The snapping elbow: a diagnostic pitfall

Snapping Triceps Syndrome: Surgical Technique

Snapping triceps syndrome is a rare cause of medial elbow pain and ulnar neuritis caused by subluxation and triggering of the medial tricipital muscle belly over the medial distal humeral ridge and condyle. The diagnosis and surgical management of snapping triceps syndrome can be challenging due to the subtlety of the symptoms and the infrequent presentation. Despite the diagnosis relying largely on clinical examination, noninvasive dynamic ultrasonography may facilitate detection. Correct recognition of this condition is crucial in the avoidance of surgical misadventure and revision surgery. This paper illustrates our surgical technique for the management of snapping triceps and reviews the available literature on this relatively obscure condition.

Ultrasonographic differential diagnosis of medial elbow pain

Medial elbow pain is a common musculoskeletal problem among individuals engaging in repetitive activities. Medial epicondylitis is the predominant cause of this pain. However, other potential causes must be considered as part of the differential diagnosis. This article discusses several etiologies of medial elbow pain, including medial epicondylitis, ulnar neuropathy, snapping triceps syndrome, ulnar collateral ligament injury, medial antebrachial cutaneous neuropathy, and diseases of the elbow joint, with an emphasis on ultrasound (US) findings. Awareness of possible diagnoses and their US features can assist radiologists in establishing a comprehensive diagnosis for medial elbow pain.

Elbow Evaluation Via Telephone and Video Visit

Background Elbow conditions and pathology are commonly seen in the outpatient clinic. Telephone and video visits can allow for expeditious assessment of elbow complaints, without the added challenges of commuting for a clinic-based evaluation. In the setting of a pandemic, the benefits of telemedicine are apparent, but the time and effort saved from being able to remotely evaluate musculoskeletal conditions are also useful in a non-pandemic situation. In this modern era of telemedicine, protocols need to be developed to provide guidance for a remote elbow evaluation. As with all musculoskeletal conditions, the history about the elbow complaint allows the clinician to develop a differential diagnosis, which is either supported or refuted based on physical examination and diagnostic studies. Appropriate questions asked over a telephone call can provide answers that lead the clinician to a specific diagnosis and treatment plan. Furthermore, responses to these same questions can be further supported by a video assessment of the affected elbow, which may provide additional evidence to support a diagnosis and plan of care. Aims To outline possible questions, responses, and video examination techniques to aid the clinician in elbow examinations conducted via telemedicine. Methods We have created a pathway for step-by-step evaluation to help physicians direct their patients through the typical elements of a thorough elbow examination via telehealth. Results We have created tables of questions, answers, and instructions to help guide the physician through different aspects of a telehealth elbow examination. We have also included a glossary of descriptive images that demonstrate each maneuver.  Conclusion This article provides a structured guide to efficiently extracting clinically relevant information during telemedicine examinations of the elbow.

[Surgical treatment of snapping triceps syndrome]

OBJECTIVE

Treatment of a persistently painful snapping triceps and possibly snapping ulnar nerve.

INDICATION

Snapping triceps.

CONTRAINDICATIONS

General surgical risks.

SURGICAL TECHNIQUE

Following the anterior transposition of the ulnar nerve (subcutaneously or submuscular), the snapping portion of the triceps tendon is transsected and reinforced, and transposition of the medial triceps margin into the central triceps portion is carried out.

POSTOPERATIVE MANAGEMENT

Cast for 5-7 days; for a total of 6 weeks functional exercise without maximum flexion and resistance exercise of the triceps. Weight loading after 3 months.

RESULTS

In the case presented, complaints were absent after 3 months. Full load exercise, e.g., push-ups, was achieved 4 months after surgery. There was no recurrent snapping within the first year. The results of this case are in agreement with the 25 patients previously reported in the PubMed literature. Recurrence, gross restrictions of movement, and complications were not observed in patients who underwent surgery.

Snapping elbow-A guide to diagnosis and treatment

AIM

To develop practical guidelines for diagnosis and treatment of the painful snapping elbow syndrome (SE).

