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.