Tear of the distal biceps branchii tendon: A new method of ultrasound evaluation

Distale Bizepssehnenruptur

Die Ruptur der distalen Bizepssehne tritt am häufigsten bei Männern im mittleren Alter auf (30 bis 50 Jahre). Der typische Mechanismus ist die exzentrische Belastung in strecknaher Ellbogenstellung in Supination, wobei diese Verletzung mit Kraftsport und körperlich belastender Tätigkeit assoziiert ist. Epidemiologische Daten weisen auf eine Zunahme von distalen Bizepsrupturen in den letzten Jahrzehnten hin. Risikofaktoren wie die Verwendung anaboler Steroide, Kraftsport und Nikotinabusus zeigen einen Zusammenhang mit der Verletzung. Bei reduziertem Patientenanspruch oder relevanten Komorbiditäten ist auch unter einer konservativen Behandlung ein gutes funktionelles Ergebnis mit subjektiv guter Patientenzufriedenheit zu erreichen, allerdings unter zu erwartender relevanter Kraftminderung in Flexion (20 %) und Supination (40 %). Durch eine operative Refixation lässt sich das beste funktionelle Resultat erzielen, allerdings einhergehend mit einem nicht unerheblichen Komplikationsrisiko.

Cadaveric and Ultrasound Validation of Percutaneous Electrolysis Approach at the Distal Biceps Tendon: A Potential Treatment for Biceps Tendinopathy

Distal biceps brachii tendinopathy is a musculoskeletal pain condition-comprising chronic intrasubstance degeneration with alterations of the tendon structure-that is difficult to treat. Preliminary evidence suggests a positive effect for pain and related disability of percutaneous electrolysis treatment in patients with tendinopathy. Ultrasound is an excellent diagnostic tool to identify tendon injuries, such as tendinopathy, and to guide treatment approaches. Different approaches using ultrasound evaluation of the biceps tendon have been described. Our aim was to determine the validity and safety of a percutaneous electrolysis approach, targeting insertion of the distal tendon of biceps brachii, in both human (ultrasound-guided) and Thiel-embalmed cadaver (not ultrasound-guided) models. There were two approaches evaluated: an anterior approach with the elbow in extension and the forearm in supination and a posterior approach with the elbow in flexion and the forearm in pronation. A needle was inserted following the tendon up to its insertion into the radial tuberosity. The anterior approach, both in cadaveric study and US-guided intervention, revealed a close relationship between the distal biceps tendon and the brachial artery. The mean distance of the depth of the biceps tendon distal to the brachial artery was 0.21 ± 0.021 cm in the cadavers and 0.51 ± 0.024 cm in subjects. It was also found that the anterior approach has a potential technical difficulty due to the anatomical location of the brachial artery. With the posterior approach, it was possible to safely identify the tendon insertion and the needle approach, since no important vascular and nervous structures were visualized in the window of insertion of the needle. The clinician rated the posterior approach as low difficulty in all subjects. Current results would support a posterior approach with US guidance as a safe approach for applying the percutaneous electrolysis technique for insertional tendinopathies of the distal biceps brachii tendon. The current study did not assess the effectiveness of the proposed intervention; accordingly, future studies investigating the clinical effectiveness of the proposed intervention are needed.

Distal biceps tendon ruptures: more efficient diagnostics for a better outcome

Distal biceps tendon ruptures are a rare pathology, but can have significant functional repercussions. Rapid, accurate diagnosis and treatment are essential for a favorable prognosis. During the diagnostic process of distal biceps tendon ruptures, several problems can emerge. An answer to the following clinical questions is given based on an extensive literature review. - Which clinical tests are the most sensitive/ specific for clinical examination? - Can ultrasound evaluation of the distal biceps tendon be optimized? - Is ultrasound an equivalent alternative to MRI in the diagnosis of distal biceps tendon injuries? An extensive literature search was conducted through Pubmed and Embase. The search strategy was developed systematically in the Medline data- base (PubMed interface), using medical subject headings as well as free text words. A standardized clinical examination of the distal biceps tendon consisting of the Hook test, the Passive Forearm Pronation Test and the Biceps Crease Interval test has a high accuracy for correct diagnosis of full-thickness ruptures. Furthermore, Cobra sign, Supinator view and Pronator view give an additional value to the standard ultrasound examination of the distal biceps tendon. Finally, ultrasound can be considered a trustworthy and cost-effective alternative to MRI in evaluation of distal biceps tendon ruptures.

