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Billone LM, Allred SJ, Flores DV. US of Acute Tendon Tears. Radiographics 2024; 44:e240060. [PMID: 39612282 DOI: 10.1148/rg.240060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2024]
Abstract
US is an effective tool for appraising acute tendon injury, allowing rapid evaluation of symptoms at bedside and paving the way for prompt diagnosis and treatment selection. It offers three main advantages in the acute or emergent setting. First, it is more sensitive and specific than physical examination. This is beneficial in tendons such as the distal triceps wherein incomplete and complete tears may manifest with similar clinical presentations. Tendon injury may also be clinically innocuous because bruising or a palpable defect is not always present and swelling may mask palpation of the tendon gap. Second, US provides important descriptors that may affect treatment selection, such as injury site, injury extent, and length of retraction. Pectoralis major tears at the tendon or musculotendinous junction warrant operative referral and are readily illustrated at US. A torn distal biceps tendon with significant retraction may require additional graft augmentation rather than reattachment to the insertion alone. Soleus and gastrocnemius strains may mimic each other clinically. Although both are managed conservatively, distinction between the two facilitates formulation of a specific rehabilitation regimen. Finally, US can narrow the differential diagnosis and rule out mimics of musculoskeletal abnormalities. Nonmusculoskeletal conditions, such as deep venous thrombosis and a ruptured Baker cyst, can manifest with the same clinical presentation as acute calf injuries and must be considered in a patient presenting with sudden calf, posterior leg, or ankle pain. The authors review the anatomic features, US techniques, and imaging findings of acute tendon injuries to aid in meaningful reporting and timely treatment selection. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Lisa M Billone
- From the Department of Diagnostic Services, Hamilton Health Sciences, Hamilton General Hospital, 237 Barton St E, Hamilton, ON, Canada L8L 2X2 (L.M.B., S.J.A.); Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada (D.V.F.); and Department of Medical Imaging, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.)
| | - Sarah J Allred
- From the Department of Diagnostic Services, Hamilton Health Sciences, Hamilton General Hospital, 237 Barton St E, Hamilton, ON, Canada L8L 2X2 (L.M.B., S.J.A.); Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada (D.V.F.); and Department of Medical Imaging, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.)
| | - Dyan V Flores
- From the Department of Diagnostic Services, Hamilton Health Sciences, Hamilton General Hospital, 237 Barton St E, Hamilton, ON, Canada L8L 2X2 (L.M.B., S.J.A.); Department of Radiology, Radiation Oncology, and Medical Physics, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada (D.V.F.); and Department of Medical Imaging, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.)
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Schinnerl C, Weber MA, Benninger E, Fischer TS, Falkowski AL. MRI of the Elbow - Update 2024. ROFO-FORTSCHR RONTG 2024. [PMID: 39532120 DOI: 10.1055/a-2416-1491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
Elbow pain can result in significant morbidity. MRI can help diagnosing the cause of elbow pain.Based on a systematic literature search as well as knowledge gained through frequent participation in conferences dedicated to advances in musculoskeletal imaging, this review aims to give a brief overview of normal anatomy and common pathologies of tendons and ligaments of the elbow on magnetic resonance imaging.Stabilization of the elbow joint is provided by osseous structures and passive ligamentous and active muscular support. Loss of these important stabilizers, due to trauma and overuse, can result in elbow instability. Additional MR views or intra-articular contrast media can be useful for the detection of specific pathologies.MRI is frequently used to detect posttraumatic or chronic conditions, which can lead to posterolateral or posteromedial elbow instability. Knowledge of normal anatomy, variants, pathologies, as well as appropriate imaging is crucial to make the diagnosis. · Epicondylitis occurs due to chronic degeneration with tendinosis and partial tendon tearing and is not related to an acute inflammatory reaction.. · Posterolateral or posteromedial elbow instability can be the result of trauma with loss of passive ligamentous and active muscular stabilization.. · The most common elbow instability is posterolateral rotatory instability with the LUCL being the most important stabilizer affected by injury.. · Schinnerl C, Weber M, Benninger E et al. MRI of the Elbow - Update 2024. Fortschr Röntgenstr 2024; DOI 10.1055/a-2416-1491.
