The elbow remains one of the more unforgiving joints in its response to both trauma and surgical intervention. The complex articular relationships of humerus, ulna and radius coupled with a tight soft tissue envelope, make the elbow one of the more challenging joints in which to restore function.
As Orthopedic hand surgeons, we are best suited to treat these complex injuries due to our understanding of the anatomy and our less aggressive approach to soft tissue handling that is a necessity in the hand.
Radial head fractures remain the most common elbow injury with many allowing conservative treatment, but the displaced fractures are often the most challenging of all articular fractures. Adherence to AO principles of internal fixation is important. The medial collateral ligament should often be explored and repaired in many of these injuries. This attention to concomitant soft tissue injury is the key to a good functional result in the elbow.
Monteggia lesions are often extremely comminuted and may require a variety of fixation techniques to achieve stability. This is important if we are to begin early motion which is particularly important in this joint that is prone to contracture. Similar principles are involved in the treatment of intercondylar humerus fractures, where strict surgical techniques coupled with rehabilitation are a must.
In some cases, techniques of arthroplasty and even arthroscopy are indicated in addition to open reduction and internal fixation. The complex distal articular humerus fracture in the elderly may be best suited for immediate cemented total joint arthroplasty. These salvage procedures may also be indicated in late complications or even nonunion scenarios about the elbow.
Arthroscopy is often ideal in managing the young and active patient. Improved visualization of the fracture as well as rapidity of recovery are reasons that will soon expand the use of this technique in also managing elbow trauma. Post-traumatic contracture will also benefit from the surgeon’s adeptness with the scope.
Complex elbow articular trauma is now being given the attention it deserves as they are some of the most difficult posttraumatic sequelae problems to resolve in orthopedics. More diverse surgical techniques along with closer attention by the hand surgeon will hopefully minimize the common late complications seen in this most challenging of joints.
Alejandro Badia, MD, FACS
Cubital tunnel syndrome is a condition brought on by increased pressure on the ulnar nerve at the elbow. There is a bump of bone on the inner portion of the elbow (medial epicondyle) under which the ulnar nerve passes. This site is commonly called the “funny bone”. At this site, the ulnar nerve lies directly next to the bone and is susceptible to pressure. When the pressure on the nerve becomes great enough to disturb the way the nerve works, then numbness, tingling, and pain may be felt in the elbow, forearm, hand, and/or fingers.
Symptoms of cubital tunnel syndrome usually include pain, numbness, and/or tingling. The numbness or tingling most often occurs in the ring and small fingers. The symptoms are usually felt when there is pressure on the ulnar nerve, such as when sitting with the elbow on an arm rest, or with repetitive elbow bending and straightening. Often symptoms will be felt when the elbow is held in a bent position for a period of time, such as when holding the phone, or while sleeping. Some patients may notice weakness while pinching, occasional clumsiness, and/or a tendency to drop things. In severe cases, sensation may be lost and the muscles in the hand may lose bulk and strength.
The diagnosis of cubital tunnel syndrome can be made based on simple clinical tests and patient symptoms, and is confirmed by a detailed nerve conduction study. This study measures the velocity and the latency of the nerve impulses across the ulnar nerve at the elbow. Nonsurgical Treatment Symptoms may sometimes be relived without surgery, particularly if the nerve conduction study shows that the pressure on the nerve is minimal. Changing the patterns of elbow use may significantly reduce the pressure on the nerve. Avoiding putting your elbow on hard surfaces may help, or wearing an elbow pad over the ulnar nerve may help. Keeping the elbow straight at night with a splint may also help.
When symptoms are severe or do not improve with conservative treatment, surgery may be needed to relieve the pressure on the nerve. Many surgeons will recommend shifting the nerve to the front of the elbow, which relieves pressure and tension on the nerve. Some surgeons may recommend trimming the bony bump on the inside of the elbow (medial epicondyle). At Badia Hand to Shoulder Center, a newer, endoscopic method is used, which does not require a large incision or lengthy recover time. A small incision is made at the inside of the elbow, and an endoscope, which is a tiny camera, is inserted. This allows the surgeon to see the nerve and make a division over the nerve. This reduces the compression over the ulnar nerve that had been causing the symptoms.