Injuries in Muscle-Tendon-Bone Units: A Systematic Review Considering the Role of Passive Tissue Fatigue

Background:

Low-cycle fatigue damage accumulating to the point of structural failure has been recently reported at the origin of the human anterior cruciate ligament under strenuous repetitive loading. If this can occur in a ligament, low-cycle fatigue damage may also occur in the connective tissue of muscle-tendon units. To this end, we reviewed what is known about how, when, and where injuries of muscle-tendon units occur throughout the body.

Purpose:

To systematically review injuries in the muscle-tendon-bone complex; assess the site of injury (muscle belly, musculotendinous junction [MTJ], tendon/aponeurosis, tendon/aponeurosis–bone junction, and tendon/aponeurosis avulsion), incidence, muscles and tendons involved, mechanism of injury, and main symptoms; and consider the hypothesis that injury may often be consistent with the accumulation of multiscale material fatigue damage during repetitive submaximal loading regimens.

Methods:

PubMed, Web of Science, Scopus, and ProQuest were searched on July 24, 2019. Quality assessment was undertaken using ARRIVE, STROBE, and CARE (Animal Research: Reporting In Vivo Experiments, Strengthening the Reporting of Observational Studies in Epidemiology, and the Case Report Statement and Checklist, respectively).

Results:

Overall, 131 studies met the inclusion criteria, including 799 specimens and 2,823 patients who sustained 3,246 injuries. Laboratory studies showed a preponderance of failures at the MTJ, a viscoelastic behavior of muscle-tendon units, and damage accumulation at the MTJ with repetitive loading. Observational studies showed that 35% of injuries occurred in the tendon midsubstance; 28%, at the MTJ; 18%, at the tendon-bone junction; 13%, within the muscle belly and that 6% were tendon avulsions including a bone fragment. The biceps femoris was the most injured muscle (25%), followed by the supraspinatus (12%) and the Achilles tendon (9%). The most common symptoms were hematoma and/or swelling, tenderness, edema and muscle/tendon retraction. The onset of injury was consistent with tissue fatigue at all injury sites except for tendon avulsions, where 63% of the injuries were caused by an evident trauma.

Conclusion:

Excluding traumatic tendon avulsions, most injuries were consistent with the hypothesis that material fatigue damage accumulated during repetitive submaximal loading regimens. If supported by data from better imaging modalities, this has implications for improving injury detection, prevention, and training regimens.

Ultrasound of the distal biceps brachii tendon using four approaches: reproducibility and reader preference

OBJECTIVES

To determine which sonographic appearance of the distal biceps brachii tendon (DBBT) is preferred by readers, and if images obtained by two different operators are reproducible.

METHODS

We performed an IRB-approved prospective sonographic evaluation of the DBBT in 50 healthy elbows using four different approaches (anterior, lateral, medial, posterior) performed by two operators. Five musculoskeletal radiologists independently reviewed the images, and ranked the four approaches based on overall appearance of echogenicity of the tendon, visualized length, and visualization of the insertion.

RESULTS

The medial approach was preferred in 79.6% of elbows, anterior in 17.6%, lateral in 2.8%, and the posterior approach was never preferred. The difference was statistically significant (P < 0.001). Kappa values for the five readers were 0.61 to 0.8 for choosing the images produced by the medial approach.

CONCLUSION

The appearance of the DBBT using the medial approach is preferred by readers and is reproducible between different operators.

