Extensor Carpi Radialis Brevis Tendon Research Articles

Late Deformities Following the Transfer of the Flexor Carpi Ulnaris to the Extensor Carpi Radialis Brevis in Children With Cerebral Palsy

The transfer of flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB) (the Green transfer) in children with cerebral palsy (CP) is a surgical option frequently used to address the typical wrist flexion deformity that is often present in these patients. We hypothesize that late deformities may occur when these transfers are performed in patients before skeletal maturity. The purpose of this investigation was to determine the frequency of these deformities and the factors that influence their development. We performed 41 FCU to ECRB tendon transfers in children with CP at our institution between 1987 and 2005 and retrospectively reviewed them. A total of 24 patients with 25 transfers had a minimum 2-year follow-up and were included in the study population. We identified patients who developed a late deformity after tendon transfer. We analyzed medical records of these patients to identify factors associated with the development of a deformity. Of the 25 transfers, 12 developed a late deformity between 10 and 105 months postoperatively. The deformities that developed were extension deformities (8), supination deformities (one), and recurrent flexion deformities (3). Of the 12 patients with deformity, 9 required revision surgeries. Of these 12 patients, 9 who were less than 13 years of age at the time of transfer developed a late deformity, compared with 3 who were older than 13 years of age. The FCU to ECRB tendon transfer remains a viable option to address the wrist flexion deformity seen in patients with CP. Care should be taken when performing this tendon transfer in patients less than 13 years of age because they may develop a postoperative deformity, commonly an extension deformity. We believe that these deformities develop when the patient enters a growth spurt and the transferred muscle-tendon unit does not lengthen at the same rate as the involved upper extremity. Therapeutic IV.

A Randomized Controlled Trial for the Efficacy of Therapeutic Class IV Laser Treatment for Tendinosis

There is little consensus regarding effective treatments for tendinosis. Low level laser therapy (LLLT) has been shown to be effective at the cellular level, increasing cytochrome C oxidase production and reversing the effects of cellular inhibitors of respiration. Previous studies on LLLT have used class III lasers (output less than 0.5W); however, recently a dual wavelength (980/808 nm) class IV laser has been developed for use in LLLT (power output 10W). These instruments can deliver 8-9 J/cm2, achieving a photochemical biomodulatory dose in only minutes. The potential for a fast, safe and effective treatment warrants further investigation. PURPOSE: To determine the efficacy of a class IV laser for the treatment of chronic epicondylitis. METHODS: Ten subjects volunteered to participate in a double blinded randomized study using LLLT (LiteCure LCT 1000), or an identical sham in which the laser was replaced with a red incandescent light. Subjects underwent clinical examination (measures of pain, range of motion, strength and ultrasonic imaging) to confirm the diagnosis of chronic tendinosis of the extensor carpi radialis brevis tendon followed by eight treatments of 10 J/cm2 over 18 days. The clinical exam was/will be repeated at completion of the treatments and at 3, 6 and 12 months post-treatment. RESULTS: No differences were noted between the two groups for any parameter before treatment. The mean duration of symptoms was 14.5±12 months, all subjects displayed pain and loss of strength and range of motion on the afflicted side, as well as ultrasonic evidence consistent with chronic tendinosis. There was a trend for increased strength (control change = -0.4±5.3 kg; LLLT change +0.8±3.7 kg; p<0.07) and decreased pain rating (change control = +0.6±3.3 units, 1/5 decreased pain; change LLLT= -2.6±3.3 units, 4/5 decreased pain; p<0.06) in the treatment group compared to the placebo group at the first post treatment exam. CONCLUSION: Preliminary results suggest that LLLT is efficacious for the treatment of chronic epicondylitis. However, it remains to be seen whether statistical significance will be achieved with a larger group and whether the ultrasonographic evidence will indicate improved tendon health at 3 months. Supported by a grant from LiteCure LLTTM

