Dr Budoff's Blog

Posts Tagged ‘Elbow injury’

Proximal Ulna Fractures

Thursday, October 21st, 2010

Proximal Ulna fractures are fairly common elbow injuries. There are two main types: olecranon fractures and coronoid fractures. Unfortunately, both types of proximal ulnar fractures frequently require surgical management.

Olecranon Fractures:
Non-displaced olecranon fractures (cracks in the bone without separation of the fragments) are fairly uncommon in adults, but are more common in children. Non-displaced olecranon fractures usually do well with 3 weeks of casting followed by protective use and physical therapy.

Displaced olecranon fractures, where the fragments have separated over 2 mm, require surgery in order to restore elbow function. The triceps tendon, the only tendon that extends your elbow, attaches to the olecranon. Failure to fix the olecranon means that triceps function will be permanently compromised. Olecranon fractures may also disrupt the elbow joint and lead to arthritis. All of these problems are minimized by surgical treatment. There are many fixation devices that can be used to treat olecranon fractures, but I believe that specially-designed locking plates are currently the best fixation available. These plates have a low complication rate and are stable enough to allow for early motion. Olecranon fractures usually do very well following surgical fixation. For an illustration of a plated olecranon fracture, please see the elbow fracture section of this website.

Coronoid Fractures:
Coronoid fractures are rarely isolated injuries to the elbow. Coronoid fractures are usually associated with other elbow fractures and ligament injuries. Coronoid fractures can be an important part of very serious elbow injuries, such as the ‘terrible triad’ injury, which involves fractures of the coronoid, fracture of the radial head, and a tear of the lateral collateral ligament. These and other complex injury patterns usually require operative fixation to have the best chance of future function.

These complex injury patterns do best in the hands of subspecialists, with the advanced training and experience to understand these injury patterns and treat them. I have extensive experience with these injuries, and most patients I’ve treated have had very good outcomes. I’ve also lectured on these injury patterns and performed research on the optimal way to fix large coronoid fractures. If the coronoid fracture is small it is usually fixed by suture. If it’s large, it is usually fixed with a special plate; often a screw is added for additional stability. For an illustration of a plated coronoid fracture, please see the elbow fracture section of this website.

While these are serious injuries, in the hands of an experienced elbow surgeon with a committed postoperative rehabilitation effort by the patient, the surgical results are usually excellent.

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Elbow Arthritis

Sunday, July 18th, 2010

Elbow arthritis can be due to osteoarthritis (wear and tear arthritis), post-traumatic arthritis (after a fracture or dislocation) or due to rheumatoid arthritis (a systemic, inflammatory disease). Elbow arthritis can limit function, cause pain, and lead to serious impairment of the arm.

Initial treatment should be nonoperative, with an injection, activity modification, and occasionally physical therapy. If that is ineffective, then options depend on how advanced the arthritis is and the symptoms it is causing. Pain at terminal motion (at full flexion or full extension) is usually due to bone spurs, which are the body’s reaction to arthritis. Pain during mid-motion is usually due to loss of the joint’s normal slippery cartilage surface. Pain during rest is usually due to reactive synovitis (inflammation of the joint lining in response to the mechanical irritation of the arthritis). Catching, locking, and feelings like something is ‘loose’ in the joint are often due to loose bodies, which are pieces of bone spurs and damaged cartilage that have broken off and are floating around the joint.

If the arthritis is mild, an arthroscopic debridement can help. Arthroscopy can remove bone spurs, inflammation, and any loose bodies in the joint. This often relieves pain during terminal motion and often at rest. Mid-motion pain will usually not be improved, and if the arthritis is significant, the inflammation and rest pain will recur. In some patients, such as those who have already had their ulnar nerve moved (putting it at risk unless it’s visualized), or those who are undergoing additional surgeries, elbow debridement may be better performed through an open incision.

If stiffness is a problem, release of the restraining joint capsule (the balloon around the joint) may be performed, either openly or arthroscopically. In order to maintain the motion that is gained during surgery, extensive physical therapy will be required after surgery. When significant stiffness is present, the ulnar nerve will usually be scarred in, and should be released or transposed (moved) to avoid problems with traction on the nerve once motion is restored.

