Description
The bursa is a slippery sac between the loose skin and the bones of your elbow. The bursa allows the skin to move freely over the underlying bone. It is located at the tip of the elbow. Normally, the bursa is flat and it’s hard to tell it is even there. If the bursa becomes irritated or inflamed, a condition known as elbow bursitis develops.

Risk Factors/Prevention
Common causes of elbow bursitis include:

• Trauma: A hard blow to the tip of the elbow could cause the bursa to produce excess fluid and swell.
• Prolonged pressure: Leaning on the tip of the elbow for long periods of time on hard surfaces such as a tabletop may cause the bursa to swell. Typically, this type of bursitis would develop over several months.
• Infection: If the tip of the elbow has an injury that breaks the skin, such as an insect bite or a scrape, bacteria may get inside the bursa and cause an infection. The infected bursa produces fluid, redness and swelling. If the infection goes untreated, the fluid may turn to pus.
• Medical conditions: Certain conditions such as rheumatoid arthritis and gout are associated with development of elbow bursitis.

Symptoms
Swelling is often the first symptom. The skin on the back of the elbow is loose, so you may not notice small amounts of swelling right away. As the swelling continues, the bursa gets larger. This causes pain as the bursa is stretched, since the bursa contains nerve endings. The swelling may get large enough to restrict motion in the elbow.

If the bursitis is infected, the skin becomes red and warm. If the infection is not treated right away, it may spread to other parts of the arm or move into the bloodstream. This can cause serious illness.

See your doctor to diagnose elbow bursitis. You may need an X-ray so the doctor can look for a foreign body or a bone spur. Bone spurs are often found on the tip of the bone in the elbow in patients who have recurrent problems with elbow bursitis.

Treatment Options: Nonsurgical
First, the doctor must determine whether the bursitis is due to an infection. If the doctor suspects this, fluid removal (aspiration) of the swollen area may be recommended. This is commonly performed as an office procedure. Fluid removal helps relieve symptoms and gives the doctor a sample that can be looked at in a laboratory to identify if any bacteria are growing.

This also lets the doctor know if a specific antibiotic is needed to fight the infection.

Often, the doctor may start you on antibiotics before the exact bacteria can be identified. This is done to prevent the infection from progressing. The antibiotic that the doctor recommends in this case will cover a number of possible infections.

If the bursitis is not from an infection, it is treated with elevation, ice and other nonoperative treatments such as an elbow pad and avoidance of direct pressure on the swollen elbow. Oral medications such as ibuprofen or other anti-inflammatories may also be used.

If the swelling and pain do not respond to these measures, your doctor may recommend removing fluid from the bursa and injecting a corticosteroid medication into the bursa. The steroid medication is an anti-inflammatory that is stronger than the medication that can be taken by mouth.

Treatment Options: Surgical
Infected bursa that do not improve with antibiotics and/or removing fluid from the elbow may require surgery. Patients who have surgery for elbow bursitis may need to stay in the hospital for a period of time.

If elbow bursitis is not a result of infection, surgery may be needed if nonoperative treatments don’t work. Surgery to remove the bursa is usually performed as an outpatient procedure. The surgery does not disturb any muscle, ligament or joint structure. Physical therapy after surgery is not always needed. Postoperative casting or prolonged immobilization is not typically required.

The biceps muscle, in the front of the upper arm, helps stabilize the upper arm bone (humerus) in the shoulder socket. It also helps accelerate and decelerate the arm during overhead movement in activities like tennis or pitching. Strong, cord-like structures called tendons connect one end of the biceps muscle to the shoulder in two places.

At the other end of the muscle, tendons connect the biceps muscle to the smaller bone (radius) in the lower arm. If the tendons become inflamed or irritated, the condition is called tendinitis.

Signs and symptoms
Injuries to the biceps tendons are commonly caused by repetitive overhead activity. Symptoms include:

• Pain when the arm is overhead or bent.
• Localized tenderness as the tendon passes over the groove in the upper arm bone.
• Occasionally, a snapping sound or sensation in the shoulder area.

Diagnosis and treatment
During the physical examination, the doctor will assess the shoulder area for range of motion, tenderness and signs of shoulder instability. He or she may ask you to raise or rotate the arm.

X-rays may be requested to uncover associated conditions that might cause irritation. The doctor may also request an MRI that can show any damage to the tendons. Overuse, aging and stress can cause the tendon to deteriorate, even if there is no inflammation present.

Initial treatment is conservative. The first step is to rest the arm and shoulder. Switch to another sport or activity for awhile. Ice applications and nonsteroidal anti-inflammatory medications such as ibuprofen can help reduce inflammation.

Your physician can also recommend stretching and progressive strengthening exercises to build muscle endurance and restore range of motion. Then you can gradually return to overhead activity.

