Mayo Edge: Painful bone spur in elbow may require surgery to restore mobility

Surgery often is a good choice for treating elbow bone spurs
that are causing problems. In many cases, it can relieve pain and
restore mobility. Using new techniques that reduce inflammation
after surgery, recovery time typically is short. In most cases,
people can return to activities of daily living in a week or less,
and to high-demand activities within two to six weeks.

Bone spurs are bony projections that develop along the edges of
joints like your elbow. They are often caused by long-term
wear-and-tear or prior injury to the joint.

In many cases, bone spurs don’t cause any symptoms and don’t
require treatment. However, if a number of bone spurs build up in
one joint, or if one cracks or breaks as in your situation, that
can lead to pain and a loss of mobility in the joint. In the elbow,
a cracked bone spur can make it difficult to fully extend or bend
your arm. Surgery to remove the bone spur may eliminate the
problem.

The surgery involves removing the cracked piece and using a
high-speed, motorized instrument to grind off a bone spur. This is
a procedure that requires experience and skill because three major
nerves are situated very close to the elbow joint. In some cases,
the surgeon needs to remove a bone spur that’s just a millimeter or
two away from one of those nerves. Experienced surgeons, however,
regularly use techniques that enhance the safety of this procedure,
which lowers the risk of nerve injury.

After surgery, a key to moving toward a quick recovery is
reducing the amount of inflammation that may occur in the joint. In
the past, surgeons expected swelling and pain after surgery and
assumed it was part of the healing process. Now, however, we’ve
learned we can greatly reduce or eliminate that inflammation by
simply squeezing extra fluid out of the elbow repeatedly during the
first three days after surgery.

This is done using a device called continuous passive motion, or
CPM machine. The patient rests his or her arm in a CPM. It moves
the arm though a range of motion continuously day and night except
for brief periods out of the machine. The result is that the fluid
is expelled from the joint, much like wringing out a washcloth. To
prevent the CPM process from being painful, patients are given a
nerve block while they use the CPM for the first three days in the
hospital.

After about three days, the pain is usually minimal and the CPM
is used by the patient at home. By this time, many people don’t
need any pain medication and can move their elbow freely, often
with almost a full range of motion. The remaining range of motion
typically recovers as people use their elbow normally. In general,
physical therapy is not required.

If you are interested in going forward with surgery to remove
the bone spur, ask your doctor to recommend a surgeon who is
skilled in elbow surgery and who works in an organization that uses
CPM technology after surgery. Those factors will help ensure that
the surgery will be effective and successfully relieve your
symptoms.
— Shawn O’Driscoll, M.D., Ph.D., Orthopedic Surgery and
Sports Medicine Center, Mayo Clinic, Rochester.

Medical Edge from Mayo Clinic is an educational resource
and doesn’t replace regular medical care. Email a question to
[email protected]. For more information, visit
www.mayoclinic.org.

Arthritis of the Elbow | Cedars-Sinai

Not what you’re looking for?

About arthritis of the elbow

For many people, arthritis of the elbow can cause pain not only when they bend their elbow, but also when they straighten it, such as to carry a briefcase. The most common cause of arthritis of the elbow is rheumatoid arthritis. Osteoarthritis and injuries can also cause arthritis in the elbow joint.

What causes arthritis of the elbow?

Rheumatoid arthritis is a disease of the joint linings, or synovia. As the joint lining swells, the joint space narrows. The disease gradually destroys the bones and soft tissues. Usually, RA affects both elbows, as well other joints such as the hand, wrist and shoulder.

Osteoarthritis affects the cushioning cartilage on the ends of the bones that enables them to move smoothly in the joint. As the cartilage is destroyed, the bones begin to rub against each other. Loose fragments within the joint may accelerate degeneration.

Trauma or injury to the elbow can also damage the cartilage of the joint. This can lead to the development of arthritis in the injured joint.

What are the symptoms of arthritis of the elbow?

Symptoms of elbow arthritis can include:

• Pain. In the early stages of rheumatoid arthritis, pain may be primarily on the outer side of the joint. Pain generally gets worse as you turn (rotate) your forearm. The pain of osteoarthritis may get worse as you extend your arm. Pain that continues during the night or when you are at rest indicates a more advanced stage of osteoarthritis.
• Swelling. This is more common with rheumatoid arthritis.
• Instability. The joint isn’t stable and gives way, making it difficult or impossible to do normal daily activities.
• Lack of full movement. You are not able to straighten or bend the elbow.
• Locking. Your elbow joint catches or locks. This can happen with osteoarthritis.
• Stiffness. This happens particularly with arthritis that develops after an injury.
• Pain in both elbows. Having pain in both elbows or pain at the wrists or shoulders (or both) as well as pain in the elbows is a symptom of rheumatoid arthritis.

How is arthritis of the elbow diagnosed?

During a physical examination, your doctor will first look for tenderness and swelling. They will also look at the range of motion you have as well as identifying what positions cause pain to your elbow. X-rays often show the joint narrowing as well as any loose bodies (for example, bony pieces). If your pain is due to arthritis following an injury, the X-ray may show an improper joining or a failure to join of the elbow bones.

How is arthritis of the elbow treated?

Nonsurgical Treatment

The first treatments used for elbow arthritis include:

• Cut back on activity. Osteoarthritis may be caused by the repetitive overuse of the joint. Avoiding certain activities or sports may be helpful. Having periods of rest after exercise or activity involving your elbow can relieve stress on the joint.
• Pain management. Acetaminophen or ibuprofen can provide short-term pain relief. More powerful drugs may be prescribed to treat rheumatoid arthritis. These include anti-malarial agents, gold salts, drugs that suppress your immune system and corticosteroids. An injection of a corticosteroid into the joint can often help.
• Physical therapy. Applying heat or cold to the elbow and gentle exercises may be prescribed. A splint to protect the elbow from the stress of moving may be helpful. Devices that reduce stress on your joints such as handle extensions, to maintain daily activities.

Surgical Treatment

If arthritis does not respond to other treatments, surgery may be discussed. The specific type of surgery may depend on the type of arthritis, the stage of the disease, your age, your expectations and your activity requirements. Surgical options include:

• Arthroscopy. Using pencil-sized instruments and two or three small incisions, the surgeon can remove bone spurs, loose fragments or a portion of the diseased synovium. This procedure can be used with both rheumatoid arthritis and osteoarthritis.
• Synovectomy. The surgeon removes the diseased synovium, the tissue that lines and lubricates the joints. Sometimes, a portion of bone is also removed to provide a greater range of motion. This procedure is often used in the early stages of rheumatoid arthritis.
• Osteotomy. The surgeon removes part of the bone to relieve pressure on the joint. This procedure is often used to treat osteoarthritis.
• Arthroplasty. The surgeon creates an artificial joint using either an internal prosthesis or an external fixation device. A total joint replacement is usually reserved for patients over 60 years old or patients with RA in advanced stages.

Key points

• Arthritis of the elbow can cause pain when the joint is bent or straightened.
• Rheumatoid arthritis, osteoarthritis and injuries can cause this disorder.
• Symptoms of elbow arthritis can include pain, swelling, instability and lack of full movement.
• First treatments of the disorder include cutting back on activity, managing the pain with over-the-counter medication or more powerful drugs, and physical therapy.
• If those don’t work, surgery may be discussed.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.

© 2000-2021 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional’s instructions.

Not what you’re looking for?

Bone Spurs – Podiatry, Orthopedics, & Physical Therapy

BONE SPURS ON THE TOES
By:  Robert H. Sheinberg, D.P.M., D.A.B.F.A.S., F.A.C.F.A.S.

A prominence of bone on the top or the inside of the toe may cause pain and an inability to wear shoes comfortably.

They are usually caused by an abnormal bone structure causing sharp or prominent bones.  Fractures, injury or dislocation to the toe in the past may also cause bone spurs to develop.  Hammertoes, curly toes or toes that are abnormally shaped that get pressure from closed shoes can also become painful.  Tight shoes, especially heels and those that are narrow in the forefoot will aggravate the condition.

Hard skin is usually seen on the top or the inside of the toe.  A callus on the outside of the fifth toenail may be mistaken for an ingrown toenail.  Redness or swelling around the toes is also seen and a prominent bone spur can be felt.  In patients with poor sensation (diabetics), an ulceration of the skin over the spur may be seen.

Wider shoe to lessen toe pressure is the primary treatment.  Removal of hard skin to lessen the pain can also provide a lot of relief.  Temporary padding of the toes may take stress off of the bone spur.  Toe spacers made out of foam may also be used to prevent the bones from rubbing against each other.  A Cortisone injection may also be needed to help to decrease inflammation and allow the foot to fit comfortably in a shoe.

When unresponsive to conservative care, surgery to remove the spur or to correct the toe deformity may be necessary.  This will not only help the foot become comfortable in a shoe but it will permanently correct the problem. 

PROBLEM:

• Prominence of bone on the top or inside of the toes causing pain and an inability to wear shoes comfortably.

CAUSE:

• Abnormal bone structure causing sharp or prominent bones.
• Friction of two bones against each other.
• Fracture, injury or dislocation to the toe causing a bone spur to develop.
• Hammertoes, curly toes or toes that are abnormally shaped.
• Tight shoes, especially heels and those that are narrow in the forefoot.

SIGNS SYMPTOMS:

• Callus on the top or inside of the toe causing pain in closed shoes.
• Callus along the outer edge of the fifth toenail, mistakenly diagnosed for an ingrown nail.
• Redness and/or swelling around the toes.
• Prominent spur can be felt.
• Bursitis on the spur increasing pain.
• Possible ulceration of the skin over the spur caused from excessive pressure.

TREATMENT:

• Wider shoe to lessen toe pressure in the shoe.
• Removal of the hard skin to lessen the pain and pressure.
• Temporarily padding the toe to take all stress off of the bone spur.
• Applying a toe spacer (lamb’s wool or foam) to prevent the bones from rubbing against each other.
• Cortisone injection to decrease inflammation.
• Surgery to remove the spur and permanently correct the problem is the treatment of choice if the condiion has been unresponsive to conservative care.

Intraop Pics of Large Bone Spur at IPJ of the Big Toe before and after removal

Bone Spur | Southern Bone & Joint Specialists

Overview

A bone spur, or osteophyte, is a projection of bone that develops and
grows along the edge of joints. Bone spurs are fairly common in people
over the age of 60. It is not the bone spur itself that is the real
problem; pain and inflammation begin to occur when the bone spur
rubs against nerves and bones.

Causes

As
we age, the discs in our spine naturally degenerate and lose some
of their natural shock-absorbing ability. Factors that contribute
to and accelerate this process include stress, injury, poor posture,
poor nutrition, and family history.

It
is not uncommon for people with osteoarthritis to get bone spurs.
Osteoarthritis is a degenerative condition in which joint cartilage
begins to wear down, causing bone to rub against bone. As a result,
the body may begin to produce new bone to protect against this,
which is how a bone spur forms.

