Distal Biceps Tendon Disruptions: Acute and Delayed Reconstruction and One- and Two-Incision Techniques



Distal Biceps Tendon Disruptions: Acute and Delayed Reconstruction and One- and Two-Incision Techniques


Matt Noyes

Edwin E. Spencer Jr.



ANATOMY



  • Mean length of the distal biceps insertion is 22 to 24 mm and the mean width is 15 to 19 mm on the proximal radius.


  • The biceps tendon inserts like a ribbon on the ulnar aspect of radial tuberosity.


  • Left tendon spirals clockwise, right tendon counterclockwise.12


  • A relatively avascular zone exists just proximal to the tendon insertion site.


  • The lacertus fibrosus typically originates from the distal short head of biceps tendon.1


NATURAL HISTORY



  • Complete ruptures



    • Distal biceps tendon ruptures are most common in the dominant extremity of men in the fourth and sixth decade.


    • Injury typically results from an eccentric muscle contraction. This often occurs when an extension force is applied to the supinated arm in 90 degrees of flexion.


    • The initial pain subsides quickly, but there is usually a noticeable deformity in the anterior brachium as the biceps muscle contracts and retracts. The degree of the retraction can be mitigated by the lacertus fibrosus which may remain intact.


    • The patients usually reports loss of flexion and supination strength. This is especially noted in patients that require repetitive supination such as mechanics and plumbers. Pain is usually not a predominant complaint, although some patients will experience fatigue-type pain and cramping in the retracted muscle belly.


    • Studies have revealed a 30% reduction in flexion strength and a 40% loss of supination strength.3,15


  • Partial ruptures



    • Partial distal biceps tendon injuries are usually more painful than complete tears. Patients usually present with pain in the antecubital fossa especially with resisted flexion and supination. There is an absence of clinical deformity.


    • These can progress to complete tears.


    • Women typically present with partial tears of the distal biceps, usually at a more advanced age (mean age of 63 years).7


    • A distinct palpable cystic mass can be found occasionally in women.7


    • Partial tears are typically from chronic degeneration without acute trauma.


    • Predisposing factors: anabolic steroids, smoking, cubital bursitis, and bony irregularities on bicipital ridge17


PHYSICAL FINDINGS



  • In acute cases of a complete distal biceps tendon rupture, there is usually a significant amount of ecchymosis in the antecubital fossa and distal brachium.


  • The distal biceps tendon is easily palpated in the antecubital fossa and lack thereof is confirmed by comparing the involved side to the uninvolved side. Local edema can make the diagnosis a little more difficult; however, the “hook test” has been found to be a very reliable diagnostic tool. To perform the test, the patient actively supinates the forearm while the examiner attempts to “hook” the distal biceps tendon lateral side to medial.16



    • The hook test has been found to have 100% sensitivity and specificity.16


  • The degree of proximal retraction of the tendon can be mitigated by the lacertus fibrosus.


  • A magnetic resonance imaging (MRI) is usually not necessary to make the diagnosis. However, the only caveat is that if the examiner feels that the distal biceps tendon is intact, then the injury might be more proximal at the myotendinous junction or only a partial tear at its insertion. It is important to make the distinction between the common complete avulsion from the radial tuberosity and an injury at the myotendinous junction, as the more proximal injuries are best treated nonoperatively.19


  • Partial tears occur at the radial tuberosity and are usually not associated with ecchymosis and demonstrate no proximal retraction. Partial tears present late with pain during resisted flexion and supination. The distal biceps tendon is palpable and frequently tender. An MRI can aid in the diagnosis of partial tendon ruptures.


DIFFERENTIAL DIAGNOSIS



  • Cubital bursitis


  • Elbow dislocation


  • Radial head fracture


  • Entrapment of lateral antebrachial cutaneous nerve


NONOPERATIVE MANAGEMENT



  • Nonoperative management of complete distal biceps tendon ruptures entails the use anti-inflammatories and physical therapy to reduce pain and swelling. Patients are allowed to use the extremity as tolerated. Strengthening should focus on elbow flexion and supination.


  • It should be discussed that complete distal biceps tendon ruptures are not usually associated with residual pain but rather
    loss of flexion (30%) and supination (40%) strength.3,15 If that is compatible with the patient’s job and lifestyle, then nonoperative management is acceptable.


  • Partial biceps tendon ruptures and ruptures at the myotendinous junction are treated in a similar manner. The patient should proceed to strengthening when full painless range of motion (ROM) is obtained. Operative intervention is considered when nonoperative management fails for partial ruptures. Usually, a minimum 3 to 4 months of observation is appropriate. Patients should be counseled that pain rather than weakness is more of a predominant complaint with these injuries.


SURGICAL MANAGEMENT


Complete and Partial Ruptures



  • The EndoButton (Smith & Nephew, Andover, MA) method of fixation has been shown to have highest ultimate tensile load.14,22 Clinical studies with the EndoButton have also demonstrated good results with few complications.2,6


  • Other methods are suture anchor and interference screw fixation.


Chronic Disruptions

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Jul 22, 2016 | Posted by in ORTHOPEDIC | Comments Off on Distal Biceps Tendon Disruptions: Acute and Delayed Reconstruction and One- and Two-Incision Techniques

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