General Information The elbow is a very stable and highly congruent joint which comprises three different portions. It serves as hinge between upper arm and ulna and enables turning movements of ulna, radius and upper arm. Stabilization is given through the bony guide, the tight capsular ligament apparatus and the muscles surrounding the joint. Nevertheless, the elbow is the second most frequently-dislocating joint. Injuries and disorders of the elbow are mostly of complex nature, and understanding different possible diseases is an essential condition for successful therapy. Especially the anatomic vicinity to nerves and vessels requires an experienced surgeon specialized in this area. Besides clinical examination, there are also conventional x-ray, sonography, MRI and CT available for diagnostics. Tennis Elbow (Epicondylitis humeri radialis) This diagnosis rather stands for a symptom. It refers to pain occurring on the lateral epicondylus of the upper arm with pain radiating to the forearm extensor muscle (fig.1). In many cases this disease is caused by unusual heavy physical activity or monotonous work (e.g. desk jobs). This triggers an inflammation of the forearm extensor muscle base at the lateral humeral condyle. Normally, when being treated early with symptomatic therapy including physiotherapy, anti-inflammatory procedures and wearing of a bandage, acute symptoms can be eased or healed. Fig. 1: Radial epicondyle Thus it is recommended to even treat chronic progressions (symptoms for more than 6 months) conservatively first for a sufficiently long time before considering surgical therapy. However, if these conservative treatment methods remain unsuccessful, operation indication is set after a differentiated diagnosis of the elbow with conventional x- ray and MRI (fig. 2). In case that surgical treatment is needed, the elbow should be operated not only open (via incision) but also arthroscopically (with camera technology). This is indispensable for identification and treatment of the reason for this chronic progression which is lying inside the joint. One of the most common causes for chronic pain development is instability of the outer capsule-ligament apparatus. 82
Depending on the severity of the instability, treatment is done by two different methods: When treating a minor instability it is often sufficient to detach the forearm extensor from the epicondylus and remove chronically inflamed tissue. Afterwards, the tendons are with slight shirring stably affixed to the bone again. Aftercare is relatively uncomplicated. Under reduced load for approx. 6-8 weeks movability is increasingly regained. Ellenbogen Elbow In case that the elbow needs further stabilization, the outer capsule-ligament apparatus is strengthened with a tendon implant which has been taken from the triceps tendon (fig. 3+4). Here, aftercare of 10-12 weeks is necessary. Operative treatment of chronic epicondylitis humeri radialis requires a differentiated view on the complete joint and comprehensive knowledge of the surgeon to understand and treat all causes of this symptomatic pain. Fig. 2: Inflammatory edema at radial epicondyle Fig. 3: Titanium screw fixation of tendon transplant Fig. 4: Inserted tendon transplant 83
Golfer s Elbow (Epicondylitis humeri ulnaris) This painful inflammation of the tendinous sheath which forms the forearm s flexion muscle base at the medial epicondylus (fig. 2) can be treated much more effective with conservative methods. Generally, this painful symptomatic is a result of overload of the attachment zone of the forearm flexor. Only in rare cases it is a consequence of complex joint diseases. Thus, if conservative therapy does not ease the pain, this chronic inflammation can be treated relatively uncomplicated in an open operation (incision). The forearm flexors are detached from the medial epicondylus, the inflamed tissue removed and the tendons sutured. Aftercare needs about 6-8 weeks and includes resting the arm while having physiotherapy with lymph drainage. Fig. 5: Epicondylitis humeri ulnaris Sulcus-ulnaris Syndrome or Cubital Tunnel Syndrome This syndrome is a chronic nerve entrapment or nerve irritation within the bone channel at the medial epicondylus. Symptoms are numbness and tingling of the 4th and 5th finger with radiating electrifying pain from the inner side of the elbow up into the hand. Sometimes, patients also have a clasping feeling over the medial epicondylus. In the advances stage it may also lead to paralysis and weakening of intrinsic hand muscles (claw hand, fig. 6). Reasons are often chronic pressure load, elbow arthrosis, rheumatoid arthritis or scarring after accidents and operations. Besides clinical examination, neurological examination with determination of velocity of nerve conduction is used for diagnostics. In case that conservative therapy with anti-inflammatory treatment, wearing of a resting splint and general care does not bring the expected relieve, operative neurolysis (release of the nerve) should be carried out. Fig. 6: Claw hand In simple cases it is enough to treat the nerve in its bed by removing possible bondings and other interfering factors (e.g. bony irritations). This is done through an incision at the inner side of the elbow. However, should become obvious that the nerve might not recover due to heavily modified anatomical conditions in the nerve channel, nerve relocation should be considered. The ulnar nerve is then placed into another area within the subcutaneous fatty tissue or the forearm s flexion muscles before the ulnar epicondylus. Immediately after surgery of the ulnar nerve the elbow can be moved again. Immobilization is generally not necessary, but special care should be observed for about 2 6 weeks. About 6 months after surgery the surgeon should carry out a second measurement of the nerve conduction velocity to control the success achieved. 84