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Symptoms

• Back
  and neck pain
• Pain
  radiating through an arm and/or leg
• Prominent
  lumps on the hands, feet or spine
• Numbness
• Burning
• Muscle
  cramps

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Diagnosis

Outlined
below are some of the diagnostic tools that your physician may use
to gain insight into your condition and determine the best treatment
plan for your condition.

• Medical
  history: Conducting a detailed medical history helps the doctor
  better understand the possible causes of your back and neck
  pain which can help outline the most appropriate treatment.
• Physical
  exam: During the physical exam, your physician will try to
  pinpoint the source of pain. Simple tests for flexibility and
  muscle strength may also be conducted.
• X-rays
  are usually the first step in diagnostic testing methods. X-rays
  show bones and the space between bones. They are of limited
  value, however, since they do not show muscles and ligaments.
• MRI
  (magnetic resonance imaging) uses a magnetic field and radio
  waves to generate highly detailed pictures of the inside of
  your body. Since X-rays only show bones, MRIs are needed to
  visualize soft tissues like discs in the spine. This type of
  imaging is very safe and usually pain-free.
• CT
  scan/myelogram: A CT scan is similar to an MRI in that it provides
  diagnostic information about the internal structures of the
  spine. A myelogram is used to diagnose a bulging disc, tumor,
  or changes in the bones surrounding the spinal cord or nerves.
  A local anesthetic is injected into the low back to numb the
  area. A lumbar puncture (spinal tap) is then performed. A dye
  is injected into the spinal canal to reveal where problems
  lie.
• Electrodiagnostics:
  Electrical testing of the nerves and spinal cord may be performed
  as part of a diagnostic workup. These tests, called electromyography
  (EMG) or somato sensory evoked potentials (SSEP), assist your
  doctor in understanding how your nerves or spinal cord are
  affected by your condition.
• Bone
  scan: Bone imaging is used to detect infection, malignancy,
  fractures and arthritis in any part of the skeleton. Bone scans
  are also used for finding lesions for biopsy or excision.
• Discography
  is used to determine the internal structure of a disc. It is
  performed by using a local anesthetic and injecting a dye into
  the disc under X-ray guidance. An X-ray and CT scan are performed
  to view the disc composition to determine if its structure
  is normal or abnormal. In addition to the disc appearance,
  your doctor will note any pain associated with this injection.
  The benefit of a discogram is that it enables the physician
  to confirm the disc level that is causing your pain. This ensures
  that surgery will be more successful and reduces the risk of
  operating on the wrong disc.
• Injections:
  Pain-relieving injections can relieve back pain and give the
  physician important information about your problem, as well
  as provide a bridge therapy.

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Treatment

The
goal when treating bone spurs is to minimize pain and prevent any
additional joint damage. Treatment methods may include weight loss,
stretching and physical therapy, rest and ice. Injections can reduce
inflammation long enough to relieve symptoms. Medications such as
ibuprofen or injections may be administered for pain. Bone spurs
can be surgically removed in the case of serious damage and deformity.

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FAQs

How
can osteoporosis impact the spine and cause a bone spur?

Osteoporosis
can have extremely serious consequences on the spine. It is a degenerative
condition in which joint cartilage can begin to wear down, causing
bone to rub against bone. As a result, the body may begin to produce
new bone to protect against this, which is how a bone spur forms.

How
can I tell if I have a bone spur?

Bone
spurs can generally be detected through X-ray, which can provide
a visual of any bony deposits.

Do
I need surgery to treat a bone spur?

Because
bone spurs are usually evidence of an underlying problem, this main
problem should be addressed first. This can include treatment methods
for degenerative disc disease, arthritis and osteoporosis. These
conditions can often be successfully treated with nonsurgical methods.

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Total Shoulder Replacement | Johns Hopkins Shoulder and Elbow Surgery

Total shoulder replacement is a complex procedure that involves replacing the shoulder joint with artificial parts. Our shoulder specialists have performed numerous shoulder replacements at Johns Hopkins and appreciate an opportunity to share their knowledge. They have provided answers to some of the most frequently asked questions about the total shoulder replacement procedure. Call us to request an appointment with one of our shoulder surgeons if you have further questions about shoulder replacement.

When is a shoulder replacement recommended?

The shoulder joint can be replaced by an artificial shoulder or shoulder replacement for pain caused by arthritis or when the shoulder is severely fractured or broken. Arthritis is when the cartilage on the ends of the bones is gone and there is bone rubbing on bone in the joint. Arthritis can be caused by fractures, rheumatoid disease, torn rotator cuff tendons or just by wear and tear over time (Figure 1).

What part of the shoulder is replaced?

The shoulder is a ball and socket joint (Figure 2). The ball is the upper part of the arm bone (humerus) and is called the humeral head. The socket is smaller and is part of the shoulder blade (scaptila). The ball is held in the socket by ligaments and by the rotator cuff tendons. The rotator cuff muscles start on the shoulder blade and turn into tendons which attach to the ball. In shoulder replacement surgery the ball is replaced with a metal ball attached to a stem (Figure 3).

The stem is inserted down the shaft of the humerus. Sometimes cement is utilized to keep the stem in place (Figure 4). The socket sometimes is replaced with a plastic piece which is usually fixed to a groove in the socket with cement. Whether a socket is used or not depends upon how bad the arthritis is in the shoulder and whether the rotator cuff tendons are intact.

How long does total shoulder replacement surgery take?

The surgery takes about three hours including time for anesthesia to be done. Anesthesia is usually a general anesthetic although local anesthetic can be used to numb the whole arm. This is done by blocking the nerves as they come out of the neck (scalene block). Most patients must have medical clearance for surgery by their family doctor prior to surgery. All patients must give a unit of blood a few weeks before surgery which may be given back to them if needed after surgery.

What is the recovery like after total shoulder replacement surgery?

Most patients are given a morphine pump after surgery so they can control their own pain medicine. After a day or so most patients switch over to pain medicine by mouth. The arm will be in a brace but it can be taken off to do therapy. Antibiotics are given by vein for a day to prevent infection. Physical therapy begins the day after surgery and begins with moving the fingers, wrist and elbow. Some motion of the shoulder is begun within a day or so after surgery. The physical therapist will show the patient a program of exercises to do at home. Most patients stay in the hospital from three to five days.

What happens when I go home after having total shoulder replacement surgery?

The exercises are to be done at least daily to prevent stiffness. Cold therapy with cryocuffs or ice bags should be used to keep down pain. The incision can get wet in the shower but no baths are recommended for 3 weeks. The stitches are removed one week after surgery. Physical therapy at a physical therapy facility is begun seven to ten days after surgery and continues for several weeks. The doctor will see you in the office every few weeks for several months. Most patients cannot drive for four to six weeks.

What are the results of total shoulder replacement surgery?

Shoulder replacement surgery is very successful for pain relief. Most patients are very satisfied with the degree of pain relief. However, these shoulder replacements are not perfect and may ache a little when the weather changes or if you are too active.

Range of motion and function can be improved by this surgery but the amount of change is less predictable than pain relief. How much motion increases depends upon many factors, such as how long the motion has been lost and whether the rotator cuff tendons are intact and working.

Most patients are very satisfied with the results of their surgery.

What are the possible complications of total shoulder replacement surgery?

Fortunately the complications rate after surgery is small (less than five percent). Infection is a concern but happens rarely since antibiotics are given to prevent it. Nerve or artery damage is very rare. Since the shoulder is a ball and socket, the ball can shift out of the socket (dislocate). Again, this is very uncommon. Lastly the components of the replacement can get loose from the bone over time, especially if the arm is used excessively. After ten years approximately 3 percent of the shoulders are loose, but revision surgery is rarely needed.

Bone tumours around the elbow: a rare entity

Abstract

• Bone tumours around the elbow are rare. Even nowadays diagnostic dilemmas and delays are common. During recent decades the management and prognosis of patients with elbow bone tumours has improved significantly.

• Benign tumours can be treated using minimally invasive procedures, whereas malignant ones require a multidisciplinary team approach based on an adjuvant therapeutic regimen of chemotherapy, radiotherapy and limb salvage procedures.

• This article reviews the most commonly encountered elbow bone tumours and their management.

Cite this article: EFORT Open Rev 2019;4:133-142. DOI: 10.1302/2058-5241.4.180086

Keywords: benign, bone tumour, elbow, malignant

Introduction

Bone tumours around the elbow are rare and their incidence is approximately 1%.¹ The literature regarding primary bone tumours of the elbow is sparse, with only two case series consisting of 75 patients and 25 patients respectively.^2,3 During recent decades advances in the diagnosis, management and prognosis of patients with bone tumours around the elbow have been made. Early diagnosis and preoperative planning is essential and can dramatically change the treatment and prognosis of these patients.

Elbow tumours pose a diagnostic challenge for orthopaedic surgeons. Physical examination and a thorough history are the cornerstones of diagnosis. Patients usually present with persistent, unexplained, non-mechanical rest pain, soft tissue swelling, change in size of the mass, fever, night sweats and chills, which would warrant a higher level of suspicion for malignancy.⁴ Diagnostic imaging is an important component of the workup of a patient with a musculoskeletal tumour and should proceed in an organized fashion.

Patients with presence of bone lysis, cortical erosion, new bone formation, mineralization or periosteal reaction in plain radiographs of the elbow should have additional workup.⁵ Magnetic resonance imaging (MRI) is crucial in providing information regarding the location, size, tissue characteristics of the lesion and involvement of peripheral neurovascular structures. Other diagnostic modalities such as computerized tomography (CT) and bone scans are only performed in cases of lesions with particularly aggressive features. For bone lesions with such worrisome and aggressive imaging features, a histologic specimen should be obtained for diagnosis. A biopsy with a fine needle aspiration (FNA) or core needle biopsy, may be performed under CT or ultrasound guidance to confirm the diagnosis. However, these techniques may not yield sufficient tissue, thus an open biopsy with immunohistochemical stains and/or molecular studies may be required. An inappropriate or inaccurate biopsy may lead to poor outcome regarding limb salvage and even survivorship of the patient.⁶ Even nowadays delay in diagnosis is common, usually because of the rarity of these lesions, the atypical clinical presentation and the low index of suspicion, with misdiagnosis incidence up to 13%.² Although these entities are rare, the treating physician must be aware of the possibility of a bone tumour in the elbow area. An algorithm for appropriate assessment of patients with a bone lesion is presented ().⁷

Algorithm for patients presenting with a bony lesion around the elbow.

