Acute Fractures & dislocations

The elbow is a hinge joint made up of 3 bones – humerus, radius and ulna. The bones are held together by ligaments to provide stability to the joint. Muscles and tendons move the bones around each other and help in performing various activities. Elbow dislocation occurs when the bones that make up the joint are forced out of alignment.

Causes of elbow dislocation

Elbow dislocations usually occur when a person falls onto an outstretched hand. Elbow dislocations can also occur from any traumatic injury such as motor vehicle accidents. When the elbow is dislocated, you may have severe pain, swelling and lack of the ability to bend your arm. Sometimes, you cannot feel your hand or may have no pulse in your wrist because arteries and nerves running along your elbow may be injured.

Diagnosis of elbow dislocation

To diagnose elbow dislocation, your doctor will examine your arm. Your doctor will check the pulses at the wrist and evaluate the circulation to the arm. An X-ray is necessary to determine if there is a break in the bone. An arteriogram, an X-ray of your artery can be helpful to know if the artery is injured.

Treatment of elbow dislocation

An elbow dislocation is a serious injury and therefore requires immediate medical attention. At home, you may apply an ice pack to the elbow to ease pain and swelling. However, it is important to visit your doctor for help. You can also check if the arteries and nerves are injured or remain intact. You can feel your pulse by pressing the tips of your fingers to the base of your wrist. They should turn white or blanch and a pink colour should come back in 3 seconds.

To check for nerves, first bend your wrist up and move your fingers apart and then touch your thumb to your little finger. You can also check for numbness all over your hand and arm. If you have problem with any of these tests you need to see your doctor right away.

You doctor will put your dislocated elbow back in place by pulling down your wrist and levering your elbow. This procedure is known as reduction. As it is a painful procedure, you may be given medications in the beginning, to relieve your pain. After the reduction, you may have to wear a splint to immobilise your arm at the elbow. After few days, you may also need to do gentle motion exercises to improve range of motion and strength.

Prevention of elbow dislocation

Elbow dislocations may be prevented if you avoid falling on an outstretched arm or avoid situations that may cause falls, such as walking at night or walking on slippery floors.

Bicep Tendon Tear at Elbow

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 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.

Cause of biceps tendon tear at the elbow

Biceps tendon tear can be caused by an injury such as falling on your outstretched arm 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 the use of corticosteroids can also result in a tendon tear.

Symptoms of biceps tendon tear at the elbow

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 up 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.

Diagnosis of biceps tendon tear at the elbow

A 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 determine whether the tear is partial or complete.

Treatment of biceps tendon tear at the elbow

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 those who want all their arm strength back, in the case of athletes and 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.

What is ulnar nerve entrapment (cubital tunnel syndrome)?

Cubital tunnel syndrome is a condition characterised by the compression of the ulnar nerve in an area of the elbow called the cubital tunnel.

The ulnar nerve travels down the back of 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 centre. The roof of the cubital tunnel is covered by a 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 cubital tunnel syndrome.

Signs and Symptoms of ulnar nerve entrapment (cubital tunnel syndrome)

In general, the signs and symptoms of cubital tunnel syndrome arise 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.
• Aching pain to the inside of the elbow
• Weakness in hand with diminished grip strength.
• Diminished sensation and fine motor control in the hand causing the person to drop objects or have difficulty in handling small objects.
• Muscle wasting in the hand and permanent nerve damage, if left untreated.

Causes of ulnar nerve entrapment (cubital tunnel syndrome)

The common causes responsible for cubital tunnel syndrome, include:

• Trauma
• Repetitive motion
• Frequent pressure on the elbow for extended periods
• Medical conditions such as bone spurs, ganglion cysts or tumours in the cubital tunnel, leading to pressure and irritation of the ulnar nerve.

Diagnosis of ulnar nerve entrapment (cubital tunnel syndrome)

Your physician will perform the following:

• Medical history
• Physical examination

Your physician may order X-ray and electro diagnostic tests such as electromyography and nerve conduction studies. These tests can assist your doctor in determining how well the nerve is functioning and locate areas of muscle wasting and nerve compression.

Treatment of ulnar nerve entrapment (cubital tunnel syndrome)

Your physician will initially recommend conservative treatment options to treat the symptoms unless muscle wasting or nerve damage is present.

Conservative treatment options may include the following:

• Avoid frequent bending of the elbow.
• Avoid leaning on the elbow and applying pressure on it. Elbow pads may be worn to decrease pressure when working at a desk.
• Wear 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 it in place.
• Avoid activities that tend to bring on the symptoms.
• NSAIDs (non-steroidal anti-Inflammatory drugs) such as ibuprofen or aspirin may be ordered to reduce swelling.
• Referral to OT (occupational therapy) for instruction in strengthening and stretching exercises may be recommended.

