Download Distal Biceps tendon rupture Distal Biceps tendon

Distal Biceps tendon rupture
Rupture of the distal biceps tendon is uncommon but seems to be increasing. It occurs in men in
their forties to sixties, it is extremely rare in females.
It usually affects the dominant arm and follows an injury where a sudden increased load is
placed on the tendon while the muscle is actively contracting.
Most people think the biceps muscle is the main muscle that flexes your elbow. This is not the
case, the main elbow flexor is a deeper muscle (Brachialis). The biceps muscle does provide
some flexion strength but its main function is powerful supination. It is important to
differentiate a rupture of the DISTAL biceps tendon (at the elbow) as opposed to a rupture of
the LONG head of biceps which happens at the shoulder.
Anatomy
The biceps muscle has two areas of attachment at the elbow:
Biceps tendon proper (distal) - This is the principal attachment, the tendon attaches to a
bony prominence on the radius called the bicipital tuberosity. The biceps tendon proper
may also have two components to it, they both attach to the bicipital tuberosity.
Lacertus fibrosis (Bicipital aponeurosis) - The lacertus fibrosis is a condensation of the
forearm fascia, is less distinct than the biceps tendon proper.
The biceps is a weak flexor of the elbow, but a strong supinator. The nerve supply is via the
musculocutaneous nerve, this nerve ends in a branch called the Lateral antebrachial cutaneous
nerve (LABCN), this supplies sensation to the lateral side of the forearm.
This is important as injury to the tendon and retraction of the muscle may pull on this nerve,
leading to pins and needles and pain radiating down the lateral aspect of the forearm.
Diagnosis
The diagnosis may be missed as the elbow can still flex/ extend and pronation and supination is
still possible using other muscles.
The history/ story is important, loading the flexed elbow and suddenly feeling something snap
in the elbow. Followed by pain and swelling around the front of the elbow. Occasionally pain
and tingling/ numbness might radiate down the forearm as one of the nerves in the elbow may
be involved.
Bruising around the elbow and forearm may develop/ come out over a few days.
A distinct tendon is no longer felt in the front of the elbow and the biceps muscle may bunch
up.
It is possible to only tear part of the tendon and part of the biceps muscle attachment may
remain intact (lacertus fibrosis). This may limit the amount the biceps bunches up.
Xrays of the elbow are often normal, but required to ensure no fracture and no bony
abnormalities of the radius.
An Ultrasound or MRI scan may be required if the history and physical examination are not
classic.
Several variations of injury exist:
Complete rupture of biceps tendon and lacertus fibrosis
Complete rupture of biceps tendon, leaving lacertus fibrosis intact
Partial rupture of the biceps tendon
Rupture of musculotendinous junction (here the muscle tears off the tendon as
opposed to the tendon pulling off the bone)
Treatment
There are two treatment options:
Non operative
Operative
As is the case with quite a lot of upper limb trauma there is no universal treatment for
everyone.
It is a case of deciding on your expectations following the injury and balancing that with the
potential risks and complications you are willing to face in order to achieve your goal.
Most people think that following a rupture of the biceps tendon they will have a very weak arm
that does not bend and will not work well.
This is not the case, with non operative treatment and rehabilitation of the other muscles
around the elbow it is possible to get a good arm, this is at very little risk.
If you want to "go for gold" so to speak and want the strongest/ best arm you can have then an
operation should be considered, with the attendant risks and complications.
Non operative treatment
treatment
Non operative treatment involves, relative rest for a few weeks waiting for the bruising and
swelling to resolve.
Keep the elbow gently moving so it does not stiffen up (see stiff elbow and stretches).
As the pain and discomfort resolves begin a gradual increase in activities and strengthening of
of the remaining muscles of around the elbow. (see stiff elbow and strengthening).
From JSES 2009 This is average
muscle strength in arm
following rupture of distal
biceps, median time from injury
2.9 months, range (2weeks to 3
years).
Loss of strength in flexion and
extension is better represented
below as a % of the uninvolved
arm.
The information is
from three different
studies all with
different angles on the
same theme. (JBJS A
1985, JBJS 2009, JSES
2009)
In essence what they
and other studies have
shown is that acutely
flexion and supination
strength decreases
with rupture of the
distal biceps tendon.