Surgical options
If the pain results from shoulder instability or from pressure on the tendon from the shoulder bones, your orthopaedist may recommend arthroscopic surgery. Using fiber optic technology and miniature instruments inserted through a small incision, the surgeon can examine the shoulder joint and anchor the tendon properly.

After surgery, your orthopaedist will prescribe a rehabilitation program that includes stretching and strengthening exercises. Early movement is important, but you should wait for your physician’s approval before doing any heavy lifting or returning to sports.

Most people are familiar with joint replacement surgery for the hip, knee, and shoulder joints. Joint replacement surgery in the wrist is less common but can be an option if you have painful arthritis that does not respond to other treatments.

Anatomy of the wrist
The wrist is a more complicated joint than the hip or the knee. At the base of the hand are two rows of bones, with four bones in each row. These are called the carpals. The long thin bones of the hand radiate out from one row of carpals toward the fingers and thumb. The two bones of the lower arm (radius and ulna) form a joint with the other row of carpals. All the bone ends are covered with a slick, elastic tissue called cartilage, which enables the bones to move smoothly against each other. However, if the cartilage is worn away or damaged by injury, infection or disease, the bones will rub against each other causing pain. During any total joint replacement, the worn-out bone ends are removed and replaced by an artificial joint (prosthesis).

Reasons for wrist replacement surgery
The typical candidate for wrist replacement surgery has severe arthritis but does not need to use the wrist to meet heavy demands in daily use. The primary reasons for wrist replacement surgery are to relieve pain and to maintain function in the wrist and hand.

• Osteoarthritis, the most common form of arthritis, results from a gradual wearing away of the cartilage covering on bones.
• Rheumatoid arthritis is a chronic inflammatory disease of the joints that results in pain, stiffness and swelling. Rheumatoid arthritis usually affects several joints on both the right and left sides of the body.

Both forms of arthritis may affect the strength of your fingers and hand, making it difficult for you to grip or pinch. In some cases, fusing the wrist bones together will reduce or eliminate pain and improve grip strength. However, if the bones are fused together, you will not be able to bend the wrist. Wrist replacement surgery may enable you to retain or recover wrist movements and improve your ability to perform daily living activities, especially if you also have arthritis in the elbow and shoulder.

Implant design
Wrist implants are made of the same kind of materials used for hip and knee joint replacements. There are several different designs. Most have two components and are made of metal; a high quality plastic called polyethylene is used as a spacer between the two components. Newer implant designs try to replicate the anatomy of the wrist.

The piece that attaches to the lower arm (radius bone component) fits into the bone of the lower arm. The top of this component has a curve that matches to the wrist part. The piece that attaches to the hand (carpal component) may have one long stem and one or two shorter stems that insert into the hand bones, or use small screws. The surface of this component is flat. The plastic spacer comes in different sizes so it can be matched to your hand. It is normally flat on one side and rounded on the other. This design enables it to fit into the carpal component while it rocks on the radial component, creating a more natural wrist motion.

Implant insertion
A wrist joint replacement can be done as an outpatient procedure, unlike a hip or knee replacement. Wrist replacement surgery is often combined with other procedures to correct deformities or disorders in the tendons, nerves, and small joints of the fingers and thumb.

The incision is made on the back of the wrist. The damaged ends of the lower arm bones are removed and the first row of carpal bones may also be removed. The radial component of the prosthesis is inserted into the center of the radius bone on the outside of the lower arm. It is held in place with bone cement. Depending on the component design, the carpal component is then inserted into the center hand bone (third metacarpal) or screwed into the remaining row of carpal bones. Bone cement may be used to hold the component in place. The carpal bones may be linked or fused together to better secure this component.

An appropriately sized spacer is used between the metal components.

After your surgery
You will have to wear a cast for the first several weeks. When the cast is removed, you will have to wear a protective splint for the next six to eight weeks. Although pain relief is immediate, you will have to do gradual exercises for several weeks to restore movement and, eventually, to increase power and endurance. Wrist arthroplasty can improve motion to about 50 percent of normal.

The physical demands that you place on the wrist prosthesis will have an effect on how long the implant lasts. You will not be able to use a hammer often or pneumatic tools. You may only be able to lift a limited amount of weight. A fall on the outstretched hand may break the prosthesis, just as it might fracture a normal wrist. So you will want to avoid activities such as roller sports that could result in a fall.

Although there have been significant advances in wrist prostheses, the implant may loosen or fail due to wear or deformation. In these cases, additional surgery may be necessary. On average, a wrist replacement can be expected to last 10 to 15 years with careful use. As with all implants, long-term follow-up is advised. Generally, you should see your hand surgeon every year or two years so that x-rays can be taken and used to identify any developing conditions or problems.