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Affiliation(s)
- Christoph Schinnerl
- Clinic of Radiology and Nuclear Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Emanuel Benninger
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Tim S Fischer
- Clinic of Radiology and Nuclear Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Anna L Falkowski
- Clinic of Radiology and Nuclear Medicine, Cantonal Hospital Winterthur, Winterthur, Switzerland
- University of Zurich, Zurich, Switzerland
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Chen KC, Ha AS, Bartolotta RJ, Avery R, Bucknor MD, Flug J, Geannette CS, Grushky AD, Hose M, Laur O, Raizman NM, Chang EY. ACR Appropriateness Criteria® Acute Elbow and Forearm Pain. J Am Coll Radiol 2024; 21:S355-S363. [PMID: 39488347 DOI: 10.1016/j.jacr.2024.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Accepted: 08/26/2024] [Indexed: 11/04/2024]
Abstract
Acute elbow pain can be the result of traumatic and atraumatic processes. Pathologic processes include osseous, ligamentous, and tendinous etiologies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Karen C Chen
- VA San Diego Healthcare System, San Diego, California.
| | - Alice S Ha
- Panel Chair, University of California Los Angeles, Los Angeles, California
| | | | - Ryan Avery
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | | | | | - Michal Hose
- VA San Diego Healthcare System, San Diego, California and University of California San Diego, San Diego, California, Primary care physician
| | - Olga Laur
- Weill Cornell Medicine, New York, New York
| | - Noah M Raizman
- The Centers for Advanced Orthopaedics, George Washington University, Washington, DC and Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; American Academy of Orthopaedic Surgeons
| | - Eric Y Chang
- Specialty Chair, VA San Diego Healthcare System, San Diego, California
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Chorba R, Hu C, Feldtmann J. Triceps Tendon Avulsion in a Soldier: A Case Report. Int J Sports Phys Ther 2024; 19:618-624. [PMID: 38707857 PMCID: PMC11065787 DOI: 10.26603/001c.116276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/20/2024] [Indexed: 05/07/2024] Open
Abstract
Background Clinical assessment of triceps brachii tendon tears is challenging, and conventional imaging methods have limitations. Timely surgical referral is important in high-grade tears to maximize patient outcomes, and musculoskeletal ultrasound (MSK US) can be used at the time of clinical examination to identify such injuries requiring advanced imaging and orthopedic referral. Hypothesis/Purpose The purpose of this case report is to describe how MSK US was used to facilitate advanced imaging and timely orthopedic referral for a patient presenting to a physical therapist with a high-grade triceps tendon avulsion. Study Design Case Report. Case Description A 35-year-old male soldier presented to a direct access sports physical therapist with acute-on-chronic right elbow pain. Physical examination and MSK US were used to identify a high-grade partial triceps brachii tendon tear. The MSK US findings informed the physical therapist's decision-making process to refer the subject for timely advanced imaging studies as well as referral to an orthopedic physician. Outcomes A high-grade partial triceps tendon avulsion was confirmed on magnetic resonance imaging (MRI). The subject was then seen by an orthopedic surgeon and underwent surgical repair of the tendon within the recommended three-week timeframe for optimal outcomes. The subject completed a post-operative rehabilitation program and returned to full physical and occupational activities. Conclusion MSK US can assist in the diagnosis of challenging triceps tendon injuries, facilitating timely advanced imaging and orthopedic referrals for high-grade injuries to optimize patient outcomes. Level of Evidence 5.
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Geyer S, Kadantsev P, Bohnet D, Marx C, Vieider RP, Braun S, Siebenlist S, Lappen S. Partial ruptures of the distal triceps tendons show only slightly lower ultimate load to failure: a biomechanical study. BMC Musculoskelet Disord 2023; 24:590. [PMID: 37468862 PMCID: PMC10357868 DOI: 10.1186/s12891-023-06720-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023] Open
Abstract
OBJECTIVE Partial ruptures of the distal triceps tendon are usually treated surgically from a size of > 50% tendon involvement. The aim of this study was to compare the ultimate load to failure of intact triceps tendons with partially ruptured tendons and describe the rupture mechanism. METHODS Eighteen human fresh-frozen cadaveric elbow specimens were randomly assigned to two groups with either an intact distal triceps tendon or with a simulated partial rupture of 50% of the tendon. A continuous traction on the distal triceps tendon was applied to provoke a complete tendon rupture. The maximum required ultimate load to failure of the tendon in N was measured. In addition, video recordings of the ruptures of the intact tendons were performed and analysed by two independent investigators. RESULTS A median ultimate load to failure of 1,390 N (range Q0.25-Q0.75, 954 - 2,360) was measured in intact distal triceps tendons. The median ultimate load to failure of the partially ruptured tendons was 1,330 N (range Q0.25-Q0.75, 1,130 - 1.470 N). The differences were not significant. All recorded ruptures began in the superficial tendon portion, and seven out of nine tendons in the lateral tendon portion. DISCUSSION Partial ruptures of the distal triceps tendon demonstrate a not statistically significant lower ultimate load to failure than intact tendons and typically occur in the superficial, lateral portion of the tendon. This finding can be helpful when deciding between surgical and conservative therapy for partial ruptures of the distal triceps tendon.
