Imaging of Elbow Injuries

Familiarity with throwing mechanics during elbow range of motion allows accurate diagnosis of sports-related elbow injuries, which occur in predictable patterns. In addition, repetitive stress-related injuries are often clinically apparent; however, imaging plays an important role in determining severity as well as associated injuries that may affect clinical management. A detailed understanding of elbow imaging regarding anatomy and mechanism of injury results in prompt and precise treatment.

The utility of botulinum toxin A in the repair of distal biceps tendon ruptures

PURPOSE

The purpose of our study is to report the outcomes and complications in patients who underwent distal biceps tendon repair with the use of Botulinum toxin A (BoNT-A) as an adjunct to surgery.

METHODS

A retrospective review of 14 patients who underwent 15 distal biceps tendon repairs was performed. All repaired tendons had their correlating muscle bellies injected intraoperatively with a mixture of 100U of BoNT-A and 10 ml of normal saline. Each patient was evaluated for surgical and post-operative complications and followed with Disabilities of the Arm, Shoulder and Hand (DASH) Disability Scores.

RESULTS

The cohort was exclusively male, 14/14 (100%). The mean age at procedure was 52.1 years (range: 29-65 years). Types of injuries repaired included: 12 acute biceps tendon ruptures, one chronic partial (> 50% of tendon) biceps tear, and two chronic biceps ruptures. Average final follow-up was 32.9 months (SD: 19.6; range: 7.07-61.72). Average time to repair of chronic injury was 5.75 months (range: 2-12 months). There were no intraoperative complications, and all patients were discharged home on the day of surgery. Average DASH score at latest follow-up was 4.9 (range: 0.0-12.5). All patients had return of function of paralyzed muscle prior to final follow-up. One patient required an incision and drainage for a deep infection 1 week post-operatively, without any further complications. Another patient required operative removal of heterotopic ossification located around the tendon fixation site, which was the result of a superficial infection treated with antibiotics 2 weeks post-operatively. This patient later healed with improvement in supination/pronation range-of-motion and no further complications.

CONCLUSIONS

Injection of BoNT-A is safe and effective to protect distal biceps tendon repair during the early phases of bone-tendon healing.

CLINICAL RELEVANCE

BoNT-A may is safe and effective to protect distal biceps tendon repair. The utility of BoNT-A as an adjunct to surgical repair may be applicable to acute or chronic tears as well as repairs in the non-compliant patient without decreases in functional scores after return of function of the biceps muscle.

LEVEL OF EVIDENCE

Level 4.

Modified Open Suprapectoral EndoButton Tension Slide Tenodesis Technique of Long Head of Biceps with Restored Tendon Tension-Length

Background:

The vast majority of biceps tendon ruptures occurs at the proximal insertion and almost always involves the long head. There are several options for long head of biceps (LHB) tenodesis with advantage and disadvantages of each technique. We believe that the suprapectoral LHB tenodesis described in this article enables the restoration of the anatomic length-tension relation in a technically reproducible manner, when following the guidelines set forth in this article, and restores biceps contour and function adequately with a low risk of complications.

Method:

We present a case of a young man who had a sudden jerk of his flexed right elbow, while involved in water skiing sports and sustained complete rupture of proximal end of long head of biceps tendon. In this article, we describe a modified surgical technique of open supra-pectoral long head of biceps tenodesis using an EndoButton tension slide technique, reproducing an anatomic length-tension relationship.

Results:

By the end of one year, patient regained symmetrical muscle bulk, shape and contour of biceps compared to other side. There were no signs of dislodgement or loosening of the EndoButton on follow-up radiographs. He regained full muscle power in the biceps without any possible complications, such as humeral fracture, infection, or nerve injury, associated with this technique.

Conclusion:

This technique is a safe, easy to reproduce, cost-effective, less time consuming and an effective method that uses a small drill hole, conserving bone, minimizing trauma to the tendon, and decreasing postoperative complications. It does not need any special instrumentation and is suitable especially for use in centers where arthroscopy facility or training is not available.