A multidisciplinary team approach should include an orthopaedic oncologist, an interventional radiologist, a pathologist, an oncologist, a vascular surgeon, and a plastic surgeon. Nowadays, benign tumours around the elbow such as juxta-articular osteoid osteoma (ΟΟ) can be treated with minimally invasive techniques such as CT-guided percutaneous radiofrequency thermal ablation (RFA) or arthroscopic excision.⁸ Moreover, the management and prognosis of patients with malignant tumours, such as Ewing sarcoma and osteosarcoma, have improved thanks to the adjuvant chemotherapeutic protocols and improved radiation therapy techniques combined with ‘en bloc’ resection of the tumour and various limb salvage procedures and reconstructions with total elbow arthroplasties, megaprostheses, allografts, vascularized autografts, or allograft-prosthetic composite reconstructions.⁹ However, reconstruction of the elbow poses a unique challenge with limited options described in the literature. The elbow joint is a complex interplay between multiple joints which need to be stabilized for the optimal wrist and hand functional outcome and sometimes it is challenging to achieve ‘safe’ oncological margins.

Benign lesions are more common than malignant ones. They usually affect the proximal ulna and radius.² The commonest benign tumours around the elbow joint are the osteoid osteoma, the giant cell tumour, the aneurysmal bone cyst and the fibrous dysplasia. Ewing sarcoma, osteosarcoma and chondrosarcoma of the elbow are the most common malignant tumours, and occur more frequently in older patients with the distal humerus more often affected.³ In a recent case series, these rare tumours continue to have significant morbidity and mortality, with recurrences which resulted in further surgery in over a quarter of the patients with a benign lesion, while the five-year mortality for the high grade malignancies was 68%.² This article summarizes the current diagnosis and treatment of these tumours around the elbow and discusses some of the features that are unique to this anatomic area.

Benign bone tumours

Osteoid osteoma

Osteoid osteoma is not so sporadic in the elbow; however, its intra-articular location is rare.^10–12 The typical age of presentation is between 7 and 30 years, but it may also be diagnosed in middle-aged and elderly patients. Symptoms at the elbow can last from weeks to years prior to diagnosis and meanwhile patients may usually be treated for other conditions. The average delay of diagnosis may be up to 2 years.¹³ Patients present with the characteristic clinical feature of pain mainly at night that usually subsides after administration of non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin, along with swelling and tenderness. Some patients, though, may also present with non-specific clinical symptoms of joint effusion and synovitis and some degree of flexion contracture, instead of the characteristic nocturnal pain responsive to salicylates.^14,15 In radiographic examination, osteoid osteoma presents as an intracortical radiolucent nidus surrounded by a rim of dense reactive bone. Thin-section (0.5 to 2.0 mm) CT with multiplanar reconstructions is the diagnostic gold standard to confirm the benign nature of the reactive bone and to identify the nidus of the lesion.¹⁶ Osteoid osteoma is usually smaller than 1.5–2.0 cm.^10–12 Bone scintigraphy may show intense isotope uptake in these lesions. The role of MRI in the evaluation of osteoid osteoma is controversial. A constant finding on MRI scan is a marked bone marrow oedema corresponding to the highly vascularized mesenchymal tissue which is reported to be observed in all patients.^16–18

Whereas some cases are self-limiting, surgical treatment options include intralesional curettage or radiofrequency ablation. The ‘en bloc’ resection and curettage of the lesion is the recommended treatment for juxta- or intra-articular osteoid osteoma of the elbow.^15,19 Nowadays, complete excision of juxta-articular osteoid osteoma of the elbow may also be performed arthroscopically.²⁰ Recently, Kamrani et al treated osteoid osteoma of the elbow through arthroscopic ablation in 10 patients.²¹ Arthroscopic excision of the lesion was performed at a mean of 23 months (range, 12–36 months) after initial symptoms. Postoperative elbow flexion–extension range of motion (ROM) (129° ± 5°) was statistically significantly higher than the preoperative (80° ± 12°). Moreover, the Mayo Elbow Performance Score and the visual analogue scale for the elbow and wrist were significantly higher compared with these before surgery (P < .001). The authors stated that arthroscopic ablation is a safe and efficient method of treatment for osteoid osteoma of the elbow, without the need for capsulectomy or intraoperative manipulation to treat the limitation of elbow ROM, and it has a relatively shorter rehabilitation time.²¹ Currently, percutaneous ablation under CT guidance, for lesion localization, with radiofrequency thermal ablation (RFA) is the most effective treatment option with a success rate of 87% to 100%.²² Radiofrequency thermal ablation has gained popularity as a cost-effective, minimally invasive method with lower morbidity and fewer complications compared to an open technique.²³ However, this technique presents a high risk for bone necrosis and soft tissue damage, especially in tumours localized at the anterior aspect of the elbow joint and near (within approximately 1.5 cm) neurovascular structures.^15,22,24 Moreover, local destruction without preserving the pathologic tissue for histological examination limits its indication in patients with unusual clinical presentation.²⁵ Albisinni et al treated 27 patients (13 cases located in the humerus, 13 in the ulna and one in the radius) with intracapsular osteoid osteoma of the elbow by CT-guided percutaneous RFA.²⁶ All patients were assessed in terms of function, successful eradication and complication rate. Twenty-five out of 27 patients (92.5%) presented with excellent functional results as their Mayo Elbow Performance Scores ranged from 90 to 100 points at final follow-up. Osteoid osteoma recurred in only one patient (3.7%) five months after the initial procedure and was successfully retreated using RFA. No major complications were observed and all patients were disease free at the final follow-up. However, the authors stated that this invasive treatment requires meticulous planning and technique application to minimize potential risks for the patient.²⁶

Giant cell tumour

Another benign tumour but with aggressive behaviour encountered in the region of the elbow is the giant cell tumour (GCT). This tumour occurs mainly after skeletal maturity and has its peak incidence in the third and fourth decades of life.²⁷ Most giant cell tumours are located within the epiphyses of long bones, they often extend to the articular subchondral bone or the cartilage, but they rarely invade the adjacent joint or its capsule. In skeletally immature patients they are often located into the metaphysis.²⁸

Pain in the elbow is the most common symptom, while swelling and deformity are associated with large lesions. Histologically GCT is characterized by the presence of multinucleated giant cells (osteoclast-like cells), neoplastic stromal cells which are the predominant proliferating cell population and secondarily recruited mononuclear histiocytic cells.²⁹ Giant cell tumours were initially classified by Enneking and later by Campanacci, based on radiographic appearance.^30,31 Three stages were described – Stage I (latent), Stage II (active), Stage III (aggressive) – which correlate with tumour aggressiveness and risk of local recurrence. Radiographically, they usually appear as an eccentric epiphyseal or metaphyseal lytic lesion with cortical thinning and a ‘soap bubble’ appearance.³²

Surgery with complete ablation to prevent recurrence and preserve the joint articulation remains the mainstay of treatment.³³ Local recurrence has been found to be a risk factor for pulmonary metastasis, which occurs in approximately 2% to 9% of patients.³⁴ The key in order to ensure an adequate curettage and complete excision of the tumour is to obtain sufficient exposure of the lesion with a large cortical ‘window’.³⁵ Curettage of the bone cavity with high-speed burr or drill and the use of adjuvant cryosurgery (liquid nitrogen or a closed system of argon and helium) is recommended. The void is filled with bone graft or polymethyl-methacrylate (PMMA) bone cement. The use of internal fixation devices is controversial. Although early mobilization is facilitated with internal fixation, postoperative follow-up for tumour recurrence is more difficult.^36–38 Giant cell tumour recurrence rates vary significantly between different centres, different methods (wide resection, curettage +/- burr +/- phenol, +/- PMMA) and the local presentation of the tumour, ranging from 0% to 65%, therefore close follow-up with serial imaging is mandatory with these benign aggressive tumours.^39–41 In patients with highly aggressive lesions or local recurrence, where the tumour may invade through the cortex of the distal humerus to the surrounding soft tissue structures, curettage is unlikely to be effective and thus preserving the joint congruity of the elbow may not be possible. Nowadays, where it is not possible for the joint to be preserved, wide resection and total elbow arthroplasty using a custom-made prosthesis with good soft tissue coverage is a viable option, as it provides good pain relief and functional improvement with lower complication rates.^42–44 In addition to skeletal reconstruction, of equal importance is to achieve good soft tissue coverage for both the implant and the elbow, as well as to preserve elbow function. Following tumour excision, hemi-articular and total elbow allografts have been used for reconstruction of these defects, but high complication rates were reported and thus these techniques are reserved as salvage procedures following failed total elbow arthroplasty.⁴⁵

In light of current molecular biological understanding regarding the implication of the RANKL molecular pathway in the pathogenesis of GCT of bone, systemic targeted therapy has been advocated. In cases of locally advanced, unresectable, recurrent and/or metastatic CGT, the use of denosumab as a RANKL inhibitor has been introduced in order to facilitate surgery at a later stage, by making the tumour resectable or even appropriate for curettage.⁴⁶ Many recent studies have shown significant clinical benefits regarding the use of denosumab in the treatment of GCT, leading to a surgical down-staging and demonstrating an objective response range from 86% to 100% of cases.^47–50

Aneurysmal bone cyst

Another benign lesion of the elbow causing pain and swelling is the aneurysmal bone cyst (ABC). This tumour occurs mainly in patients under 20 years of age and may present either as a primary bone lesion (70% of cases), when no precursor bone lesion is identified or as a secondary bone lesion (30% of cases) when a pre-existing osseous lesion can be identified.⁵¹ In the Mayo Clinic’s experience, only eight examples of aneurysmal bone cysts were found in the elbow region.³⁷ It is an osteolytic bone neoplasm characterized by several sponge-like blood or serum-filled, generally non-endothelialized spaces of various diameters.³⁷ Regarding its aetiology, theories range from a post-traumatic reactive vascular malformation to a genetic predisposed bone tumour.^52,53 The formation of an arteriovenous fistula within bone, caused by increased venous pressure and resultant dilation and rupture of the local vascular network has been the most common theory over the long term.^54,55 However, studies have also demonstrated the clonal neoplastic nature of the cyst.⁵⁶

Patients usually present with pain, swelling, enlarging mass and even a pathologic fracture in the elbow area. The symptoms are usually presented for several weeks to months before the diagnosis. Neurologic symptoms may also develop secondary to pressure or tenting of the nerve structures in the elbow area. Radiographically, ABC usually presents as a metaphyseal eccentric lesion, that may elevate the periosteum and progressively cause erosion of the cortex. These tumours may be confused with malignancy, as imaging studies, even CT scan and MRI, do not always provide clear diagnostic criteria for the diagnosis. Nevertheless, the zone of rarefaction is usually well circumscribed, eccentric, and is associated with an obvious soft tissue extension (–).⁵⁷ Differential diagnosis of ABC includes unicameral bone cyst, eosinophilic granuloma and giant cell tumour.⁵⁸

(a) Anteroposterior and (b) lateral radiographs of the elbow showing an aneurysmal bone cyst of the distal humerus in 17-year-old female. (c) Τ1 and (d) T2 magnetic resonance images of the elbow. (e) Intraoperative images showing the gross destruction of the distal humerus. (f) The lesion was treated with curettage and bone grafting. (g) Anteroposterior and (h) lateral radiographs of the elbow 11 years postoperative showing a good incorporation of the graft and no sign of recurrence.