Release of the painful ulnar nerve at the elbow is a common operation that is virtually always done via a large open incision. At Badia Hand to Shoulder Center, we have been doing the technique endoscopically, via a mini portal incision using an endoscope to release the ulnar nerve, often called the “funny bone”. This alleviates the numbness and pain, and allows the patient to use the arm immediately as this is done in Miami (Doral) as an outpatient procedure with local anesthesia. Virtually no therapy is required and the complications such as scarring, neuromas, and continued pain are almost never seen with the endoscopic approach.
E.R. is a 26 year old male lifeguard who had a severe, unfortunate accident the first time he ever mounted a motorcycle. He was in a coma for many months with head trauma and had fractured his right elbow and forearm at the time of injury. He developed a condition called Heterotopic Ossification which meant that multiple joints “froze-up” due to deposits of calcium in the joint capsules. He was not able to walk until both hips were operated on by an internationally known hip surgeon who then referred him to Dr. Badia to address the stiff Right elbow and deformed forearm. In fact, at the initial visit, the patient stated that he had not moved the right elbow AT ALL for nearly 4 years and was unable to feed or groom himself with that hand. After a series of 3 operations to reconstruct both the elbow and forearm, this young man has gone back to swimming, work and a normal lifestyle.
The pictures depict the application of the dynamic external fixator, which stabilized and provided early motion to the rigid elbow after aggressive release of the capsule and bone excision.
MIAMI, Florida — What is Cubital Tunnel Syndrome? Cubital Tunnel Syndrome is a condition brought on by increased pressure on the ulnar nerve at the elbow. There is a bump (made of bone) on the inner portion of the elbow (the medial epicondyle) under which the ulnar nerve passes. This site is commonly called the “funny bone”. It is here that the ulnar nerve lies directly next to the bone and is susceptible to pressure. When the pressure on the nerve becomes great enough to disturb the way the nerve works, then numbness, tingling, and pain may be felt in the elbow, forearm, hand, and/or fingers. Dr. Alejandro Badia is the one and only doctor in South Florida currently performing a minimally invasive procedure curing Cubital Tunnel Syndrome. Symptoms: Cubital tunnel syndrome symptoms usually include pain, numbness, and/or tingling. The numbness or tingling most often occurs in the ring and little fingers. The symptoms are usually felt when there is pressure on the nerve, such as sitting with the elbow on an armrest, or with repetitive elbow bending and straightening. Often symptoms will be felt when the elbow is held in a bent position for a period of time, such as when holding the phone, or while sleeping. Some patients may notice weakness while pinching, occasional clumsiness, and/or a tendency to drop things. In severe cases, sensation may be lost and the muscles in the hand may lose bulk and strength. The cubital tunnel.Treatment without Surgery: Symptoms may sometimes be relieved without surgery, particularly if the EMG/NCS testing shows that the pressure on the nerve is minimal. Changing the patterns of elbow use may significantly reduce the pressure on the nerve. Avoiding putting your elbow on hard surfaces may help, or wearing an elbow pad over the ulnar nerve and “funny bone” may help. Keeping the elbow straight at night with a splint also may help. A session with a therapist to learn ways to avoid pressure on the nerve may be needed. Endoscopic Cubital Tunnel Release Procedure: The innovative, newer endoscopic method performed by the American Hand Institute surgeons does not require a large incision or lengthy recovery time. This procedure, which the surgeons at the American Hand Institute perform, is less invasive, less painful and typically allows for faster recovery. “It is very important that patients know about this new alternative to treat the Cubital Tunnel Syndrome. Through a tiny incision a faster procedure can be done with less stress for the patient and less recovery time than the traditional surgery for this health condition. My patients have experienced an immediate disappearance of CTS symptoms after this procedure.” affirms Dr Alejandro Badia, world-renowned upper limb surgeon, who is now in India and has been in Jordan, Aman and Dubai, teaching colleagues this and other innovative new minimally invasive surgical procedures. CTS- Minimally