The Resolution

 Differential Diagnosis

  • Acute avulsion fracture of the radial tuberosity
  • Bicipitoradial tendinitis/bursitis
  • Partial biceps tear
  • Tear at the myotendinous junction

Diagnosis

The x-ray reveals multiple chip avulsion fractures anterior to the radial tuberosity and a flattened radial tuberosity. The patient experienced an acute biceps tendon tear at the insertion site on the radial tuberosity, with avulsion fracture of the radial tuberosity.

Learnings/What to Look for

  • Radial tuberosity is a localized bony protrusion below the radial neck. It is a major elbow flexor and forearm supinator
  • Biceps tendon avulsion tears occur when excessive tension/force is applied when the arm is extended from a flexed position to the extended position. Tears usually occur at the insertion site on the radial tuberosity
  • Clinical history is that of a painful pop, localized pain on supination, and weakness
  • Clinical findings are palpable defect in the biceps tendon region, retracted belly of biceps, and loss of flexion and supination strength
  • Radiographic findings include avulsion fracture of the radial tuberosity. Diagnosis may be confirmed on MRI study, which reveals a completely torn and retracted biceps tendon from its insertion and attached bone fragment
  • Contributory factors include male gender, smoking, use of anabolic steroids, and chronic impingement between the bones

 Pearls for Urgent Care Management and Considerations for Transfer

  • Treatment in older, sedentary, low-demand patients is usually conservative, with immobilization, analgesia, and later physical therapy. This results in diminished strength in sustained supination, flexion, and the grip strength
  • In healthy young patients, surgical repair is indicated with re-implantation of the biceps tendon on the radial tuberosity

 Acknowledgment: Images and case provided by Teleradiology Specialists, www.teleradiologyspecialists.com.

A 59-Year-Old Man with a Painful Elbow After a Fall
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