- Elbow Dislocation
- Elbow Fractures
- Locking of the Elbow
- Elbow Replacement
- Continuous Passive Motion Therapy
- Tennis Elbow/Lateral Epicondylitis
- Distal Biceps Repair
- Platelet Rich Plasma Injection Therapy
- Extracorporal Shockwave Treatment
- Golfers elbow
- Snapping triceps
- Ulnar Nerve Release
- Olecranon Bursitis
Elbow dislocations are common, and represent the second commonest major joint dislocation after the shoulder. Prompt accurate assessment and treatment is necessary to achieve the best possible outcome and prevent complications such as redislocation and loss of motion. Depending on the complexity of the injury, most elbow dislocations are managed in a removable splint or hinge brace to allow early movement.
Fracture of the radial head with associated instability of the elbow joint
3 dimensional CT reconstruction images showing the fracture clearly
Surgical fixation of the radial neck with mini plate and screws
Fracture of the olecranon treated with locking plate and screws
Examples of loose bodies within the elbow joint, which can sometimes give rise to the sensation of locking in the elbow. This can be rectified with arthroscopic keyhole surgery.
Primary and Revision Total Elbow Replacement
Prosthetic replacement of the elbow joint was first described in 1947. Since then, there has been vast improvement in the design of the prosthesis and nowadays, the implant survival data nearly approached that of knee replacements. It may be indicated in complex trauma of the elbow, osteoarthritis and rheumatoid arthritis. It is usually an operation that requires one or two nights stay in hospital followed by a period of rehabilitation and specialist physiotherapy. Sometimes, an old elbow replacement which has been implanted a long term ago becomes worn out, and may need to be revised or changed to a new one.This is an example of the Souter Strathclyde which was inserted 20 years ago and has become loose
The appearance of the elbow above following revision
Continuous Passive Motion Therapy (CPM)
Sometimes, the affected elbow may need supplementary treatment in a Continuous Passive Motion machine. This machine helps to bend the elbow even when you are resting in bed. It is most useful for painful stiff elbows, sometimes in combination with surgical treatment. The machine can be hired on a short term basis (weeks to months) and taken home for daily treatment. It is entirely painless and reliably produces rewarding results if the essential principles of CPM are followed and compliance is achieved.
Tennis Elbow/Lateral Epicondylitis
Tennis elbow, or lateral epiconylitis, is probably the most common elbow complaint. It occurs on the lateral side of the elbow joint, the side which is furthest away from the centre of the body. The muscles and tendons which are responsible for extending the wrist, opening the hand and turning the palm up are most at risk of this problem. It is commonly associated with playing tennis although other sports such as golf, squash, weightlifting, fly and cast fishing, swimming, cycling, track events can also cause a similar injury. This condition is also seen more commonly in certain occupational activities including repetitive computer keyboard and prolonged intensive mouse activity, typing, writing, carpentry, plumbing, meat cutting and repetitive assemble line activity.
Is it a tendinitis or tendinopathy and what is the difference?
Traditionally, the pain that occurs in and around tendons, often associated with overactivity, has been termed tendinitis. This terminology implies that the pain is resulting from an inflammatory process. However, there are fundamental problems with this approach. Histological studies have shown that there is little or no inflammation actually present within these tendons which are exposed to overuse. Instead, there is evidence of degenerative changes within the tendon such as disorganization of collagen fibers, increased cellularity, tendon thickening and loss of mechanical properties.
Why does it cause pain?
As we now know that the pathological cause of lateral epicondylitis is not inflammatory, it is best described as a partially reversible degenerative overuse tendinopathy of the common extensor origin of the lateral side of the elbow. Not surprisingly, historical treatment which has focused at reducing inflammation have had limited success in treating these chronic, painful conditions arising from overuse of tendons. Tendinopathy is a result of an imbalance between the protective/regenerative changes and the pathologic responses that result from repetitive tendon overuse. The net result is tendon degeneration, weakness, tearing and pain.
How can you prevent tennis elbow?
Prevention is always better than cure. The correct technique of a sport or occupation not only enhances activity performance but also less likely to cause injury. If you are one of the very unlucky ones that have developed tennis elbow following tennis, then here are some practical tips:Internal Factors
- Warm Up
- Cool Down
- Correct racket size
- Grip Size
- Racket string tension
- Stroke technique
Prevention of Elbow injury in tennis
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What treatments are there?
Distal Biceps Repair
The incidence of distal biceps tendon injury seems to be increasing. It is usually caused by a sudden heavy load against resistance from an elbow in 90 degrees of flexion. Early diagnosis and prompt treatment is the key to successful outcome. If surgical repair is not performed, there is a permanent decrease in supination and sometimes elbow flexion strength.There is usually a characteristic popeye bulge deformity
Technique of surgical fixation and repair
Platelet Rich Plasma (PRP)
Platelet rich plasma therapy is a new emerging orthobiological treatment which aims to reduce pain by enhancing the body’s natural ability to heal itself. It has shown significant potential for alleviating symptoms associated with conditions such as tennis elbow, golfers elbow, rotator cuff repair, acute and chronic muscle strain, muscle fibrosis, ligamentous sprains, and joint capsular laxity.