Surgical Treatment

If conservative treatment options fail to resolve the condition or if muscle wasting or severe nerve compression is present, your surgeon may recommend a surgical procedure to treat your condition.

The goal of cubital tunnel surgery is to reduce the pressure on the ulnar nerve by providing more space for the nerve to move freely and increase blood flow to promote healing of the ulnar nerve. There are different surgeries that can be performed to treat your condition, such as:

• 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 options are best for you depending on your specific circumstances.

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

Post-operative Care

After surgery, you will be given guidelines to follow depending on the type of repair performed and your surgeon’s preference. Common postoperative guidelines include:

• A bulky dressing with a plaster splint is usually applied following surgery for 10-14 days.
• Elevating the arm above heart level and moving the fingers are important to prevent swelling.
• The arm dressing and sutures are removed after 10-14 days.
• Elbow immobilisation for 3 weeks after surgery is usually indicated, longer depending on the repair performed.
• Ice packs are applied to the surgical area to reduce swelling. Ice should be applied over a towel to the affected area for 20 minutes every hour. Keep the surgical incision clean and dry. Cover the area with plastic wrap when bathing or showering.
• Occupational therapy will be ordered a few weeks after surgery for strengthening and stretching exercises to maximise the use of the hand and forearm

Risks and Complications

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 numbness around the elbow or forearm
• Elbow instability
• Elbow flexion contracture
• Pain at the site of scar
• Symptoms unresolved even after the surgery

Distal Biceps Rupture

The biceps muscle is located in front of your upper arm. It helps in bending your elbow, rotational movements of your forearm and in maintaining stability in the shoulder joint. The biceps muscle has two tendons, one of which attaches it to the bone in the shoulder and the other attaches at the elbow. The biceps tendon at the elbow is called the distal biceps tendon.

A tear in this tendon will make it difficult for you to move your arm from the palm down to palm up position. Once the distal biceps tendon is torn, it cannot regrow back to the bone and heal by itself. Permanent weakness during rotatory movements of the forearm may occur if the tendon is not repaired surgically.
Biceps tendon tears can be complete or partial. In partial biceps tendon tear, the tendon does not tear completely. Complete tendon tears will cut the tendon into two parts. Tears of the distal biceps tendon are usually complete tears and the muscle gets separated from the bone.

What are the causes of distal biceps tendon rupture?

Distal biceps tendon ruptures most often result from a sudden injury or lifting a heavy object. Additional risk factors, such as advancing age, smoking and use of corticosteroid medications, can also result in increased muscle and tendon weakness, which can lead to the tendon rupture.

What are the signs and symptoms of distal biceps tendon rupture?

The most common symptom is a sudden, severe pain in the upper arm or at the elbow. You may feel a “pop” at the elbow when the tendon tears. Other symptoms include swelling, visible bruising, weakness in the elbow, trouble turning your arm from a palm up to a palm down position, and a gap in the front of the elbow, caused by the absence of the tendon. A bulge may also appear in your arm caused by the recoiled, shortened biceps muscle.

How is distal biceps tendon rupture diagnosed?

Distal biceps tendon rupture 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 tendon by palpating the front part of your 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 elbow pain. Using an MRI scan, your doctor can determine whether the tear is partial or complete.

What are the treatment options of distal biceps tendon rupture?

There are several procedures to accomplish reattachment of the distal biceps tendon to the forearm bone. Some techniques require two incisions while in others one incision may be sufficient. In some cases, the tendon is reattached using stitches passed through holes drilled in the bone. Sometimes, a small metal implant may be used to attach the tendon.

How is the surgery performed?

During distal biceps tendon repair, your surgeon makes a small incision over the upper forearm, where the biceps muscle attaches to the radius bone. The torn biceps tendon is brought up through the incision. Then, the radius bone is prepared for tendon reattachment and to promote healing. Two suture anchors are inserted into the bone. These serve as anchorage for the tendon. The sutures from the suture anchors are passed through the tendon in a particular interlocking manner so as to ensure a strong tendon repair.

After the repair is complete, a hinged elbow brace is applied with your elbow bent at 90 degrees. The brace is removed after 6 weeks and it may take up to 6 months to 1 year to regain full strength.

Elbow Arthritis

Although the elbows are not weight-bearing joints, they are considered to be most important for the functioning of the upper limbs. Hence, even minor trauma or disease affecting the elbow may cause pain and limit the movements of the upper limbs. Arthritis is one of the common disease conditions affecting the elbow joint.

Symptoms of osteoarthritis of the elbow

It is an inflammatory condition that causes pain, swelling, stiffness, and interference with the use of the arm.

Causes of osteoarthritis of the elbow

Arthritis can affect all ages but is most commonly seen in people aged over 40 years. The most common cause is wear-and-tear. Apart from that, traumatic injuries, fractures and dislocations make you more susceptible to arthritis.

