Elbow tendon injuries Flashcards
Distal biceps avulsion Lateral epicondylitis medial epicondylitis
What is distal biceps avulsion?
- 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
Describe the epidemiology of distal biceps tendon avulsion?
- 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 90o flexion
- Assoc conditions
- may lead to median n compression
Describe the anatomy of biceps brachii?
- 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

What is the presentation of distal biceps rupture?
- 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

What is seen on imaging of a distal biceps rupture?
- Xrays
- usually normal
- MRI
- important
- distinguish bertween complete vs partial tear- see pic
- muscle substance vs tendon tear
- degree of retraction

What is the tx of distal biceps rupture?
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 110o of flexion & moderate supination

What are complications to fixation of biceps tendon?
- 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
What is lateral epicondylitis?
- aka Tennis elbow
- overuse injury involving eccentric overload at origin of common extensor tendon
- -> tendinosis and inflammation at orign of ECRB

Describe the epidemiology of lateral epicondyltitis?
- 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
Name any assoc condition of lateral epicondylitis and its prognosis?
- Radial Tunnel sydrome
- in 5% pts
- prognosis
- non op tx effective in 95% cases
Name the muscles that insert onto the lateral epicondyle
- 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
What is the presentation of lateral epicondyltitis?
- 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
What is seen on imaging of lateral epicondylitis?
- Xrays
- usually normal
- MRI
- increased signal intensity at ECRB seen

What is seen on histology of lateral epicondyltitis/ ECRB tissue?
- Fibroblast hypertrophy
- Disroganised collagen
- Vascular hyperplasia
What is the tx of lateral epicondyltitis?
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
What are the complications of release and debridment of ERCB for lateral epicondylitis?
-
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
What is medial epicondylitis?
- Aka Golfer’s elbow
- An overuse syndrome of the flexor-pronator mass
- more difficult to tx than lateral epicondylitis
What is the epidemiology of medial epicondylitis?
- 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
Name associated condiitons of medial epicondylitis?
-
Ulnar neuropathy
- inflammation may affect ulna nerve
- Ulnar collateral ligament insufficiency
What does the flexor pronator mass compose of?
- Pronator teres - median n
- Flexor Carpi Radialis- median n
- Flexor digitorium superificialis- median n
- Palmaris longus- median n
- Flexor carpi Ulnaris- ulnar n
what are the symptoms of Medial epicondylitis?
- 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
What is seen on imaging of medial epicondylitis?
- MRI
- tendinosis of pronator teres and FCR
*
- tendinosis of pronator teres and FCR

What is the tx of medial epicondylitis?
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
What are the complications of medial epicondylitis?
-
Medial antebrachial cutaneous nerve neuropathy
- may result from transectionor avulsion
- if noticed in surgery transpose nerve to brachialis muscle