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Affiliation(s)
- Stephanie Geyer
- Department of Sports Orthopeadics, Technical University of Munich, Klinikum Rechts Der Isar, Ismaninger Straße 22, Munich, 81675, Germany
- St. Vinzenz Kliniken Pfronten Im Allgäu, Pfronten, Germany
| | - Pavel Kadantsev
- Department of Sports Orthopeadics, Technical University of Munich, Klinikum Rechts Der Isar, Ismaninger Straße 22, Munich, 81675, Germany
| | - Daniel Bohnet
- Department of Sports Orthopeadics, Technical University of Munich, Klinikum Rechts Der Isar, Ismaninger Straße 22, Munich, 81675, Germany
| | - Christian Marx
- UMIT - Private Universität für Gesundheitswissenschaften, Medizinische Informatik und Technik, Private University Hall, Hall/Tirol, Austria
| | - Romed P Vieider
- Department of Sports Orthopeadics, Technical University of Munich, Klinikum Rechts Der Isar, Ismaninger Straße 22, Munich, 81675, Germany
| | - Sepp Braun
- UMIT - Private Universität für Gesundheitswissenschaften, Medizinische Informatik und Technik, Private University Hall, Hall/Tirol, Austria
- Gelenkpunkt - Sports and Joint Surgery Innsbruck, Innsbruck, Austria
| | - Sebastian Siebenlist
- Department of Sports Orthopeadics, Technical University of Munich, Klinikum Rechts Der Isar, Ismaninger Straße 22, Munich, 81675, Germany.
| | - Sebastian Lappen
- Department of Sports Orthopeadics, Technical University of Munich, Klinikum Rechts Der Isar, Ismaninger Straße 22, Munich, 81675, Germany
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Trizepssehnenrupturen. ARTHROSKOPIE 2023. [DOI: 10.1007/s00142-022-00572-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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Ricci V, Güvener O, Chang KV, Wu WT, Mezian K, Kara M, Leblebicioğlu G, Pirri C, Ata AM, Dughbaj M, Jain NB, Stecco C, Özçakar L. EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Elbow. Am J Phys Med Rehabil 2022; 101:e83-e92. [PMID: 34930863 DOI: 10.1097/phm.0000000000001915] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT In this dynamic protocol, ultrasound examination of the elbow using different maneuvers is described for several/relevant elbow problems. Scanning videos are coupled with real-time patient examination videos for better understanding. The authors believe that this practical guide-prepared by an international consensus of several experts (EURO-MUSCULUS: European Musculoskeletal Ultrasound Study Group and USPRM: Ultrasound Study Group of ISPRM [International Society of Physical and Rehabilitation Medicine])-will help musculoskeletal physicians perform a better and uniform/standard approach.
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Affiliation(s)
- Vincenzo Ricci
- From the Physical and Rehabilitation Medicine Unit, Luigi Sacco University Hospital, ASST Fatebenefratelli-Sacco, Milan, Italy (VR); Department of Physical and Rehabilitation Medicine, Mersin University Medical School, Mersin, Turkey (OG); Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan (K-VC, W-TW); National Taiwan University College of Medicine, Taipei, Taiwan (K-VC); Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic (KM); Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey (MK, LÖ); The Hand Clinic, Ankara, Turkey (GL); Department of Neurosciences, Institute of Human Anatomy, University of Padova, Padova, Italy (CP, CS); Ankara City Hospital, Physical Medicine and Rehabilitation Hospital, Ankara, Turkey (AMA); Physical Medicine and Rehabilitation Hospital, Ministry of Health, Kuwait City, Kuwait (MD); and Departments of Physical Medicine and Rehabilitation, Orthopaedics, and Population and Data Sciences, University of Texas Southwestern, Dallas, Texas (NBJ)
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Cell-based therapy of the elbow: evidence for lateral tendinopathy-a review on current treatments. Knee Surg Sports Traumatol Arthrosc 2022; 30:1152-1160. [PMID: 33885945 DOI: 10.1007/s00167-021-06541-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/16/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Cell-based therapies are on the rise in treating intra and extraarticular pathologies, trying to avoid surgical intervention and support local repair processes. Therefore, the aim was to summarize current evidence-based treatment options for a cell-based therapy around the elbow. METHODS Through a literature review up-to date treatment algorithms and therapies have been identified and have been rated according to their evidence level for clinical recommendation. RESULTS Regarding the four extraarticular anatomical regions of the elbow (anterior, medial, posterior and lateral) and the joint itself, the lateral elbow and its´ tendinopathies as well as the use of cell-based treatment options have been extensively studied and, therefore, allow for clear and evidence-based recommendations. The remaining three regions as wells as the intraarticular application do not show enough evidence for a clinical recommendation. CONCLUSION In conclusion the cell-based approach for treating elbow pathologies can only be recommended for the lateral elbow, as there has been shown sufficient evidence for the extraarticular application. It has to be mentioned, that the results from the lateral elbow maybe transferred to other extra-articular tendinopathies, as the lack of evidence may be due to the rare appearance of posterior, medial and anterior tendon affection. No recommendation can be given for intra-articular use. LEVEL OF EVIDENCE IV.
