Elbow Arthritis

Dr Senthil Velan.

MBBS, D Ortho, FRCS (Ortho),

FEBOT, Fellow European Board Orthopaedics and Trauma.

Consultant Shoulder and Elbow Surgeon

Apollo Hospitals Ayanambakkam, Chennai, India.

Apollo Clinic, Annanagar.

For appointments Contact 082205009176/velansenthil78@yahoo.com

What is it?

Arthritis of Elbow joint can be of two types .Primary Osteoarthritis or Rheumatoid arthritis. Arthritis means wear and tear of the cartilage of joint. Normal joint has cartilage which provides lubrication for smooth gliding of joint. In arthritis this cartilage wears away resulting in roughening of joint surface .The body forms new bone around the worn joint and these are called “osteophytes” and these can reduce movements of joint

CT scan showing Elbow arthritis Changes.

What is its cause?

The most common cause of elbow arthritis is due to ageing. There is wear and tear of joint and this is called “Primary Osteoarthritis”. Sometimes arthritis can occur in this joint after a previous Elbow fracture or dislocation. This type of arthritis is called “Secondary Post traumatic arthritis”. In case of Rheumatoid arthritis the body’s own immune system mistakenly forms cells that damage joint cartilage.

What are the symptoms and how is elbow arthritis diagnosed?

The early symptom is stiffness of elbow and pain gradually worsens as arthritis becomes worse. Some patients develop symptoms of “locking” which is caused by loose bodies which get dismantled from arthritis bone and get lodged inside the joint.

The pain gradually worsens and causes limitation to day to day activities. The pain is especially worse after lifting activities. Sometimes the nerve around the funny bone (medial epicondyle) can get compressed and the patient can experience tingling/weakness of hand.

Will further tests or investigations be needed?

X rays are usually needed to assess extent of arthritis. MRI Scan/CT scan would be needed to plan treatment. Sometimes a Nerve conduction study would be required to assess whether the nerve is compresses at elbow.

CT scan showing evidence of Elbow arthritis

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What is the treatment?

1. Initial conservative management include Pain Killers, Physiotherapy and splinting. If the nerve is compressed it requires surgery to release the pressure at the level of elbow even at early stages. This is to prevent further deterioration secondary to compression of nerve.

2. Key Hole Surgery(Arthroscopy)- If the patients predominant symptoms are “locking”  and loss of movement , this can be helped by doing a key hole operation to remove loose bodies from joint. This immediately alleviates the symptoms.

Arthroscopic (Key Hole Surgery)  involves two small stab incisions are made in the elbow through which small telescope and instruments are used to remove loose bodies, inflammatory tissue or bony spurs.

Elbow Arthroscopy

3. Elbow debridement (OK procedure): This type of surgery is advised for marked

arthritis that is causing significant loss of movement and pain. An incision of about

10cm is needed on the back of the elbow. At surgery all loose bodies and bony

spurs that are blocking movement are removed. A fenestration is made in the

distal humerus (end of the arm bone) and loose bodies or spurs in the front of the

elbow are also removed. The elbow is put in a splint, in an extended position, at

night only, for 2-3 weeks. Physiotherapy after surgery is critical.

4. Total elbow replacement: Joint replacement of the elbow is usually a successful

operation. The pictures below show x-rays of the replacement in a patient who

has rheumatoid arthritis. Replacement is usually avoided in young people but is a

good option for patients with rheumatoid arthritis or those having low demands on

the elbow. The operation will lead to significant pain relief and improved functional

range of movement. The elbow in put in splint, in an extended position, at night

only, for 2-3 weeks. Physiotherapy after surgery is critical.

X ray showing Total Elbow Replacement

What happens if it is not treated?

Some patients are able to cope with pain and conservative measures are usually enough to alleviate symptoms. Some patients have progression of arthritis and the pain worsens with limitation of range of movements.

What is the success of surgical treatment?

Arthroscopic removal of loose bodies will nearly

always stop symptoms such as locking. More than 80% patients will achieve a better

range of movement and significant improvement in their pain after debridement of the

elbow. In more than 95% of patients, the elbow replacement will lead to a pain free

elbow with a good functional range of movement.

What are the complications of surgical treatment?

Scar tenderness, Nerve damage, Persistant symptoms are all possible complications after surgery. In the long term, the elbow joint replacement may fail and will need to be revised. However, it is expected that nearly 90% of elbow replacements will still be successful after 10 years, in low demand patients.

Any surgical intervention has the risk of developing complications / setbacks

which are unpredicted. These complications may have the potential to leave the

patient worse than before surgery..

When can I do various activities?

• Following arthroscopic surgery, patients should be able to return to a desk job

within 7 days. 

• Following elbow debridement or replacement, patients should be able to return to

a desk job within 4-6 weeks of the operation and perform reasonable tasks with

the limb by that time. 

• Manual work after surgery should be avoided for 8-12 weeks. 

