Elbow tendon injuries

Question 1

What is distal biceps avulsion?

Answer 1

• Either
• complete distal biceps tendon avulsion
• partial distal biceps tendon avulsion
  
  • occur primarily on radial side of tuberosity foot print
• Intersubstance msucle transection
  
  • when rope wrapped arm in tug of war

Question 2

Describe the epidemiology of distal biceps tendon avulsion?

Answer 2

• Rare
• >M
• 40-60 yrs
• usually dominant arm
• Risk factors
  
  • Hypovascularity of tendon
  • intrinsic degeneration of tendon
  • mechanical impingment in space available for biceps tendon
• mechanism
  
  • eccentric overload with elbow at 90^o flexion
• Assoc conditions
  
  • may lead to median n compression

Question 3

Describe the anatomy of biceps brachii?

Answer 3

• Origin
  
  • short head- tip of coracoid process
  • long head- supra glenoid tubercle of scapula
• Insertion
  
  • tuberosity of radius and fascia of forearm via biciptial aponeurosis
• Action
  
  • supinated forearm adn when supine flexes forearm
• innervation
  
  • musculocutaneous n ( C5/6)
• Blood supply
  
  • Muscular branches of brachial artery

Question 4

What is the presentation of distal biceps rupture?

Answer 4

• Hx - hears pop
• pain in antecubital fossa

O/E

• Popeye deformity- muscle bulge more prominent seen in long head of biceps tear
• for distal rupture- reverse popeye
• palpate defect
• Hook test
  
  • w a partial tear or no tear the examiner will be able to get their finger under the tendon nr the insertion
• Loss of supination/flexion strength
• loose more supination > flexion

Question 5

What is seen on imaging of a distal biceps rupture?

Answer 5

• Xrays
  
  • usually normal
• MRI
  
  • important
  • distinguish bertween complete vs partial tear- see pic
  • muscle substance vs tendon tear
  • degree of retraction

Question 6

What is the tx of distal biceps rupture?

Answer 6

Non operative

• Supportive tx followed by physio
  
  • for older pt who are willing to sacrifice function
• outcomes
  
  • will lose 40-50% supination
  • will lose 30% flexion
  • will lose 15% grip strength

​​Operative

• Surgical repair of tendon to tuberosity using endobutton
  
  • ​http://www.ijoonline.com/article.asp?issn=0019-5413;year=2012;volume=46;issue=1;spage=71;epage=76;aulast=Gupta
  • interval between brachialis and brachioradialis to epxose radial head- full supination to pretect PIN
  • post op : imobiise in 110^o of flexion & moderate supination

Question 7

What are complications to fixation of biceps tendon?

Answer 7

• Lateral antebrachial cutaneous n injury
• Radial nerve
  
  • by doing 2 incisions you avoid deep dissection in antecubital fossa and minimise injury to radial n
• Synostosis
• Heterophic ossification

Question 8

What is lateral epicondylitis?

Answer 8

• aka Tennis elbow
• overuse injury involving eccentric overload at origin of common extensor tendon
• -> tendinosis and inflammation at orign of ECRB

Question 9

Describe the epidemiology of lateral epicondyltitis?

Answer 9

• Most common cause for elbow symptoms in pt with elbow pain
• up to 50% of all tennis players develop it
• Mechanism
  
  • repetitive pronation and supination with arm in extension
  • esp tennis players- backhand
• pathology
  
  • usually begins as microtear of orgin of ECRB
  • may also involve microtears of ERCL/ECU
  • microscopically of tear tissue
    
    • angiofibroblastic hyperplasia
    • disorganised collagen

Question 10

Name any assoc condition of lateral epicondylitis and its prognosis?

Answer 10

• Radial Tunnel sydrome
  
  • in 5% pts
• prognosis
  
  • non op tx effective in 95% cases

Question 11

Name the muscles that insert onto the lateral epicondyle

Answer 11

• Extensor carpi radialis longus
• extensor capri radialis brevis
• Extensor carpi ulnaris
• Extensor digitorium
• Extensor digiti minimi
• Anconeus
  
  • shares same attachment site as ERCB
• Don’t forget also the lateral collateral ligaments- LUCL, LCL (radial), Accessory LCL and Annular Lig

Question 12

What is the presentation of lateral epicondyltitis?