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Distal Triceps Tendon Tears: Magnetic Resonance Imaging Patterns Using a Systematic Classification. J Comput Assist Tomogr 2022; 46:224-230. [PMID: 35081601 DOI: 10.1097/rct.0000000000001265] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to evaluate distal triceps tendon tear patterns using a systematic classification based on the tendon's layered structure. METHODS We retrospectively identified Magnetic resonance imaging (MRI) examinations with triceps tendon tears that underwent reconstructive surgery. Magnetic resonance images were reviewed independently by 2 musculoskeletal radiologists to determine tendon layer involvement and ancillary findings, including tear size, involvement of triceps lateral expansion, and presence of olecranon bursal fluid. Surgical reports were scrutinized for level of anatomic detail and correlation with imaging findings. RESULTS We identified 69 triceps tendon tears in 68 subjects (61 men, 7 women; mean age, 45 ± 12 years) who underwent surgical reconstruction. On MRI, the superficial layer was always involved with either a partial or full-thickness tear. The most common tear pattern was a combination of superficial layer full-thickness tear with deep layer partial tear (25 of 69 [36%]). Mean tear length was 24 ± 12 mm. We found no cases of isolated deep layer tears. Involvement of triceps lateral expansion and presence of bursal fluid correlated positively with tear severity of superficial and deep layers (P < 0.001). Detailed surgical correlation was limited, with only 9 of 69 (13%) of surgical reports containing information specifically addressing individual tendon layers. CONCLUSIONS Triceps tendon tears show tear patterns following its layered structure and can be assessed by MRI. Radiologists and surgeons are encouraged to describe tear patterns considering both superficial and deep tendon layers.
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Lee JH, Ahn KB, Kwon KR, Kim KC, Rhyou IH. Differences in Rupture Patterns and Associated Lesions Related to Traumatic Distal Triceps Tendon Rupture Between Outstretched Hand and Direct Injuries. Clin Orthop Relat Res 2021; 479:781-789. [PMID: 33181575 PMCID: PMC8083823 DOI: 10.1097/corr.0000000000001550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 10/07/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traumatic distal triceps tendon rupture results in substantial disability in the absence of an appropriate diagnosis and treatment. To the best of our knowledge, differences in the degree of injury according to the injury mechanisms and associated lesions are not well known. QUESTIONS/PURPOSES In this study, we asked: (1) What differences are seen in triceps tear patterns between indirect injuries (fall on an outstretched hand) and direct injuries? (2) What are the associated elbow and soft tissue injuries seen in indirect and direct triceps ruptures? METHODS Between 2006 and 2017, one center treated 73 elbows of 72 patients for distal triceps tendon rupture. Of those, 70% (51 of 73 elbows) was excluded from this study; 8% (6 of 73) were related to systemic diseases, 59% (43 of 73) sustained open injuries, and 3% (2 of 73) were related to local steroid injections. We retrospectively collected data on traumatic distal triceps tendon rupture in 30% (22 of 73) of elbows at a single trauma center during a 10-year period. A fall on an outstretched hand was the cause of injury in 15 patients and direct blow by object or contusion were the cause in seven. MRI and surgery were performed in all patients. Traumatic distal triceps tendon rupture was classified by the Giannicola method, which is classified according to the depth and degree of the lesion based on MRI and surgical findings. Associated fractures and bone contusions on MRI were characterized. Ligament injuries on MRI was divided into partial and complete rupture. Agreement between the MRI and intraoperative findings for the presence of a traumatic distal triceps tendon rupture was perfect, and the Giannicola classification of traumatic distal triceps tendon rupture was good (kappa = 0.713). RESULTS In the indirect injury group (fall on an outstretched hand), 15 of 15 patients had injuries that involved only the tendinous portion of the distal triceps, but these injuries were not full-thickness tears, whereas in the direct injury group, three of seven patients had a full-thickness rupture (odds ratio [OR] 1.75 [95% CI 0.92 to 3.32]; p = 0.02). The direct injury group had no associated ligamentous injuries while 14 of 15 patients with indirect injuries had ligamentous injuries (OR 0.13 [95% CI 0.02 to 0.78]; p < 0.001; associated injuries in the indirect group: anterior medial collateral ligament [14 of 15], posterior medial collateral ligament [7 of 15], and lateral collateral ligament complex [2 of 15]). Similarly, one of seven patients in the direct injury group had a bone injury (capitellar contusion), whereas 15 of 15 patients with indirect ruptures had associated fractures or bone contusions (OR 16.0 [95% CI 2.4 to 106.7]; p < 0.001). CONCLUSION A fall on an outstretched hand may result in an injury mostly to the lateral and long head of distal triceps tendon and an intact medial head tendon; however, direct injuries can involve full-thickness ruptures. Although a traumatic distal triceps tendon rupture occurs after a fall on an outstretched hand, radial neck, capitellar, and medial collateral ligament injury can occur because of valgus load and remnant extensor mechanisms. Based on our finding, the clinician encountering a distal triceps tendon rupture due to a fall on an outstretched hand should be aware of the possibility of remaining elbow extensor mechanism by intact medial head tendon portion, and associated injuries, which may induce latent complications. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Ji Ho Lee
