Distal biceps tendon rupture
What is it?
The biceps muscle is located anteriorly in the arm and is attached to the shoulder and elbow by tendons - strong fibrous bands that attach muscles to the bones.
Biceps tendon ruptures in the elbow are uncommon and are most often caused by a sudden trauma, of forced extension against resistance mainly when lifting a weight. The ruptures may involve only part of the tendon (partial breaks) or all of it (total breaks); usually the ruptures are total and give rise to important weakness of the arm, essentially of supination of the forearm, that is, passage upwards of the palm of the hand initially turned downwards.
It usually occurs in men 30 years and older and both smoking and corticosteroid medication are risk factors for the condition.
What are the associated symptoms?
Usually the patient feels a "snap" at the elbow when the tendon ruptures. The pain is intense initially but resolves in a week or two. Other symptoms include edema of the elbow, visible ecchymosis of the elbow and forearm, weakness in elbow flexion and forearm twisting (supination), swelling in the most proximal portion of the forearm, and a gap in the anterior aspect of the elbow caused by the absence of tendon
What is the diagnosis based on?
The diagnosis is based primarily on the data provided by the patient and the physical examination performed by the physician. Elbow radiographs may be performed to exclude other causes of pain, but it is the ultrasound that best helps to establish the diagnosis. MRI is generally unnecessary.
What is the treatment
Once ruptured, the tendon will not re-attach to the bone or heal spontaneously. To regain strength to normal levels, surgery is usually recommended. In patients with low functional requirement, non-surgical treatment may be a reasonable option.
Non-surgical treatment includes:
- Rest: avoid lifting weights or activities above the head, to relieve pain and limit edema; the use of antebrachial suspension may be indicated for a short period of time.
- Non-steroidal analgesic and anti-inflammatory medication to decrease pain and edema.
- Physiotherapy: after pain reduction, for arm muscle strengthening exercises, to restore the mobilities as much as possible.
The surgical approach should be performed within the first 2 to 3 weeks after injury. After this period, the muscle and tendon begin to heal and shorten, so restoration of function with surgery may not be possible. Later surgical techniques are usually more complex and less successful.
In the acute phase (in the first 2 to 3 weeks) the surgical procedure is based on the reinsertion of the tendon in the forearm bone (radio), using points through bone holes created for the passage of the wires; anchors may also be used for this purpose.
Surgical complications are rare and usually temporary - tingling or weakness of the forearm, formation of new bone around the tendon, or re-rupture of the tendon (unusual).
Immediately after surgery, the upper limb is immobilized in plaster, splint or orthosis. Since the tendon takes about 3 months to heal completely, it is important to protect the repair by restricting activities. However early physiotherapy and mobilization are key to maintaining elbow mobilities.
Following these principles, the vast majority of patients have complete mobilities and normal strength at the end of follow-up.