Dr. Budoff's Blog

Snapping Elbow (Plica)

December 9th, 2011

One of the most common causes of a snapping elbow is a plica. A plica is an inflamed part of the joint lining that catches in between the bones of the elbow with motion. A plica can be caused by anything that inflames the elbow, typically either an injury or overuse.

Although symptoms may vary, the snapping usually occurs when the elbow is bent approximately 90 degrees, with the palm of the hand facing away from the body. The popping usually hurts on the outside of the elbow and may be associated with swelling. Other conditions that may cause elbow popping include loose bodies from arthritis, trauma, or osteochondritis dissecans (OCD: see previous blog).

The diagnosis of a plica is best made on physical examination. A steroid injection placed into the elbow serves two purposes: 1) diagnostic: if an injection inside the joint decreases elbow pain, then the problem is located inside the elbow, 2) therapeutic: the anti-inflammatory effects of the plica can reduce its size, decreasing symptoms.

While MRIs are very good at detecting arthritis, they miss plicas 25% of the time, and cannot be relied upon to diagnose a plica.

If the pain recurs following an injection, the plica can usually be very well treated with an arthroscopic excision. This is an outpatient procedure that is not very painful. In order to maximize treatment results and minimize complications, this procedure should be performed only by experienced elbow arthroscopists. Please note that just because a surgeon performs many arthroscopies of the knee and shoulder, that does not mean that they are skilled elbow arthroscopists. This is a separate skill set and involves an understanding of elbow arthroscopy’s more complex anatomy. The plica needs to be removed in both the front and the back of the elbow.


Figure 1. Plica in Front of Elbow Figure 2. Shaving Front of Plica Figure 3. Front of Plica Removed
Figure 4. Plica in Back of Elbow Figure 5. Shaving Back of Plica Figure 6. Back of Plica Removed

Figure 1 shows the plica and inflammation (which looks like seaweed) at the front of the elbow. This inflamed tissue became entrapped between the bones of the joint with motion, leading to painful snapping. Figure 2 shows the motorized shaver used to remove the plica and its associated inflammation. Figure 3 shows the front of the elbow joint with the plica and its associated inflammation removed. Figure 4 shows the plica in the back of the joint. The plica needs to be removed in both the front and the back of the elbow in order to eliminate the symptoms. Figure 5 shows the motorized shaver used to remove the plica from the back of the elbow. Figure 6 shows the back of the elbow joint with the plica removed.

After surgery, the elbow should be kept clean and dry for 3 days. After 3 days the dressing can be removed and the elbow can get wet in a shower. Elbow motion is begun to regain full motion. Band-aids are applied to the arthroscopy portals and submersion under water is avoided until the stitches are removed at the first post-operative appointment at 2 weeks.

In conclusion, painful elbow snapping and popping is often due to an inflamed plica. Fortunately, plicas can be easily treated by arthroscopic excision.

Tags: ,,,,,,,
No Comments »

Proximal Ulna Fractures

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.

Tags: ,,,,,,,,,,,,,
No Comments »

Elbow Arthritis

October 2nd, 2010

Elbow arthritis can limit function, cause pain, and lead to serious impairment of the arm. Initial treatment includes a steroid injection and decreasing any painful activities. Sometimes a rubber-like sleeve worn over the elbow can help decrease pain by providing some stability, warmth and compression. You can try some non-steroidal anti-inflammatory medications, like Ibuprofen or Naprosyn. If those don’t work, then surgery can be very effective. There are different surgical options, depending on how advanced the arthritis is and where it is.

Pain that occurs mainly at full flexion or full extension is usually due to arthritic bone spurs. These can often be removed by either arthroscopic or open surgery (if the bone spurs are really big), improving symptoms. The arthritis may continue to progress, but many years of increased comfort may be provided. Pain at rest is usually due to the inflammation of arthritis. This can be removed during the surgery. Any catching or locking due to pieces of bone spurs that have broken off and are floating around the joint can also be addressed.

If stiffness is a problem, this surgery may often improve motion by removing the joint capsule, which is the balloon around the joint. If increased motion is desired, then after surgery a fairly extensive physical therapy program will be required in order to maintain the motion that is gained at the time of surgery. If significant stiffness is present, an endoscopic cubital tunnel release will be required to release the ulnar nerve, which is often caught up in the scar, in order to avoid problems with this nerve following surgery.

