The elbow joint is a complex hinge joint formed between the distal end of the humerus in the upper arm and the proximal ends of the ulna and radius in the forearm. The elbow allows for the flexion and extension of the forearm relative to the upper arm, as well as rotation of the forearm and wrist.
The rounded distal end of the humerus is divided into two joint processes – the trochlea on the medial side and the capitulum on the lateral side. The pulley-shaped trochlea forms a tight joint with the trochlear notch of the ulna surrounding it.
Like all other synovial joints, a thin layer of smooth articular cartilage covers the ends of the bones that form the elbow joint. The joint capsule of the elbow surrounds the joint to provide strength and lubrication to the elbow. Slick synovial fluid produced by the synovial membrane of the joint capsule fills the hollow space between the bones and lubricates the joint to reduce friction and wear.
It is usually injured from direct trauma or sports-related injuries, most commonly in overhead athletes.
The rotator cuff is a major group of tendons in the shoulder joint providing support and enabling a wide range of motion. Major injury to these tendons can result in a tear know as a rotator cuff tear. It is one of the most common causes of shoulder pain in middle aged adults and older individuals. It may occur with repeated use of arm for overhead activities, while playing sports or during motor accidents. Rotator cuff tear causes severe pain, weakness of the arm, and crackling sensation on moving shoulder in certain positions. There may be stiffness, swelling, loss of movements, and tenderness in the front of the shoulder.
Rotator cuff tear is best viewed on magnetic resonance imaging. Symptomatic relief may be obtained with conservative treatments – rest, shoulder sling, pain medications, steroidal injections and certain exercises. However surgery is required to fix the tendon back to the shoulder bone. Rotator cuff repair may be performed by open surgery or arthroscopic procedure. In arthroscopy procedure space for rotator cuff tendons will be increased and the cuff tear is repaired using suture anchors. These anchor sutures help in attaching the tendons to the shoulder bone. Following the surgery you may be advised to practice motion and strengthening exercises.
Shoulder impingement is also called as swimmer’s shoulder, tennis shoulder, or rotator cuff tendinitis. It is the condition of inflammation of the tendons of the shoulder joint caused by motor vehicle accidents, trauma, and while playing sports such as tennis, baseball, swimming and weight lifting.
Individuals with shoulder impingement may experience severe pain at rest and during activities, weakness of the arm and difficulty in raising the hand overhead. X-rays and MRI scans show the injury and inflammation. Shoulder impingement can be treated with rest, ice packs, anti-inflammatory drugs, and avoiding the activities involving the shoulder. Physical therapy may be advised to strengthen the muscles and steroid injections may be given if pain persists. Arthroscopic surgery is recommended if the rotator cuff tendons are torn and to remove the bony spurs.
Frozen shoulder is a condition that limits shoulder movements because of pain and inflammation. It is also called adhesive capsulitis and may progress to where an individual may find it very hard to move the shoulder. It is more common in older adults aged between 40 and 60 years and is more common in women than men.
Frozen shoulder is caused by inflammation of the ligaments holding the shoulder bones to each other. The shoulder capsule becomes thick, tight, and stiff bands of tissue called adhesions may develop. Individuals with shoulder injury, shoulder surgeries, shoulder immobilized for long periods of time, other disease conditions such as diabetes, hypothyroidism, hyperthyroidism, Parkinson’s disease and cardiac diseases are at risk of developing frozen shoulder.
Frozen shoulder may cause pain and stiffness and limit the movements of shoulder. Condition can be diagnosed by the presenting symptoms and radiological diagnostic procedures such as X-rays or MRI scans. Treatment for frozen shoulder includes nonsteroidal anti-inflammatory drugs and steroid injections for pain, treatment of underlying risk factors, and shoulder arthroscopy surgery. During surgery, the scar tissue will be removed and tight ligaments, if any, will be dissected. Following surgery physical therapy will be advised to bring full range of motion and strengthen the muscles.
The surgery is performed under sterile conditions in the operating room under spinal or general anesthesia. An incision is made over the affected shoulder to expose the shoulder joint. The upper arm bone (Humerus) is separated from the glenoid socket of the shoulder blade (Scapula). The humeral head which is arthritic is cut off. The surgeon concentrates on the glenoid (socket). The arthritic part of the socket is removed and prepared to take the glenoid component. The glenoid component is then pressed into the socket. The upper arm bone is prepared to take the new humeral component. The humeral component is then inserted into the upper arm bone. This may be press fit relying on the bone to grow into it or cemented depending on a number of factors such as bone quality and surgeon’s preference. The humeral head component is then placed on the humeral stem. This component is made of metal. The artificial components are fixed in place. The Joint capsule is stitched together. The muscle and tendons are then repaired and the skin is closed.
