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9/14/2018 0 Comments

BiCeps Tendon Rupture


Incidence
  • Rare
  • Distal biceps tendon rupture represents about 10% of biceps ruptures, with majority being proximal
  • Ruptures tend to occur in the dominant elbow (86%) of men (93%) in their 40s
Risk factors
  • Your muscle builders with their anabolic steroids
  • Smoking has 7.5x greater risk than nonsmokers
  • Typically, patients will report a snap or pop as the elbow is eccentrically loaded from flexion to extension

  • Weakness and pain, primarily in supination, are hallmarks of this injury
  • May produce mid-arm "ball", also be referred to as the reverse “Popeye’s sign” = change in contour of the muscle
  • Motor exam often shows loss of supination and flexion, with mostly loss of supination
  • Distal swelling and tenderness over antecubital fossa
    • For most complete tears, there will be an Inability to palpate distal biceps tendon in antecubital fossa
    • However, there is a great provocative test you can perform called the Hook test. This was a technique first described in 2007 in an article published in the AJSM (Dr. Shawn O’Driscoll), which was found to be ~100% sensitive and specific
      • Performed by asking the patient to actively flex the elbow to 90° and to fully supinate the forearm. Using you index finger, attempt to hook the lateral edge of the biceps tendon.
      • With an intact / partially torn tendon, finger can be inserted 1 cm beneath the tendon
    • Follow-up study using the Hook test has shown once again near 100& specificity, however lower sensitivity at 82%, but overall a great physical exam maneuver if you have high suspicion!
  • The biggest challenge is going to be distinguishing between complete tear and partial tears
  • Biceps tendon is absent in complete rupture and palpable in partial rupture (otherwise they have a very similar clinical picture)

Evaluation
  • Obtain radiographs to rule-out avulsion fracture (Usually normal)
    •  However, occasionally shows a small fleck or avulsion of bone from the radial tuberosity
  • Ultrasound can help with diagnosis--> Use linear probe (high frequency probe) to assess for tendon defects
  • Ideally, outpatient MRI will often be used to distinguish between complete tear vs. partial tear or muscle substance vs. tendon tear
Management
  • Proximal rupture
    • Sling, ice, NSAIDS, physical therapy, referral to ortho
  • Distal
    • Nonoperative
      • Supportive treatment followed by physical therapy
      • Older, low-demand or sedentary patients who are willing to sacrifice function. Most becoming asymptomatic at 4-6 weeks
    • Operative
      • Surgical repair of by fixation of tendon to tuberosity 
      • Indications
        • Young healthy patients who do not want to sacrifice function 
        • Partial tears that do not respond to nonoperative management
        • Surgical treatment should occur within a few weeks from the date of injury
        • Further delay may preclude a straightforward, primary repair
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