When you bend your elbow, you can easily feel its “tip,” a bony prominence that extends from one of the lower arm bones (the ulna). That tip is called the olecranon (oh-lek’-rah-nun). It is positioned directly under the skin of the elbow, without much protection from muscles or other soft tissues. So it can easily break if you experience a direct blow to the elbow or fall on a bent elbow.

Signs and symptoms

• Sudden, intense pain.
• Bruising around the elbow.
• Rupture or abrasion of the overlying skin.
• Possible deformity, if there is also a dislocation of the bone.
• Tenderness and swelling over the bone site.
• Numbness in one or more fingers.
• Pain with movement of the joint.

Evaluation and classification
It is important to see a physician and verify that there is no associated damage to nerves or blood vessels. Your physician will use X-rays to confirm the diagnosis and classify the type of fracture. Fractures are generally divided into three types, depending on the stability of the joint and the amount of separation among the broken pieces of bone. (Note: Some fractures can have characteristics of more than one category.)

• Type I fractures are generally stable with little displacement. These fractures can generally be treated nonsurgically.
• Type II fractures are the most common. They are relatively stable, although there is displacement of the bone pieces.
• Type III fractures are displaced and involve more than 50 percent of the joint surface, resulting in joint instability.

Treatment
Treatment depends on the type of fracture.

• Type I fracture can usually be treated with a splint or sling to hold the elbow at a 90 degree angle. The physician will request a second set of X-rays after 10 days to make sure that the broken pieces have not become displaced. Gentle motion is permitted, and hand and wrist exercises should be done daily.
• Type II fracture is best treated surgically. The orthopaedic surgeon will use a plate or a combination of wires and pins or screws to hold the bones in place. Physical therapy to maintain range of motion will start a day or two after the operation, and continue for at least six weeks.
• Type III fractures are also treated surgically, usually with a plate that fits under the ulna and around the tip of the elbow. Screws hold the plate in place. You will have to wear a splint for a couple of days, then physical therapy to maintain range of motion will begin.

Fractures of the tip of the olecranon that do not involve the joint are may be treated by removing the small fragment and repairing the tendon that has pulled off. Elderly people who experience a type II or type III fracture may be treated with a sling and early range of motion instead of surgery. Athletes who have stress fractures of the olecranon are treated with activity restriction, stretching and range of motion exercises, and substitution activities for 8 to 12 weeks, although complete recovery may take three to six months.

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.

Arthroscopy (ar-THROS-ka-pea) is an outpatient surgical procedure used by orthopaedic surgeons to diagnose and treat problems inside a joint. The surgeon makes small incisions, less than half an inch long, and inserts a pencil-sized instrument called an arthroscope. The arthroscope contains a small lens, a miniature camera and a lighting system.

This projects three-dimensional images of the joint on a television monitor, enabling the surgeon to look directly inside the joint and identify the trouble. Tiny probes, forceps, knives and shavers can then be used to correct many problems at the same time.

Arthroscopy has been used for several years to treat conditions in large joints such as the knee and the shoulder. As cameras and instruments became smaller and more refined, arthroscopy was applied to other joints, including the wrist. The wrist is a complex joint, with eight small bones and many connecting ligaments. Arthroscopy enables the surgeon to see the anatomic parts and their movements and to make a more accurate diagnosis.

Diagnostic arthroscopy
Diagnostic arthroscopy may be used if the cause of your wrist pain cannot be identified or if wrist pain continues for several months despite nonsurgical treatment.

Before surgery, your doctor will do:

• A physical examination that focuses on your hand and wrist. Your doctor will also ask about your medical history.
• Provocative tests that involve moving your hand in ways that reproduce the pain.
• Imaging studies, such as X-rays of your hand and wrist. In some cases, additional imaging studies may be needed. These can include an MRI (magnetic resonance image) or an arthrogram, in which a contrast agent is injected into the joint before the image is taken.

Usually, regional anesthesia is used during arthroscopic surgery. This numbs your arm and hand. You may also be given a sedative to further relax you and enable you to doze through the surgery. Two or more small incisions (portals) are made on the back of the wrist, through which the arthroscope and instruments are inserted. After the surgery, the incisions are closed with a small stitch and a dressing is applied. Sometimes a splint may also be used.

Arthroscopic surgical treatment

Several conditions can be treated using arthroscopic surgery, including chronic wrist pain, wrist fractures, ganglion cysts and tears in the ligaments or the triangular fibrocartilage complex (TFCC). Wrist arthroscopy may also be used to smooth the bone surfaces and remove inflamed tissue. Arthroscopy can also be used to surgically treat carpal tunnel syndrome, but in that diagnosis, the arthroscope is not inserted into the wrist joint itself.

• Chronic wrist pain: Arthroscopic exploratory surgery may be used to diagnose the cause of chronic wrist pain when other tests are inconclusive. Often, there may be areas of inflammation, cartilage damage, or other findings after a wrist injury. In some cases, after the diagnosis is made, the condition can be treated arthroscopically as well.
• Wrist fractures: Doctors can remove small fragments and fracture debris, align the broken pieces of bone, and stabilize them by using pins, wires, or screws.
• Ganglion cysts: These cysts commonly grow from a stalk between two of the wrist bones. During an arthroscopic procedure, the surgeon can remove the stalk, which may also reduce recurrence of the cysts.
• Ligament/TFCC tears: Ligaments are fibrous bands of connective tissue that link or hinge bones. They provide stability and support to the joints. The TFCC is a cushioning structure within the wrist. A fall on an outstretched hand can tear ligaments, the TFCC or both, resulting in pain with movement or a clicking sensation. During arthroscopic surgery, the surgeon can trim or repair the tears.
• Carpal tunnel release: Carpal tunnel syndrome is characterized by numbness or tingling in the hand, and sometimes with pain up the arm. It is caused by pressure on a nerve that passes through the carpal tunnel, which is formed by the wrist bones and a thick tissue roof. Pressure can build up within the tunnel for many reasons, including irritation and swelling of the tissue (synovium) that covers the tendons. If the syndrome does not respond to conservative treatment, your doctor may recommend surgery to cut the ligament roof and enlarge the tunnel, thus reducing pressure on the nerve and relieving symptoms. This can sometimes be done using an arthroscope.

After surgery, you will need to keep your wrist elevated for the first two or three days and keep your bandage clean and dry. You can ice your wrist to help keep swelling down. Your doctor and/or your physical therapist will teach you exercises to help maintain motion and rebuild your strength. Analgesic medications will help relieve any postoperative pain, which is usually mild.

Complications
Complications during or after arthroscopic wrist surgery are unusual, but may include infection, nerve injuries, excessive swelling or bleeding, scarring or tendon tearing. An experienced surgeon, particularly one who specializes in treating the hand, can reduce the likelihood of complications.

Summary
Arthroscopic surgery is a valuable diagnostic and treatment tool. It is minimally invasive, and patients generally experience fewer problems and a more rapid recovery than with open surgery. Because it is an outpatient procedure, most patients are home several hours after surgery.