Pain throughout the entire range of elbow motion is usually due to cartilage loss, causing the joint to be ‘bone on bone’. In cases of arthritis this advanced, simply removing loose bodies, bone spurs, inflammation and the joint capsule will not be enough. The placement of a new joint surface will be required.

In older patients, a total elbow replacement is an effective option. Total elbow replacement often requires a hospital stay of 1-2 nights. The elbow is splinted for 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 these restrictions, the best operation is often a fascial-interposition arthroplasty, where the Achilles tendon from a cadaver is used to resurface the elbow joint. The Achilles tendon is broad and slippery, and can provide a pain-free surface for an elbow. This surgery also usually requires a night in the hospital. In order to keep the joint surfaces apart to allow healing and motion, an “external fixator” is placed around the elbow. This external fixator consists of 2 metal screws placed into the humerus (the large bone above the elbow) and 2 metal screws placed into the ulna (one of the forearm bones), connected by a hinge to allow motion. This device remains in place for 4-5 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 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.

For the best advice, and often the best results, consult an elbow specialist to find out what the best treatment is for your arthritic elbow.

Tags: ,,,,,,,,,,,,,,
No Comments »

When is Carpal Tunnel Syndrome Not Carpal Tunnel Syndrome?

September 25th, 2010

Carpal tunnel syndrome is the most common nerve compression in the arm. It causes the fingers of the hand to fall asleep, become numb, burn or tingle. But that doesn’t mean that everything that causes numbness about the hand is carpal tunnel syndrome.

If the small and ring fingers are the only digits involved, then the numbness is probably caused by cubital tunnel syndrome, ie. compression of the ulnar (funny bone) nerve about the elbow.

Sometimes elbow or shoulder pain, from tennis elbow, rotator cuff disease, etc. can cause pain to radiate down the arm as far as the hand. But these referred pains don’t go all the way down to the fingers and make them numb.

The median nerve, the same nerve that is pinched by carpal tunnel syndrome at the wrist, can also be pinched further ‘upstream’ about the elbow. This is known as pronator syndrome. Often times, pronator syndrome can occur at the same time with carpal tunnel syndrome; this is known as a ‘double crush’, because the nerve is compressed in two places at once.

Pinched nerves at the neck can also cause numbness in the fingers. These usually affect the thumb, but any fingers can be involved, depending on the nerve root that is being pinched.

Of course, the opposite also happens. People often think that they have a pinched nerve in their neck when they’ve really got carpal tunnel syndrome. This happens fairly often because carpal tunnel syndrome is so common and nerve studies fail to diagnose carpal tunnel syndrome in approximately 20-33% of patients.

So how do you know where the problem is?

First, you should see a hand surgeon, who should be an expert in diagnosing conditions affecting the hand. General orthopaedic surgeons, plastic surgeons, and other types of physicians may have some knowledge about hand disorders, but don’t have the subspecialty training and experience to predictably diagnose some of the less common conditions, especially when the signs are subtle. You know what they say about jacks of all trades. You want to see a specialist to give you the best chance of getting the correct diagnosis. The physical examination that a specialist does can usually determine the real source of the problem.

For some ‘quick and dirty’ rules, that aren’t 100% accurate, but can point you in the right direction: carpal tunnel syndrome usually bothers people more at night and when gripping things: a book, a steering wheel, etc. It can affect the thumb, index, middle and ring fingers in any combination. It can also affect the small finger, but not the small finger alone; if the small finger (and maybe the ring finger) are the only fingers involved, then it’s not carpal tunnel syndrome. It may be cubital tunnel syndrome, thoracic outlet syndrome or a pinched nerve in the neck.

Numbness that is worse with activities and is associated with an ache in the forearm near the front of the elbow is often pronator syndrome. Numbness that is worse when the neck is moved all the way to one side is often due to a pinched nerve at the neck. Numbness on the back of the hand is often referred from the elbow or shoulder, and not due to carpal tunnel syndrome.

However, for the best chance of an accurate diagnosis, go see a hand surgeon specialist who has the extra training and experience to best diagnose conditions of the hand.