Types of osteoarthritis of the elbow

There are several types of arthritis, the most common being the following:
Osteoarthritis or degenerative joint disease is the most common type of arthritis that affects older people. It causes the cartilage, the tissue that cushions and protects the ends of bones in a joint, to wear off, causing painful rubbing of bones.

Rheumatoid arthritis is an autoimmune disease in which the body’s immune system attacks healthy joints, tissues and organs. It can cause pain, stiffness, swelling, deformity and loss of function in joints.
Post-traumatic arthritis develops after an injury to the elbow. The condition may develop years after the trauma such as a fracture, severe sprain or ligament tears.
Psoriatic arthritis occurs in some, as a result of psoriasis, a scaling skin disorder.

Diagnosis of osteoarthritis of the elbow

Arthritis in the elbow is diagnosed through a thorough physical exam and X-ray.

Treatment of osteoarthritis of the elbow

Treatment can include conservative options such as medications and steroid injections to relieve pain, activity modification, and use of splints. Surgery is usually considered if nonsurgical treatment fails to provide relief. Total elbow replacement is a surgical procedure used to restore the function and relieve pain in the elbows affected by arthritis. In total elbow replacement surgery, the damaged regions of the elbow joint are replaced with artificial components.

Golfer’s Elbow

What is golfer’s elbow?

Golfer’s elbow, also called medial epicondylitis, is a painful condition occurring from repeated muscle contractions in the forearm that leads to inflammation and microtears in the tendons that attach to the medial epicondyle. The medial epicondyle is the bony prominence that is felt on the inside of the elbow.
Golfer’s elbow and tennis elbow are similar except that golfer’s elbow occurs on the inside of the elbow and tennis elbow occurs on the outside of the elbow. Both conditions are a type of tendonitis, which means “inflammation of the tendons”.

Signs and symptoms

The signs and symptoms of golfer’s elbow can include the following:

• Elbow pain that appears suddenly or gradually
• Achy pain to the inner side of the elbow during activity
• Elbow stiffness with decreased range of motion
• Pain that may radiate to the inner forearm, hand or wrist
• Weakened grip
• Pain that worsens with gripping objects
• Pain that is exacerbated in the elbow when the wrist is flexed or bent forward toward the forearm

Causes of golfer’s elbow

Golfer’s elbow is usually caused by the overuse of the forearm muscles and tendons that control the wrist and finger movement, but may also be caused by direct trauma such as with a fall, car accident or work injury.
Golfer’s elbow is commonly seen in golfer’s, hence the name, especially when poor technique or unsuitable equipment is used when hitting the ball. Other common causes include any activity that requires repetitive motion of the forearm such as painting, hammering, typing, raking, pitching sports, gardening, shovelling and fencing.

Diagnosis of golfer’s elbow

Golfer’s elbow should be evaluated by an orthopaedic specialist for proper diagnosis and treatment.

• Medical history
• Physical examination
• X-ray to rule out a fracture or arthritis as the cause of your pain
• Further confirmatory tests to confirm golfer’s elbow such as MRI, ultrasonography and injection test

Conservative treatment options for golfer’s elbow

Your physician will recommend conservative treatment options to treat the symptoms associated with golfer’s elbow. These may include the following:

• Activity restrictions: Limit the use and rest the arm from activities that worsen symptoms.
• Orthotics: Splints or braces may be ordered to decrease stress on the injured tissues.
• Ice: Ice packs applied to the injury will help diminish swelling and pain. Ice should be applied over a towel to the affected area for 20 minutes four times a day for a couple of days. Never place ice directly over the skin.
• Medications: Anti-inflammatory medications and/or steroid injections may be ordered to treat the pain and swelling.
• Occupational therapy: OT may be ordered for strengthening and stretching exercises to the forearm once your symptoms have decreased.
• Pulsed ultrasound: This is a non-invasive treatment used by therapists to break up scar tissue and increase blood flow to the injured tendons to promote healing.
• Professional instruction: Consulting with a sports professional to assess and instruct in proper swing technique

Surgery for golfer’s elbow

If conservative treatment options fail to resolve the condition and symptoms persist for 6 -12 months, your surgeon may recommend surgery to treat golfers elbow. The goal of surgery to treat golfers elbow is to remove the diseased tissue around the inner elbow, improve blood supply to the area to promote healing, and alleviate the patient’s symptoms.

Wrist Fracture

What is a wrist fracture?

The wrist is comprised of two bones in the forearm, the radius and ulna, and eight tiny carpal bones in the palm. The bones meet to form multiple large and small joints. A wrist fracture refers to a break in one or more of these bones.