Curettage of the cyst remains the gold standard for treatment and it is usually curative. Local recurrence rates after curettage and polymethyl-methacrylate (PMMA) bone cement and curettage and bone grafting are reported at 17% and 37% respectively.⁵⁴ Although wide resection of the lesion can lessen recurrence rates, these treatments require complicated reconstructive procedures and are not generally indicated in long bones.^51,55 A plethora of new therapies has been proposed for the treatment of ABC which still remains controversial. New methods include embolization with sclerotherapy regiments based on an alcoholic solution of zein and intralesional implantation of demineralized bone particles with promising results; however, because of the serious side effects, they are mainly used in cases where the extent of the cyst makes the operative intervention hazardous.^59,60 Modern sclerotherapy treatment utilizes polidocanol, which is regarded as a safe regiment with no serious side effects. Rastogi et al reported a healing rate of 97% in a case series of 72 patients treated with percutaneous intralesional injections of polidocanol, whereas Varshney et al reported that while sclerotherapy was equally effective to intralesional excision, it was accompanied by less morbidity.^61,62 Therefore, due to the promising results, sclerotherapy is advocated in many centres as the treatment of choice. Reddy et al described the curopsy, a percutaneous limited curettage during biopsy, as another minimally invasive technique. The authors removed the lining membrane from various areas of the lesion and reported a healing rate of 81%. Although having an inferior success rate compared to curettage, the technique has a considerably faster recovery time, is safe, efficient and has good functional outcomes.⁶³

Fibrous dysplasia

Fibrous dysplasia (FD) is a rare disease which typically occurs in spine, ribs, scull and diaphysis of long bones and accounts approximately for 5% to 7% of all benign bone tumours. However, in a large series of 75 patients FD was the most common (20% of cases) benign tumour encountered in the elbow.² It commonly presents in adolescents and young adults, and may be either monostotic (70% to 80% of cases) or polyostotic.^64,65 Most monostotic lesions are asymptomatic and are discovered when plain radiographs of the involved region are made for other reasons or because a pathological fracture has developed.⁶⁶ At first presentation about 67% of patients may have pain at the site of the lesion and up to 20% of patients may have a pathological fracture at presentation.⁶⁷ It may occasionally affect the structural integrity of the affected area and thus result in a bowing deformity.⁶⁵ Histologically, FD is considered to be the result of excessive proliferation of fibrous tissue within the bone marrow, due to poorly differentiated mutated osteoblasts. The osteoblasts then produce a high amount of interleukin 6, resulting in significant osteoclastic activity, which consequently leads to the formation of lytic lesions within the fibrous tissue and surrounding normal bone.⁶⁸ In radiographic examination FD usually has a characteristic radiolucent ‘ground-glass’ appearance with well-defined thick sclerotic borders. At times, calcified cartilaginous foci may also be evident within the lesion.⁶⁵

When the diagnosis is confirmed by a biopsy, most lesions around the elbow can be treated non-operatively with immobilization in a cast. Non-steroidal anti-inflammatory drugs, opioids and bisphosphonates have been used to treat patients reporting bone pain, with the most favourable outcomes detected in individuals treated with bisphosphonates, mainly pamidronate.^69,70 Although most lesions respond well to non-operative treatment, there are a few indications for surgery, including non-union after a pathologic fracture, persistent pain and severely progressive deformity. Intralesional curettage and bone allograft or vascularized bone graft, with or without internal fixation, have been used, whereas in cases with severe bone deformity corrective osteotomies and rigid internal fixation have satisfactory results and no major complications.^67,71,72 Fibrous dysplasia has a good prognosis; however, malignant transformation can occur in up to 4% of patients.⁷³

Malignant bone tumours

Ewing sarcoma

Management of Ewing sarcoma has improved remarkably within recent decades. Many theories have evolved regarding how Ewing sarcomas arise. While the origin of these tumours is still not definitively known, most cases of Ewing sarcoma (85%) are the result of a translocation between chromosomes 11 and 22, which fuses the EWS gene on chromosome 22 to the FLI1 gene on chromosome 11. Other translocations are at t(21;22) and t(7;22).⁷⁴ Because a large percentage of Ewing sarcomas and primitive neuroectodermal tumours (PNET) have identical translocation, these two tumours have been grouped into a class of cancers entitled Ewing Sarcoma Family of Tumours (ESFT).⁴³ Nowadays, immunohistochemical stains and molecular genetic testing are required for a definitive diagnosis.⁷⁵ Patients usually experience extreme bone pain, intermittent fevers, anaemia, and other symptoms of inflammatory systemic illness. Ewing sarcoma may arise in any bone, including those in the region of the elbow. It is more frequent in children than adults. Radiographically Ewing sarcoma is a highly destructive moth-eaten radiolucent lesion without evidence of bone formation associated with periosteal elevation.⁷⁴

The prognosis of patients with Ewing sarcoma has improved dramatically. Although 20% to 25% of patients with Ewing sarcoma are metastatic at presentation, overall survival in patients with lesions of the extremities now ranges between 40% and 75%.³⁴

Osteosarcoma

Osteosarcoma is another malignant tumour occurring in the elbow joint, although it is not so frequent as in the distal femur, proximal tibia and proximal humerus.⁷⁸ The prognosis for patients with non-metastatic osteosarcoma nowadays is significantly improved and 70% to 90% of these patients may be long-term survivors.^44,79 Symptoms around the elbow joint may be present for weeks, months, or longer before osteosarcoma is diagnosed. The most common presenting symptom is pain, which is exaggerated with activity, and swelling. Patients may complain of a sprain or ‘growing’ pain. The patient often has a history of trauma. Systemic symptoms, such as fever and night sweats, are rare.¹ Radiographically, osteosarcomas usually appear to be aggressive, with evidence of cortical erosion and reactive periosteal new bone formation. In the distal humerus, the classic ‘sunburst’ appearance may be evident.⁸⁰ Nevertheless, the precise extent of the lesion may not be apparent on plain radiographs. Histologically, the majority of osteosarcomas are high-grade tumours. Approximately 8–15% of patients originally diagnosed with osteosarcoma have metastatic disease.⁸¹

Chondrosarcoma

Chondrosarcoma is the third most common primary malignant tumour of bone, though is remarkably rare in the elbow.² It is a malignant bone tumour that develops from cartilaginous tissue but can also arise de novo in extra-skeletal tissue. There are a few case reports of chondrosarcoma arising from synovial chondromatosis of the elbow.⁸² Late diagnosis because of slow progression of the tumour and inadequate first treatment occurred frequently.^82,83 Chondrosarcoma of the elbow has a poor prognosis and lung metastases occurred frequently at the time of diagnosis.⁸³

Treatment of malignant bone tumours

Treatment of malignant bone tumours in the region of the elbow is more challenging than in other anatomic areas because of limited soft tissue envelope and neurovascular structures in close proximity to the tumour. For these anatomic considerations, in the past amputation was the treatment of choice. Nowadays, the majority of patients with Ewing sarcoma and osteosarcoma of the elbow can be treated with adjuvant chemotherapy, wide excision of the tumour and limb salvage procedures.³⁴ The choice between amputation and limb-sparing resection must be made by an orthopaedic oncologist taking into account tumour location, size, extramedullary extension, distant metastatic disease and patient factors. Reconstructive options are limited and technically challenging and include endoprosthetic replacements, resection arthroplasty, interposition arthroplasty, arthrodesis, elbow osteoarticular allograft reconstruction, or allograft-prosthesis composite arthroplasty and vascularized fibular grafts.^43,76,84 There is limited literature supporting the ability to achieve en bloc extra-articular excision of the tumour in the elbow area, with most case series describing trans-articular hemi-resection through the elbow joint.^43,85–88

A total elbow arthroplasty in patients with large defects may result in instability with high rates of complications such as implant loosening and failure and postoperative infection. Endoprosthetic replacement using a constrained hinged megaprosthesis (–) cannot allow good function compared to that after a total elbow arthroplasty (TEA), in which the soft tissue ‘envelope’ is largely preserved.⁸⁶ Infection is one of the major concerns in this group of immunocompromised patients. There is emerging evidence in the literature to support the finding that silver-coated megaprostheses can reduce postoperative infection, as silver has antimicrobial properties.⁸⁹ Complex soft tissue reconstruction techniques such as pedicled myocutaneous latissimus dorsi rotation flap and reconstruction of the triceps may be necessary in these cases.⁷⁷ In skeletally immature adolescent patients with Ewing sarcoma, an expandable elbow endoprosthesis may be used. Ayoub et al treated eight patients with Ewing sarcoma of the humerus with limb salvage with extensible endoprosthesis, with 90% five-year survival.⁹⁰

(a) A rapidly enlarging mass in the right arm of a 69-year-old female. (b) Anteroposterior radiograph of the distal humerus showing a lytic lesion with permeation of lateral cortex. (c) High-grade sarcoma was diagnosed. Pathological fracture of the distal humerus. (d) T1-MRI image showing the tumour mass. (e) Intraoperative image of the right humerus after excision of the tumour with preservation of the neurovascular elements. (f) Elbow reconstruction using a custom-made cemented megaprosthesis (Link megaprostheses, Hamburg, Germany). (g) Anteroposterior and (h) lateral radiographs of the elbow 13 months postoperatively, showing the elbow endoprosthesis with no sign of local recurrence. Postoperatively, the patient had adjuvant chemotherapy. She died at 13 months due to lung metastatic disease.

Allograft elbow reconstructions, total or hemi-articular, although they provide certain advantages, are rarely undertaken due to the unpredictable outcomes and high complications rates.^76,91,92 A vascularized fibular grafting including the fibular head can be used for reconstruction after excision of a malignant tumour in the proximal ulna. Kimura et al treated an eight-year-old girl with a Ewing sarcoma in of the proximal ulna using wide excision and reconstruction with a vascularized osteocutaneous fibular graft including the fibular head. Four years after surgery the patient was disease free with excellent elbow function and the upper extremity was growing without deformity.⁹³ Recently, Graci et al presented the case of a 12-year-old girl with parosteal osteosarcoma of the right distal humerus treated with en bloc resection, intraoperative extracorporeal irradiation and implantation. The authors inserted a non-vascularized fibular autograft through the middle of the irradiated graft to obtain a greater stability. Ten years after surgery the patient had no recurrence with an excellent functional result.⁹⁴

In cases where complete excision of the tumour is impossible, amputation is recommended. Radiation therapy is mandatory in cases of Ewing sarcoma with marginal resection or with poor response to chemotherapy with dose of 4500 to 6000 cGy, delivered over six to eight weeks.^34,74

Conclusion

Bone tumours around the elbow are rare and pose a diagnostic challenge for orthopaedic surgeons. Delay in diagnosis is common because of atypical clinical presentation and the low index of suspicion. Treatment, even that of the benign varieties, remains challenging because of the interference of the tumour with neurovascular structures and inadequate soft tissue coverage. Nowadays, benign tumours can be treated using minimally invasive techniques, and malignant ones with limb salvage procedures. Various reconstruction options include endoprosthetic replacements, resection arthroplasty, interposition arthroplasty, arthrodesis, elbow osteoarticular allograft reconstructions, allograft-prosthesis composite arthroplasty and vascularized fibular grafts including the fibular head. Surgical options for reconstruction of the elbow joint remain technically challenging. Management strategies with a multidisciplinary team approach are mandatory and should be individualized and address the characteristics of the bone tumour while respecting the patient’s trajectory of illness.