 References:

1. Master Techniques in Orthopaedic Surgery: The Elbow, 2nd Edition

Copyright ©2002 Lippincott Williams & Wilkins

Cubital Tunnel Syndrome

Dr Senthil Velan 

MBBS, D Ortho, FRCS (Ortho), FEBOT, Fellow European Board Orthopaedics and Trauma.

Fellowship in Shoulder Elbow Surgery (Bournemouth, UK)

Consultant Shoulder Elbow,Hand Surgeon

Apollo Hospitals ,Ayanamabakkam, Chennai, India

Apollo Clinic Annanagar.

For appointments contact 09566222533/velansenthil78@yahoo.com

What is it?   

A nerve called ulnar nerve supplies the index and ring fingers.It runs underneath the inside part of bone in the elbow(medial epicondyle) and tip of elbow(olecranon).It can get compressed in this tunnel and this is known as Cubital tunnel syndrome..

Picture showing Ulnar nerve and Cubital Tunnel(1)

What is the cause?         

In most of cases no underlying cause can be found. In some patients it is due to sustained stretch , or pressure on inside of elbow for prolonged periods of time which can cause thickening of tissue over the tunnel(Osborne’s ligament). This can cause compression of nerve.

This condition is also found more in people who have diabetes, Rheumatoid arthritis, elbow arthritis, or previous elbow fracture.

What are the symptoms and how is the condition diagnosed?    

Patients usually complain of pins and needles in ring and little fingers .This is because of compression of nerve in tunnel at the elbow. The tingling is worse when the elbow is bent and for this reason most people experience worse symptoms at night time.(as most people keep their elbow bent over had while sleeping)    

In later stages patients notice weakness in grip, and may drop things frequently. Muscle weakness in hand muscles can occur if left untreated and can cause deformity.

How is it diagnosed?

Testing of hand muscles and Elbow will be done by Specialist Elbow surgeon and he can determine whether the compression is minimal or severe. The diagnosis is mostly made on clinical examination but usually supplementary nerve testing is required.

Will further tests or investigations be needed?   

          

The diagnosis of cubital tunnel syndrome is made clinically but you will nearly always be referred for electrical tests (nerve conduction studies). The tests may be to confirm the diagnosis in patients in whom the symptoms and signs are not typical and also to confirm that the nerve is not compressed elsewhere (usually in the neck from where it begins or rarely on the front of the wrist).  Other medical conditions like diabetes or thyroid disease need to excluded using lab investigations.

What is the treatment?         

Initial treatment consists of Splints to elbow to help in reduction of symptoms. Night time splinting is achieved with a custom made long arm splint that the patient will wear at night time and as often as possible during the day. Unfortunately it is cumbersome to keep the arm out straight all the time and therefore this is usually used only at night.

If symptoms persist even after conservative measures Surgery can be done to relieve the symptoms.

The procedure is described below

                       

Decompression of the ulnar nerve: This is a standard operation advised and is an open

surgical release of the cubital tunnel. A skin incision of 5 cm is required and at surgery the  roof of the cubital tunnel is opened, thereby decompressing the ulnar nerve. The  procedure can be carried out under local or general anaesthesia, as a day case. After the  operation, a sticky dressing is applied over the surgical wound. A bulky supportive cotton wool dressing then goes on top of that. This supportive dressing is reduced after a couple  of days. The small sticky dressing should be left for 10 -12 days when the stitches will  need to come out.

Light use of the limb should be  possible immediately after the day of surgery. Active movements of the fingers/ wrist/  shoulder are recommended soon after surgery. 

Other surgical procedures like transpositions of Ulnar nerve or medial epicondylectomy are done for resistant  cases.

When certain other conditions like (rheumatoid) arthritis are present, clearing of the soft  tissue lining (synovectomy) or excision of any bony spurs, may be needed.   

What happens if it is not treated?  

            

If left untreated the tingling and numbness may become progressively worse. Compression of nerve for prolonged time can result in weakness of  hand muscles, wasting and can result in deformity.

What is the success of surgical treatment?          

      

The operation has a very good success rate in the early stages. It results in good resolution of  night pain and tingling within a few days. However if the condition has been present for a long  time, then recovery from symptoms of constant numbness and muscle weakness is unpredictable. However one of the aims and benefits of surgery is to stop the nerve from  deteriorating due to constant compression. Thus even if the procedure does not reverse the  symptoms, it will help to prevent progressive worsening of the nerve function.   

What are the complications of surgical treatment?

1. Infection of the wound is possible and in the early stages can be successfully treated with antibiotics.  If pain increases after surgery infection needs to be ruled out. 

2. Damage to the ulnar nerve is possible but very rare when the open surgical technique is used

When can I do various activities?

Return to work depends on many factors including the nature of the job and hand dominance. 

Generally patients can return to a desk job within a few days and perform reasonable tasks with the hand. 

References

1.Linda D Det al. Radiographics2010;30:1373