Radial tunnel syndrome

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a. Diagnosis. Entrapment of the posterior interosseous nerve, a branch of the radial nerve at the elbow, is a diagnosis that can be difficult to make. These patients frequently are indistinguishable from those with lateral elbow pain caused by work trauma (see section IV.A.l.b). Exquisite but dull pain over the anterior lateral elbow, distinct from the lateral epicondyle, may be present. Direct pressure over this same area should reproduce the symptoms. Weakness and pain during active extension of the middle finger can be present but is not necessarily diagnostic of this condition. Nerve conduction studies and electromyography have not been helpful the way they are in carpal tunnel syndrome.

b. Treatment. Surgical release of the radial and posterior interosseous nerves has been advocated for this condition, but consistent and effective treatment remains elusive.

3. Radial head fracture. People who fall on an outstretched hand are at special risk for this fracture.

a. The diagnosis is frequently missed because of inadequate radiography and examination. The symptoms may be a vague discomfort of the elbow, with little swelling. An ipsilateral fracture of the distal radius (Colles' fracture) may draw attention away from the elbow, and the radial head fracture goes unrecognized. Palpation of the radial head during gentle passive pronation and supination can be diagnostic, revealing exquisite tenderness or crepitation. Anteroposterior and lateral radiographs usually are diagnostic.

b. Treatment depends on the degree of displacement and other features. Most nondisplaced fractures require no splinting and benefit from early active motion.

4. Bicipital tendinitis and distal biceps rupture. Distal bicipital tendinitis can occur and may presage a distal biceps rupture.

a. Diagnosis. A patient who describes a heavy lifting activity followed by tenderness and soreness along the distal biceps tendon should be warned and the arm put at rest. A bone scan at this time can show increased uptake along the tendon, down to the insertion at the proximal radius. The biceps tendon can rupture at either end, but it is the distal end that can present as elbow pain or weakness. The rupture is usually seen in men 40 to 50 years of age, but it can also occur in younger weight lifters. Most patients feel a sudden snap or tearing in the elbow while lifting and notice a sudden bulge in the distal forearm with weakness of supination. Ecchymosis may or may not be evident. Given the appearance of the arm, the amount of discomfort can be surprisingly minimal.

b. Treatment. The decision to repair this rupture surgically must be individualized. If repair is contemplated, it is best accomplished within days of injury.

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