Distal Biceps Tendon Rupture

Video

Western Health Orthopaedic Registrar presentation Distal Biceps Ruptures By Dr Andrew Salipas

Reviewed by

Dr Terry Stephens
BSc(hons), MBBS, PhD
Unaccredited Orthopaedic Registrar

Definition

• Dominant extremity in men aged 40-60 years
• Unexpected extension force to the flexed elbow
• Rupture typically occurs at tendon insertion into radial tuberosity at area of pre-existing tendon degeneration

Aetiology

• single traumatic event involving flexion against resistance, with elbow at right angle results in sudden sharp tearing sensation
  • Mechanism
    • sudden load applied to elbow in flexion
    • eccentric contraction of flexed elbow
• Predisposing Factors
  • Decreased vascularity
  • tendon impingement
  • degenerative changes

Epidemiolgy

• uncommon injury
• 3% of all biceps tendon ruptures
• Incidence 1.2/100 000 
• Male 
• 40’s 
• Dominant elbow 
• Smokers 
  • 7.5 times greater risk 
• Literature
  • 54 articles pre 1995 
  • 70 articles last 3 years 

Anatomy

• Biceps
  • Origin 
    • Long head: superior glenoid 
    • Short head: corochoid process 
  • Insertion 
    • Bicipital tuberosity (radial tuberosity) 
    • Bicipital aponeurosis 
• Cubital fossa
  • Boundaries – line joining epicondyles, brachioradialis, pronator teres
  • Roof – deep fascia, bicipital aponeurosis (medially)
  • Floor – brachialis, supinator (inferolateral)
  • Medial lies – medial antebrachial cutaneous nerve, median basilic v
  • Lateral lies – lateral antebrachial cutaneous nerve, median cephalic v
• Contents of cubital fossa (medial lateral)
  • Median nerve: lying under bicipital aponeurosis
  • Brachial artery & vein
  • Bicipital tendon
  • Recurrent branch of radial artery
  • Radial nerve
    • entering betw brachialis & brachioradialis
  • Superficial br continues under BR
  • Deep br (PIN) courses around lateral aspect of radius & passes betw humeral & radial heads of supinator

Pathology

• consequences of loss of strength
  • 30 % flexion strength
  • 40 % supination strength
• biceps tendonitis & median nerve compression may be common following this injury
• partial biceps tendon rupture:
  • biceps tendon will still be palpable in antecubital fossa

Classification

• Full thickness vs Partial
• Acute vs Chronic

History

• presents wirh painful swollen elbow usually in 50-60 yo active male
• Initial
  • History of painful tearing sensation in antecubital region
    • Eccentric loading of biceps muscle 
  • Painful pop
  • Gradually subsides into a dull ache
• Weakness of flexion & supination
• Pain – particularly in supination 

Examination

• Look
  • Popeye sign 
  • Bruising in the cubital fossa with tenderness in same region
• Feel
  • carefully palpate for residual biceps tendon in antecubital fossa
  • Hook Test
• Move
  • weakness of flexion & supination

Investigations

Xrays

• rule out bone injury
• often negative
• may show irregularity or enlargement of radial tuberosity or avulsion fragment

Ultrsound

MRI

• may be useful if diagnosis is in question
• may show partial tears of biceps tendon or degenerative changes (not often easy to separate)
• MRI may show gap between tendon & its insertion site on tuberosity

Treatment

• Anatomic repair to radial tuberosity necessary to obtain strength & endurance of flexion & supination

Partial rupture

• Non-operative management
  • If fails then detach & debride degenerative fibres & reattach as for complete tears

Acute rupture

• Nonoperative treatment
  • reserved for elderly/ sedentary patients
  • Results in ↓ strength & endurance & may get activity-related pain
    • supination
      • strength ↓ 50%
      • endurance ↓ 40%
    • flexion
      • strength ↓ by 35-40%
  • patients complain of prolonged pain
  • patients will note that loss of supination strength is more significant than loss of flexion strength
  • all patients treated nonsurgically remain weak, especially in supination
• Operative treatment
  • Repair aim 
    • Early functional recovery 
  • Most authors recommend anatomic repair
    • must be performed early to avoid scarring down of biceps
    • with inadequate mobilization of biceps, elbow will have to be left in flexion (up to 70 deg flexion)
  • if flexion beyond 70 deg is required for tendon opposition to radial tuberosity, consider need for semitendinosus autograft
  • with delayed treatment
    • biceps may be attached to brachialis
    • this does not improve supination strength, but does improve flexion strength
    • alternatively, consider use of tendon autograft
  • Techniques
    • Approach
      • Traditional
        • Two Incision Approach (Boyd Anderson)
      • Modern
        • Single Incision
          • Anchors
          • Endobutton
        • Endoscopic
    • Fixation
      • Bone tunnell/transosseous suture 
        • Radial tuberosity burred 
        • Sutures passed through pre drilled holes 
        • Requires dual incision 
      • Suture anchor 
        • Extended anterior incision or transverse 
        • Tuberosity is scuffed 
        • Anchors x2 on tuberosity 
          • Distal 1st 
            • Increases foot print maximising tendon to bone contact 
      • Interosseous screw 
        • Extended anterior incision or transverse 
        • Whipstitch Tuberosity drilled and reamed Suture passed through bone Tendon secured in bone with a bioabsorbale tenodesis screw 
      • Suspensory cortical button 
        • Endobutton Whipstitch in tendon
        • Radial tuberosity burred
        • Sutures passed
          • Volar radius 
          • Out skin dorsal 
          • Must keep supinated 
        • Tension of suture and secure endobutton
      • Comparison
        • Biochmechanical study 
          • Endobutton 440N
          • Suture anchor 381N
          • Tunnel 310N
          • Interference screw 232 

Chronic rupture

• More difficult
• Easier if bicipital aponeurosis intact restricts retraction of tendon
• Often need to use autograft (semitendinosus or rolled fascia lata) to extend length of tendon
• Tendon sheath often scarred down making dissection more difficult
• must identify & protect radial n
• Complications
  • Radial nerve palsy
  • Radio-ulnar synostosis

Complications

• Neuropraxias 
  • Lateral cutaneous nerve of the forearm 
  • Posterior interosseous nerve 
• Re-rupture 
  • Outside perioperative period uncommon 
• Radiounar Synostosis 
  • HO releases 
  • Early complication 
  • If severe may need to release tendon and reattach 
  • Particularly dual incision 

Prognosis

• post repair expect return to near full strength both supination and elbow flexion 
  • Suture anchors 
    • < 10 degree loss of motion at 7 years 
    • 5% loss of strength 
    • 10% increase in endurance 
  • Bone tunnel 
    • 30% of patients reduced strength (supination most affected)
    • 5-20% reduced ROM 
  • Endobutton 
    • 80% recovery of supination (strength)
    • 91% recovery of flexion (strength)
  • Comparative study 
    • ROM slightly better suture anchor v tunnel 
    • No difference strength 

References

• Surgical Treatment of Distal Biceps Rupture,  Sutton, Dodds, Ahmad, Sethi  JAAOS 18; 139-148, 2010.