Arthroscopic tennis elbow release

Lateral epicondylitis, originally referred to as "tennis elbow," affects between 1% and 3% of the population and is usually noted in patients aged between 35 and 50 years old. Although it was first thought lateral epicondylitis was caused by an inflammatory process, most microscopic studies of excised tissue demonstrate a failure of reparative response in the extensor carpi radialis brevis tendon in any of these associated structures. Most cases of lateral epicondylitis respond to appropriate nonoperative treatment protocols. Nonoperative management includes medication, bracing, physical therapy, corticosteroid injections, shock wave therapy, platelet-rich plasma, and low-dose thermal ablation devices. When these are unsuccessful, however, surgical measures may be performed with a high rate of success. Satisfactory results of the arthroscopic surgical procedures have been documented, with reported improvement rates of 91% to 97.7%. The recent advances in arthroscopic repair and plication of these lesions, along with the recognition of the presence and repair of coexisting lesions, have allowed arthroscopic techniques to provide results superior to other measures.

Sonographic probe induced tenderness for lateral epicondylitis: an accurate technique to confirm the location of the lesion

The purpose of this study is to evaluate the hypothesis that ultrasonographic probe-induced tenderness is a useful adjunct to the simple sonography in confirming the location of the pathology within the extensor carpi radialis brevis tendon in patients with lateral epicondylitis of the elbow. We conducted a case controlled study by evaluating 27 consecutive patients in the age group of 37-59 years (median 44) who had typical symptoms of lateral epicondylitis and a visual analogue score of more than 4 and evaluating a same number of asymptomatic healthy volunteers in the age group of 37-59 years (median 43) by means of ultrasound examination of the lateral elbow in a period of 5 months from 2007 to 2008. When we identified sonographic anechoic or hypoechoic lesions within the common extensor tendon we compressed it with the ultrasound probe to elicit tenderness so as to confirm the site of lesion within the affected tendon. We observed that the abnormal lesion detected by ultrasonography corresponded to the point of maximal tenderness when compressed by the probe in all the symptomatic patients. We therefore conclude that as it is essential to accurately detect the lesion within the extensor carpi radialis brevis for the purpose of diagnosis and treatment of lateral epicondylitis of elbow the technique of inducing tenderness at site of abnormal shadow on ultrasound within the extensor carpi radialis brevis tendon improves the accuracy of identifying the site of lesion, prevents the misinterpretation of anisotropy as pathological lesion and also can be useful to maximize the efficacy of interventions aimed in treating the lateral epicondylitis.

Small flake, big problem: an unreported cause of extensor pollicis longus tendon rupture

Fracture of the base of the third metacarpal with associated avulsion of the extensor carpi radialis brevis tendon is a rare injury. We report such a fracture and the unusual resulting complication of division of the extensor pollicis longus tendon by the avulsed bony fragment. Careful monitoring using lateral radiographs is needed to make the diagnosis and displacement of the avulsed fragment warrants open reduction and internal fixation.

Follow-Up Motion Laboratory Analysis for Patients With Spastic Hemiplegia Due to Cerebral Palsy: Analysis of the Flexor Carpi Ulnaris Firing Pattern Before and After Tendon Transfer Surgery

To compare the preoperative and postoperative pattern of firing of the flexor carpi ulnaris (FCU) in a grasp and release functional activity for children treated with an FCU to extensor carpi radialis brevis tendon transfer for wrist flexion deformity associated with spastic hemiplegia from cerebral palsy. Seven children, evaluated by a preoperative EMG video analysis and treated with an FCU to extensor carpi radialis brevis transfer, had a follow-up postoperative EMG/video motion laboratory analysis at an average follow-up of 3.5 years (range, 1.0-6.8 years). Each preoperative and postoperative EMG/video was reviewed for the task of lifting heavy cans, as described by Jebson et al. The EMG activity of the FCU was described as active or relaxed during grasp and during release. Preoperatively, the most common pattern was to activate the FCU during grasp and to relax the FCU during release (4 patients). Postoperatively, 6 patients activated the FCU during grasp and relaxed the FCU during release; 1 patient activated the FCU during both grasp and release. Of the 7 patients studied, the FCU changed phase from preoperative to postoperative in only 1. This study concludes that most commonly the FCU does not predictably change phase when transferred from a position of wrist flexion to wrist extension. Therapeutic IV.

