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Distal Biceps Tendon Injury
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Contents
Other Names
- 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
- Lateral antebrachial cutaneous nerve: sensory branch of Musculocutaneous Nerve
- Posterior Interosseus Nerve
- Bicepital Aponeurosis (lacertus fibrosus)
Associated Conditions
- Rarely, Median Nerve Injury
Risk Factors
- Manual labour
- Weight training
- Anabolic steroids
- Tobacco Use
- 7.5 fold greater risk[1]
Differential Diagnosis
- Fractures
- Adult
- Pediatric
- Dislocations & Instability
- Tendinopathies
- Bursopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Other
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
Clinical Features
- 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
Radiographs
- Standard Radiographs Elbow
- Screening tool to exclude other etiologies
US
- Lobo et al: 95% sensitivity, 71% specificity, and 91% accuracy for the diagnosis of complete versus partial DBT tears[5]
- DBT had 97% sensitivity, 100% specificity, and 98% accuracy for complete tear versus normal tendon
MRI
- Demonstrates[6]
- 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)[7]
- 100% sensitive for complete tears, 59% sensitive for partial tears[8]
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
- Non-operative approach is considered first line
- Brief period of splinting, preferably with Posterior Short Arm Splint
- Activity modifications
- NSAIDS
- Physical Therapy
- Note: There are case reports of partial tears progressing to complete tears[9]
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[10][11]
- 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
- Posterior Short Arm Splint or Posterior Short Arm Cast with early mobilization
- NSAIDS
- Physical Therapy
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
- General
- Residual weakness
- Loss of strength
- Disability
- Surgical
See Also
- Internal
- External
- Sports Med Review Elbow Pain: https://www.sportsmedreview.com/by-joint/elbow/
References
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ Athwal GS, Steinmann SP, Rispoli DM. The distal biceps tendon: footprint and relevant clinical anatomy. J Hand Surg Am 2007;32:1225-1229.
- ↑ 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.
- ↑ Falchook FS, Zlatkin MB, Erbacher GE et-al. Rupture of the distal biceps tendon: evaluation with MR imaging. Radiology. 1994;190 (3): 659-63.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ 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:
16 December 2022 06:54:43
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