Rupture of the short head component of a bifurcated distal biceps tendon

Management of distal biceps tendon ruptures: a survey of fellowship-trained subspecialist elbow surgeons

BACKGROUND

There are several approaches to the management of distal biceps tendon ruptures, with no consensus on what constitutes best practice.

METHODS

An online survey queried the perceptions and management of distal biceps tendon ruptures amongst fellowship-trained subspecialty elbow surgeons, which primarily comprised of members of the Shoulder and Elbow Society of Australia, the national subspecialist interest group of the Australian Orthopaedic Association and the Mayo Clinic Elbow Club (Rochester, MN, USA).

RESULTS

One hundred surgeons responded. The median (IQR) experience as orthopedic surgeons amongst respondents was 17 (10-23) years; 78% of respondents saw >10 cases of distal biceps tendon ruptures annually; 95% of respondents would recommend surgery for symptomatic radiologically-confirmed partial tears, the most common indications being pain (83%), weakness (60%), and tear size (48%). Forty-three percent of respondents would have grafts available for tears older than 6 weeks. The one-incision approach (70%) was preferred over two incisions (30%); 78% of one-incision users believed that their repair location was anatomic, compared to 100% of two-incision users. One-incision users were more likely to have encountered lateral antebrachial cutaneous nerve (78% vs. 46%) and superficial radial nerve palsies (28% vs. 11%). Two-incision users were more likely to have encountered posterior interosseus nerve palsy (21% vs. 15%), heterotopic ossification (54% vs. 42%), and synostosis (14% vs. 0%). Re-ruptures were the most common cause of reoperation. The more conservative a respondent's postoperative immobilization was, the less likely they were to have ever encountered re-rupture (14% amongst cast users, 29% amongst splint/brace users, 49% amongst sling users, 100% amongst non-immobilizers). Thirty percent of respondents who placed elbow strength restrictions for 6 months postoperatively encountered re-rupture, compared to 40% amongst those who restricted for 6-12 weeks postoperatively.

CONCLUSIONS

The operation rate for repair of distal biceps tendon ruptures amongst subspecialist elbow surgeons is high, as seen in our cohort. However, there is a large variation in the approach toward its management. One incision (anterior) was preferred over two incisions (anterior and posterior). Complications from repair of distal biceps tendon ruptures can be expected even amongst subspecialists, and are associated with surgical approach. The responses imply that more conservative postoperative rehabilitation may be associated with a lower risk of re-rupture.

Ultrasound Assessment of an Isolated Rupture of the Medial Bundle of a Bifid Distal Biceps Tendon

This case study describes a patient with a clinically ruptured distal biceps tendon, with ultrasound detecting an isolated rupture of the medial bundle of a bifid distal biceps tendon. A 45-year-old male presented to the accident and emergency department with a week-old history of a right elbow injury. The ultrasound scan demonstrated a hypoechoic, corrugated distal biceps tendon with a tendon stump close to the radial tuberosity insertion in keeping with a rupture. However, a small caliber accessory or bifid distal biceps tendon was also identified and was intact. Typically, distal biceps tendon ruptures occur following a traumatic event with most detected clinically although imaging is required to confirm the diagnosis. Ultrasound is utilized to assess these injuries, and several different techniques or approaches are described in the literature. A combination of these approaches is required to make an accurate diagnosis. Detection of bifid distal biceps tendons is important for patient management, especially if a surgical repair is considered. This case highlights the anatomical variant of a bifid distal biceps tendon, which was ruptured clinically. The ultrasound diagnosis of distal biceps tendon ruptures can be challenging, especially when there is limited tendon retraction. This case also demonstrated the importance of dynamic ultrasound in the assessment of tendon ruptures.

Return to Play After Distal Biceps Tendon Repair

PURPOSE OF REVIEW

Distal biceps tendon ruptures (DBTR) are uncommon injuries in 40- to 50-year-old men but occur at a younger age in the athlete population. The distal biceps tendon is an important supinator of the forearm and flexor of the elbow. A complete injury results in limiting function in the upper extremity. The current review evaluates the different options in management and the current literature on return to play in athletes.