Distal Biceps Brachii Tendon Insertion: A Simple Method of Ultrasound Evaluation

Different ultrasound approaches have been proposed to evaluate the distal biceps brachii tendon, such as lateral, posterior, medial, and anterior, all allowing good visualization of the distal biceps tendon and its pathologic appearances. Here we describe a new method of ultrasound evaluation of the distal biceps tendon insertion with the patient in the so-called crab position. The crab position is used to evaluate the posterior compartment of the elbow but also the lateral and medial compartments. This position allows for coverage of 75% the elbow in a single position, with less discomfort for the patient and a fair amount of saved time. In this position, after the evaluation of the common extensor tendon in the long axis, turning the transducer 90° and moving it distally allows for optimal visualization of the distal biceps brachii tendon in the axial plane. It is a simple, quick approach that allows for excellent visualization of the insertion of the distal biceps brachii tendon while avoiding an anisotropic effect.

Ultrasound assessment in distal biceps tendon injuries: Techniques, pearls and pitfalls

Ultrasound assessment of the distal biceps tendon is challenging. The tendon has two components which are continuations of the long and short heads of the muscle, and these undergo 90° of rotation along their course. The tendon has a deep insertion to the radial tuberosity. Therefore, a combination of approaches and examination techniques are utilized to ensure complete evaluation. The various ultrasound approaches used to assess the distal biceps tendon, with their advantages and limitations, will be described. Selected examples of distal biceps tendon injuries, with magnetic resonance imaging (MRI) correlation in challenging cases, will be demonstrated.

[Muscular injuries of athletes : Importance of ultrasound]

CLINICAL/METHODICAL ISSUE

Muscular injuries represent the most common musculoskeletal lesions. Especially in professional athletes an imaging clarification is essential in order to define the exact location of the lesion, the affected muscles, the extent and degree of the injury as well as to define possible concomitant complications. The best possible therapy can be initiated and a necessary rest period for a low risk resumption of sporting activity can be individually specified.

STANDARD RADIOLOGICAL METHODS/METHODICAL INNOVATIONS

Due to technical improvements, for example mobile devices and thus increased rapid availability as well as relative cost-effectiveness compared to other modalities, the imaging evaluation of muscle injury would nowadays be unthinkable without ultrasound.

PERFORMANCE

The article discusses general prerequisites for the performance of muscle ultrasound as well as a standardized examination algorithm of muscle injuries beginning with general and leading to special tips and tricks.

ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS

Despite the known investigator dependence, ultrasound enables a reliable and unerring imaging clarification of muscle injuries. For this reason, ultrasound should be considered as the first-line diagnostic imaging modality when dealing with muscle trauma.

High-resolution ultrasound in the assessment of the distal biceps brachii tendinous complex

OBJECTIVE

To establish a high-resolution US technique that enables a systematic morphometric examination of the three components that form the distal biceps brachii tendinous complex; the internal bicipital aponeurosis, the distal biceps brachii tendon and the external bicipital aponeurosis (also known as lacertus fibrosus).

MATERIALS AND METHODS

Fifty cryopreserved cadaver body donor elbows were dissected to obtain morphometric reference values and to establish reliable landmarks for the US examination. Then, a systematic US technique was designed and validated by a one-to-one US/dissection analysis of 11 cryopreserved cadaver body donor elbows. Finally, the systematic US technique was carried out in 44 healthy volunteers and morphometric parameters were compared to those obtained in the first part of the study.

RESULTS

Mean dissection reference values: internal bicipital aponeurosis width 39.61 mm (10.02 SD) and thickness 0.75 mm (0.24 SD), distal biceps brachii tendon width 8.38 mm (1.87 SD) and thickness 2.73 mm (0.69 SD), external bicipital aponeurosis width 11.17 mm (5.84 SD) and thickness 0.85 mm (0.28 SD). One-to-one US/dissection correlation was overall good (intraclass correlation coefficient 0.876, p < 0.0001). When comparing volunteer US/dissection measurements, significant differences were encountered in all measures except for internal bicipital aponeurosis width. However, the overall magnitude of such significant differences was < 0.7 mm.