- J. H. Lee, K. B. Ahn, K. C. Kim, I. H. Rhyou, Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, SM Christianity Hospital, Pohang, South Korea
- K. R. Kwon, Department of Radiology Semyeong Christianity Hospital, Pohang, South Korea
| | - Kee Baek Ahn
- J. H. Lee, K. B. Ahn, K. C. Kim, I. H. Rhyou, Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, SM Christianity Hospital, Pohang, South Korea
- K. R. Kwon, Department of Radiology Semyeong Christianity Hospital, Pohang, South Korea
| | - Kwi Ryun Kwon
- J. H. Lee, K. B. Ahn, K. C. Kim, I. H. Rhyou, Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, SM Christianity Hospital, Pohang, South Korea
- K. R. Kwon, Department of Radiology Semyeong Christianity Hospital, Pohang, South Korea
| | - Kyung Chul Kim
- J. H. Lee, K. B. Ahn, K. C. Kim, I. H. Rhyou, Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, SM Christianity Hospital, Pohang, South Korea
- K. R. Kwon, Department of Radiology Semyeong Christianity Hospital, Pohang, South Korea
| | - In Hyeok Rhyou
- J. H. Lee, K. B. Ahn, K. C. Kim, I. H. Rhyou, Department of Orthopedic Surgery, Upper Extremity and Microsurgery Center, SM Christianity Hospital, Pohang, South Korea
- K. R. Kwon, Department of Radiology Semyeong Christianity Hospital, Pohang, South Korea
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Akamatsu FE, Negrão JR, Rodrigues MB, Itezerote AM, Saleh SO, Hojaij F, Andrade M, Jacomo AL. Is there something new regarding triceps brachii muscle insertion? Acta Cir Bras 2020; 35:e202001007. [PMID: 33237178 PMCID: PMC7709896 DOI: 10.1590/s0102-865020200100000007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 09/19/2020] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Previous studies have questioned whether the triceps brachii muscle tendon (TBMT) has a double or single insertion on the ulna. Aiming to provide an answer, we describe the anatomy of the TBMT and review a magnetic resonance imaging (MRI) series of the elbow. METHODS Forty-one elbows were dissected to assess the details of the triceps brachii insertion. Elbow plastination slices were analyzed to determine whether there was a space on the TBMT. Magnetic resonance imaging from the records of the authors were also obtained to demonstrate the appearance of the pre-tricipital space on MRI. RESULTS A virtual space on the medial aspect near the TBTM insertion site in the olecranon was consistently found on anatomic dissections. It was a distal pre-tricipital space. Magnetic resonance imaging demonstrated the appearance of the pre-tricipital space on MRI, and its extension was measured longitudinally either in elbow flexion or extension. There was no statistically significant difference between the measurements of this space in the right and left elbows or between flexion and extension (p > 0.05). The coefficient of variation was <10% for all measurements. CONCLUSION Knowledge of this structure may be essential to avoid incorrect diagnosis and unnecessary therapeutic interventions.
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12
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Dixit A, Dandu N, Hadley CJ, Nazarian LN, Cohen SB, Ciccotti M. Ultrasonographic Technique, Appearance, and Diagnostic Accuracy for Common Elbow Sports Injuries. JBJS Rev 2020; 8:e19.00219. [PMID: 33186208 DOI: 10.2106/jbjs.rvw.19.00219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Ultrasonography is a valuable diagnostic imaging tool because of its availability, tolerability, low cost, and utility in real-time dynamic evaluation. Its use in diagnosing elbow injuries has expanded recently and continues to do so. In particular, stress ultrasonography represents a unique imaging technique that directly visualizes the ulnar collateral ligament (UCL) and allows the assessment of ligament laxity, offering an advantage over magnetic resonance imaging and magnetic resonance arthrography in this patient population. Furthermore, ultrasonography has shown particular usefulness in instances where invasive techniques might be less desirable. This is particularly important in athletes since more invasive procedures potentially result in lost time from their sport. Ultrasonography is an important imaging tool that complements a thorough history and physical examination in the evaluation of elbow injuries in athletes. The use of ultrasonography in orthopaedic sports medicine has been investigated previously; however, to our knowledge, there has been no comprehensive review regarding the utility of ultrasonography for common elbow injuries in athletes. The current study provides a comprehensive, detailed review of the utility and indications for the use of ultrasonography for common elbow injuries in athletes.
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Affiliation(s)
- Anant Dixit
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Pasadena, California
| | - Navya Dandu
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Christopher J Hadley
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Levon N Nazarian
- Thomas Jefferson University Hospital at Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Steven B Cohen
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael Ciccotti
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Abstract
Distal triceps ruptures are uncommon, usually caused by a fall on an outstretched hand or a direct blow. Factors linked to injury include eccentric loading of a contracting triceps, anabolic steroid use, weightlifting, and traumatic laceration. Risk factors include local steroid injection, hyperparathyroidism, and olecranon bursitis. Initial diagnosis can be complicated by pain and swelling, and a palpable defect is not always present. Plain radiographs can be helpful. MRI confirms the diagnosis and directs treatment. Incomplete tears can be treated nonsurgically; complete tears are best managed surgically. Good to excellent restoration of function has been shown with surgical repair.