Elbow Dysplasia – Fitzpatrick Referrals

What is canine elbow dysplasia?

The word “dysplasia” means “abnormality of development”. The elbow is a complex joint because it involves the articulation of three bones. If the three bones do not fit together absolutely perfectly as a result of abnormal development, the consequence is abnormal concentration of forces on a specific region of the elbow joint.

Forms of primary cartilage disease may also constitute abnormal development of the elbow joint resulting in significant clinical consequences. The term ‘developmental elbow diseases’ may be a more descriptive nomenclature for this condition since most people will have heard of ‘dysplasia’ only in reference to the hip joint. Elbow dysplasia and hip dysplasia both mean that the conformation of the joint is abnormal. In hip dysplasia, the end result of the abnormality in all dogs will be osteoarthritis accompanied by pain and reduced range of motion. Treatment mostly consists of management of the osteoarthritis or joint replacement. In elbow dysplasia, the forces concentrated on specific areas of the joint will not only result in osteoarthritis (as happens with hip dysplasia) but also in discrete pathological entities like fractures within the joint that may need to be managed separately and alongside the osteoarthritis.

Until recently it was believed that these disease entities were the manifestations of different elbow pathology but as they were commonly seen in combination with each other and they all resulted in elbow osteoarthritis, the term elbow dysplasia was used as an umbrella term for all of them. We now believe that these disease entities are the manifestation of the same pathology, which is the abnormal conformation of the joint and therefore we often see them in combination with each other. Although we still use the term elbow dysplasia to describe them, this term is now mostly used to describe the main pathology and not as an umbrella term for different joint disease entities.

How can I tell if my dog has elbow dysplasia?

Video 1 from Fitzpatrick Referrals on Vimeo: This is a pronounced head nod typical of a dog with elbow origin lameness.

Elbow dysplasia is the most common cause of forelimb lameness in young, large and giant breed dogs. Most dogs have a limp on one or both front legs. This can be seen as a nodding of the head when the good leg is placed and lifting of the head when the bad leg is placed. Some dogs that limp on both front legs will not have a limp, but will have an unusual “paddling” gait. Lameness is often triggered by prolonged rest and exercise. For this reason, many dogs will be lame when they wake up but after a warm up they will exercise freely and limp again afterwards. Although most dogs will be diagnosed before they are two years old, some dogs will not limp until they are older. Collectively, elbow dysplasia and elbow osteoarthritis are the commonest causes of forelimb lameness in dogs of any age. Small dogs can also be affected by elbow dysplasia and this problem should be suspected in any dog with forelimb lameness that has not been caused by trauma.

What is the cause of elbow dysplasia?

Figure 1: This image shows the pattern of stress fracture radiating from part of the coronoid process of the ulna.

Picture 2: This is a microscopic image of a crack forming beneath the surface before it is visible at the surface. Fitzpatrick Referrals were responsible for the landmark research that showed that medial coronoid disease began in the bone beneath the surface and was not primarily a disease of cartilage.

This condition is primarily of genetic cause although environmental factors, such as obesity during puppyhood, may influence whether an animal with the genes coding for elbow dysplasia will develop a clinical problem. Current estimates state that more than one hundred genes code for elbow dysplasia. Our ultimate goal will be to genetically map affected animals and tailor breed programmes to minimise this disease.

What is happening inside an affected joint?

Video 2 from Fitzpatrick Referrals on Vimeo: Microcracks coalesce to form visible cracks in the coronoid process much like an earthquake as in this video.

In most dogs affected by elbow dysplasia, the pathology involves concentration of abnormal forces on a part of the joint called the coronoid process of the ulna. These abnormal forces cause microscopic stress fractures within this process, resulting in pain and lameness. In many dogs, either a small portion of the process or the entire process, will separate from the remaining bone. This problem is called fragmented coronoid process (FCP) and is one of the disease entities accompanying elbow dysplasia. Whilst standard radiographs are very helpful in diagnosis of this condition, CT can provide more specific information regarding the “fit” of the bones and regarding subtle bone pathology below the cartilage. Arthroscopy can provide additional information regarding the joint surfaces which, in combination with the findings from radiography and CT, will allow efficacious treatment. Investigation of the joint with radiographs and/or CT and subsequent arthroscopy is considered the standard of care at Fitzpatrick Referrals.

The pattern of abnormal development is not the same in all affected elbow joints. In order to offer the optimal treatment for a dog with elbow dysplasia, it is essential that we identify and neutralise the abnormal forces acting on the affected elbow. These forces are summarised below:

Elbow incongruity due to a relatively short radius:

Elbow incongruity can be transient or permanent. Subtle differences in the growth rate of the two bones that make up the forearm (the radius and ulna) can cause severe overloading of the prominent coronoid process of the ulna. In some dogs, it may be that this incongruity has resolved by the time the diagnosis of elbow dysplasia is made, but the consequence of this transient incongruity is stress fracturing of the coronoid process. Treatment of this problem is usually by arthroscopic fragment removal or subtotal coronoid ostectomy. With the latter, not only do we remove the fragmented coronoid process but also some of the unfragmented part which could still contribute to joint pathology due to its abnormal conformation and ongoing inflammation. In elbows, in which this type of incongruity is permanent, treatment is usually accompanied by proximal ulnar osteotomy in an effort to allow the longer bone (ulna) to find a more “convenient” place in the joint.

Video 3 from Fitzpatrick Referrals on Vimeo: Short radius syndrome.

Short radius syndrome.

Coronoid process overloading due to conflict with the radius:

In some affected elbow joints, stress fractures of the coronoid process of the ulna could be the consequence of repetitive impact from the adjacent radial head. The anatomical structure with most contribution to this repetitive impact is a branch of the biceps tendon. This could be because every time the biceps muscle contracts it causes the radius to impact the ulna around an area known as radial incisure of the ulna (incisuar radialis ulnae). Treatment of this problem may be undertaken by a surgical procedure called ‘biceps ulnar release’.

Ulnar notch incongruity

In some cases, the notch of the ulna is excessively elliptical or simply the wrong shape relative to the humerus, resulting in severe overload of the extremities of the notch. In some dogs, this can cause severe cartilage erosion. When this happens, treatment options depend on the disease entities accompanying the developmental disorder and the extent of osteoarthritis present.

What is the long-term consequence of elbow dysplasia?

Video 8 from Fitzpatrick Referrals on Vimeo: Even if the fragment is removed, sometimes the humerus continues to rub on the ulna, much like a break on a break-pad in a car, if the humero-ulnar joint is incongruent.

Every dog with elbow dysplasia is affected by some degree of elbow osteoarthritis at the time of diagnosis. This can be the consequence of a loose fragment acting like a “stone in a shoe” within the joint or of untreated elbow incongruity such as radio-ulnar or humero-ulnar conflict.

Surgical treatments for elbow dysplasia aim to treat the current source of pain and also to minimise the likelihood of osteoarthritis progression. Non-surgical treatments for elbow dysplasia aim to treat elbow pain and maintain mobility but do not have the potential to minimise osteoarthritis progression. Rehabilitation of elbow dysplasia can be provided through our rehabilitation service whereby one of our chartered physiotherapists will design a home care physiotherapy and exercise plan for you to follow at home between outpatient physiotherapy and hydrotherapy appointments.

The clinical impact of elbow osteoarthritis is unpredictable and, regardless of treatment, arthritis will progress to some extent for all affected joints. In some dogs, lameness can be mild and intermittent, whilst in others, lameness can cause severe and permanent disability. Where persistent cartilage erosion occurs, it is generally in the inner (medial) part of the elbow, constituting the joint between the humerus and the ulna (coronoid process). This could be the result of any form of elbow incongruity, such as a short radius, an abnormally shaped ulnar notch or just abnormal three-dimensional rotation conflict. In these situations, depending on the degree of poor fit, surgical treatment could include proximal ulnar osteotomy, sliding humeral osteotomy, canine unicompartmental replacement or total elbow replacement.

How is elbow dysplasia diagnosed?

Clinical examination:

At home, you will have noticed lameness or stiffness and your primary care vet will have noticed elbow pain in your dog. During your consultation at Fitzpatrick Referrals, one of our orthopaedic clinicians will perform a thorough, clinical examination to isolate definitive pain to the elbow and will discuss further investigation requirements and possible surgical intervention options should they be indicated.

Radiography:

If your primary care vet had a suspicion of elbow dysplasia, they may have obtained radiographs of the elbow joints. Radiographs will usually show changes in affected dogs although this is not always the case. At times, changes can be very subtle and difficult to detect and therefore the position in which the elbow is placed and the type of radiograph taken will have a great bearing on the ability to perceive pathology. At Fitzpatrick Referrals, our advanced diagnostic imaging service has the most advanced direct digital radiography yielding crystal clear images to optimise diagnostic opportunity including more advanced imaging techniques such as CT and MRI.

Computed tomography (CT):

In addition to radiography, we use computed tomography (CT) and arthroscopy to facilitate diagnosis of elbow dysplasia. CT can be performed under sedation or general anaesthesia. It is a very sensitive method for the diagnosis of stress fracturing of the coronoid process of the ulna and for the assessment of elbow incongruity and the bone underneath the cartilage. CT gives us very useful information for planning the best treatment of elbow dysplasia in your dog. We offer CT to most cases when elbow dysplasia is suspected. The entire study can be completed in minutes and gives us a three-dimensional picture of the disease process.

Elbow arthroscopy:

Arthroscopy is the gold standard technique for diagnosis of problems within a joint. It is a keyhole surgical technique that is performed under general anaesthesia. Arthroscopy allows us to obtain a magnified panoramic view of the inside of a joint. In dogs requiring treatment of problems in both elbows, arthroscopy and surgery are performed as part of a single surgical procedure under the same general anaesthetic. When resolution of the problem can be arthroscopically achieved, your dog will generally be walking well the following day and recovery times are usually rapid.

Noel performing elbow arthroscopy. It is necessary to dim the lights so the surgeon can have optimum visualisation of the images of the inside of your dog’s elbow.

Pictures 14, 15, 16 and 17: these pictures illustrate tip and radial incisure fragmentation of the medial coronoid process, which are the two most common kinds of fragmentation. The arthroscopy images are accompanied by schematic representations to illustrate the two patterns of the disease. It’s important to realise that these two forms may require different treatment and at Fitzpatrick Referrals, we have pioneered research designed to optimise the most appropriate treatment for each individual patient.

How is elbow dysplasia treated?

