Shoulder and Elbow cases complicated cases of lateral epicondylitis

A 44-year-old, right-hand-dominant female is in the office with persistent lateral elbow pain of 2 years duration. She has pain at the lateral aspect of her elbow, as well as a deep aching pain that radiates down the dorsal aspect of her forearm. She has tried NSAIDs, physical therapy, bracing, and multiple injections to her lateral epicondyle without relief. On examination, she is neurovascularly intact distally with tenderness over the lateral epicondyle as well as in the proximal portion of her forearm. She has pain with resisted wrist extension, resisted long finger extension, and resisted supination. She has weakness of her finger extensors.

In addition to her extensor carpi radialis brevis, what other anatomic structure is most likely affected?

1. Extensor digitorum communis to the long finger

2. Extensor indicis proprius

3. Extensor carpi radialis longus

4. Radial nerve

5. Ulnar nerve

 

Discussion

The correct answer is (D). The patient has an atypical presentation of lateral epicondylitis, and it is important to rule out associated conditions such as radial tunnel syndrome. Radial tunnel syndrome is a compression neuropathy of the radial nerve, which unlike carpal tunnel and cubital tunnel syndromes, does not lend itself to quick and easy pattern recognition (Fig. 2–125). It can coexist with lateral epicondylitis in few cases, making diagnosis more difficult. Patients can have variable involvement of the dorsal sensory radial nerve and the posterior interosseous nerve. Symptomatology typically involves aching pain in the dorsal forearm, as well as tenderness to palpation distal to the typical site at the lateral epicondyle. Provocative tests such as pain with resisted long finger extension and resisted pronation/supination are described, although sensitivity and specificity of these tests is not well described. Nerve conduction studies are unreliable in diagnosis. Local anesthetic injection at the site of radial nerve compression has been described as a highly specific diagnostic modality.

 

 

 

Figure 2–125 Markings depicting typical area of dysesthesia for posterior cutaneous nerve of the forearm neuroma. (Reproduced with permission from Dellon AL, Kim J, Ducic I. Painful neuroma of the posterior cutaneous nerve of the forearm after surgery for lateral humeral epicondylitis. J Hand Surg Am. 2004 May;29(3):387–90.)

 

The patient opts for open debridement of the extensor carpi radialis brevis origin, as well as radial tunnel decompression. Postoperatively, she develops pain and catching in her elbow when pushing up out of a chair.

What structure is at risk and may have been injured in this case?

1. Annular ligament

2. Lateral ulnar collateral ligament

3. Radial nerve

4. Extensor carpi radialis brevis

5. Extensor digitorum communis

 

Discussion

The correct answer is (B). Surgical management of lateral epicondylitis is recommended when pain and dysfunction persist after 6 to 12 months of conservative treatment. The extensor carpi radialis brevis may be released open, percutaneously, or arthroscopically. Specific open debridement techniques vary but generally involve a 2 to 3 cm incision centered distal to the lateral epicondyle. Using sharp dissection, the degenerative tissue within the extensor carpi radialis brevis is debrided, the underlying bone is decorticated, and the tendon is reattached to the bone. With excessive debridement, the lateral ulnar collateral ligament may be

compromised resulting in iatrogenic posterolateral rotatory instability. Keeping debridement anterior to the equator of the radial head prevents destabilization of the elbow (Fig. 2–126).

 

 

 

Figure 2–126 Safe zone for debridement to avoid the lateral ulnar collateral ligament. (Reproduced with permission from Calfee RP, Patel A, DaSilva MF, Akelman E. Management of lateral epicondylitis: current concepts. J Am Acad Orthop Surg. 2008 Jan;16(1):19–29.)

 

Neuroma formation is another potential complication of open epicondylar debridement. What nerve does this usually affect?

1. Radial

2. Posterior interosseous

3. Median

4. Lateral antebrachial cutaneous

5. Posterior antebrachial cutaneous

 

Discussion

The correct answer is (E). Painful neuroma is one possible cause of persistent pain after lateral epicondylar debridement. The posterior antebrachial cutaneous nerve (Fig. 2–127) is at risk with any approach to the lateral elbow. It branches from the radial nerve in the upper third of the humerus and travels in the subcutaneous tissue in the posterolateral aspect of the upper arm toward the elbow. At the elbow it is 1.5 cm anterior to the lateral epicondyle. Dellon et al. reported on a series of nine consecutive patients treated for this complication after lateral epicondylar debridement. Patients reported cutaneous dysesthesia distal and posterior to the incision. The diagnosis was made preoperatively by using a local anesthetic block

to obtain symptomatic relief. Subsequently, the neuromas were excised and the proximal nerve stumps were buried within muscle.

 

 

 

Figure 2–127 Intraoperative photo of a posterior cutaneous nerve of the forearm neuroma. (Reproduced with permission from Dellon AL, Kim J, Ducic I. Painful neuroma of the posterior cutaneous nerve of the forearm after surgery for lateral humeral epicondylitis. J Hand Surg Am. 2004 May;29(3):387–90.)

 

Which other structure shares a proximal attachment with the extensor carpi radialis brevis?

1. Palmaris longus

2. Pronator teres

3. Brachioradialis

4. Extensor digiti minimi

5. Extensor pollicis longus

 

Discussion

The correct answer is (D). This is a pure anatomy question regarding the common extensor origin. The muscles originating from the lateral epicondyle include the common extensor tendon, which includes the extensor digitorum longus, extensor digitorum communis, extensor digiti minimi, and extensor carpi ulnaris. The extensor carpi radialis longus originates from the lateral supracondylar ridge and by a few fibers from the lateral epicondyle. The supinator and anconeus also originate from the lateral epicondyle. The palmaris longus and pronator teres originate from the common flexor tendon on the medial epicondyle. The brachioradialis originates from the lateral supracondylar ridge, while the extensor

pollicis longus originates from the ulna and interosseous membrane.

 

Objectives: Did you learn...?

 

Discuss treatment options for refractory or complicated cases of lateral epicondylitis?

 

Recognize complications associated with surgical treatment for lateral epicondylitis?