Loose Joint Bodies Symptoms are clear. It generally is a sensation of entrapment with limitation of movability, a painful joint, grinding and cracking. Ellenbogen Elbow Loose joint bodies (fig. 7) are usually the result of an already existing disease such as arthrosis (loss of cartilage with damage of the joint), Osteochondrosis dissecans (circulatory disorder of a bone area with loss of cartilage), instabilities, synovial chondromatosis (formation of cartilaginous bodies within the synovial membrane) or the consequence of an accident. In most cases conservative therapy would not bring the result expected as loose joint bodies form a higher risk of irreparable consequential damages to the joint cartilage. In order to not only ease pain but also retain the joint it is recommendable to remove those loose joint bodies with arthroscopic surgery (minimally-invasive camera technique). If necessary, the real cause for the disorder can be treated at the same time. Osteochondrosis Dissecans or Aseptic Bone Necrosis (Morbus Panner) loose joint body Fig. 7: Removal of loose joint body This disease mostly occurs with active and sportive children/teens and rather with boys than with girls. It is a circulatory disorder of the humerus near the joint surface of the radial head. Most obvious symptom is load-dependent pain, and depending on the stage of the disease also the sensation of entrapment and limitation of movability. This circulatory disorder of the bone leads to displacement of its cartilage layer what in turn results in further consequences (as with loose joint bodies). The best prognosis is given when the disease is recognized at an early stage. By reducing pressure load and resting the elbow, a pain-free condition can be achieved and rejection of the cartilage prevented. However, should the disease already be in an advanced stage with (partial-) displacement of cartilaginous tissue, good results can better be achieved with arthroscopic surgery by drilling the affected area and carrying out an appropriate cartilage therapy (fig. 8+9). Fig. 8: Drilling of damaged cartilage bone area Fig. 9: Cartilage therapy by microfracture surgery after removal of loose joint body 85
Stiff Elbow and Elbow Arthrosis Mobility limitations of the elbow are either the result of changed soft tissue conditions or bony, mechanical barriers. In most cases it is a combination of both. Reasons for these movement restrictions may be accidents and their consequences (e.g. step joints with resulting joint degeneration, loose joint bodies, adhesions within the joint, scarring after operations) or a normal arthrosis (wear and tear of joint cartilage and bony sections of the joint). But limitation can also occur without visible radiological changes. In these cases limitation is mostly caused by adhesions within the joint (arthrofibrosis) with an additional shortening/shrinkage of the joint capsule. Depending on the form of elbow stiffness, conservative therapy may be enough to increase mobility again. Useful may be manual therapy with physical Fig. 10-12: Before and after joint cleansing of an arthritic joint exercise, anesthesiologic methods such as local pain catheters, or usage of special mobilizing splints. In most cases however (depending on discomfort and level of limitation) the joint needs operative treatment (open or arthroscopic) in order to regain a satisfactory level of mobility. The aims of arthrolysis (operative loosening of adhesions - possible in arthroscopic or open surgery) are restoration of mobility and furthermore improvement of joint mechanics. Thus depending on the diagnosis, disturbing bone spurs and loose joint bodies are removed, the cartilage surface smoothed, adhesions mobilized and shortened joint capsules cut. With this, pain is considerably reduced, often even eliminated. And the long-term prognosis is noticeably improved. With completely destroyed joints or after exhausted joint-preserving therapy, the elbow can also be replaced by an artificial joint/prosthesis. 86 86
Elbow Prostheses Elbow prostheses offer perfect mobility, pain reduction and durability. However, they should not be load with more than 4-5 kg in order to avoid loosening or break-off. This low loading capacity is the main reason why prostheses should rather be used with elderly patients. They are mainly used for rheumatoid arthritis and posttraumatic conditions. Ellenbogen Elbow Fig. 13: Osteosynthesis as attempt to preserve the joint Fig. 14: Endoprosthetic joint replacement with so-called coupled prosthesis Fig. 15: Radial head prosthesis after posttraumatic arthritis 87
Luxations and Instability An acute luxation needs prompt action. The dislocated elbow (fig. 16) should be put back in place within six hours in order to avoid threatening damages to vessels and nerves. Putting back the joint is generally performed under a short general anesthesia. Still under anesthesia the surgeon can determine necessary aftercare by checking stability. The severity of instability and bony concomitant injuries is decisive for further procedures. For better assessment of possible consequential injuries, focused diagnosis with x- ray, radioscopy, MRI and/or CT is necessary. Treatment of young, but also of chronic consequential injuries/instabilities requires comprehensive knowledge and operative spectrum of the treating surgeon. Offering the best possible treatment for such complex injuries in most cases requires individual assessment. Fig. 16: Soft tissue injury caused by luxation Fig. 17: Luxated elbow joint Fig. 18: Stabilization with external fixation and reconstruction of capsular ligament apparatus Fig. 19: After removal of external fixation (6 weeks after surgery) 88