Non-surgical treatments for elbow dysplasia

Non-surgical therapies may be a preferable management option for some dogs with elbow dysplasia and osteoarthritis. We are proud to offer an Osteoarthritis Clinic, which provides comprehensive non-surgical management of osteoarthritis and complements the surgical expertise already in place. The traditional cornerstones of non-surgical treatment are body weight management, physiotherapy, exercise modification and medication (anti-inflammatory painkillers). We also offer regenerative medicine therapies such as stem cells and platelet-rich plasma to help combat the pain and inflammation associated with osteoarthritis, and are working hard to provide useful outcome data, as publications are currently lacking in this area.

At Fitzpatrick Referrals, we have a team of chartered physiotherapists and hydrotherapists formulating protocols for treatment of all forms of joint disease, including those patients not surgically treated and for postoperative rehabilitation of surgical patients. The protocols are custom-designed to your dog to optimise outcomes. Physiotherapy will not cure any arthritic changes in the joint or remove pain on its own, but it can significantly help mobility and improve function for arthritic joints, and it can significantly improve outcomes achieved after surgery.

Surgical treatments for elbow dysplasia

Picture 18: In many cases, the fragment represents the tip of the iceberg. SCO is used to remove the part of the coronoid process of the ulna that is affected by microscopic stress fracturing. This procedure is a keyhole surgical technique, as shown in video 10

Arthroscopic fragment removal:

In some cases, the problem at the time of diagnosis is confined to an isolated fragment of the coronoid process of the ulna. In dogs having arthroscopic fragment removal alone, the CT scan and arthroscopy will have shown no evidence of current elbow incongruity or radio-ulnar conflict, and any remaining coronoid process will have been assessed as having a low risk for stress microfracture. The majority of dogs will make a rapid clinical improvement after arthroscopic fragment removal, and in some cases this improvement will be maintained in the long-term. The long-term prognosis is dependent on the degree of osteoarthritis in the remainder of the elbow joint and this is discussed by your orthopaedic clinician on an individual basis.

Biceps ulnar release (BURP):

In some cases, we recognise a specific pattern of stress fracturing of the coronoid process of the ulna typical of radio-ulnar conflict. This conflict is contributed to by excessive and repetitive forces imparted by one of the branches of the biceps muscle which attaches on the coronoid process itself. Although the tendon itself is not diseased, it exerts force on a badly fitting bone geometry which contributes to the micro-fractures and ultimate fragmentation. Arthroscopic surgical release of this branch allows neutralisation of these forces. The remaining biceps insertion on the radius is not affected, and because the biceps shares its function of flexing the elbow joint with another muscle (the brachialis), there is no deleterious mechanical consequence of biceps ulnar release. This procedure was also pioneered at Fitzpatrick Referrals.

Subtotal coronoid ostectomy (SCO):

In elbows where there is diffuse stress fracturing of the coronoid process of the ulna, the majority of the process should be removed using arthroscopy. This particular surgery was developed at Fitzpatrick Referrals. In common with arthroscopic fragment removal, the majority of dogs will make a good clinical improvement after SCO and in many cases this improvement is maintained in the longer term. However, osteoarthritis is progressive for all forms of medial coronoid disease regardless of whether fragment removal alone or SCO is performed. In many cases however, this does not produce noticeable lameness and rehabilitation of osteoarthritis advice can be provided by our chartered physiotherapists.

Video 9 from Fitzpatrick Referrals on Vimeo.

Proximal ulnar osteotomy (PUO):

In some elbow joints, stress fracturing of the coronoid process of the ulna is caused by the presence of a relatively short radius, and this incongruity can be permanent. In these elbows, the incongruity is corrected in order to treat the current elbow pain and also to attempt to limit the future progression of osteoarthritis. This is achieved by cutting the ulna below the elbow joint. Cutting the bone at this point does not prevent the limb from being used normally and healing of the bone occurs in a new position that provides a more congruent elbow joint. The same technique may be employed to treat elbows affected by a poor fit between the humerus and the ulnar notch. Appropriate motion of the cut portion of the ulna and subsequent healing is facilitated by a specific angle of cut termed ‘dynamic oblique’. The specific nature of this technique was established by Fitzpatrick Referrals.

Picture 19 and video 10: This image and video represents the effect of a bi-oblique dynamic proximal ulnar osteotomy on the medial coronoid process.

Proximal abducting ulnar (PAUL) osteotomy:

PAUL surgery falls into the group of surgeries called load-altering osteotomies. An osteotomy involves a controlled surgical cut of a bone. The PAUL osteotomy procedure involves an ulnar osteotomy which is secured with a plate and screws to stabilise the bone while it heals in the new position. The surgery aims to unload the medial compartment of the elbow, thus reducing pain and improving limb use and function.

Sliding humeral osteotomy (SHO):

In some dogs with advanced elbow dysplasia, there is severe secondary osteoarthritis. A specific pattern of osteoarthritis, in which cartilage is severely damaged or absent on the medial (inside) aspect of the joint but appears relatively healthy on the lateral (outside) aspect of the joint, can be treated by SHO. This type of elbow pathology is known as medial compartment disease (MCD). SHO is an advanced procedure that is currently offered in only a few veterinary hospitals worldwide. It involves cutting the humerus (upper arm bone) and fixing it in a new position using a special stepped bone plate and screws. This transfers weight away from the diseased medial joint to the healthier lateral joint. In young dogs, there is the potential for some cartilage regeneration in the medial compartment after SHO. This isn’t normal functional cartilage but serves as evidence of unloading and a decrease in pain associated with friction between the humerus and the ulna (humero-ulnar conflict). The original SHO technique was refined by Noel Fitzpatrick and the surgery now uses custom-made implants which are manufactured to fit the exact dimensions of the patient’s bone.

Canine unicompartmental elbow replacement (CUE):

CUE is an alternative to SHO in selected, mature dogs suffering from medial compartment disease. This advanced surgical procedure involves the resurfacing of the weight-bearing portion of the medial (inside) elbow where cartilage is absent.

Total elbow replacement (TER):

In some dogs, elbow osteoarthritis can be extremely severe, with little or no healthy cartilage remaining. In these dogs, TER is used as a salvage procedure i.e. it is performed as a last resort where other treatments will be ineffective. The entire elbow joint surface is replaced with a custom elbow prostheses. Currently, we are one of the few practices in the UK able to provide this procedure.

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Spotlight on: Canine Developmental Elbow Disease (Elbow Dysplasia)

By Professor Noel Fitzpatrick

Patient story

Elbow spur: treatment, diagnosis, reasons

The concept of “elbow spur” in medicine is defined as a pathological growth of bone tissue that forms a joint. Basically, the disease is diagnosed in people over 50 years old, but it can also develop in younger people. Usually, the treatment of an elbow spur is carried out conservatively, but if the pathology is neglected, the patient may require surgical intervention. To quickly get rid of the bone build-up, you should begin therapeutic measures when the first signs of the disease appear.

Causes of occurrence

The main reason for the formation of a spur on the elbow is repeated damage to the ulna. Tennis and volleyball athletes often face this problem. Inflammation of the bursa or tendons can provoke the development of a growth, as a result of which the movement of the elbow is disrupted and the bone grows. A spur on the elbow joint appears in elderly people due to metabolic disorders in the body. Strong and elastic cartilage with age lends itself to gradual destruction.Then the load falls on the surface of the articular bones, and the lost cartilage tissue is replaced by bone.

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How to recognize?

It is important to know the main symptoms of an elbow spur in order to recognize the ailment in time and begin treatment measures.

The first signs of skin growth on the elbow joint are as follows:

• Painful sensations. Due to the growth of the bone, friction occurs, in which the nerve can be clamped, which causes painful discomfort.
• Decreased physical activity. Elbow movement becomes difficult, it becomes difficult to control the forearm.
• The elbow joint may swell and hurt in the area of ​​the inflamed growth.

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Diagnosis of the elbow spur

X-ray allows you to make an accurate diagnosis of the patient.

Before starting treatment of an elbow spur, it is necessary to undergo a diagnostic examination and make sure that the diagnosis is accurate. Bone growth can be identified using X-ray examination of the joints.Such a procedure allows you to accurately diagnose, as well as determine possible complications or secondary signs of an ailment affecting other organs and systems. On an X-ray, a medical professional can see bone growths along the edge of the cartilage tissue and abnormalities on the surface of the joint. In the future, X-ray allows you to monitor the dynamics of therapy.

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Treatment of pathology

The therapeutic course is based on taking medications, the main purpose of which is to stop painful symptoms and eliminate the focus of inflammation.For the treatment of the elbow joint, physiotherapy methods are used that destroy the spurs. If conservative measures are unable to cope with the pathology, doctors resort to surgical intervention.

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How Can Traditional Medicine Help?

Typically, spurs are treated with physiotherapy. This technique improves blood circulation, accelerates tissue regeneration, relieves puffiness and painful discomfort. The elbow spur is treated with electrophoresis, UHF, ultrasound or laser.Massage effectively eliminates pain, however, you should know that it should be done exclusively by a qualified specialist. Otherwise, you can only aggravate the situation, and not achieve a positive treatment result. Along with massage and physiotherapy, it is advisable to take anti-inflammatory and analgesic drugs.

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How to use folk remedies?

Clay compress relieves inflammation in the problem area well.

A spur on the elbow is not a problem for alternative medicine either.Traditional healers suggest relieving pain and inflammation with the help of baths based on decoction of marigolds, chamomile inflorescences and essential oils with an analgesic effect. Along with this, compresses with clay and medicinal herbs, which have anti-inflammatory properties, are highly effective. The elbow spur is excellently treated with a bath with soda-saline solution.

It must be remembered that self-medication can be dangerous, so you should resort to traditional medicine after consulting a doctor.

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Surgical removal of the build-up

Surgery is prescribed to the patient in extreme cases, when the spur on the elbow joint grows rapidly and causes severe intolerable pain. The specialist will open the joint and excise the bone growth. After the operation, the patient needs rehabilitation and adherence to the general recommendations of doctors.

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Doctor’s advice

To make the rehabilitation period easier and faster, as well as in order to prevent the re-formation of bone growth, qualified doctors strongly recommend excluding smoked, fatty, salted foods.It is important to reduce the consumption of carbonated and alcohol-containing drinks, enrich the diet with useful minerals and vital vitamins. To restore cartilage tissue, you need to eat foods rich in gelatin.

Elbow spur: treatment, causes of development, symptoms

Pain that occurs in the elbow for no particular reason, as well as the appearance of a bony protrusion, often indicates that it is an elbow spur. Small and soft growths lead to significant discomfort.Having no pronounced manifestations at the initial stage, over time it causes complications and gives an indication for surgical intervention.

What are the reasons for development?

The structure of the elbow joint consists of 3 bones: humerus, radius, ulna. They are placed in the joint capsule and connected by ligaments for functional movement of the elbow. Factors of manifestation of the disease:

• injuries and microtrauma, cracks and fractures;
• inflammation of the tendons, joint bags;
• excessive stress, nerve entrapment, deformities;
• Age-related changes in the form of cartilage wear, which increases friction between bones.