If mid-motion pain is prominent, then cartilage loss has probably occurred. Simple debridement of bone spurs will not provide pain relief. In older patients, a total elbow replacement is an effective option. Total elbow replacement usually involves a hospital stay of 1-2 nights. The elbow is splinted for approximately 2 weeks, and then motion is begun. Pain relief and function are very good, but elbow replacements can loosen over time. To protect against this, there is a lifetime lifting limit of 1-2 pounds repetitively and 5-10 pounds for a single time once in a while.

In young patients who cannot live with this restriction, the best operation may be a fascial-interposition arthroplasty, where the achilles tendon from a cadaver is used to resurface the elbow joint. This tendon is broad and slippery, and may provide a pain-free surface for the reconstructed elbow. This surgery also usually requires a night in the hospital. In order to keep the joint surfaces apart to maximize healing and motion, an external fixator is placed about the elbow. This involves placing 2 metal screws into the humerus (the large bone above the elbow) and 2 metal screws into the ulna (one of the forearm bones), connected by a hinge to allow motion. The fixator remains in place for 3-6 weeks, and is then removed under general anesthesia as a second procedure. While fascial-interposition arthroplasty is not as predictable as a total joint replacement, it does very well in select patients without ligament or bone loss. And unlike a total elbow replacement, once the fascial-interposition arthroplasty is healed, the elbow can be used within the limits of pain, without lifting restrictions.

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Osteochondritis Dissecans (OCD)

Saturday, June 12th, 2010

Recently, I wrote a blog on medial collateral ligament (MCL) injuries in teenage pitchers. The throwing motion puts a lot of stress on the elbow. There’s significant tension on the inside of the elbow, potentially leading to MCL injuries. The other side of this coin is that there’s also a lot of compression on the outside of the elbow. Injuries can occur here as well, when the compressive overload injures the cartilage and bone in this area. This is called osteochondritis dissecans (OCD). In essence, the excessive compression injures the blood supply to the elbow, causing the bone supporting the outside of the elbow to die. This is analogous to a heart attack of bone. In a heart attack, the blood is cut off from the heart, killing part of it. In a stroke, the blood is cut off from the brain, killing part of it. In a bone, when the blood supply is cut off, part of the bone dies, leading to OCD. In the elbow, this most commonly happens in the area of bone known as the capitellum.

OCD causes pain, swelling, and stiffness of the elbow, and often leads to arthritis. In addition, the dead bone and cartilage can break off and form loose bodies that lead to painful locking and catching. It’s a very serious problem.

The best way to treat early OCD, before loose body formation, is to rest the elbow. No throwing, using the arm to bear weight or heavy lifting for 6 months. If that fails to quiet the symptoms, or if there are loose bodies from fragmented bone and cartilage, elbow arthroscopy is often helpful. Elbow arthroscopy can remove loose bodies and smooth down loose cartilage edges that may get caught between the bones of the elbow during motion. In addition, ‘micro-fracture’ can be used to treat the area of OCD. This is similar to what many professional athletes have done to focal areas of arthritis in their knees and ankles. A sharp awl is used to punch small holes in the affected area of bone to hopefully stimulate a healing response that can lead to the production of new cartilage. While the new cartilage formed from micro-fracture is not normal, and not as good as natural cartilage, it may be enough to stop the pain, swelling and the progression to arthritis. After a brief period of splinting to rest the elbow down surgery, motion is encouraged to help the cartilage mature. There is no heavy elbow use for 6 months.

If symptoms persistent for over 6 months following surgery, if the OCD lesion is large, or if the outside rim of bone (that helps stabilize the joint) is lost from the OCD, then a second procedure is indicated. In this procedure, living bone and cartilage is taken from the outside of the knee and placed into the area of the elbow affected with OCD. The hope is that the transplanted cartilage will heal and allow the elbow to function normally. If not, the natural history of OCD is that 50% of patients will continue to have pain and swelling and go on to develop arthritis.

Therefore, as for MCL tears, the best treatment is prevention. Parents, protect your teenage pitchers. Follow the pitch counts religiously. Rest painful elbows. Otherwise, many of the best pitchers will have their careers ended due to injury before they graduate high school. Remember: teenage athletes are more vulnerable to overuse injuries than adult athletes. A little patience and rest in the short run can prevent the end of a promising career in the long run.

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