Comparison of effects of a home exercise programme and a supervised exercise programme for the management of lateral elbow tendinopathy

BackgroundHome and supervised exercise programmes consisting of stretching and eccentric exercises have been recommended for the management of lateral elbow tendinopathy (LET). No studies have examined their comparative efficacy effectiveness.ObjectiveIn...

In chronic lateral epicondylitis, apoptosis and autophagic cell death occur in the extensor carpi radialis brevis tendon

Despite its common occurrence, lateral epicondylitis is poorly understood from a cellular and molecular perspective. We hypothesize that apoptosis and autophagic cell death are involved in the development of chronic lateral epicondylitis. In 10 patients undergoing surgery for chronic recalcitrant lateral epicondylitis, tendon samples were taken from the extensor carpi radialis brevis (ECRB) tendon and were processed for hematoxylin and eosin, terminal deoxynucleotidyl transferase-mediated deoxy uridine triphosphate nick-end labeling (TUNEL) assay, and immunostaining. Extracellular matrix structure was graded I to III according to collagen fiber structure and arrangement. Apoptotic rate, autophagic cell death rate, cell density, and type I collagen content were measured and compared between areas with different collagen grade. Apoptotic and autophagic cell death occur in the ECRB tendon and varied with the grade of collagen structure. In grade I matrix with relatively less disrupted collagen structure, the apoptosis rate was 23.2% +/- 4.8% and the autophagy cell death rate was 7.6% +/- 2.2%. In grade II matrix with more advanced breakdown of collagen structure, the apoptosis rate increased to 34.4% +/- 4% (P < .05) and the autophagic cell death rate to 13.7% +/- 3% (P < .05). This study demonstrated that apoptosis and autophagic cell death occur in the ECRB tendon in chronic lateral epicondylitis. The markedly elevated apoptotic rate and autophagic cell death rate in the grade II matrix may be responsible for the decrease in cellularity and further deterioration of collagen quality seen in end-stage grade III matrix, and this eventually compromised the tendon's ability to maintain its integrity and resulted in tendon tear. Both apoptosis and autophagic cell death play an important role in the development of tendon degeneration in chronic lateral epicondylitis.

Der dorsale Zugang zum Handgelenk: Fallbericht über eine anatomische Variante und Diskussion der relevanten Literatur

The extensor carpi radialis longus tendon and the extensor carpi radialis brevis tendon are important landmarks for the dorsoradial approach to the wrist. This case report presents an anatomic variant: both tendons are divided into two different reins. Knowledge about this anatomic variant is of importance in order to avoid misinterpretations.

Comments on Pretell et al: Distal fascia lata lengthening: an alternative surgical technique for recalcitrant trochanteric bursitis

Dear Editor, We read the paper by Pretell et al. entitled Distal fascia lata lengthening: an alternative surgical technique for recalcitrant trochanteric bursitis [1], which was received by the Journal on November 28, 2008 and published online on February 12, 2009. The authors described this surgical method for treating refractory greater trochanteric pain (GTP). They stated that this method had not been described in the literature previously. We would like to draw the attention of the authors and the readers of the Journal to our description of this method (which was given the name Pedersen-Noor in our paper Distal lengthening of ilio-tibial band by Z-plasty for treating refractory greater trochanteric pain after total hip arthroplasty (Pedersen-Noor operation) [2]. The paper was published online (PubMed) on July 12, 2008. This method was first introduced by Dr. Eskild Pedersen in 1997 who applied an already known surgical technique used to treat lateral epiconylites of the elbow with distal lengthening of the extensor carpi radialis brevis tendon into a new location to alleviate refractory GTP. Since then more than 50 patients (mostly middle-aged females) have been operated upon with this method in our hospital and the technique has shown good to excellent outcomes. In our paper we reported the results in a special category of GTP patients—those with previous total hip arthroplasty. The method, results, discussion and conclusion presented by Pretell et al. in their paper [1] seem to be a repetition of those presented in our paper [2]. It is highly recommended that authors make a final review of the literature directly prior to submitting their work for publication in order to avoid unnecessary inaccuracy of facts in their paper.