How does platelet rich plasma work?
Blood contains plasma, red blood cells, white blood cells, and platelets. Red Blood Cells function to transport oxygen throughout the body and remove carbon dioxide. White Blood Cells protect the body from viruses and bacteria that can infect the body. Platelets are responsible for blood clotting, construction of new connective tissue, and revascularization. When the human body suffers an acute musculoskeletal injury, it responds by delivering platelet cells to the injured area. When activated in the body, platelets release healing proteins called growth factors, including PDGF, IGF and TGF-b, which accelerate tissue and wound healing. However, a typical blood specimen contains only 6% Platelets with the remainder made up of RBC (93%) and WBC (1%). Platelet rich plasma therapy enables the blood ratio to be reversed thereby decreasing red blood cells to 5%, which are less useful in the healing process, and increasing the concentration of platelets to 94% to stimulate tissue healing and regeneration.
How is platelet rich plasma carried out?
A sample of blood is taken from the body and is placed in a high speed centrifuge where the blood is spinned.
Are there any side effects?
Since the platelet produced is directly from the patient’s own blood, there is no risk of transmissible infection but tissue recovery can be dramatically enhanced.
Is there any evidence that it works?
Randomized controlled trial with 2-Year follow-up comparing platelet-rich plasma versus corticosteroid injection in lateral epicondylitis.
Click here for article on Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis
Extracorporeal Shock Wave Therapy (ESWT)
Extracorporeal Shock Wave Therapy has been used in the treatment of musculoskeletal disorders for more than a decade. In the upper limb, it is primarily used in the treatment of sports related over-use tendinopathies such as lateral epicondylitis of the elbow (tennis elbow), medial epicondylitis (golfer’s elbow) and calcific tendinitis of the shoulder. Mr Lam uses the Swiss DolorClast Extracorporeal Shockwave Therapy device which has gained approval from the Food and Drug Administration (FDA) in America, and also has been reviewed by the National Institute of Health and Clinical Excellence (NICE) guidance in the UK for the treatment of refractory tennis elbow.
How does ESWT work?
ESWT involves the passage of shockwaves through the skin to the injured part of the body. The shockwaves are generated by a projectile that is propelled at high speed by compressed air inside a hand-held applicator. The impulses delivered through the skin to the injured tissue cause microtrauma to the affected area and thereby initiating an inflammatory response which helps to promote natural healing by increasing blood flow and formation of new capillaries (neovascularisation) at the diseased tendon site, thereby enhancing tissue regeneration.
Is there there any evidence that this works?
The National Institute of Clinical Excellence has produced guidelines on the use of ESWT in the treatment of refractory tennis elbow.
(See additional NHS Guidance document for Extracorporeal Shock Wave Therapy)
What is the success rate of ESWT?
The success rate has been reported to range from 65% to 91%.
What are the potential benefits of ESWT?
- No need for any anaesthetic (general or local)
- Non-invasive procedure
- No need for surgery or medication
- No need for time off work
- Treatment sessions last for an average of 10 to 15 minutes
- No hospital admission
- Transient analgesic effect after treatment
- Negligible side effects
How long does treatment take?
A typical session of ESWT with the Swiss DolorClast will last for around 15 minutes and a typical treatment programme would consist of three sessions, one every week.
Is ESWT treatment painful?
Some patients have noted minor discomfort during treatment but most patients have been able to tolerate this without the need for any medication. It is worth noting that patients who find the treatment uncomfortable often have better clinical outcomes.
Will I be in pain after the treatment?
Patients normally experience a reduction in pain or no pain at all immediately after treatment. A dull thumping feeling may be present for a few hours after treatment, but rarely lasts beyond a day or so.
What should I do if I'm in pain after the treatment?
ESWT works by initiating an inflammation-like condition in the tissue that's being treated. The body responds by increasing the metabolic activity around the impact area which in turn accelerates the body's own healing processes. Patients are advised to use prescription-free painkillers in they experience any discomfort after treatment. However, patients should not us anti-inflammatory medicine or try to cool down the treated area because this will interfere with the body's natural healing abilities.
What if I have no pain after treatment?
Some patients emerge from treatment with no discomfort whatsoever, but we strongly recommend they refrain from intensive activities that stress the treated area for at least the next 48 hours.
What if ESWT treatment doesn't work for me?
Even though the response to ESWT treatment is normally exceptionally good within the first few weeks, it may take several months before the maximum effect is achieved. If patients do not experience a pronounced improvement after 3 or 4 months, your clinician will be able to advise you on the next suitable step to take.
Are there any contradictions or precautions I need to consider?
Yes. Cortisone injections should not be administered during the month before treatment starts, haemorrhage tendencies and coagulation system disturbances with supporting medication, heart conditions and blood circulation disturbances, acute inflammation in the treatment area, and cancer and pregnancy.
For further information regarding Swiss Dolorclast, please click here