Risks and Complications
As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. Complications can be medical (general) or specific to the shoulder Medical complications include those of the anesthetic and your general wellbeing. Almost any medical condition can occur so this list is not complete. Complications include
- Allergic reactions to medications
- Blood loss requiring transfusion with its low risk of disease transmission
- Heart attacks, strokes, kidney failure, pneumonia, bladder infections.
- Complications from nerve blocks such as infection or nerve damage.
- Serious medical problems can lead to ongoing health concerns, prolonged hospitalization or rarely death.
Risks and Complications: Specific Complications:
- Infection: Infection can occur with any operation. Infection rates vary. If it occurs, it can be treated with antibiotics but may require further surgery. Very rarely your prosthesis may need to be removed to eradicate infection.
- Dislocation: This means the humeral head is popping out of its socket. Precautions need to be taken with your new shoulder forever. If a dislocation occurs it needs to be put back into place with an anesthetic. Rarely this becomes a recurrent problem needing further surgery.
- Fractures (break) of the humerus (upper arm bone) or scapula (shoulder blade): This is also rare but can occur during or after surgery. This may prolong your recovery or require further surgery.
- Damage to nerves or blood vessels: Also rare but can lead to weakness and loss of sensation in part of the arm. Damage to blood vessels may require further surgery if bleeding is ongoing.
- Blood clots (Deep Venous Thrombosis): These can form in the arm muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life threatening. If you get calf pain or shortness of breath at any stage, you should notify your surgeon.
- Wound irritation: Your scar can be sensitive or have a surrounding area of numbness. This normally decreases over time and does not lead to any problems with your new joint.
- Arm length inequality: It is very difficult to make the arm exactly the same length as the other one. Occasionally the arm is deliberately lengthened to make the shoulder stable during surgery. There are some occasions when it is simply not possible to match the arm lengths.
- Wear: All joints eventually wear out. The more active you are, the quicker this will occur.
- Failure to relieve pain: Very rare but may occur, especially if some pain is coming from other areas such as the spine.
- Unsightly or thickened scar: Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.
Shoulder instability is a chronic condition that causes frequent dislocations of the shoulder joint. A dislocation occurs when the end of the humerus (the ball portion) partially or completely dislocates from the glenoid (the socket portion) of the shoulder. A partial dislocation is referred to as a subluxation whereas a complete separation is referred to as a dislocation. The common symptoms of shoulder instability include pain with certain movements of the shoulder; popping or grinding sound may be heard or felt, swelling and bruising of the shoulder may be seen immediately following subluxation or dislocation. Visible deformity and loss of function of the shoulder occurs after subluxation or sensation changes such as numbness or even partial paralysis can occur below the dislocation as a result of pressure on nerves and blood vessels.
The risk factors that increase the chances of developing shoulder instability include:
- Injury or trauma to the shoulder
- Falling on an outstretched hand
- Repetitive overhead sports such as baseball, swimming, volleyball, or weightlifting
- Loose shoulder ligaments or an enlarged capsule
The goal of conservative treatment for shoulder instability is to restore stability, strength, and full range of motion. Conservative treatment measures may include the following:
- Closed Reduction: Following a dislocation, your orthopedist can often manipulate the shoulder joint, usually under anesthesia, realigning it into proper position. Surgery may be necessary to restore normal function depending on your situation
- Medications: Over the counter pain medications and NSAID’s can help reduce the pain and swelling. Steroidal injections may also be administered to decrease swelling
- Rest: Rest the injured shoulder and avoid activities that require overhead motion. A sling may be worn for 2 weeks to facilitate healing
- Ice: Ice packs should be applied to the affected area for 20 minutes every hour
When these conservative treatment options fail to relieve shoulder instability, your surgeon may recommend shoulder stabilization surgery. Shoulder stabilization surgery is done to improve stability and function to the shoulder joint and prevent recurrent dislocations. It can be performed arthroscopically, depending on your particular situation, with much smaller incisions. Arthroscopy is a surgical procedure in which an arthroscope, a small flexible tube with a light and video camera at the end, is inserted into a joint to evaluate and treat of the condition. The benefits of arthroscopy compared to the alternative, open shoulder surgery are smaller incisions, minimal soft tissue trauma, less pain leading to faster recovery.