| Objective:1. The anatomical positions of the commom tenderness on the lateral of elbow were examined to comprehend the pathogenesis of pain on the lateral aspect of the elbow and to help guide the clinical treatment. These sites of tenderness include condylus lateralis humeri, septum of humeroradial joint, septum between capitulum radius and radial tuberosity, arcade of Frohse and supinator muscle.2. To supply the evidence for the diagnosis of lateral epicondylitis, humeroradial arthrosynovitis, humeroradial bursitis and posterior interosseous nerve syndrome, the method of location on the patients who complained of pain on the lateral aspect of the elbow was studied and the characteristics in distribution of tenderness were explored.3. The anatomical architectures of the tenderness on the lateral of elbow were dissected and the method of location on the patients was studied to make the name of pain on the lateral aspect of the elbow in diagnosis standand.Methods:1.Anatomic observation:Seven upper limbs were used in the study. The dissection was started at the septum between extensor digitorum and extensor carpi radialis brevis to reveal the supinator muscle. And then followed this septum up to the proximal elbow joint about 4～5 cm distant, down to the distal border about 2～3 cm distant from the wrist joint. Then we observed the anatomical architectures of the tenderness on the lateral of elbow, including condylus lateralis humeri, septum of humeroradial joint, septum between capitulum radius and radial tuberosity, arcade of Frohse and supinator muscle. Alterations of the anatomy and relations of the supinator and the nerve were noted during passive supination and during passive pronation. After cutting the supinator muscle tunnel along the posterior interosseous nerve, the interior of the tunnel was exposed completely. Finally, the data as follows should be obtained:the distance from septum of humeroradial joint to the interepicondylar line S1, the distance from the intersection at which the posterior interosseous nerve pierced the supinator muscle to the interepicondylar line S2, the distance from that intersection to the median line S3, the width of the annular ligament, the length and width of the arcade of Frohse, the length of the supinator muscle tunnel and the angle between the tunnel and the median line.2. Clinical study:Materials were 120 patients who complained of pain on the lateral of elbow in NanFang Hospital and Yuexiu Orthopedics Hospital. Of these cases, there were 30 patients with lateral epicondylitis,18 males and 12 females; 30 with humeroradial arthrosynovitis,15 males and 15 females; 30 with humeroradial bursitis,13 males and 17 females and 30 with posterior interosseous nerve syndrome, 16 males and 14 females.The method of location on the cases:Firstly, make sure the elbow flex to 90°, keep the palm facing with the anterior chest, paralleling to the coronal plane, perpendicular to the horizontal plane, and then sign the condylus lateralis humeri on the patients and measure the amplitude of the tenderness L1. and then measure the distance from septum of humeroradial joint to the interepicondylar line L2, the distance from the septum between capitulum radius and radial tuberosity to the interepicondylar line L3, the distance from the arcade of Frohse to the interepicondylar line L4, to the median line L5.All statistical analyses were performed with the SPSS 13.0 package. All values are given as mean±standard deviation. Differences between the male and female were examined with the Independent-Samples T test.Results:1. Anatomy examination:(1)The condylus lateralis humeri was the bony process at the lateral of the capitulum humeri to which the extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimus and extensor carpi ulnaris were attached, and where the brachioradialis and the supinator muscle arised together.(2) The anterior floor of the septum of humeroradial joint was the fibrous stratum of capsula articularis cubiti and the lateral floor was radial collateral ligament.(3) The annular articular surface was covered with annular ligament whose medial edge was attached to the anterior and posterior edge of the lunate sinus of ulna while lateral edge to the inferior extremity of the lateral condyle of humerus by the radial collateral ligament. The annular ligament was (9.70±1.43) mm in width, whose front was entheses of biceps brachii, lateral was brachioradialis, postlateral was the fiber of the supinator muscle. Humeroradial bursa located at septum between capitulum radius and radial tuberosity.(4)There were two branches of the radial nerve adjoining to the elbow joint:the motor branch of the radial nerve and the posterior interosseous nerve. The posterior interosseous nerve passed through the collum radii to the supinator muscle and then coursed beneath the arcade of Frohse, which was the proximal edge of the superficial layer of the supinator muscle. The arcade of Frohse had a well-developed tendinous arch in 3 of the specimens(42.9%), membranous in 2 specimens(28.6%) and the mixture in the remaining 2 specimens(28.6%), of which 5 was semi-ring(71.4%) in shape,2 was loop in shape(28.6%). The length and width of the arcade of Frohse were (6.86±2.19) mm and (9.14±2.04) mm respectivly. The supinator muscle tunnel was described as a (30.14±3.24) mm long furrow bounded by superficial layer and beneath layer of the supinator muscle. The angle between the tunnel and the median line was (25.71±4.27)°. The supinator muscle tunnel became tense and the posterior interosseous nerve would be compressed during passive pronation. However, the tunnel became loose and the posterior interosseous nerve would not be compressed during passive supination. The superficial layer and beneath layer of the supinator muscle formed the floor of the tunnel.