Types of wrist fracture

Types of wrist fractures include:

• Simple wrist fractures are those in which the fractured pieces of bone are well aligned and stable.
• Unstable fractures are those in which fragments of the broken bone are misaligned and displaced.
• Open (compound) wrist fractures are severe fractures in which the broken bones cut through the skin. This type of fracture is more prone to infection and requires immediate medical attention.

Causes of wrist fracture

Wrist fractures may be caused due to fall on an outstretched arm, vehicular accidents or workplace injuries. Certain sports such as football, snowboarding or soccer may also be a cause of wrist fractures. Wrist fractures are more common in people with osteoporosis, a condition marked by brittleness of the bones.

Signs and symptoms of wrist fracture

Common symptoms of a wrist fracture include severe pain, swelling, and limited movement of the hand and wrist. Other symptoms include:

• Deformed or crooked wrist
• Bruising
• Numbness
• Stiffness

Diagnosis of wrist fracture

Your doctor performs a preliminary physical examination followed by imaging tests such as an X-ray of the wrist to diagnose a fracture and check the alignment of the bones. Sometimes a CT scan may be ordered to gather more detail of the fracture, such as soft tissue, nerves or blood vessel injury. MRI may be performed to identify tiny fractures and ligament injuries. Your doctor will order a bone scan to identify stress fractures due to repeated trauma. The radioactive substance injected into the blood gets collected in areas where the bone is healing and is detected with a scanner.

Treatment of wrist fracture

Your doctor may prescribe analgesics and anti-inflammatory medications to relieve pain and inflammation.
Fractures that are not displaced are treated with either a splint or a cast to hold the wrist in place.
If the wrist bones are displaced, your surgeon may perform fracture reduction to align the bones. This is performed under local anaesthesia. A splint or a cast is then placed to support the wrist and allow healing.

Surgery for wrist fracture

Surgery is recommended to treat severely displaced wrist fractures and is carried out under the effect of general anaesthesia.
External fixation, such as pins may be used to treat the fracture from the outside. These pins are fixed above and below the fracture site and are held in place by an external frame outside the wrist.
Internal fixation may be recommended to maintain the bones in proper position while they heal. Devices such as rods, plates and screws may be implanted at the fracture site.
Crushed or missing bone may be treated by using bone grafts taken from another part of your body, bone bank or using a bone graft substitute.
During the healing period, you may be asked to perform some motion exercises to keep your wrist flexible. Your doctor may recommend hand rehabilitation therapy or physical therapy to improve function, strength and reduce stiffness.

Risks and Complications

• As with any procedure, wrist fracture surgery involves certain risks and complications. They include:
• Infection
• Residual joint stiffness
• Arthritis

Hand Fracture

The hand is one of the most flexible and useful parts of our body. Because of overuse in various activities, the hands are more prone to injuries, such as sprains and strains, fractures and dislocations, lacerations and amputations while operating machinery, bracing against a fall and sports-related injuries.

Fractures

A fracture is a break in the bone, which occurs when force greater than the bearable limit is applied against a bone. The most common symptoms of any fracture include severe pain, swelling, bruising or bleeding, deformity, discolouration of the skin and limited mobility of the hand.

Finger fracture

Fingers are fine structures of the human body that assist in daily routine activities through coordinated movements. Any abnormality affecting the fingers can have a huge impact on the quality of life. A finger fracture is not a minor injury, and if left untreated can lead to stiffness, pain, disruption of the alignment of the whole hand and interference with specialised functions such as grasping or manipulating objects. Finger fractures commonly occur during sports activities, when you break a fall or while operating machinery.

Diagnosis

The diagnosis of a hand or finger fracture is based on history, physical examinations and X-ray imaging to determine the type and severity of the fracture. X-rays are the most widely used diagnostic tools for the evaluation of fractures.

Treatment

The objective of early fracture management is to control bleeding, provide pain relief, prevent ischemic injury (bone death) and remove sources of infection such as foreign bodies and dead tissues. The next step in fracture management is the reduction of the fracture and its maintenance. It is important to ensure that the involved part of the body returns to its function after the fracture heals. To achieve this, maintenance of fracture reduction with immobilisation technique is done by either non-operative or surgical methods.

Non-operative Therapy

The bones can be realigned by manipulating them into place. Following this, splints, casts or braces made up of fibreglass or plaster of Paris material are used to immobilise the bones until they heal. The cast is worn for 3 to 6 weeks.

Surgical Therapy

During surgery, the fracture site is adequately exposed, the bones realigned, and reduction of the fracture is done internally using wires, plates and screws and intramedullary nails.

Rehabilitation

Fractures may take several weeks to months to heal completely. You should limit your activities even after the removal of the cast or brace so that the bone becomes solid enough to bear stress. Rehabilitation program involves exercises and gradual increase in activity levels to strengthen the muscles and improve range of motion.