Endoscopic Repair of Acute and Chronic Retracted Distal Biceps Ruptures

Distal biceps tendon (DBT) ruptures are infrequent injuries that result in pain, weakness, and cosmetic deformity. Severe retraction of the ruptured DBT can occur at the time of injury, or in chronic neglected ruptures, and surgical exposure is performed using a single incision or a 2-incision technique. The technique presented here describes an endoscopic approach using 3 portals that provide access to the retracted DBT, biceps sheath, and radial tuberosity. Preoperative sonographic localization of the retracted DBT and neurovascular structures is used to guide portal placement. The parabiceps portal is used for visualization of the biceps sheath remnant, and the midbiceps portal is used to visualize and retrieve the retracted tendon in the arm. The retracted DBT is shuttled through the biceps sheath into the upper forearm, and 2 suture anchors are passed into the radial tuberosity under direct endoscopic vision. The DBT is whipstitched via the distal anterior portal, and nonsliding knots are tied to securely reattach the DBT to the prepared radial tuberosity.

'A torn shoulder': an emergency department case study

BACKGROUND

Rupture of the biceps is not a very common presentation to the emergency departments; as a result, it is poorly documented, especially in nursing literature. It is important that these patients are appropriately managed by registered advanced nurse practitioners. As the diagnosis of rupture is usually made on clinical grounds with imaging assisting in the diagnosis, left untreated these injuries can lead to considerable functional deficits.

METHODS

The following paper is a case study based on a patient who presented to the emergency department with a proximal biceps rupture following trauma. The paper focuses on the clinical assessment and management of patients who present to the emergency department with these injuries.

RESULTS

This case study increases awareness of bicep ruptures and its management in the ED. Discussion points include the neurovascular assessment of these patients, the appropriateness of diagnostic imaging, and in-depth clinical examination techniques.

CONCLUSION

Rupture of the biceps tendon is often a result of a sudden forceful extension of the elbow against a previously contracted biceps and flexed elbow. The patient often describes a popping noise and presents with a 'popeye' deformity over their biceps. It is important to be vigilant with these injuries as early recognition will optimise the patients' outcomes.

Anatomic reinsertion of the distal biceps tendon rupture through a single anterior approach: extensile or mini-invasive approach? A retrospective study at mean 45-month follow-up

PURPOSE

To evaluate and compare clinical results and complication rate of a standard and mini-invasive reconstruction technique for distal biceps tendon rupture.

METHODS

Twenty-eight cases of biceps tendon rupture were evaluated at mean 45-month follow-up. A standard anterior approach was used in 19 cases, and a less invasive anterior approach was used in nine cases. Suture anchors were used for tendon reconstruction in all cases. Elbow range of motion (ROM), subjective strength recovery, time to return to work and sports activities, and complications were recorded. Disability of the Arm, Shoulder and Hand Score (DASH) the Oxford Elbow Score (OES), and the Mayo Elbow Performance Score (MEPS) were obtained for all patients.

RESULTS

Mean ROM recovery was almost complete. Mean subjective strength recovery allowed full return to sports and work in 93 % of cases, within mean 3-month postoperative. Mean DASH, OES, and MEPS scores were good. The clinically relevant complications rate was 17.8 %, all associated with the standard extensile approach group (Group A). Asymptomatic heterotopic ossifications were detected in four cases (14.3 %), not affecting functional recovery.

CONCLUSIONS

Clinical results and complications rate of anatomical reconstruction of the distal biceps tendon rupture were comparable to the literature. Comparison between Group A and B showed no significant differences in terms of ROM, and OES and MEPS scores. Strength recovery, time to return to sports and work, and DASH score showed a positive trend in Group B. The clinically relevant complications rate was 0 % in Group B and 26 % in Group A.