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 midarm “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 bicep 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 and the elbow flexed 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. Patients with triceps tendon ruptures 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°, and forearm hanging in a relaxed position, squeezing the triceps muscle should produce extension of the forearm unless a complete tear is present.
Diagnosis and Differential
Diagnosis is clinical. Obtain radiographs to exclude an associated avulsion fracture.
Emergency Department Care and Disposition
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.
The majority of elbow dislocations are posterolateral. On examination, the patient holds the elbow in 45° flexion. Significant swelling of the elbow often obscures the olecranon, which is directed posteriorly. Neurovascular assessment is essential (Table 171-1). An open dislocation, absence of radial pulse before reduction, and presence of systemic injuries are all factors associated with arterial injury.
Table 171-1 Sensory and Motor Function Testing of the Radial, Median, and Ulnar Nerves |Favorite Table|Download (.pdf)
Table 171-1 Sensory and Motor Function Testing of the Radial, Median, and Ulnar Nerves
Test for sensory function
Dorsum of the thumb index web space
Two-point discrimination over the tip of the index finger
Two-point discrimination over the little finger
Test for motor function
Extend both wrist and fingers against resistance
“OK” sign with thumb and index finger; abduction of the thumb (recurrent branch)
Abduct index finger against resistance
Diagnosis and Differential
Radiographs confirm the diagnosis. The lateral view reveals both the ulna and radius displaced posterior. The AP view reveals either medial or lateral displacement of the ulna and ...