Lateral epicondylitis: Anatomic relationships of the extensor tendon origins and implications for arthroscopic treatment

The purpose this study was to provide an understanding of the location of the extensor carpi radialis brevis (ECRB) and its relationship to surgically relevant landmarks. In part I, 20 fresh-frozen cadaveric elbows were dissected, and the anatomic boundaries of the ECRB origin were determined, including its relationship to the extensor carpi radialis longus, the extensor digitorum communis, the lateral epicondyle, the radiocapitellar joint, the lateral collateral ligament, and the elbow capsule. All measurements were made by 3 separate investigators. Whereas the ECRB and extensor digitorum communis converged distal to the radiocapitellar joint, the bony origin of the ECRB was reliably identified beneath the distal-most aspect of the supracondylar ridge, with a mean dimension of 13 +/- 2 mm in length by 7 +/- 2 mm in width. Part II was performed on 10 separate specimens to document whether the ECRB tendon could be identified and released arthroscopically. In all specimens, the ECRB origin was safely and completely released, by use of the landmarks defined in part I. When the ECRB is released arthroscopically, the elbow capsule must be resected and the tendinous origin of the ECRB released from the top of the capitellum to the midline of the radiocapitellar joint.

Strain Reduction of the Extensor Carpi Radialis Brevis Tendon Proximal Origin Following the Application of a Forearm Support Band

Experimental laboratory design. To measure the strain at the proximal origin of the extensor carpi radialis brevis (ECRB), and to determine the influence of a forearm support band. A forearm support band is often used with the intent to decrease stresses around the origin of the wrist extensors. However, the influence of the location of the band has not been studied. The forearm support band was applied on 8 cadaver arms (mean +/- SD age, 78.4 +/- 10.3 years) and 2 experimental conditions were performed. First, strain measurements were made without applying tension to the distal ECRB tendon, then strain measurements were made with a traction force of 21.5 N being applied to the distal ECRB tendon. Strain of the proximal origin of the ECRB, 1.0 cm distal from the lateral epicondyle, was recorded using a strain gauge. The band was mounted on the forearm at distances equal to 80%, 70%, 60%, 50%, 40%, 30%, and 20% of the forearm length as measured from the wrist. Testing order was randomized. Tension applied to the band was 19.6 N. When no tension was applied to the ECRB, there was no statistically significant difference (P>.05) in strain values at the ECRB origin by mounting the band at any of the forearm positions. In the tension condition, the average (SD) strain with no band was 2.40% (1.40%). The average strain value of 0.85% (0.65%), when the band was mounted 80% of the forearm length proximal to the wrist, was statistically smaller than that obtained without the band (P<.05). The strain on the ECRB origin was less when the forearm support band was applied 80% proximal from the wrist joint. Therapy, level 5.

Communicating Foramen Between the Tendon Sheaths of the Extensor Carpi Radialis Brevis and Extensor Pollicis Longus Muscles: Imaging of Cadavers and Patients

The purpose of this study was to examine the anatomic features and imaging appearance of the intersection of the extensor pollicis longus (EPL) tendon with the extensor carpi radialis brevis (ECRB) and longus (ECRL) tendons in cadavers and patients. MR and CT tenography were performed on 10 cadaveric wrists, and tenosynovial endoscopy and dissection of the EPL tendon sheath were performed on five additional cadaveric wrists. A computer-assisted search of dictated MRI reports identified 12 wrists of patients with simultaneous EPL tenosynovitis and ECRB and ECRL tenosynovitis. The relation between EPL tenosynovitis and ECRB and ECRL tenosynovitis was studied with chi-square testing. Interobserver agreement was calculated with kappa statistics. MR and CT tenography revealed a communicating foramen between the sheaths of the ECRB and EPL tendons in all 10 cadavers studied. Endoscopic evaluation and dissection of five additional cadaveric wrists further confirmed the presence of foramina. In the patients, the presence of EPL tenosynovitis and that of ECRB and ECRL tenosynovitis had strong correlation (p < 0.001). The incidence of simultaneous EPL tenosynovitis and ECRB and ECRL tenosynovitis in our referral population of wrist MRI examinations was 0.8% (12/1,540). A normal foramen exists between the sheaths of the EPL and ECRB tendons where they intersect in the wrist. Such foramina allow synovial fluid to communicate between the tendon sheaths and probably account for the high prevalence of tenosynovitis in more than one tendon on clinical MRI studies.