Tags: ,,,,,,,,,,,,,,,,,,,,
No Comments »

Tennis Elbow

September 2nd, 2010

Tennis elbow is very common. It occurs most commonly on the outer side of your elbow, but may also occur on the inner side, and occasionally even in the back of the elbow. When it occurs on the inner side of the elbow it’s called “golfer’s elbow,” but it’s really the same problem. The problem is tendon over-use, leading to tendon breakdown. This is called tendinosis, which means tendon degeneration. We used to call it tendinitis, which means tendon inflammation, but we now know that this is incorrect. The pain comes from the breakdown and degeneration of overused tissue, not from inflammation.

Any activity that stresses these tendons, including tennis, golf, sports and manual labor (heavy lifting, etc) can lead to tennis elbow. Despite its name, up to 95 percent of cases of “tennis elbow” occur in non-tennis players, who subject themselves to repetitive stresses may develop tennis elbow.

There is a balance between the stresses you apply to your arm and the strength of the small muscles to handle these stresses. Once the applied stresses become too much, injury and pain can occur. Therefore, to get rid of your pain and avoid future injury you can either decrease the stresses on your elbow or increase the strength of the forearm muscles about the elbow.

For sports, proper technique is very important. For golf, tennis, throwing, etc. you’re supposed to generate the force to swing the racket or club, or throw the ball from the large muscles of your legs and trunk. The shoulder and elbow are simply supposed to transfer these forces to the ball, club or racket. If you’re using your shoulder or elbow to generate power, your form is incorrect and you’re putting yourself at risk of overuse injuries. At work, utilizing proper mechanics and avoiding provocative activities can be helpful.

“Counterforce” bracing has also been shown to be effective in reducing the stresses to your forearm muscles. Counterforce braces absorb some of the stress so that the tendons don’t have to.

The more important treatment is to increase the strength quality of your muscles and tendons. This is done through rehabilitative strengthening exercises. The muscle groups that you need to strengthen are the wrist extensors, wrist flexors and the forearm rotators. For strengthening, I prefer an elastic resistance, such as an isotube, rather than a dumbbell or free weight.

Exercise should not cause pain. If pain occurs during strengthening, you’re either using too much resistance or doing them too many times. The idea is to strengthen the weakened muscles, not to over-stress them. Wear the counterforce brace while exercising. To start, I recommend only one set of 10-12 repetitions per day for each exercise. During exercises, the elbow should be bent and the forearm supported.

Steroid injections provide temporary pain relief in over 50% of cases. Unfortunately, steroid injections do not provide a permanent cure, and are no better than placebo at 3 months. However, injections are useful to decrease pain enough so that you can perform the exercises better. Understand that the repeated use of cortisone injections is inappropriate. There is no advantage, and considerable disadvantage, in having more than two such injections. Repetitive injections may weaken the surrounding normal tissues, potentially leading to further damage.

Rehabilitative exercises, combined with appropriate bracing, successfully treats about 75-95% of patients with tennis elbow. The others continue to have pain that limits their activities. This occurs because the amount of tissue damage is too great for the body to repair. If you’re in this situation, then you can either accept the condition and limit your activities accordingly, or elect to undergo a simple surgical solution that is approximately 97% effective. It involves a small incision, only about 2″ long, through which the damaged, abnormal, unhealthy tendon is removed.

There are other, older surgeries still used that tried to “release” the origin of the tendons from the bone, repair the tendon, or take out the bone itself. Not only do these not work well, but they can hurt a lot, lead to stiffness and/or residual pain and can weaken the forearm muscles. Some of these operations leave some damaged and degenerated tissue behind. In addition, releases may damage the elbow ligaments located directly beneath the tendons, which may lead to further pain and elbow instability. And once you’ve had an unsuccessful surgery, the chances that an appropriate surgery can help you decreases to about 84%.

The take home message is this: tennis elbow is relatively common, but can be minimized by using proper techniques, both during athletics and at work. The vast majority of people with tennis elbow can be treated with a counterforce brace and a good muscle strengthening program. And for the minority of patients who do come to surgery, modern techniques of tennis elbow excision have an excellent rate of success.

Tags: ,,,,,,,,,
No Comments »

Elbow Arthritis

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.