Answer 12

• Pain w resisted wirst extension
• Pain w gripping activities
• Decreased grip strength

O/E

• point tenderness at ECRB insertion to lat epicondyle ( few mm distal to tip of lateral epicondyle)
• may have reduced grip strength
• provocation tests- pain at lateral epicondyle
  
  • pain on resisted extension long finger
  • max flexion of wrist
  • resisted wirst extension w elbow fully extended

Question 13

What is seen on imaging of lateral epicondylitis?

Answer 13

• Xrays
  
  • usually normal
• MRI
  
  • increased signal intensity at ECRB seen

Question 14

What is seen on histology of lateral epicondyltitis/ ECRB tissue?

Answer 14

• Fibroblast hypertrophy
• Disroganised collagen
• Vascular hyperplasia

Question 15

What is the tx of lateral epicondyltitis?

Answer 15

Non operative

• activity modificaiton, ice, nsaids, physio, ultrasound
  
  • first line
  • tennis modification ( larger grip, more flexible racket)
  • steriod injection
  • stretching extensors

Operative

• Release and debridmet of ERCB origin
  
  • if no response 9-12 months consx
  • http://www.orthobullets.com/video/view?id=609

Question 16

What are the complications of release and debridment of ERCB for lateral epicondylitis?

Answer 16

• Iatrogenic LUCL injury
  
  • excessive resection of LUCL
  • should not extend beyong equator of radial head
  • may lead to posterolateral instability
• Missed radial n entrapement syndrome
  
  • common in 5% pts
• Iatrogenic neurovascular injury
  
  • radial n injury

Question 17

What is medial epicondylitis?

Answer 17

• Aka Golfer’s elbow
• An overuse syndrome of the flexor-pronator mass
  
  • more difficult to tx than lateral epicondylitis

Question 18

What is the epidemiology of medial epicondylitis?

Answer 18

• 5x less common than lateral epidondylitis
• M=F
• dominant extremity 75% cases
• mechanism
  
  • activities that require repeitive wrist flexion/forearm pronation
  • common in golfers, pitchers, racket sports, plumbers
• micro trauma to insertion of flexor pronator mass
• pronator teres and flexor carpi radialis commonly affected

Question 19

Name associated condiitons of medial epicondylitis?

Answer 19

• Ulnar neuropathy
  
  • inflammation may affect ulna nerve
• Ulnar collateral ligament insufficiency

Question 20

What does the flexor pronator mass compose of?

Answer 20

• Pronator teres - median n
• Flexor Carpi Radialis- median n
• Flexor digitorium superificialis- median n
• Palmaris longus- median n
• Flexor carpi Ulnaris- ulnar n

Question 21

what are the symptoms of Medial epicondylitis?

Answer 21

• Pain over medial epicondyle
  
  • worse with wrist & foreram motion

O/E

• Tenderness over origin of PT & FCRat medial epicondyle
• provac test
  
  • pain with resisted forearm pronation and wrist flexion
  • http://www.orthobullets.com/video/view?id=469

Question 22

What is seen on imaging of medial epicondylitis?

Answer 22

• MRI
  
  • tendinosis of pronator teres and FCR
    *

Question 23

What is the tx of medial epicondylitis?

Answer 23

Non operative

• Rest, ice, activity modification, PT, bracing, nsaids, corticosteriod injections
  
  • first line tx
  • counter force bracing
  • uSS benefical

Operative

• Open debridement of PT/FCR and reattachment of flexor- pronator group to medial epicondlye
  
  • up to 6 months post consx tx
  • medial approach to elbow
  • symptoms severe affecting quality of life
  • gd-excellent outcome 80%
  • avoid volar flexion of wirst in immediate post op period

Question 24

What are the complications of medial epicondylitis?

Answer 24

• Medial antebrachial cutaneous nerve neuropathy
  
  • may result from transectionor avulsion
  • if noticed in surgery transpose nerve to brachialis muscle