With time as the injury resolves and the other muscles around the elbow and forearm take up
some of the work of the biceps muscle, the deficit in strength reduces.
On average with non operative treatment you are likely to regain:
70% flexion strength around 3 months (JSES 2009)
85% flexion strength after 1 year (JBJS 2009)
50% Supination strength around 3 months (JSES 2009)
75% supination strength after 1 year (JBJS 2009)
This is maximum strength.
Patients often complain of a degree of fatiguability of the muscles. In reality the muscles do not
fatigue faster, the symptoms of fatiguability probably relate to the fact that you start off with
relatively lower peak strengths.
This is most likely to be noticed in actions requiring repeated supination (eg. using a
screwdriver).
Operative treatment
Operative treatment involves re-atachment of the biceps tendon to the bicipital tuberositity.
There are several methods of exposing the tendon and several methods of re-ataching the
tendon to bone, using transosseous sutures, bone anchors, endobuttons and or inteference
screws.
I use a single incision endobutton technique for acute repairs.
It is much easier to repair the tendon if done acutely (within 3-4 weeks). If delayed longer than
this the skin wound needs to be larger and if the muscle and tendon have retracted proximally a
long way then on occasion the gap needs to be grafted. I use a hamstring from behind the knee.
As with all surgery there are always the potential of risks and complications.
The more difficult the surgery the higher the potential for risks and complications.
It is important to balance these potential risks and complications with the potential benefits
(gain in function) after surgery.
In essence an acute repair (ie within 3-4 weeks) is relatively straightforward and can usually be
accomplished through a 4 cm cut on the front of the forearm.
If surgery is delayed longer than this things become more complicated, rehab time may be
longer and I always discuss the potential need for a tendon graft if the muscle has retracted
proximally a long way.
Complications of operative treatment
Complication rates of up to 25% have been reported following surgical repair . Mostly related to
injuries of the nerves around the elbow.
Other complications include:
Nerve injury
Heterotopic ossification (the formation of extra bone, this is a bigger problem with the
two incision technique)
Persistent pain
Stiffness (both flexion and extension, more problematic is rotation)
Infection
Complex regional pain syndrome
Re rupture
Ultimately no right or wrong
Benefits of operative treatment
Surgery can restore near full flexion and supination strength (over 90%).
Some patients treated non operatively will have persistent pain. It is still possible to operate at a
later date but is technically more demanding and a primary repair may not be possible, needing
a tendon graft.
Cosmetically, with non operative treatment the shape of the biceps muscle will never return to
normal.
Benefits of Non operative treatment
Avoid all the risks of surgery. No restriction on return to activity/ work, as bruising and swelling
resolves increase use of arm gradually loading and rehabilitating the tendon. Acute loss of
strength will improve with time achieving 85% of flexion strength and 75% supination strength.
Ending up with good residual strength and arm function and little overall disability.
If you want a good arm with very little risk and are willing to accept the cosmetic appearance
and only slightly reduced strength then it is best not to have an operation. Avoiding all the
potential risks and complications of an operation
If you want to go for Gold and have the strongest arm and more normal appearance AND you
are willing to undertake the risks and potential complications of an operation then it is best to
have an acute repair.
References
Proximal radial fracture after revision of distal biceps tendon repair: A case report; Alejandro
Badia, S.N. Sambandam, Prakash Khanchandani; Journal of Shoulder and Elbow Surgery; March
2007 (Vol. 16, Issue 2, Pages e4-e6)
Elbow strength and endurance in patients with a ruptured distal biceps tendon.; Nesterenko S,
Domire ZJ, Morrey BF, Sanchez-Sotelo J.; J Shoulder Elbow Surg. 2009 Aug 5
Nonoperative Treatment of Distal Biceps Tendon Ruptures Compared with a Historical Control
Group; Carl R. Freeman, Kelly R. McCormick, Donna Mahoney, Mark Baratz, and John D. Lubahn;
J. Bone Joint Surg. Am., Oct 2009; 91: 2329 - 2334.
Rupture of the distal tendon of the biceps brachii. A biomechanical study; Morrey BF, Askew LJ,
An KN, Dobyns JH. . J Bone Joint Surg Am. 1985;67:418-21