RECENT FINDINGS

The distal biceps tendon inserts on the posterior aspect of the radial tuberosity as two independent heads. The long head footprint is more proximal and posterior giving it a better lever arm for supination. The short head footprint is more distal and anterior giving it a better lever arm for flexion. Surgical anatomic repair is highly recommended among the athlete population, to restore proper function of the upper extremity. There is scarce literature on return to play among athletes. The most recent studies on high-performance athletes are on National Football League (NFL) players. These studies showed that 84-94% of NFL players returned to play at least one game after distal biceps repair. Compared to matched control groups, there was no difference in the player's performance after surgery. Anatomic repair of DBTR results in excellent outcomes, high return to work, and high rate of return to play among athletes. When compared to matched control groups, NFL players have the performance score and play the same number of games after surgery.

Partial Distal Biceps Avulsion Results in a Significant Loss of Supination Force

BACKGROUND

Partial avulsions of the short and/or long head of the distal biceps tendon cause pain and loss of strength. The goal of the present study was to quantify the loss of supination and flexion strength following a series of surgical releases designed to simulate partial and complete short and long head traumatic avulsions.

METHODS

Mechanical testing was performed to measure supination moment arms and flexion force efficiency on 18 adult fresh-frozen specimens in pronation, neutral, and supination. The distal biceps footprint length was divided into 4 equal segments. In 9 specimens (the distal-first group), the tendon was partially cut starting distally by releasing 25%, 50%, and 75% of the insertion site. In the other 9 specimens (the proximal-first group), the releases started proximally. Mechanical testing was performed before and after each release.

RESULTS

Significant decreases in the supination moment arm occurred after a 75% release in the distal-first release group; the decrease was 24% in pronation (p = 0.003) and 10% in neutral (p = 0.043). No significant differences in the supination moment arm (p ≥ 0.079) or in flexion force efficiency (p ≥ 0.058) occurred in the proximal-first group.

CONCLUSIONS

A simulated complete short head avulsion significantly decreased the supination moment arm and therefore supination strength.

CLINICAL RELEVANCE

A mechanical case can be made for repair of partial distal biceps tendon avulsions when the rupture involves ≥75% of the distal insertion site.

Distal biceps short head tears: repair, reconstruction, and systematic review

BACKGROUND

Isolated short head tears of the distal biceps are uncommon and often underappreciated. The aim of this study was to describe the presenting features and management of acute and chronic short head ruptures treated at our unit and in the published literature.

METHODS

Six short head ruptures in 5 patients are described. The clinical and radiographic findings, operative techniques, and postoperative outcomes are reported for all patients. A systematic review of the existing literature was also performed.

RESULTS

All patients presented with pain and weakness following an acute traumatic event. One patient presented with bilateral tears 3 years apart. Four of the ruptures underwent acute repair. Two ruptures presented chronically with retracted short head tears and were treated with allograft reconstruction of the short head. Preoperative magnetic resonance imaging findings demonstrated retraction of the short head affecting only 1 muscle belly, and in all patients the hook test was intact. All patients reported excellent functional outcome scores with no postoperative complications. The systematic review identified 9 previously reported cases, of which 8 were treated surgically with a successful outcome. Detailed analysis of these cases demonstrated clinical findings consistent with our cases, and these are outlined in depth in the article.

DISCUSSION/CONCLUSIONS

Isolated short head ruptures are a rare and distinct form of distal biceps tear that present with consistent clinical findings that can aid in diagnosis. They present acutely, have a poor natural history akin to complete tears, and have good outcomes with acute and delayed reconstruction.

Isolated Rupture of the Short Head of the Biceps at the Proximal Musculotendinous Junction: A Report of Two Cases

CASE

Two men aged 19 and 21 years sustained wakeboarding injuries where the towrope was forced against the anterior region of the arm. Physical examination revealed bruising and tenderness over the biceps with weakness in elbow flexion. Magnetic resonance imaging demonstrated complete musculotendinous rupture of their short head of biceps. Surgical repair followed by cast immobilization led to an excellent outcome in both cases.

CONCLUSIONS

This is a unique series of complete musculotendinous rupture of the short head of the biceps occurring in wakeboarding accidents, with the mechanism of injury resisted shoulder adduction and flexion.