Practical Orthopedics-What to Do … When To Refer •
T. Dunlop PGY 5 Division of Orthopedic Surgery University of Saskatchewan
This presentation has received no support from any organization .
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Objectives §
Participants will be able to: • Recognize both proximal and distal biceps tendon rupture using practical clinical tools • Appropriately manage and refer when necessary
DISTAL BICEPS www.usask.ca
Demographics
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Anatomy
1.2 per 100,000 persons / year § 86% dominant elbow § 93% men in their 40’s §
• Case reports of females
Mean age 30-50 § 7.5x greater risk in smokers §
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Bicipital Aponeurosis (Lacertus Fibrosus) Arises from the medial aspect of the muscle belly at the junction of the musculotendinous unit and the distal biceps tendon § Passes distally and medially across the antecubital fossa §
www.usask.ca Di s t al Bi ceps Tendon
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I nj ur i es . M i l l et t et al . J BJ S Cur r ent Concept s Revi ew 2010
Mechanism Rapid, unexpected Eccentric load § Elbow at 90o of flexion § §
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I nj ur i es . M i l l et t et al . J BJ S Cur r ent Concept s Revi ew 2010
History
Examination
Sudden, sharp, tearing sensation § Painful “pop/tearing sensation” at time of injury § Intense pain subsides in few hours § Dull ache can last for weeks § Subjective weakness in supination
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Proximal retraction of muscle belly Change in contour Medial ecchymosis Loss of biceps continuity • •
Underlying brachialis tendon may also be mistaken for biceps Lacertus fibrosis may remain intact
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Hook test
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Flex elbow to 90 degrees Fully supinate forearm Index finger hooked from the lateral edge of biceps tendon When there is no cordlike structure to hook under
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Sensitivity and specificity 100%
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•
The tendon is not intact
The Hook Tes t f or Dis t al Bic eps Tendon Avuls ion.
O’Dr is coll
et al. Am J Spor t s M ed Nov 2007, 35 1865- 1869
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www.usask.ca Th e Ho o k Test fo r Distal Bicep s Ten d on Av ulsion . O’Drisco ll et al. Am J S p orts M ed No v 2 00 7, 35 18 65 -18 6 9
Can be hard to distinguish between complete and partial ruptures clinically
• Entrapment of the lateral antebrachial cutaneous nerve
X-ray • Occasionally show small fleck or avulsion of bone from radial tuberosity • Rule out associated elbow injuries
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Imaging §
Ultrasound
Ultrasound • Should not be used for routine use •
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False negative rate
MRI • • • •
When dx is unclear Complete vs partial tear Muscle substance vs tendon tear Degree of retraction •
Chronic tear www.usask.ca
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MRI §
Although all these imaging modalities are nice…
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This is mainly a clincial diagnosis
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Why is it important?
Management §
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Non-operative • •
What function do you loose? • Up to 50% loss of supination • Up to 40% loss of flexion strength • Significant loss of endurance
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Low-demand or medically unfit Painless function with weakness and early fatigue in supination associated with nonsurgical tx
Operative •
Ideally occur within few weeks from injury
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Superior flexion strength (30%) Superior supination strength (40%)
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Superior endurance
S u rg ical treatmen t o f d istal b icep s ru p ture. JAAOS 2 01 0; 18 : 13 9-1 48
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When to Refer?
Operative Treatment Techniques
Refer all complete or questionable distal biceps for consideration of surgery via ACAL § While surgery within a ‘few weeks’ is technically ok – if these referrals all start coming by fax to people’s offices it will be difficult to get them in
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Post Op Care §
Partial Biceps Rupture
Generally:
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• +/- Immobilized in flexion with the forearm in neutral rotation x 1-6 weeks •
Many do not immobile if good quality repair
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• Early controlled ROM • No resistance until >3 months
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Painful and require prolonged recovery Initial treatment = NSAIDs + PT If failure of non-surgical = consider surgery Tears 50% tear = detachment of partial tear with repair of the distal biceps insertion If any question regarding partial vs complete…refer!