Anatomic Factors Related to the Cause of Tennis Elbow

The pathogenesis of lateral epicondylitis remains unclear. Our purpose was to study the anatomy of the lateral aspect of the elbow under static and dynamic conditions in order to identify bone-to-tendon and tendon-to-tendon contact or rubbing that might cause abrasion of the tissues. Eighty-five cadaveric elbows were examined to determine details related to the bone structure and musculotendinous origins. We identified the relative positions of the musculotendinous units and the underlying bone when the elbow was in different degrees of flexion. We also recorded the contact between the extensor carpi radialis brevis and the lateral edge of the capitellum as elbow motion occurred, and we sought to identify the areas of the capitellum and extensor carpi radialis brevis where contact occurs. The average site of origin of the extensor carpi radialis brevis on the humerus lay slightly medial and superior to the outer edge of the capitellum. As the elbow was extended, the undersurface of the extensor carpi radialis brevis rubbed against the lateral edge of the capitellum while the extensor carpi radialis longus compressed the brevis against the underlying bone. The extensor carpi radialis brevis tendon has a unique anatomic location that makes its undersurface vulnerable to contact and abrasion against the lateral edge of the capitellum during elbow motion.

Dynamic Tendon Transfer for Claw Hand Deformity

In low median-ulnar nerve palsy, the complete loss of intrinsic motor muscles (interosseous, lumbrical, thenar, and hypothenar muscles) produces a claw hand deformity. The net effects of intrinsic muscle loss include the disturbance of precision and fine motor coordination, diminished muscle volume, severe impairment of power pinch and grasp, and creation of posture deformity to the index, middle, ring, and little fingers. We describe a 29-year-old man suffering low median-nerve and ulnar-nerve palsy with claw hand deformity. We corrected the claw hand deformity using free tendon grafts to transfer the flexion tension of the extensor carpi radialis brevis tendon unit to the metacarpophalangeal joints.

A New Surgical Technique for the Ligament Reconstruction of the Trapeziometacarpal Joint

Isolated traumatic dislocation of the trapeziometacarpal joint is rare compared with fracture-dislocation of the joint. The mechanism of injury is usually axial loading on a flexed thumb metacarpal, leading to dorsal dislocation of the joint. Closed reduction with immobilization is an acceptable method of treatment if the joint is stable after the reduction. Otherwise, early ligamentous reconstruction is recommended to reduce the likelihood of secondary arthritis. Various surgical techniques have been used to reestablish the ligamentous integrity of the joint; however, these techniques usually reconstruct only 1 or 2 ligaments around the joint. The current technique is aimed to reconstruct all 4 ligaments of the trapeziometacarpal joint using a half strip of extensor carpi radialis brevis tendon.

Tennis Elbow: Blending Basic Science with Clinical Practice

Tennis elbow defines a condition of varying degrees of pain or point tenderness on or near the lateral epicondyle. It is prevalent in individuals who perform a combination of forceful and repetitive activities including athletes and wheelchair users. The most common work-related disorder at the elbow is tennis elbow. Histopathological findings indicate that tennis elbow is a degenerative condition, called tendinosis, of the common extensor tendon, with the extensor carpi radialis brevis tendon more commonly implicated as the primary location of tendinosis. Despite the absence of inflammation, patients with tennis elbow still present with pain. Neurochemicals including glutamate, substance P, and calcitonin gene-related peptide have been identified in patients with chronic tennis elbow and in animal models of tendinopathy. Their presence provides an alternative mechanism for pain mediation. Based on what is known about tissue changes within chronic tendinopathies, implications for therapy including examination and interventions are discussed.

