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

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.