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SOFT TISSUE INJURIES

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Biceps and Triceps Tendon Ruptures

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Clinical Features
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Patients with proximal long-head biceps tendon ruptures typically describe a “snap” or “pop” and complain of pain in the anterior shoulder. Examination reveals tenderness, swelling, and crepitus over the bicipital groove in the anterior shoulder. A mid-arm “ball” (the distally retracted biceps) appears when the elbow is flexed. Elbow flexion strength is maintained due to the preserved action of the brachialis and supinators. This is in contrast to distal biceps tendon rupture where elbow flexion and supination is weak. Examination of distal biceps rupture reveals swelling, ecchymosis, tenderness, and inability to palpate the tendon in the antecubital fossa. With the patient seated, the elbow flexed 60 to 80 degrees, and forearm resting on the patient's lap, the examiner squeezes the muscle belly of the biceps causing the forearm to supinate (biceps squeeze test). If no supination is noted, then this is a positive test indicating a distal biceps tendon rupture. Triceps tendon ruptures are rare, and the majority occur distally. Patients present with pain, swelling, and tenderness proximal to the olecranon; a sulcus with a proximal mass (the proximally retracted triceps tendon) may be palpable. Forearm extension is weak. A modified Thompson test can be used to assess triceps function. With the arm supported, elbow flexed at 90 degrees, and forearm hanging in a relaxed position, squeezing the triceps muscle should produce extension of the forearm unless a complete tear is present.

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Diagnosis and Differential
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Diagnosis is clinical. Obtain radiographs to exclude an associated avulsion fracture.

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Emergency Department Care and Disposition
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Treatment includes sling, ice, analgesics, and referral to an orthopedic surgeon for definitive management. Complete tendon tears in young active individuals often require surgical repair.

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Overuse Syndromes

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Clinical Features
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Lateral epicondylitis or "tennis elbow" is more common than medial epicondylitis or "golfer's elbow." Lateral epicondylitis affects the forearm and wrist extensors, and medial epicondylitis affects the forearm and wrist flexors. Patients with medial epicondylitis may develop an ulnar neuropathy. Both syndromes result from repetitive activity involving these muscle groups.

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Diagnosis and Differential
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Diagnosis is clinical. Radiographs may help in ruling out an associated avulsion fracture of the lateral or medial epicondyle.

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Emergency Department Care and Disposition
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Management is conservative including rest, ice, anti-inflammatory medications, and bracing. Occupational therapy can be useful in treating these syndromes. Surgery is reserved for refractory cases.

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ELBOW DISLOCATIONS

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Clinical Features

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The majority of elbow dislocations are posterolateral and often occur as a result of a fall on an outstretched hand. On examination, the patient holds the elbow in 45 degrees of flexion. Significant swelling of the elbow often obscures ...

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