CONCLUSIONS

Using the systematics hereby proposed, high-resolution US is reliable for the morphometric assessment of the distal biceps brachii tendinous complex. The external bicipital aponeurosis is morphometrically the most variable structure.

Ultrasound classification of traumatic distal biceps brachii tendon injuries

OBJECTIVE

The present work is aimed at analysing ultrasound findings in patients with distal biceps brachii tendon (DBBT) injuries to assess the sensitivity of ultrasound in detecting the different forms of injury, and to compare ultrasound results with magnetic resonance imaging (MRI) and surgical results.

MATERIALS AND METHODS

A total of 120 patients with traumatic DBBT injuries examined between 2011 and 2015 were analysed. We compared ultrasound results with MRI results when surgery was not indicated and with MRI and surgical results when surgery was indicated.

RESULTS

For major DBBT injuries (complete tears and high-grade partial tears), the concordance study between exploration methods and surgical results found that ultrasound presented a slight statistically significant advantage over MRI (ultrasound: κ = 0.95-very good-95% CI 0.88 to 1.01, MRI: κ = 0.63-good-95% CI 0.42 to 0.84, kappa difference p < 0.01). Minor injuries, in which most tendon fibres remain intact (tendinopathies, elongations and low-grade partial tears), are the most difficult to interpret, as ultrasound and MRI reports disagreed in 12 out of 39 cases and no surgical confirmation could be obtained.

CONCLUSIONS

Based on present results and previous MRI classifications, we establish a traumatic DBBT injury ultrasound classification. The sensitivity and ultrasound-surgery correlation results in the diagnosis of major DBBT injuries obtained in the present study support the recommendation that ultrasound can be used as a first-line imaging modality to evaluate DBBT injuries.

Elbow US: Anatomy, Variants, and Scanning Technique

As with other musculoskeletal joints, elbow ultrasonography (US) depends on the examination technique. Deep knowledge of the relevant anatomy, such as the bone surface anatomy, tendon orientation, nerves, and vessels, is crucial for diagnosis. It is important to be aware of the primary imaging pitfalls related to US technique (anisotropy) in the evaluation of deep tendons such as the distal biceps and peripheral nerves. In this article, US scanning technique for the elbow as well as the related anatomy, primary variants, and scanning pitfalls are described. In addition, an online video tutorial of elbow US describes a possible approach to elbow evaluation. Online supplemental material is available for this article.

Sonographically guided distal biceps tendon injections: techniques and validation

OBJECTIVES

The primary purpose of this investigation was to describe and validate sonographically guided techniques for distal biceps peritendinous/intratendinous injections using a cadaveric model.

METHODS

A single experienced operator completed 18 sonographically guided distal biceps peritendinous injections and 15 sonographically guided distal biceps intratendinous injections in 18 unembalmed cadaveric elbow specimens (11 male and 7 female; age, 53-100 years; body mass index, 19.4-42.2 kg/m(2)). Four different peritendinous approaches were used to inject 3 mL of diluted yellow latex: (1) anterior/superficial, (2) posterior/superficial, (3) posterior/deep/short-axis (to the distal biceps tendon), and (4) posterior/deep/long-axis (to the distal biceps tendon). Three different intratendinous approaches were used to inject 1 mL of diluted blue latex: (1) anterior, (2) anterior/pronator window, and (3) posterior. The feasibility of all 7 injections was assessed by the operator in all specimens, and execution difficulty was recorded after each injection. Specimens were subsequently dissected to assess injectate placement.