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Distal insertional anatomy of the triceps brachii muscle: MRI assessment in cadaveric specimens employing histologic correlation and Play-doh ® models of the anatomic findings. Skeletal Radiol 2020; 49:1057-1067. [PMID: 31993688 DOI: 10.1007/s00256-020-03382-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/18/2020] [Accepted: 01/21/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Assess the insertional anatomy of the distal aspect of the triceps brachii muscle using magnetic resonance imaging (MRI) in cadavers with histologic correlation and Play-doh® models of the anatomic findings. MATERIALS Elbows were obtained from twelve cadaveric arm specimens by transverse sectioning through the proximal portion of the humerus and the midportion of the radius and ulna. MRI was performed in all elbows. Two of the elbow specimens were then dissected while ten were studied histologically. Subsequently, Play-doh® models of the anatomic findings of the distal attachment sites of the triceps brachii muscle were prepared. RESULTS MRI showed a dual partitioned appearance of the distal attachment sites into the olecranon in all specimens. In the deeper tissue planes, the medial head muscle insertion was clearly identified while superficially, the terminal portion of the long and lateral heads appeared as a conjoined tendon. Histologic analysis, however, showed continuous tissue rather than separate structures attaching to the olecranon. CONCLUSION Although MRI appeared to reveal separate and distinct attachments of the triceps brachii muscle into the olecranon, histologic analysis delineated complex but continuous tissue related to the attachments of the three heads of this muscle. The Play-doh® models were helpful for the comprehension of this complex anatomy and might serve as a valuable educational tool when applied to the analysis of other musculoskeletal regions.
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Barco R, Sánchez P, Morrey ME, Morrey BF, Sánchez-Sotelo J. The distal triceps tendon insertional anatomy-implications for surgery. JSES OPEN ACCESS 2017; 1:98-103. [PMID: 30675548 PMCID: PMC6340860 DOI: 10.1016/j.jses.2017.05.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Improved knowledge of the distal triceps insertion is needed as a result of an increase in procedures involving this area, including distal triceps repair, posterior capsulectomy, and olecranon tip osteotomy for coronoid reconstruction. Materials and methods Five pair-matched upper limbs were dissected to study the morphology and dimension of the distal triceps tendon, triceps tendon insertion, capsular insertion on the olecranon, and triceps lateral retinaculum. Muscle origins of the triceps insertions were identified proximally. Results Three distinct insertional areas were found in the olecranon corresponding to the posterior capsular insertion, the deep muscular portion, and the superficial tendinous portion of the triceps with areas of 1.5, 1.2, and 2.8 cm2, respectively. The deep muscular head corresponded to the medial head of the triceps and the tendinous portion corresponded to the long and lateral heads and correlated with the height of the specimen. The triceps width at insertion was 2.6 ± 0.5 cm (standard deviation), and the triceps lateral retinaculum extended the tendon laterally for 2.5 ± 0.7 cm. The tendinous portion of the triceps tendon extended proximally 15.3 ± 1.4 cm. The triceps inserted at a mean of 1.1 cm from the tip of the olecranon. Conclusions The distinct insertional heads of the triceps provides additional knowledge that can aid in diagnosing and treating partial triceps tears. In addition, a safe zone for capsulectomy and olecranon tip osteotomy is described that can be used to increase the safety of these procedures.
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Affiliation(s)
- Raul Barco
- Shoulder & Elbow Unit, Hospital Universitario La Paz, Madrid, Spain
| | | | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bernard F Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Shuttlewood K, Beazley J, Smith CD. Distal triceps injuries (including snapping triceps): A systematic review of the literature. World J Orthop 2017; 8:507-513. [PMID: 28660143 PMCID: PMC5478494 DOI: 10.5312/wjo.v8.i6.507] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/13/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To review current literature on types of distal triceps injury and determine diagnosis and appropriate management.
METHODS We performed a systematic review in PubMed, Cochrane and EMBASE using the terms distal triceps tears and snapping triceps on the 10th January 2017. We excluded all animal, review, foreign language and repeat papers. We reviewed all papers for relevance and of the papers left we were able to establish the types of distal triceps injury, how these injuries are diagnosed and investigated and the types of management of these injuries including surgical. The results are then presented in a review paper format.