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Chronic Ruptures
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Chronic ruptures
Often result of missed diagnosis Rarely report pain § Present with loss of supination strength § MRI – location of tear and amount of retraction § Surgically challenging §
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Management • Extensile anterior approach to localize stump • Interposition grafting may be required
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Autograft (semitendinosus tendon)
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Allograft (achilles tendon)
• Tissue retraction • Loss of elasticity • Early atrophy
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Complications § §
PIN palsy (1-4%) LABCN palsy (0-11%) •
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Summary § §
Occurs most commonly in 30-50 year old males Have a high clinical suspicion given classic history and physical •
Classically one incision technique
Symptomatic HO (4-7%) Re-rupture (1-2%) All complications are higher in surgical repair of chronic tears
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• § §
Physical exam is key for diagnosis
Consider imaging modalities to help with diagnosis Healthy, active persons with distal biceps tendon ruptures may benefit from early surgical repair Thus needs referral in necessary in a timely fashion (ACAL)
Loss of forearm rotation, HO, radioulnar synostosis, and nerve injury can occur with surgical management Chronic ruptures are more difficult to manage
C o mp l i cati o n s fo l l o wi ng d i stal bi cep s rep ai r. J Han d Su rg Am. 20 1 2 Oct;3 7(1 0):2 11 2-7
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PROXIMAL BICEPS h ttp s://www.g o o g le.ca/search ?q = jo h n+ elway + su per+ b o wl&esp v
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Shoulder Girdle
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Function of LHB §
Cadaveric and anatomic studies • •
Contributes to glenohumeral stability in all directions Restraining abnormal translations
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Humeral head depressor
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LHB is a secondary stabilizer for the above functions* Lo n g h ead o f the b icep s ten din op ath y: diag n osis an d man ag emen t. Nh o et al., JAAOS 2 01 0; 1 8: 64 5-6 56
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h ttp s://www.sh o u ld erd oc.co .u k/article/1 4 31
LHB Tedinopathy
LHB Tendon Rupture
Spectrum from inflammatory tendinitis to degenerative tendinosis § Arises secondary repetitive traction, friction and GH rotation § Correlated with rotator cuff tendinopathy § Isolated biceps tendinitis in younger
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Rupture mostly commonly at tendon’s origin and at exit of bicipital groove near musculotendinous junction § Most common > 50 yo § Associated with biceps tendinitis
• Overhead sports Lo n g h ead o f the b icep s ten din op ath y: diag n osis an d man ag emen t. Nh o et al., JAAOS 2 01 0; 1 8: 64 5-6 56
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Causes §
Risk Factors Age Heavy overhead activities § Shoulder overuse § Smoking § Corticosteroid medications §
Two main causes: •
Injury • •
•
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Fall hard on an outstretched arm Sudden biceps flexion against stronger apposing force
Overuse •
Wearing down and fraying of the tendon • • •
Rupture with little or no trauma Occurs slowly over time It can be worsened by overuse
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History § § § § § § §
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Physical exam
Sudden, sharp pain in the upper arm Audible pop or snap Cramping of the biceps muscle Bruising from the middle of the upper arm Pain or tenderness at the shoulder and the elbow
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Pain with AROM of shoulder and elbow Bruising and discoloration Popeye sign Weakness with elbow flexion •
Will resolve with time
Weakness in the shoulder and the elbow Difficulty turning the arm palm up or palm down www.usask.ca
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Imaging §
Plain radiograph shoulder • •
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Rule out other conditions Seldom helpful in diagnosis of LHB tendonitis and rupture
U/S – highly accurate for detection of full thickness ruptures •
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Imaging
Also rule out other pathologies
MRI allows visualization of biceps tendon, bicipital groove and bony osteophytes
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Imaging for proximal biceps tendon ruptures is also used to assess for concomitant rotator cuff or other pathology § As in the case of distal biceps ruptures, this is mainly a clinical diagnosis §
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Treatment §
Nonsurgical Management
Nonoperative
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Most middle aged and older patient • Should be considered for all
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Rest NSAIDs § Activity modification § PT
Reconstructive/Tenodesis
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Management §
Indications for surgical Management
Conservative treatment usually results in relatively little function impairment of the shoulder •
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No difference at elbow joint in forearm supination or elbow flexion strength when comparing tenotomy, tenodesis and nonsurgical
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• §
vs •
Mostly for cosmetic deformity Unresolved weakness / cramping / pain Those who require complete recovery of strength
Some suggest tenodesis results in less strength loss of supination, less risk of cramping and improved cosmetic result
Manual laborers / athletes
Consists of: • Arthroscopy • Separate incision to find ruptured tendon stump • Tenodesis • • •
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Biciptal groove Suprapec Subpec
Multiple fixation methods h ttp s://www.sh o u ld erd oc.co .u k/article/1 4 31
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Post op protocol
Summary
Sling x 4-6 weeks § Progress to full active and passive shoulder ROM during first 6 weeks § Active elbow flexion and suspiration exercises after 6 weeks
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LHB tendinopathy common source of shoulder pain and can lead to tendon rupture § Treated non-operatively once diagnosis established § Operative treatment mainly for cosmesis
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