0:00

Okay, welcome back everybody.

0:02

And, uh, we will move on with the second part of,

0:05

uh, today's program.

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Again, concentrating on the elbow.

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I'm gonna spend about 40

0:13

to 45 minutes talking about the major tendons, uh,

0:17

about the elbow discussing their anatomy

0:20

and their patterns of failure.

0:24

Just to give you an overview of what I plan to cover

0:27

during this period of time.

0:29

We'll start with the anterior structures, the biceps

0:33

and the brachialis.

0:35

We will then, uh, be talking about, uh,

0:38

posterior structures, triceps, and then the medial

0:42

and lateral structures, the flexor pronator,

0:45

and extensor groups.

0:47

And we'll be covering the major abnormalities

0:50

and give you some anatomic points that may help you

0:53

as you try to identify them.

0:57

Well, let's start with a tendon

0:58

with which you're probably most familiar,

1:00

and that is the biceps tendon.

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Biceps is a, uh, fusiform muscle with two sites of origin.

1:09

As you know about the shoulder,

1:11

the short head arises from the cricoid process.

1:16

The long head arises both from bone

1:19

and soft tissue in the majority of us,

1:21

but sometimes just from the supra, glenoid tubercle

1:25

or the labrum, not from both structures.

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And then they converge

1:30

and join somewhere about the region of the upper humerus

1:35

and continue down as a distal tendon

1:38

or tendons, as we have talked about, attaching

1:42

to the radial tuberosity in the proximal

1:45

portion of the radius.

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So when we study this particular tendon,

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we're studying it over a long length,

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and as we're talking about the elbow in terms

1:56

of studying the biceps tendon about the elbow,

1:59

we usually start somewhere around the mid shaft

2:02

of the humerus, and we must follow it down all the way

2:06

to its attachment on the radial tuberosity.

2:10

I emphasize that particular point

2:12

because in fact,

2:14

sometimes we end up not including the radial tuberosity

2:19

in the field of view,

2:20

and without that, you're really not able to evaluate one

2:24

of the major regions where it suffers

2:27

and where it may be abnormal.

2:30

Now the short head and the long head differ.

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In fact, the short head is a better flexor than supinator.

2:36

The long head is a better supinator than flexor.

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Now we'll talk also, uh, about some

2:44

of the other structures intimate with these tendons of the,

2:47

uh, uh, biceps.

2:49

Here's what it looks like on the sagittal view.

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I'm showing you three particular, uh,

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images going from more medial site to a more lateral, uh,

2:59

at the top to a more lateral site at the bottom.

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And you can see the region of the myo tendonous junction.

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And then we follow it down here in front of the brachialis,

3:11

and then we can see its attachment to the proximal radius.

3:15

Unfortunately, it is generally impossible

3:19

to include the entire biceps muscle

3:22

tendon unit on a single sagittal image.

3:25

You have to trace it on series of, uh, sagittal images.

3:31

Now, there is a another structure

3:33

that is particularly important that's seen distally

3:37

about the biceps tendons

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and extends over in a medial direction to the area

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of the flexor muscles.

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And this, of course, is designated the lacer fibrosis,

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I'm showing you with the blue arrow here tends

3:53

to be a little bit narrow at the level of the tendons

3:57

and becomes more broader as it extends over to the, uh,

4:01

flexor musculature.

4:03

And there have been some articles to indicate

4:06

that it extends through or around that musculature

4:08

and attaches to the ula.

4:10

But tracing it all the way to its bone attachments, I think

4:15

can be, uh, very, very difficult.

4:17

Here. You can appreciate what it looks like.

4:20

You can see how it gets broader as it extends.

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Uh, distally becoming intimate here with the flexors,

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the pronator, uh, terce now contracture

4:30

of the medial flexor muscles

4:32

because of their intimate association with erti.

4:37

Hes the erti fibrosis.

4:39

And that increased tension on that erti

4:44

leads to a medial or pulling of the biceps tendent medially.

4:49

And there's some who believe that in fact it's

4:52

that effect on the biceps tendon that leads at least

4:57

or contributes to injury to the biceps tendon.

5:02

To give you an idea of what the ERUs fibrosis, uh,

5:05

looks like, I show you two transverse images.

5:09

The one on the top is a little bit superior

5:12

to the one at the bottom.

5:14

Here we can see at the level of the distal humerus,

5:17

the biceps myotendinous region.

5:20

And here is, sorry. Here is the ERUs fibrosis.

5:24

As we extend down a little bit, again,

5:27

we can see the biceps in here is the ERUs fibrosis

5:31

extending over to the region of the flexor, uh, muscle.

5:37

Now, when there are injuries of the biceps tendon,

5:40

you can see disruption

5:41

or at least irregularity of the fibers of the ERUs fibrosis.

5:46

But much more evident in these cases is edema in the

5:51

expected location of lacer fibrosis as shown in this case.

5:57

It is suggested with regard to injury

5:59

of the erti fibrosis.

6:01

It occurs in about 50% of, uh, cases of tears

6:06

of the distal bte.

6:09

Significant retraction of the torn distal

6:13

BS tend requires injury to the erti fibrosis.

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I can't give you a distance.

6:20

I've tried to find one in the literature with regard to

6:24

how much proximal retraction requires

6:28

that the erti fibrosis is torn.

6:31

But I can tell you the more proximal is the retracted

6:35

tendon, the more likely there is an injury

6:38

to the ERUs fibrosis.

6:41

And although I'm not gonna emphasize repair

6:43

of the torn biceps tendon, I can tell you

6:46

that recent literature, I've come across articles

6:50

that suggest that if you repair the biceps tendon,

6:53

you might wanna also consider repairing the erti fibrosis

6:58

because the strength of the biceps muscle will be greater

7:03

if the erti is also repaired.