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Distal Biceps Tendon Injury

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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

Associated Conditions


Risk Factors

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

Differential Diagnosis


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

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[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

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

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. 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.
  6. Falchook FS, Zlatkin MB, Erbacher GE et-al. Rupture of the distal biceps tendon: evaluation with MR imaging. Radiology. 1994;190 (3): 659-63.
  7. 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.
  8. 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.
  9. 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.
  10. 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
  11. 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:
7 April 2022 12:29:49
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