Validation of the Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) for Children with Hemiplegic Cerebral Palsy

The Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) is a video-based tool for the assessment of upper extremity function in children with hemiplegic cerebral palsy. This tool includes spontaneous functional analysis and dynamic positional analysis and assesses the ability to perform grasp and release. The purpose of the present study was to assess the reliability, concurrent validity, and construct validity of this instrument. The Shriners Hospital for Children Upper Extremity Evaluation studies for eleven subjects with hemiplegic cerebral palsy were selected for the evaluation of intraobserver and interobserver reliability. Concurrent validity was determined through analysis of the Shriners Hospital for Children Upper Extremity Evaluation, Pediatric Evaluation of Disability Inventory, and Jebson-Taylor Test of Hand Function scores for twenty children. Construct validity was determined through analysis of Shriners Hospital for Children Upper Extremity Evaluation scores for eighteen children before and after flexor carpi ulnaris to extensor carpi radialis brevis tendon transfer. The absolute mean differences between the two scoring sessions for three raters were 1.2 and 1.0 for the spontaneous functional analysis and the dynamic positional analysis, respectively. Although the mean differences were significantly different from 0 (p < 0.001 and p = 0.003), the differences were small and not clinically important with regard to the total possible score. There was excellent intraobserver reliability between the two sessions with regard to both spontaneous functional analysis (r = 0.99) and dynamic positional analysis (r = 0.98). Assessment of interobserver reliability revealed absolute mean differences between four raters of 3.8 and 3.7 for the spontaneous functional analysis and the dynamic positional analysis, respectively. These differences were significantly different from 0 (p < 0.001); however, the magnitudes of these differences were not important with regard to total score or clinical interpretation. There was excellent interobserver reliability for both the spontaneous functional analysis (r = 0.90) and the dynamic positional analysis (r = 0.89). There was 100% agreement within and between examiners for the grasp-and-release section. The Shriners Hospital for Children Upper Extremity Evaluation showed fair correlation with the self-care scaled score from the Pediatric Evaluation of Disability Inventory (r = 0.47) and good inverse correlation with the non-dominant total time section of the Jebson-Taylor test (r = -0.76). The Shriners Hospital for Children Upper Extremity Evaluation wrist score improved for all eighteen subjects after the flexor tendon transfer, and the mean improvement was significant (p < 0.001). The present study establishes the clinical reliability, concurrent validity, and construct validity of the Shriners Hospital for Children Upper Extremity Evaluation for the assessment of upper extremity function in children with hemiplegic cerebral palsy.

A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy

Background: The use of ice as a supplement to an exercise programme has been recommended for the management of lateral elbow tendinopathy (LET). No studies have examined its effectiveness. Objectives:...

Modeled evidence of force reduction at the extensor carpi radialis brevis origin with the forearm support band

Purpose: Although the forearm support band has been hypothesized to reduce force and thus inflammation and degeneration at the extensor carpi radialis brevis (ECRB) origin, little evidence exists to support an actual effect. We present both a cadaveric and clinical model that show the effect and principles of the forearm support band. Method: The cadaver model measured forces at the ECRB origin as various pressures were applied to the forearm support band and while the ECRB tendon was loaded distally. For clinical correlation support band pressure during rest and activity was measured in healthy individuals. Results: Our results revealed an increased forearm support band effect with increased band pressure and a decreased relative effect with increased force applied distally. For clinical correlation the support band pressure during activity was measured in 21 healthy volunteers while controlling for the application pressure in 2 common support band designs. This resulted in activity pressures ranging from 43 to 192 mm Hg dependent on the starting pressure of application. Conclusions: Although further clinical evaluation is necessary to determine the most appropriate clinical indications and application pressures for the forearm support band these combined results suggest that the forearm support band may be most effective when applied to 30 to 50 mm Hg at rest, resulting in up to 120 mm Hg pressure during activity. According to our model this would result in a force reduction at the ECRB origin of approximately 13% to 15% throughout a range of activity levels. (J Hand Surg 2003;28A:279-287. Copyright © 2003 by the American Society for Surgery of the Hand.)