METHODS

Clinical studies were searched in the databases PubMed and Scopus for the phrases “SE”, “snapping triceps”, “snapping ulnar nerve” and “snapping annular ligament”. A total of 36 relevant studies were identified. From these we extracted information about number of patients, diagnostic methods, patho-anatomical findings, treatments and outcomes. Practical guidelines for diagnosis and treatment of SE were developed based on analysis of the data. We present two illustrative patient cases-one with intra-articular pathology and one with extra-articular pathology.

RESULTS

Snapping is audible, palpable and often visible. It has a lateral (intra-articular) or medial (extra-articular) pathology. Snapping over the medial humeral epicondyle is caused by dislocation of the ulnar nerve or a part of the triceps tendon, and is demonstrated by dynamic ultrasonography. Treatment is by open surgery. Lateral snapping over the radial head has an intra-articular pathology: A synovial plica, a torn annular ligament or a meniscus-like remnant from the foetal elbow. Pathology can be visualized by conventional arthrography, magnetic resonance (MR) arthrography, high resolution magnetic resonance imaging (MRI) and arthroscopy, while conventional MRI and radiographs often turn out normal. Treatment is by arthroscopic or eventual open resection. Early surgical intervention is recommended as the snapping can damage the ulnar nerve (medial) or the intra-articular cartilage (lateral). If medial snapping only occurs during repeated or loaded extension/flexion of the elbow (in sports or work) it may be treated by reduction of these activities. Differential diagnoses are loose bodies (which can be visualized by radiographs) and postero-lateral instability (demonstrates by clinical examination). An algorithm for diagnosis and treatment is suggested.

CONCLUSION

The primary step is establishment of laterality. From this follows relevant diagnostic measures and treatment as defined in this guideline.

"Snapping triceps": A rare and misleading condition - a clinical case report

Snapping triceps corresponds to subluxation of the medial head of the triceps brachii over the medial epicondyle during active elbow flexion. It is a rare and misleading condition that is often associated with ulnar nerve instability. The latter can result in the snapping triceps being missed. Diagnosis requires a detailed clinical examination. Surgical treatment consists of anterior translocation of the nerve with an adipose flap to stabilize it and transfer of the distal attachment of the medial head of triceps brachii.

The snapping medial antebrachial cutaneous nerve

Snapping elbow is a well-known condition where elbow flexion and extension elicits a painful, popping sensation. The most frequent etiology is anterior dislocation of the ulnar nerve over the medial epicondyle. Four patients (3 females and 1 male) presented with complaints of a popping sensation in the elbow, pain over the medial aspect of the forearm, and ulnar neuritis. All patients underwent preoperative dynamic ultrasound and surgical exploration of the medial elbow. Intraoperatively, snapping of the MABC over the medial epicondyle was discovered in all four patients. In three patients, there was abnormal displacement of the medial triceps and ulnar nerve: in two of these, both structures dislocated over the medial epicondyle and in one patient both structures subluxated. In each case, the MABC was decompressed (n = 1) and transposed (n = 3), and in three cases, the medial triceps and ulnar nerve were addressed as well. Symptomatic improvement was achieved in all cases. Retrospective review of the ultrasound revealed the snapping MABC, though it was less effective prospectively in the cases when snapping MABC was not suspected. In conclusion, snapping of the MABC broadens the spectrum of disorders that results in snapping elbow. To our knowledge, we are unaware of prior reports of this entity.

Ultrasonographic diagnosis of snapping annular ligament in the elbow

Elbow snapping by annular ligament is rare and may be difficult to diagnose, when this Epub ahead of print condition is not familiar. We report a case of elbow snapping by annular ligament diagnosed by ultrasonography, which was confirmed by arthroscopic observation. The ultrasonographic findings were thickening of the annular ligament and snapping in and out of the radiocapitellar joint during elbow flexion and extension on dynamic ultrasonography.

Painful snapping elbow in patients with congenital radioulnar synostosis: report of two cases

Two patients with congenital radioulnar synostosis presented with painful snapping on elbow motion in one case and locking of the elbow joint in the other. Elbow arthroscopy revealed the presence of tight fibrous tissue trapping the radial head. Arthroscopic removal of this tight fibrous tissue resulted in painless joint motion without recurrence of snapping or locking.