Tags: ,,,,,,,,,,,,,
4 Comments »

Cubital Tunnel Syndrome (Does your small finger go numb?)

July 2nd, 2010

While carpal tunnel syndrome is the most common nerve problem, cubital tunnel syndrome is the second most common nerve problem. Cubital tunnel syndrome occurs when the ulnar nerve (the “funny bone” nerve) gets pinched at the elbow. It is a common source of nerve pain, especially at night.

What are the symptoms of cubital tunnel syndrome?
Cubital tunnel syndrome leads to tingling and numbness of the small finger, and often the ring finger. If the other fingers are involved, then carpal tunnel syndrome may also be present, as these problems often occur together. The ulnar nerve gets pinched more when the elbow is bent. Symptoms may also occur when the nerve is pressed on, such as when resting the elbow on a hard surface.

How is the diagnosis of cubital tunnel syndrome made?
The diagnosis of cubital tunnel syndrome is made by your physician asking you specific questions and examining your arm. A symptom that is classic for cubital tunnel syndrome is waking up in the middle of the night with the small finger tingling or “numb”. This occurs mainly because we all sleep in the fetal position, with our elbows bent. This numbness also occurs other times when the elbow is bent, like when talking on the phone. If bending your elbow or pressure on your elbow causes the small and/or ring finger to tingle, then you have cubital tunnel syndrome. Nerve conduction studies are usually obtained, but are not especially accurate, and may miss the diagnosis of cubital tunnel syndrome in up to 40-50% of cases.

How is cubital tunnel syndrome treated?
Unless your ulnar nerve is damaged, treatment for cubital tunnel syndrome starts with avoiding pressure over the cubital tunnel/funny bone area by not resting the elbow on desks or other hard objects when using the computer or driving. Prolonged elbow flexion should also be avoided. If you’re on the phone a lot, use your other hand to hold it, or get a hands-free device.
At night, try to prevent the elbow from fully bending during sleep. This is very difficult to do, and many people have trouble sleeping like this. Strategies that can be tried are rolling a towel around the elbow, wearing a tennis elbow brace over the elbow, or cutting a hole in a pillow case and putting the arm through it next to the pillow so that the pillow prevents the elbow from fully bending. If this fails and the symptoms are bothersome, surgical treatment is very successful.

What are the different surgeries for cubital tunnel syndrome?
There are many different surgeries for cubital tunnel syndrome. Some involve removing bone (ie. a medial epicondylectomy) and are very painful. Some involve transposing (moving) the ulnar nerve to the front of the elbow. The nerve can be placed under the skin or under the muscle. These work well, but there are less-invasive options available.
The literature since 2005 has shown that patients with cubital tunnel syndrome do just as well following a simple cubital tunnel release as following the bigger, more invasive, more painful operations. A cubital tunnel release is a simple, less invasive and less painful operation. It is very similar to a carpal tunnel release, in that it simply releases the fascia (ligament-like tissue) over the nerve. This releases the nerve’s compression and allows the nerve to heal and stops the pain.
Just like a carpal tunnel release, a cubital tunnel release can be performed endoscopically, through a small incision. This is an outpatient procedure. No splint is needed, and after surgery activities can be resumed within the limits of pain. Typing and computer use can be performed immediately. In order to minimize pain and swelling, heavy activiites should probably be avoided for 2-3 weeks. .
The nerve recovers just as well as it does following the bigger operations, with less pain and sufferering, a quicker return to activies and a lower complication rate in skilled hands. A video of this procedure can be viewed at www.Rearmyourselftexas.com. Occasionally, a patient’s nerve may sublux (move) following release. While this is uncommon, I always check to see if this occurs, and if it does I transpose (move) the nerve to the front of the elbow.
Results are mainly affected by how damaged the nerve is from the compression that occurred prior to the surgery. In other words, those who had cubital tunnel syndrome longer and had more nerve damage recovered less following surgery than those with lesser degrees of nerve damage. As with most things in life, it’s usually easier and better to address problems early on, when they are still small.

Tags: ,,,,,,,,,,,,
No Comments »

Osteochondritis Dissecans (OCD)

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.

Tags: ,,,,,,,,,,
1 Comment »