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Distal Biceps Tendon Injury

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Other Names

Anatomy illustration of the biceps brachii
  • Distal Biceps Tendon Condition
  • Biceps Tendon Tear
  • Biceps Tendon Partial Tear
  • Bicipitoradial Bursitis
  • Distal Biceps Tendon Rupture

Background

  • This page refers to complete, incomplete and strains of the distal biceps tendon of the Biceps Brachii
  • A spectrum of disorders can be characterized including bicipitoradial bursitis, partial tears, acute and chronic complete tears

Epidemiology

  • Rare occurrence
  • Most common in active, middle age males
  • Dominant extremity most commonly involved (86% in one study)[1]

Distal Biceps Tendon Rupture

  • Most common form of distal biceps tendon injury (need citation)
  • 1.2 - 2.55 ruptures per 100,000 person years[1][2]

Pathophysiology

Pathogenesis

  • Typically involves some form of trauma
  • Most commonly, a heavy, uncontrolled eccentric load from a flexed position
  • Seiler et al: hypovascular zone of ~ 2 cm seen in cadavar study[3]
    • Thus poor blood supply in a watershed area suspected as a predisposing risk factor

Pathoanatomy

  • Distal biceps tendon is composed of two heads
    • Short Head: Medial, inserts distally, includes the apex of the bicipital tuberosity[4]
    • Long Head: Lateral, deep to short head, inserts more proximally on the bicipital tuberosity
  • Associated anatomy

Associated Conditions


Risk Factors

  • Manual labour
  • Weight training
  • Anabolic steroids
  • Tobacco Use
    • 7.5 fold greater risk[1]

Differential Diagnosis


Clinical Features

Arrow points to biceps muscle belly retracted proximally suggesting a distal biceps tendon rupture
Ultrasound findings typical of bicipitoradial bursitis. The encysted fluid with echoes and septations around the distal biceps tendon. Note the neurovascular structures are marked but not labeled[5]
  • History
    • Patients typically report a specific injury (i.e. lifting a heavy object), although sometimes injury can be more insidious
    • May have heard or felt a 'popping' sensation
    • Reports pain, weakness with elbow flexion and supination
  • Physical: Physical Exam Elbow
    • Inspection: evaluate for ecchymosis, swelling, deformity of muscle belly with proximal retraction of muscle belly
    • The bicepital aponeurosis can feel like an intact tendon despite a tear
    • Pain, weakness in flexion and supination
  • Special Tests (for tendon rupture)
    • Hook Test: Examiner should be able to 'hook' finger under tendon if intact
    • Biceps Squeeze Test: Squeezing biceps muscle to see if supination occurs

Evaluation

MRI Elbow demonstrating distal biceps tendon rupture with significant tendon retraction.

Radiographs

US

  • Lobo et al: 95% sensitivity, 71% specificity, and 91% accuracy for the diagnosis of complete versus partial DBT tears[6]
  • DBT had 97% sensitivity, 100% specificity, and 98% accuracy for complete tear versus normal tendon

MRI

  • Demonstrates[7]
    • Absence of the tendon distally
    • Fluid-filled tendon sheath
    • Antecubital fossa mass
    • Muscle edema and atrophy are non-specific
  • May not be indicated in patients with obvious complete rupture requiring surgical management
  • Consider FABS position (lexed, abducted, supinated position)[8]
  • 100% sensitive for complete tears, 59% sensitive for partial tears[9]

Classification

  • Partial (insertional or intrasubstance) vs Complete tears
  • Acute (< 4 weeks) vs chronic (> 4 weeks)
  • Intact or ruptured lacertus fibrosus

Management

Nonoperative

Partial Tears, Bursitis

Acute Tears

  • Most experts agree than acute tears are a surgical injury with patients generally having good results
  • Outcomes are better in surgically treated patients[11][12]
  • Nonoperative management can be considered in low-demand, sedentary patients after discussion of risks/benefits
    • Lose: 50% supination strength, 30% flexion strength, 15% grip strength (need citation)
  • Treatment

Chronic Tears

  • Needs to be updated

Operative

Partial Tears, Bursitis

  • Indication
    • Failure of non-operative management
  • Technique
    • Tenotomy and then tendon repair with debridement of surrounding tissue

Acute Tears

  • Operative management is indicated in most cases
  • Technique
    • Single- or double- incision

Chronic Tears

  • Challenging to manage surgically due to tendon retraction and muscle atrophy, scarring of fibrous tissue

Rehab and Return to Play

Rehabilitation

  • Operative
    • Immobilized in flexion for a period ranging from 1-6 weeks
    • Early range of motion
    • Strengthening begins at the 6 week mark

Return to Play

  • Needs to be updated

Complications


See Also


References

  1. 1.0 1.1 1.2 Safran, Marc R., and Scott M. Graham. "Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking." Clinical Orthopaedics and Related Research (1976-2007) 404 (2002): 275-283.
  2. Kelly, Mick P., et al. "Distal biceps tendon ruptures: an epidemiological analysis using a large population database." The American journal of sports medicine 43.8 (2015): 2012-2017.
  3. Seiler JG 3rd, Parker LM, Chamberland PD, Sherbourne GM, Carpenter WA . The distal biceps tendon. Two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. J Shoulder Elbow Surg. 1995;4:149-56
  4. Athwal GS, Steinmann SP, Rispoli DM. The distal biceps tendon: footprint and relevant clinical anatomy. J Hand Surg Am 2007;32:1225-1229.
  5. Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 48835
  6. Lobo LdaG, Fessell DP, Miller BS, et al. The role of sonography in differentiating full versus partial distal biceps tendon tears: correlation with surgical findings. AJR Am J Roentgenol 2013;200:158-162.
  7. Falchook FS, Zlatkin MB, Erbacher GE et-al. Rupture of the distal biceps tendon: evaluation with MR imaging. Radiology. 1994;190 (3): 659-63.
  8. Giuffrè BM, Moss MJ. Optimal positioning for MRI of the distal biceps brachii tendon: flexed abducted supinated view. AJR Am J Roentgenol 2004;182:944-946.
  9. Festa A, Mulieri PJ, Newman JS, et al. Effectiveness of magnetic resonance imaging in detecting partial and complete distal biceps tendon rupture. J Hand Surg Am. 2010;35(1):77– 83.
  10. Kelly EW, Steinmann S, O’Driscoll SW. Surgical treatment of partial distal biceps tendon ruptures through a single posterior incision. J Shoulder Elbow Surg. 2003;12(5):456 – 461.
  11. Chillemi C, Marinelli M, De Cupis V . Rupture of the distal biceps brachii tendon: conservative treatment versus anatomic reinsertion—clinical and radiological evaluation after 2 years. Arch Orthop Trauma Surg. 2007;127:705-8
  12. Hetsroni I, Pilz-Burstein R, Nyska M, Back Z, Barchilon V, Mann G . Avulsion of the distal biceps brachii tendon in middle-aged population: is surgical repair advisable? A comparative study of 22 patients treated with either nonoperative management or early anatomical repair. Injury. 2008;39:753-60
Created by:
John Kiel on 18 June 2019 01:55:03
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Last edited:
5 September 2023 15:48:56
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