(5) The origin of supinator musle combined with that of extensor carpi ulnaris at condylus lateralis humeri and the common tendon of extensor of forearm. Its tendon was connected to the annular ligament and the supinator crest of the ulna. The fiber of supinator went downward and outward, then circled the radius and ended at the anterior surface of the upper 1\3 of radius, which was covered by the brachioradialis, the extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum and extensor carpi ulnaris from the anterior to the posterior.2. Clinical studyWe did not observe any significant difference in the location of tenderness on the patients between males and females (P>0.05). Furthermore, the tenderness of lateral epicondylitis was within (5.50±0.65) mm adjoining to condylus lateralis humeri; That of humeroradial arthrosynovitis was (9.18±1.36) mm distant from the interepicondylar line; That of humeroradial bursitis was (27.171±5.60) mm distant from the interepicondylar line; That of posterior interosseous nerve syndrome was (47.80±7.72) mm distant from the interepicondylar line and (34.99±6.59) mm distant from the median line.Conclusions:1. Morphologically, the condylus lateralis humeri was the bony process at the lateral of the capitulum humeri to which the extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimus and extensor carpi ulnaris were attached, and where the brachioradialis and the supinator muscle arised together. This is the anatomic basis of the lateral epicondylitis without any doubt. However, whether the pathological change was due to inflammation or to retrogression was not sure at present. The septum of humeroradial joint was full of plica synovialis and fatty tissue. The hyperemia and edema of plica synovialis and fatty tissue would result in humeroradial arthrosynovitis, which presented arthroedema as well as damages to articular cartilage and restriction of joint function etc. We had seen some plica synovialis and fatty tissue reaching to the septum of humeroradial joint during the dissection. There were some bursa existing in the septum between capitulum radius and radial tuberosity. With the frequent activity, the capsule wall was vulnerable to damages, but it would recovery soon. The millipore of capsule wall was blocked by the scar or the new synovial membrane after the repeated repairing process, resulting in the bad balance of production and secretion in cyst fluid, so that the pressure of bursa was gradually high. Then the pain and indisposition appeared, which was called humeroradial bursitis. The posterior interosseous nerve was vulnerable to be compressed by the arcade of Frohse because of trauma, strain, space occupying lesion and rheumatoid arthritis. Posterior interosseous nerve syndrome was compression of the posterior interosseous nerve at the arcade of Frohse. Compression of the posterior interosseous nerve at this site typically led to forearm pain and weakness in the muscles it innervated. These muscles included the digit extensors, thumb extensors, extensor carpi ulnaris, and abductor pollicis longus. We always came across some people whose tenderness was not at a point, but diffusing off the whole supinator musle. I regarded it as supinator musle syndrome, which was caused by the strain of supinator musle, having nothing with the posterior interosseous nerve.2. The tenderness of lateral epicondylitis was within(5.50±0.65) mm adjoining to condylus lateralis humeri. We should select the very tenderness to inject the steroid until the needle arrive at the bone. Then draw the injector back about 2mm, continue to inject the drugs into the entheses of the common extensor tendon slowly in circle. The tenderness of humeroradial arthrosynovitis located at the septum of humeroradial joint, (9.18±1.36)mm distant from the interepicondylar line, where the steroid injection and aspiration of fluidify were operated. The tenderness of humeroradial bursitis located at septum between capitulum radius and radial tuberosity, (27.17±5.60) mm distant from the interepicondylar line. The steroid injection should puncture the bursa and the drugs should be injected into it after aspirating the cyst fluid. The tenderness of posterior interosseous nerve syndrome was (47.80±7.72) mm distant from the interepicondylar line, (34.99±6.59) mm from the median line. We can use the method of locating the tenderness described above to inject the steroid. Make sure that use the micro needle in order to decrease the harm by the repeated puncture.3. Besides lateral epicondylitis, the humeroradial arthrosynovitis, humeroradial bursitis and posterior interosseous nerve syndrome, etc. were also the causes of the pain in elbow. Thus, we shouldn't diagnose them all as'tennis elbow' generally. In addition, the disease name'tennis elbow' was based on the etiological factor only, and it couldn't reflect the anatomic basis of the disease. However, the name of the disease shoul be based on the anatomical basis of the tenderness. If the tenderness was merely limited within (5.50±0.65) mm around the condylus lateralis humeri, it should be diagnosed as lateral epicondylitis, the tenderness at the septum of humeroradial joint as the humeroradial arthrosynovitis, at the septum between capitulum radius and radial tuberosity as humeroradial bursitis, at the arcade of Frohse as posterior interosseous nerve syndrome, and if the tenderness diffused off the whole supinator musle, it should be regarded as supinator musle syndrome, but not as posterior interosseous nerve syndrome. The distinction of them was that:the posterior interosseous nerve syndrome was caused by compression of the posterior interosseous nerve at the entrance and (or) exit or the supinator musle tunnel. The tenderness of the posterior interosseous nerve syndrome was punctiform or setuliform. Otherwise, the supinator musle syndrome was caused by strain of supinator musle, and its tenderness was scattered. As to treatment the former needed operation to remove the compression factor if the nonoperative treatment didn't work, the latter needed rest and physical therapy.
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