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Symptoms of an elbow spur

A spur on the elbow is manifested by a painful point on the outside, joint tension and a bent arm. Signs to look out for first:

• Pain. The increase in bone causes friction and crunching. This leads to clamping of nerve fibers, pressure on the periarticular tissues. Pain syndrome disrupts a person’s usual life activities.
• Limited arm span. Hyperemia and immobility leads to restricted movement of the forearm.

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Diagnostic measures

Treatment of spurs on the elbow joint is chosen by the doctor in accordance with the patient’s symptoms.

In case of manifestation of disease factors, you should contact your local therapist. After finding out the reason for the patient’s complaint, the doctor will refer him to a narrow specialist (traumatologist, neurologist or rheumatologist), who will prescribe further treatment. The doctor examines and palpates the affected area of ​​the hand. To confirm the diagnosis of an elbow spur, additional examinations are prescribed:

• radiography;
• computed tomography;
• arthroscopy;
• ultrasound examination of the joint;
• laboratory analyzes;
• puncture.

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Treatment of articular growth

Contracture is the stiffness of the articular cartilage in which the arm is not fully flexed or extended. It arises as a result of the formation of osteophytes inside the joint, and gives an indication for surgical intervention. The therapy used for the elbow spur is conservative. In case of severe pain syndrome in a patient, doctors recommend bed rest. The spur on the elbow joint responds favorably to such measures as:

• Medication.Pain relievers, corticosteroid injections and anesthetics are prescribed, as well as topical hormones. Various ointments are used to relieve inflammation, for example, “Diklak”, “Ketoprofen”.
• Physiotherapy procedures, including ultrasound, magnetotherapy and electrotherapy.
• Gentle exercise in the form of exercise therapy. By themselves, they are not very effective, but in combination with other methods of therapy, they will give a positive result. It is important that the arm is fixed with special orthoses.
• Application of ice. Cold helps to relieve pain and relieve swelling. Before applying pieces of ice to the damaged area, cover it with a thin cloth or towel.
• Plaster of paris (in case of dislocation as a result of trauma).
• Arthroscopy. During the operation, the joint is not fully open. Two small incisions are made, one for the arthroscope and one for the surgical instrument that removes the growths.

Proper physical activity on the elbow increases the strength and mobility of the joint.

The course of the disease is often asymptomatic and manifests itself only in the process of inflammation of tissue structures and tendons. A bone spur is painful and uncomfortable. First aid for a disease is getting rid of pain syndrome and referring to a highly qualified specialist. Complex anti-inflammatory therapy of soft tissues leads to a cure.

What are the most common symptoms of a bone spur on the elbow?

The most common symptoms of a bone spur at the elbow are pain, blockage of the joint, and loss of movement of the elbow.Bone spurs are most commonly seen in patients with osteoarthritis, a degenerative bone disease. Many people do not experience any symptoms from a bone spur, unless it reaches a certain size or shape near the tendon or ligament.

Bone spurs, also called osteophytes, are bony growths that form in certain joints of the body. They are caused by constant stress on the bone, such as overuse of the elbow, or as a result of a medical condition such as osteoarthritis or bursitis.Elbow injury can also lead to spur formation.

Osteoarthritis is the most common cause of a bone spur on the elbow. In osteoarthritis, the cartilage that protects and surrounds the bone wears away, causing the bones to rub or stick out. If there is injury to the bones of the elbow, the healing process can overcompensate and create a build-up of calcium, which in turn creates a bone spur.

If pain is caused by a spur, it usually means that the area of ​​overgrowth is large enough to pressurize surrounding tissue, compress a nerve, or rub another bone.In addition to pain, there may be swelling, redness, and inflammation. If a bone spur looses, it can get stuck in the joint and temporarily block the elbow until it moves again.

In most cases, bone spurs are asymptomatic, especially in the early stages. They are often only found on an x-ray or other test that shows a different problem. Bone spurs usually do not heal if this is the case. If there are any symptoms, such as pain, loss of movement, or joint blockage, surgery may be required.Cortisone and anti-inflammatory drugs are often given first to see if they reduce pain or swelling.

Surgery for an elbow spur is usually the last resort, as most symptoms can be treated with medication. In the case of osteoarthritis or any other disease that can lead to bone spurs, the root cause must be addressed so that additional spurs do not develop.

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Arthropant works great when applied correctly and regularly on clean skin.It is advisable to take a hot bath or a relaxing shower before rubbing in the cream: “steamed” joints and the spine will take the medicine better, instantly providing a regenerative effect and anesthetizing problem areas.

The effect of using a spur on the elbow joint treatment with folk remedies

packs per year. Relieves pain and swelling in the joints. Restores joints and tissues. Helps with arthritis and arthrosis. Effective in osteochondrosis. Artropant is made according to the ancient recipe of the Selkups who inhabit the northwest of Siberia.The recipe is passed down from generation to generation and is kept in the strictest confidence. The northern people entrusted the recipe to our company with one condition – to produce no more than 1500 cans of cream per year.

Expert opinion

Arthropant works great when applied correctly and regularly on clean skin. It is advisable to take a hot bath or a relaxing shower before rubbing in the cream: “steamed” joints and the spine will take the medicine better, instantly providing a regenerative effect and anesthetizing problem areas.

How to order

In order to place an order for a spur on the elbow joint treatment with folk remedies, you must leave your contact information on the website. The operator will contact you within 15 minutes. Will clarify all the details with you and we will send your order. In 3-10 days you will receive the parcel and pay for it upon receipt.

Customer Reviews:

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Before, I simply didn’t go to bed without pain relievers, so I was tormented by the wound bones on my legs. Diklalofenac, prescribed by a doctor, did not give any analgesic effect at all. But Artropant ointment came to me right away. Already in a day I could go to bed without taking Nise at night.The composition is natural, which is especially pleasing, since the constant use of painkillers constantly hurts the stomach.

Since childhood, my mother has had problems with her legs, one of them is a little shorter and because of this, a great load falls on her healthy leg. Apparently for this reason, the inter-articular cartilage on the leg is erased faster and severe pain appears. A month ago, they began to rub Antropant into the knee joint for my mother, and now I can say that it, like no other ointment, really helps.The pain syndrome became less pronounced after the first application, and now the leg practically does not hurt at all. Mom uses ointment three times a day. Where to buy a spur on the elbow joint treatment with folk remedies? Arthropant works great when applied correctly and regularly on clean skin. It is advisable to take a hot bath or a relaxing shower before rubbing in the cream: “steamed” joints and the spine will take the medicine better, instantly providing a regenerative effect and anesthetizing problem areas.

An elbow spur is a pathological condition characterized by the growth of bone tissue. Causes of occurrence. The spur on the elbow joint develops slowly. … Folk remedies cannot be the main methods of treatment. No physiotherapy and medicinal treatments. With a spur on the elbow joint, doctors most often choose conservative treatment in the form of analgesic procedures, but. Treatment of the elbow joint with folk remedies. The main load falls on the elbow joint, and if it is affected by any disease or injured, we.An elbow spur is an abnormal growth of the bones that form a joint. … Treatment of the elbow joint with folk remedies. the load falls on the elbow joint and if it is affected by any disease or injured, we become limited in performing the simplest. Symptoms and causes of elbow spurs, methods of its treatment. The use of medicines, traditional medicine when. An elbow spur is an abnormal growth of the bones that form a joint. It resembles a thorn located on the back of the elbow.Treatment of the elbow joint with folk remedies. The main load falls on the elbow joint and if it is affected by any disease or. A bone spur on the elbow joint can cause pain and restriction of movement of the elbow. The elbow joint is smaller compared to the knee joint. How to use folk remedies? The elbow spur is not a problem for alternative medicine either. … Treatment is necessary if the spur disrupts the normal functioning of the elbow joint, pinches the nerves or blood vessels. Therapy in most cases is conservative, but consult with.The spur on the elbow joint develops slowly. The peculiarity of this pathology is that it never. Treatment of arthrosis with folk remedies. This disease is characterized by limitation of joint mobility and its crunching. If the treatment is not started on time, the process can begin. For the treatment of the elbow joint, physiotherapy methods are used that destroy the spurs. … The elbow spur is not a problem for alternative medicine either. Traditional healers suggest relieving pain and inflammation with the help of trays based on decoction of marigolds, chamomile inflorescences, etc.Elbow spur. An elbow spur is an abnormal growth of the bones that form a joint. … For the treatment of joints, our readers are successfully using Artrade. Seeing such popularity of this tool, we decided to offer it to your attention. Read more here … The spur on the elbow joint develops slowly. The peculiarity of this pathology is that it never has a primary character, that is, it cannot. Arthritis treatment with folk remedies. Treatment of deforming osteoarthritis. Treatment of bursitis with folk remedies.Drug therapy.

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spur on the elbow joint treatment with folk remedies

Arthropant works great when applied correctly and regularly on clean skin.It is advisable to take a hot bath or a relaxing shower before rubbing in the cream: “steamed” joints and the spine will take the medicine better, instantly providing a regenerative effect and anesthetizing problem areas.

Artropant is a divorce. Clinical researches. Reviews of doctors. Instructions for use. … Artropant is a divorce. Despite the fact that the manufacturer speaks of the joint cream as a remedy with a wide spectrum of action, negative reviews of the drug periodically appear on the Internet.The official website of the drug Artropant ointment. Read real reviews, opinions of doctors, prices, composition, methods of application and possible results. … Arthropant cream is a sensational medicine for joints! Arthropant cream for joints. Instructions for use, price, reviews, analogues. … Patient reviews are quite contradictory, but when studying the composition, you can see that the drug contains many components that have a beneficial effect on cartilage and bone tissue. Arthropant cream for joints: benefits, composition, reviews, price, indications…. Artropant: short description and composition. The arthropant is thick. The instructions for use recommend using the cream for a month up to 3 times a day. If necessary, treatment can be continued after. Reviews of experts. Where to buy Artropant, price. Arthropant cream – description. … Artropant cream is available in 50 ml jars, packed in boxes. It also contains instructions for use. Artropant reviews of doctors: Still do not believe that Artropant cream is an active active agent with proven effectiveness? Listen to the opinion of an experienced doctor: I always recommend Artropant cream to my patients if they have any joint diseases.The cream acts locally – it is. I bought Artropant cream for joints. I have already tried a bunch of gels and creams and it seems to me that Artropant cream is mine. Today I want to share a review of the “Artropant” joint cream. … The cream came in boxes with instructions, etc. Read full review Recommended review: 1 0. 18 55op77as. Therefore, it is impossible to buy Artropant cream at a pharmacy in Kaliningrad. The cream contains. Doctors strongly recommend the use of Artropant cream for joint pain and for prophylactic purposes.7 Arthropant – Ways to Apply Joint Cream: Instruction and Treatment. Arthropant Joint Cream – Real Reviews: Divorce or Really? There are fewer grateful reviews on the Internet than judgmental ones, and there is an explanation for this. The people Artropant has helped are overwhelmed. Pharmacy of Kaliningrad. Artropant: reviews, instructions, descriptions, contraindications. … Arthropant joint cream can be bought in an online pharmacy, at a price, with delivery in Kaliningrad. Joint cream Artropant. Composition, instructions and reviews of doctors.Buy Artropant in Kaliningrad: price at a pharmacy 990. Arthropant is a unique remedy developed by scientists on the basis of not only common patient complaints, but also the reasons for the development of arthrosis and arthritis. The drug solves. ARTROPANT instructions for use, reviews, analogues, prices and availability in pharmacies. ARTROPANT: Indications for use, Method of administration, Side effects, Contraindications, Pregnancy, Interaction with others.

