Bilateral proximal biceps tendon ruptures are rare. The majority of biceps tendon ruptures involve the long head of the biceps and occurs proximally. When the tendon ruptures, the biceps muscle bunches up in the distal portion of the arm. Ruptures cause a “Popeye muscle” appearance. Both proximal heads of the biceps muscle arise from the scapula. The short head of the biceps originates from the coracoid process. The long head of the biceps originates from the supraglenoid tubercle just above the shoulder joint. Rupture of the long head of the biceps tendon occurs at the bicipital groove and the muscle then moves towards the elbow (popeye muscle). The short head of the biceps remains attached to the coracoid. Usually, there is less disability with the proximal biceps tendon rupture than the distal biceps tendon rupture.
The patient may experience cramping, pain, and cosmetic problems with proximal biceps tendon ruptures. The physician may need to perform a surgical procedure called tenodesis of the biceps tendon especially if there is an associated rotator cuff tendon pathology.
Osteoarthritis is a degenerative condition of the cartilage. There is no clear etiology. Osteoarthritis is not related to tumors, inflammation, infection, gout, or trauma. Osteoarthritis is different from rheumatoid arthritis—which is an inflammatory condition. This distal interphalangeal joint (DIP) is the joint that is most often involved with osteoarthritis. The trapeziometacarpal joint (TM) is the most involved joint with osteoarthritis. When the trapeziometacarpal joint is involved, it causes pain with a weak pinch and grip.
Osteoarthritis of the fingers involves the following:
DIP (Heberden’s Nodes) – Heberden’s nodes are bony swellings (osteophytes) that can develop in the distal interphalangeal joints (DIP) due to the effects of osteoarthritis on these joints. Heberden’s nodes are a sign of osteoarthritis caused by osteophyte formation (bony outgrowth) of the articular cartilage in response to repeated microtrauma at the joint. Heberden’s nodes are more common in women then in men.
PIP (Bouchard’s Nodes) – Bouchard’s nodes are also associated with osteoarthritis and they are similar bony growths which develop in the proximal interphalangeal (PIP) joints. Bouchard’s nodes, like Heberden’s nodes, may or may not be painful. Swollen, hard, and painful finger joints (Heberden’s and Bouchard’s nodes) is the classical sign of DIP and PIP joint osteoarthritis.
Mucous Cyst– Small, fluid-filled sacs that form between the DIP joint of the finger and the bottom of the fingernail are another sign of osteoarthritis. The best treatment is a surgical excision of the cyst and removal of the underlying osteophyte to decrease the risk of recurrence.
Fibular fractures are usually associated with a complex injury; however, they can be an isolated fracture. Fibular fractures typically occur with a fracture of the tibia, part of an ankle fracture, a pilon fracture, or Maisonneuve fractures. Maisonneuve fractures involve a fracture of the proximal fibula associated with an occult injury of the ankle.
Isolated fibular fractures are rare and are usually the result of a direct trauma. The fibular carries approximately 15% of the axial load and is the site of muscle attachment for the peroneus muscles and the flexor hallucis longus muscle. If the physician has a patient with a fibular fracture and no other fracture involving the tibia, they will want to rule out a possible Maisonneuve fracture, especially if there is no history of direct trauma to the leg.
The physician should look for sign of a syndesmotic injury. These signs include
- Unexplained increase in medial clear space
- Tibiofibular clear space is widened (should be less than 5mm)
The x-ray will show the fracture to be rotational or oblique.
Maisonneuve fractures will require surgery to fix the syndesmosis. The fracture will need to be reduced and fixed. Syndesmotic screws are the screw of choice. It is important to determine if the injury is a Maisonneuve fracture or an isolated fibular fracture, as an isolated fibular fracture will not need surgery.
There are 12 vertebrae in the thoracic region. The spinal canal in the thoracic region is relatively small, however, the spinal cord could be easily compressed or injured in this area. Pain in the thoracic region can occur from cardiovascular origin, tumors, infection, compression fractures, and mediastinal structures. A point of consideration is thoracic disc herniation. It occurs more in the lower thoracic region, usually during the fifth decade of life. This disc herniation causes pain to radiate to the ribs and anteriorly at the same level. A thoracic disc herniation is uncommon and most are asymptomatic.
Clinically, a thoracic disc herniation will present itself as a radicular pain, anteriorly towards the rib (nerve root irritation).Myelopathy can occur from spinal cord compression. The patient could have a gait disturbance, leg weakness, as well as bladder and bowel dysfunction. Myelopathic findings are usually subtle. The physician should look for upper motor neuron signs such as hyperreflexia, clonus, and Babinski. A diagnosis is usually determined with magnetic resonance imaging (MRI). MRIs will help in ruling out the presence of fractures, tumors, or infections. Although an MRI is the study of choice, it has a high false positive rate. Asymptomatic patients may show a thoracic disc abnormality in their MRI.
Conservative treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy. Surgery is indicated when the patient has pain that is not responding to conservative treatment for 6 months or if the patient has a thoracic disc herniation with myelopathy. Most surgeries are performed with an anterior approach with or without fusion. Fusion is done for spine instability and significant chronic pain. A laminectomy is contraindicated.