbow and olecranon impingement.
Tennis elbow or lateral epicondylitis is a disabling, painful problem which presents with pain on the outside of the elbow, which is exacerbated by resisted extension of the wrist. Contrary to popular belief, this does not just happen to tennis players. Treatment of this condition rests on confirmation of the diagnosis, because other problems such as radial nerve entrapment around the elbow may seem similar first glance. Initial treatment is always non-surgical with local injection, non-steroidal anti-inflammatory medication use, activity modification and bracing. If over the period of 6 to 9 months, conservative treatment fails, a minor surgical release of the extensor origin may be required.
Golfers elbow is a similar problem to tennis elbow, but involves the common flexor muscle origin on the inside of the elbow joint. Treatment is also similar.
Olecranon bursitis or students elbow is a condition where a fluid filled sack develops over the bony prominence at the back of the elbow. Usually this occurs due to excessive repetitive microtrauma such as resting elbow on a desk while studying. Treatment of this condition involves drainage of the fluid, local injection and the use of a compression garment. If repeated nonsurgical treatment is not successful, excision of the bursa may be required. If olecranon bursitis develops after a abrasion or laceration over the area, this requires treatment with antibiotics and possibly early drainage of a developing abscess. Surgery is by no means always required and this requires careful orthopaedic assessment.
Ulnar nerve entrapment is a common problem around the elbow and is further discussed in the section on hands.
Olecranon impingement is a painful condition, which is usually seen in martial artists. Pain at the back of the elbow develops due to repetitive forced extension of the elbow during punching. This problem is extremely disabling and may initially be treated with injections and activity modification, if this fails, the fat pad and a section of the distal humorus need to be removed. This can be done with an arthroscopic or keyhole surgery.
Mechanical elbow problems are not dissimilar to mechanical problems in the knee and may often be treated with arthroscopic debridement of various loose bodies inside the elbow joint.