invasive procedure.Open Cubital Tunnel Release Procedure: Many surgeons will recommend shifting the nerve to the front of the elbow, which relieves pressure and tension on the nerve. The nerve may be placed under a layer of fat, under the muscle, or within the muscle. Some surgeons may recommend trimming the bony bump (medial epicondyle). Following surgery, the recovery will depend on the type of surgery that was performed. Restrictions on lifting and/or elbow movement may be recommended. Therapy may be necessary. According to the American Hand Institute only a few surgeons in the country offer this particular procedure. Dr. Alejandro Badia is the only one to offer it in South Florida. Alejandro Badia, MD, FACS is a hand and upper extremity surgeon. He studied physiology at Cornell University and obtained his medical degree at NYU, where he also trained in orthopedics. A hand fellowship at Alleghany General Hospital in Pittsburgh was followed by an AO trauma fellowship in Freiburg, Germany. He runs an active international hand fellowship, serves on the editorial board of two hand journals, and organizes a yearly Miami meeting for surgeons and therapists that are devoted to upper limb arthroscopy and arthroplasty (www.miamihandcourse.com). This international meeting is held at the world-renowned Miami Anatomical Research Center (M.A.R.C.), the world’s largest surgical cadaveric training lab that Dr. Badia co-founded in 2005. Endoscopic Cubital Tunnel Release scar. In 2008, he completed the Badia Hand to Shoulder Center, a fully integrated clinical facility for the upper limb encompassing digital radiography, MRI extremity imaging, Integra rehabilitation facility and the Surgery Center at Doral. More recently, Dr. Badia inaugurated OrthoNOW, the first immediate orthopedic care center in South Florida which is staffed by surgeons from the International Orthopedic Group (IOG), a group of surgeons from lower extremity, upper limb and spine subspecialties who also treat elective orthopedic problems in international patients. He is member of the ASSH, AAHS, AAOS as well as honorary member of many foreign hand surgery societies and President of ISSPORTH. Dr. Badia can be reached via www.drbadia.com, a patient education portal and website for hand surgeon academic exchange. Or by email: firstname.lastname@example.org. Photo 1: The cubital tunnel. Photo 2: CTS- Minimally invasive procedure. Photo 3: Endoscopic Cubital Tunnel Release scar. View Article »
Athletic injuries in the hand and wrist are often misdiagnosed and under treated for a variety of reasons. Chronic and overuse injuries often go untreated due to the athlete’s reluctance to seek medical attention. This is because in many sports, the athlete can compensate with some of these injuries while this may be more difficult in weight bearing joints such as the knee and ankle. However, a more preventable issue may be the inaccurate diagnoses and inadequate treatment often afforded the hand and upper extremity in athletes. This is where the physician and ancillary health specialist can improve their management of these challenging and often obscure injuries. In many instances, the hand surgeon should be involved at an early stage of treatment and to ensure an accurate diagnosis.
The common injuries in the hand and wrist are often sports specific and often aptly named. For example, jersey finger is an avulsion of the flexor profundus tendon that occurs when the athlete grabs the opponents jersey as they pull away. This leads to a sudden and resisted hyperextension force that avulses the tendon at its insertion site. A strong surgical repair is necessary followed by appropriate therapy to maximize the passive range of motion and later the active flexion. Subsequent strengthening is of obvious particular importance in the competitive athlete. Blunt injuries can occur to the extensor mechanism as well and the wide range of complex joints in the hand and wrist.
Small joint arthroscopy now gives us a more accurate method to diagnose many of these subtle injuries and of course provide treatment. Wrist arthroscopy indications have been well worked out, but newer techniques using metacarpophalangeal and thumb carpometacarpal arthroscopy are evolving. This includes better methods of fixation, radiofrequency probes to ablate and shrink tissue, and improved post-op methods of rehabilitation including splinting techniques and passive range of motion protocols.
These newer techniques are currently being refined at the Miam Hand Center arthroscopy laboratory as well as other clinical research centers.