Orthopedist – Megion City Hospital

Orthopedics is a branch of clinical medicine that studies the prevention, diagnosis and treatment of deformities and disorders of the musculoskeletal system, which are the result of birth defects, malformations, the consequences of injury or disease.

You should see an orthopedist for the following complaints:

• neck pain
• Pain in shoulder, elbow, wrist, hand and fingers
• spine pain
• pain in the hip joint, knee joint, lower leg, foot, toes
• limitation of mobility of the neck, spine, shoulder, joints
• numbness, lumbago in the neck, spine, arms, legs
• deformity of the knee joint
• curvature of the foot and toes
• consequences of bone fractures
• dislocations, subluxations of joints and their consequences
• sprains, injuries, tears of the tendons and ligaments of the joints of the arms and legs
• transverse and longitudinal flat feet in children and adults
• limitation of mobility
• Painful muscle tension
• swelling, bone aches
• gait change
• discomfort or crunch in joints

Orthopedic diseases

congenital:

• malformations of limbs
• malformations and deformities of the spine
• chest defects and deformities

acquired:

• deforming arthrosis
• osteochondrosis
• spondylosis
• Static deformations of feet
• post-traumatic deformities
• false joints
• condition after injury or surgery on bones, joints
• arthritis
• heel spur
• tunnel syndromes
• flat feet
• cutaneous and intradermal formations
• damage to tendons, nerves, ligaments.

Methods of examination in orthopedics:

• X-ray of joints, spine
• MRI of joints, spine
• arthroscopy
• densitometry
• consultations of other specialists

The need and expediency of certain studies and methods of treatment is determined by the doctor.

Orthopedist – Kondinsky District Hospital

Orthopedics is a branch of clinical medicine that studies the prevention, diagnosis and treatment of deformities and disorders of the musculoskeletal system, which are the result of birth defects, malformations, the consequences of injury or disease.

You should see an orthopedist for the following complaints:

• neck pain
• Pain in shoulder, elbow, wrist, hand and fingers
• spine pain
• pain in the hip joint, knee joint, lower leg, foot, toes
• limitation of mobility of the neck, spine, shoulder, joints
• numbness, lumbago in the neck, spine, arms, legs
• deformity of the knee joint
• curvature of the foot and toes
• consequences of bone fractures
• dislocations, subluxations of joints and their consequences
• sprains, injuries, tears of the tendons and ligaments of the joints of the arms and legs
• transverse and longitudinal flat feet in children and adults
• limitation of mobility
• Painful muscle tension
• swelling, bone aches
• gait change
• discomfort or crunch in joints

Orthopedic diseases

congenital:

• malformations of limbs
• malformations and deformities of the spine
• chest defects and deformities

acquired:

• deforming arthrosis
• osteochondrosis
• spondylosis
• Static deformations of feet
• post-traumatic deformities
• false joints
• condition after injury or surgery on bones, joints
• arthritis
• heel spur
• tunnel syndromes
• flat feet
• cutaneous and intradermal formations
• damage to tendons, nerves, ligaments.

Methods of examination in orthopedics:

• X-ray of joints, spine
• MRI of joints, spine
• arthroscopy
• densitometry
• consultations of other specialists

The need and expediency of certain studies and methods of treatment is determined by the doctor.

arthropant reviews of doctors

arthropant reviews of doctors

arthropant reviews of doctors

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What is arthropant reviews of doctors?

If, after the end of the course of treatment with Arthropant, you again feel discomfort in the articular tissue or the spine, just repeat the treatment, the remedy will heal the tissues and restore strength and mobility to the bones.

The effect of the use of arthropant doctors reviews

About 5 years ago my knee started to hurt, I could hardly walk. After the X-ray, the doctor diagnosed arthritis. They offered to undergo an operation, I refused and began to look for medicines on my own. I found out about Artropant, made a purchase on the official website. On the 10th day of use, the pain subsided, the gait improved.

Expert opinion

The main active ingredient of the cream for joint pains Artropant is the antlers of the maral living in the Altai mountains.Antlers are harvested from the horns of a cloven-hoofed animal, which the deer drops once a year during the spring rut. Every year, at the very beginning of summer, hundreds of hunters and fishermen go in search of discarded mammalian horns scattered across the vast mountain plains.

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In order to place an order for arthropant, doctors’ reviews, you must leave your contact information on the site. The operator will contact you within 15 minutes. Will clarify all the details with you and we will send your order.In 3-10 days you will receive the parcel and pay for it upon receipt.

Customer Reviews:

Nika

Clinical trials of ARTROPANT were carried out in the fall of 2014 in Russia. They were attended by over 5,000 people suffering from joint diseases. For 40 days, the subjects used ARTROPANT 2 times a day. The results of the experiment amazed even the doctors! All study participants noted significant improvements as a result of using ARTROPANT.Almost 90% of people get rid of arthritis. No other currently known remedy for the treatment of diseases of cartilage and connective tissue can be compared with such a high efficiency.

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About 3 years ago in February my knee got sick. First, I had an x-ray and was told that I had arthritis. I could barely walk. Like a disabled person. Doctors suggested doing knee surgery. I didn’t want to go to the operating table. I began to study this problem on my own.It’s good that I didn’t listen to them. I found out about the new Artropant cream and ordered it on the official website. The cream came in 7 days, smeared it, as written in the instructions. On the 11th day, I ran to prepare for the city marathon. The knee does not bother !!

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Artropant is a divorce. Clinical researches. Reviews of doctors. … Artropant is a divorce. Despite the fact that the manufacturer speaks of the joint cream as a remedy with a wide spectrum of action, on the Internet from time to time.Reviews of doctors about the drug Artropant. Olga Ivenkova, neurologist. 12 years of experience. I have been working with the consequences of osteochondrosis for more than ten years. Clinical researches. Reviews of doctors. Instructions for use. … The forum has positive and negative reviews about the action of Artropant. You can find angry comments where the gel is called divorce for. Doctor’s reviews! Briefly: I will tell you how to buy Artropant cream, what it is for, what it treats, what you can read about it. I will also give recommendations and doctor’s reviews! Hello everyone.I was fortunate enough to have an internship with one. All reviews are fake. This cream does not seem to exist at all. … Hello everyone! I bought Artropant cream for joints. I have already tried a bunch of gels and creams and it seems to me that Artropant cream is my favorite. All the virtues. Reviews of the cream Artropant. Thanks to reviews on independent sites. Doctors prescribe it to their patients for diagnoses associated with impaired function. There are fewer grateful reviews on the Internet than judgmental ones, and there is an explanation for this.The people whom Artropant has helped are overwhelmed with joy and wonder. Arthritis, rheumatism, arthrosis – even half a century ago, these ailments were considered an age-related feature. But, according to the International Health Association, joint diseases have long gone beyond the age plane and have grown into. Arthropant cream for joints reviews of doctors, recommendations, composition and application. Positive and negative reviews about Artropant cream, analogs and properties. Negative reviews. Please tell me if it’s really possible.Reviews of doctors about Arthropant. Artropant is a cream for joints, reviews of which are left not only by ordinary buyers. Rheumatologists, orthopedists, traumatologists and other specialists actively use the drug in their practice. Absolutely each of us is periodically faced with joint pain, and for a certain category of people this problem is constant. Artropant – divorce or not. Clinical researches. Reviews of doctors. … As a result, there are many negative reviews about Artropant, in which the action of the medication is called a deception for suckers.Reviews of Artropant are controversial: most doctors give a negative assessment of its effectiveness, calling it a divorce. The truth is, as always, in the middle: the cream can provide a mild pain reliever and.

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About 5 years ago, my knee began to hurt, I could barely walk. After the X-ray, the doctor diagnosed arthritis. They offered to undergo an operation, I refused and began to look for medicines on my own. I found out about Artropant, made a purchase on the official website. On the 10th day of use, the pain subsided, the gait improved.

arthropant reviews of doctors

If, after the end of the course of treatment with Arthropant, you again feel discomfort in the joint tissue or spine, just repeat the treatment, the remedy will heal the tissues and restore strength and mobility to the bones.
An elbow spur is a pathological condition characterized by the growth of bone tissue. Causes of occurrence. The spur on the elbow joint develops slowly. … Folk remedies cannot be the main methods of treatment. No physiotherapy and medicinal treatments. With a spur on the elbow joint, doctors most often choose conservative treatment in the form of analgesic procedures, but. Treatment of the elbow joint with folk remedies. The main load falls on the elbow joint, and if it is affected by any disease or injured, we.An elbow spur is an abnormal growth of the bones that form a joint. … Treatment of the elbow joint with folk remedies. the load falls on the elbow joint and if it is affected by any disease or injured, we become limited in performing the simplest. Symptoms and causes of elbow spurs, methods of its treatment. The use of medicines, traditional medicine when. An elbow spur is an abnormal growth of the bones that form a joint. It resembles a thorn located on the back of the elbow.Treatment of the elbow joint with folk remedies. The main load falls on the elbow joint and if it is affected by any disease or. A bone spur on the elbow joint can cause pain and restriction of movement of the elbow. The elbow joint is smaller compared to the knee joint. How to use folk remedies? The elbow spur is not a problem for alternative medicine either. … Treatment is necessary if the spur disrupts the normal functioning of the elbow joint, pinches the nerves or blood vessels. Therapy in most cases is conservative, but consult with.The spur on the elbow joint develops slowly. The peculiarity of this pathology is that it never. Treatment of arthrosis with folk remedies. This disease is characterized by limitation of joint mobility and its crunching. If the treatment is not started on time, the process can begin. For the treatment of the elbow joint, physiotherapy methods are used that destroy the spurs. … The elbow spur is not a problem for alternative medicine either. Traditional healers suggest relieving pain and inflammation with the help of trays based on decoction of marigolds, chamomile inflorescences, etc.Elbow spur. An elbow spur is an abnormal growth of the bones that form a joint. … For the treatment of joints, our readers are successfully using Artrade. Seeing such popularity of this tool, we decided to offer it to your attention. Read more here … The spur on the elbow joint develops slowly. The peculiarity of this pathology is that it never has a primary character, that is, it cannot.