RESULTS

All 18 peritendinous distal biceps tendon injections accurately placed latex around the tendon without injecting into the tendon proper. All posterior/superficial peritendinous injections delivered injectate to the ulnar side of the tendon. All posterior/deep peritendinous injections delivered injectate to the radial side of the tendon, with the long-axis approach being technically easier than the short-axis approach. Anterior/superficial peritendinous injections delivered injectate predominantly to the anterior side of the tendon and resulted in 1 brachial artery injury. All but 1 of 15 distal biceps intratendinous injections (93%) accurately placed injectate into the tendon proper, with 1 of 5 anterior injections delivering injectate primarily deep to the paratenon. The posterior intratendinous approach was technically the easiest. No intratendinous injection resulted in neurovascular injury.

CONCLUSIONS

Sonographically guided distal biceps peritendinous/intratendinous injections are feasible and therefore may play a role in the management of patients presenting with distal biceps tendinopathy/bursopathy.

Tendon and ligament imaging

MRI and ultrasound are now widely used for the assessment of tendon and ligament abnormalities. Healthy tendons and ligaments contain high levels of collagen with a structured orientation, which gives rise to their characteristic normal imaging appearances as well as causing particular imaging artefacts. Changes to ligaments and tendons as a result of disease and injury can be demonstrated using both ultrasound and MRI. These have been validated against surgical and histological findings. Novel imaging techniques are being developed that may improve the ability of MRI and ultrasound to assess tendon and ligament disease.

Magnetic resonance imaging of the elbow in athletes

Acute and chronic elbow pain is common, particularly in athletes. Although plain radiographs, ultrasound, and computed tomography all have a role to play in the investigation of elbow pain, magnetic resonance imaging (MRI) has emerged as the imaging modality of choice for diagnosis of soft tissue disease and osteochondral injury around the elbow. The high spatial resolution, excellent soft-tissue contrast, and multiplanar imaging capabilities of MRI make it ideal for evaluating the complex joint anatomy of the elbow. This article reviews imaging of common disease conditions occurring around the elbow in athletes, with an emphasis on MRI.

Sonographic evaluation of the distal biceps tendon using a medial approach: the pronator window

OBJECTIVE

The purpose of this report is to describe and demonstrate the potential advantages of a technique to image the distal biceps tendon using a medial approach: the pronator window.

METHODS

Distal biceps tendon imaging via the medial approach was shown using real-time sonography on an asymptomatic volunteer as well as cadaveric anatomic dissection.

RESULTS

The medial approach images the biceps tendon with minimal anisotropy while providing several potential advantages, including (1) complete visualization of the ulnarly facing radial tuberosity and the tapered distal biceps insertion, (2) increased contrast and reduced beam attenuation at the interface between the biceps tendon and overlying brachial artery, and (3) avoidance of the beam-attenuating effects of the supinator encountered when imaging the tendon from a lateral approach.

CONCLUSIONS

The medial approach to image the distal biceps tendon complements previously described techniques and should be considered in the evaluation of patients presenting with distal biceps tendon disorders. Future clinical studies may elucidate the relative advantages and disadvantages of sonographic distal biceps imaging techniques in specific patient populations.

Distal biceps tendon insertion: an anatomic study

Knowledge of the exact location of the distal biceps brachii insertion is crucial when performing tendon reconstruction or repair. To quantitatively describe the morphology of the distal biceps brachii insertion, 20 cadaveric arms were examined. Linear and angular measurements, including the footprint dimensions and shape, radial tuberosity dimensions and irregularities, and the rotational position of the tuberosity and footprint, were obtained. The axial and transverse dimensions of the radial tuberosity and distal biceps tendon footprint measured 24.2 x 12 mm and 18.7 x 3.7 mm, respectively. The insertion footprint is on the posterior/ulnar aspect of the radial tuberosity centered at approximately 30 degrees anterior to the lateral/coronal plane with the forearm fully supinated. This explains why any preoperative limitation in supination may make an anatomic repair difficult through a single anterior incision. To our knowledge, this is the first study to quantitatively describe the angular location of the radial tuberosity and the relationship of the distal biceps tendon on the tuberosity.