RESULTS Three hundred and seventy-nine papers were identified of which 65 were relevant to distal triceps injuries. After exclusion we had 47 appropriate papers. The papers highlighted 2 main distal triceps injuries: Distal triceps tears and snapping triceps. Triceps tear are more common in males than females occurring in the 4th-5th decade of life and often due to a direct trauma but are also strongly associated with weightlifting and American football. The tears are diagnosed by history and clinically with a palpable gap. Diagnosis can be confirmed with the use of ultrasound (US) and magnetic resonance imaging. Treatment depends on type of tear. Partial tears can be treated conservatively with bracing and physio whereas acute tears need repair either open or arthroscopic using suture anchor or bone tunnel techniques with similar success. Chronic tears often need augmenting with tendon allograft or autograft. Snapping triceps are also seen more in men than women but at a mean age of 32 years. They are characterized by a snapping sensation mostly medially and can be associated with ulna nerve subluxation and ulna nerve symptoms. US is the diagnostic modality of choice due to its dynamic nature and to differentiate between snapping triceps tendon or ulna nerve. Treatment is conservative initially with activity avoidance and if that fails surgical management includes resection of triceps edge or transposition of the tendon plus or minus ulna nerve transposition.
CONCLUSION Distal triceps injuries are uncommon. This systematic review examines the evidence base behind diagnosis, imaging and treatment options of distal triceps injuries including tears and snapping triceps.
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Hall MM, Woodroffe L. Ultrasonic Percutaneous Tenotomy for Recalcitrant Calcific Triceps Tendinosis in a Competitive Strongman. Curr Sports Med Rep 2017; 16:150-152. [DOI: 10.1249/jsr.0000000000000353] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Elbow Ultrasound. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-016-0182-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Acute triceps ruptures are an uncommon entity, occurring mainly in athletes, weight lifters (especially those taking anabolic steroids), and following elbow trauma. Accurate diagnosis is made clinically, although MRI may aid in confirmation and surgical planning. Acute ruptures are classified on an anatomic basis based on tear location and the degree of tendon involvement. Most complete tears are treated surgically in medically fit patients. Partial-thickness tears are managed according to the tear severity, functional demands, and response to conservative treatment. We favor an anatomic footprint repair of the triceps to provide optimal tendon to bone healing and, ultimately, functional outcome.
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Affiliation(s)
- Jay D Keener
- Department of Orthopaedic Surgery, Washington University, CB# 8233, 660 South Euclid Avenue, St Louis, MO 63110, USA.
| | - Paul M Sethi
- The ONS Sports and Shoulder Service, 6 Greenwich Office Park, Greenwich, CT 06831, USA
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Kose O, Kilicaslan OF, Guler F, Acar B, Yuksel HY. Functional outcomes and complications after surgical repair of triceps tendon rupture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1131-9. [PMID: 26164405 DOI: 10.1007/s00590-015-1669-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 07/03/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The purpose of this study was to present the functional outcomes and complications after primary repair of triceps tendon ruptures (TTR). PATIENTS AND METHODS A retrospective review was performed on eight patients (six males, two females) who underwent transosseous suture repair for TTR. Mayo elbow score, range of motion, muscle strength and patient satisfaction were evaluated after at least 1-year follow-up. RESULTS The mean age of the patients was 25.1 years (range 16-42). The mechanism of injury was a sports injury in three patients, simple fall (fall on outstretched hand) in four and motorcycle accident in one patient. Two patients had associated radial head fracture, and one had a radial head fracture and trochlear fracture, and one patient had a medial epicondyle fracture. In two patients the diagnosis was missed at the initial admission to ED (delay, 20 and 75 days). Only one patient, who was a bodybuilder, had a history of anabolic steroid use, and the rest had no underlying disease or a predisposing factor for TTR. One of the patients with radial head fracture (displaced three parts) underwent simultaneous fixation using two headless screws. Patients were followed up for a mean of 18.8 months (range 12-26). At the final follow-up, all patients were satisfied with the treatment and the Mayo elbow score was excellent in six patients and good in two patients. There was 5° extension loss in two patients. Triceps muscle strength was 5/5 in all patients. Ulnar nerve entrapment occurred in one patient, so ulnar nerve release and anterior transposition were performed 3 months after surgery. Posterior interosseous nerve palsy occurred in one patient who underwent simultaneous radial head fracture fixation, but eventually returned back to normal 3 months postoperatively. All patients returned to their previous level of activity and occupation. CONCLUSION Transosseous suture technique is a safe and effective treatment method for acute TTR with a low rate of complications and excellent functional outcomes. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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Affiliation(s)
- Ozkan Kose
- Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, Uncalı mahallesi Toroslar caddesi, Samut Comfort Palace E Blok No: 2, Konyaaltı, Antalya, Turkey.
| | - Omer Faruk Kilicaslan
- Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, Uncalı mahallesi Toroslar caddesi, Samut Comfort Palace E Blok No: 2, Konyaaltı, Antalya, Turkey
| | - Ferhat Guler
- Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, Uncalı mahallesi Toroslar caddesi, Samut Comfort Palace E Blok No: 2, Konyaaltı, Antalya, Turkey
| | - Baver Acar
- Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, Uncalı mahallesi Toroslar caddesi, Samut Comfort Palace E Blok No: 2, Konyaaltı, Antalya, Turkey
| | - Halil Yalçın Yuksel
- Department of Orthopedics and Traumatology, Antalya Education and Research Hospital, Uncalı mahallesi Toroslar caddesi, Samut Comfort Palace E Blok No: 2, Konyaaltı, Antalya, Turkey
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Abstract
As with other musculoskeletal joints, elbow ultrasonography (US) depends on the examination technique. Deep knowledge of the relevant anatomy, such as the bone surface anatomy, tendon orientation, nerves, and vessels, is crucial for diagnosis. It is important to be aware of the primary imaging pitfalls related to US technique (anisotropy) in the evaluation of deep tendons such as the distal biceps and peripheral nerves. In this article, US scanning technique for the elbow as well as the related anatomy, primary variants, and scanning pitfalls are described. In addition, an online video tutorial of elbow US describes a possible approach to elbow evaluation. Online supplemental material is available for this article.
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Affiliation(s)
- Alberto S Tagliafico
- From the Institute of Anatomy, Department of Experimental Medicine (DIMES) (A.S.T.), and Department of Health Sciences (DISSAL) (B.B., C.M.), University of Genoa, Largo Rosanna Benzi 8, 16132 Genoa, Italy
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Irwin RW, Wolff ET. Assessment of neuromuscular conditions using ultrasound. Phys Med Rehabil Clin N Am 2014; 25:531-43, vii. [PMID: 25064787 DOI: 10.1016/j.pmr.2014.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Upper extremity pain in persons with spinal cord injury is a common cause of morbidity. Ultrasound of nerve, muscle, and tendon has the potential to become a valuable modality in assessing this population, and has the advantage of reduced health care costs, portability, and use in populations that cannot tolerate MRI. It has the potential to detect issues before the onset of significant morbidity, and preserve patient independence. Upper extremity ultrasound already has many studies showing its utility in diagnosis, and newer techniques have the potential to enhance its use in the diagnosis and management of musculoskeletal conditions.
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Affiliation(s)
- Robert W Irwin
- Department of Rehabilitation Medicine, Miller School of Medicine, University of Miami, 1120 North West 14th Street, Miami, FL 33136, USA; Medical Education, Miller School of Medicine, University of Miami, 1120 North West 14th Street, Miami, FL 33136, USA.
| | - Erin T Wolff
- Department of Rehabilitation Medicine, Miller School of Medicine, University of Miami, 1120 North West 14th Street, Miami, FL 33136, USA
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Donaldson O, Vannet N, Gosens T, Kulkarni R. Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies. Shoulder Elbow 2014; 6:47-56. [PMID: 27582910 PMCID: PMC4986646 DOI: 10.1111/sae.12022] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 04/19/2013] [Indexed: 01/17/2023]
Abstract
In the second part of this review article the management of medial elbow tendinopathy, distal biceps and distal triceps tendinopathy will be discussed. There is a scarcity of publications concerning any of these tendinopathies. This review will summarise the current best available evidence in their management. Medial elbow tendinopathy, also known as Golfer's elbow, is up to 6 times less common than lateral elbow tendinopathy. The tendinopathy occurs in the insertion of pronator teres and flexor carpi radialis. Diagnosis is usually apparent through a detailed history and examination but care must be made to exclude other conditions affecting the ulnar nerve or less commonly the ulnar collateral ligament complex. If doubt exists then MRI/US and electrophysiology can be used. Treatment follows a similar pattern to that of lateral elbow tendinopathy. Acute management is with activity modification and topical NSAIDs. Injection therapy and surgical excision are utilised for recalcitrant cases. Distal biceps and triceps tendinopathies are very rare and there is limited evidence published. Sequelae of tendinopathy include tendon rupture and so it is vital to manage these tendinopathies appropriately in order to minimise this significant complication. Their management and that of partial tears will be considered.
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Affiliation(s)
| | - Nicola Vannet
- Department of Orthopaedics, Royal Gwent Hospital, Newport, UK
| | - Taco Gosens
- Department of Orthopaedics and Traumatology, St Elisabeth Hospital, Tilburg, Netherlands
| | - Rohit Kulkarni
- Department of Orthopaedics, Royal Gwent Hospital, Newport, UK
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Abstract
OBJECTIVE Overuse and traumatic injuries of the elbow are common, occurring in both athletes and nonathletes. This article will discuss the commonly encountered soft-tissue and osseous pathologic abnormalities around the elbow and their imaging appearance on MRI and ultrasound. CONCLUSION The current treatment of tendon disease of the elbow is reviewed, with a focus on platelet-rich plasma injection.
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Abstract
Context: Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic surgeons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment outcomes will enable the appropriate management of patients and their expectations. Evidence Acquisitions: The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy. Results: Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments. Conclusions: Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate benefit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diagnosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury.
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