A few early reports describe satisfactory results with nonoperative treatment1,2 or non-anatomic repair.3 However, biome-chanical studies and clinical reports highlighting the role of th
Trang 1Once thought to be an uncommon
injury, distal biceps tendon
rup-tures are being seen with
increas-ing frequency A few early reports
describe satisfactory results with
nonoperative treatment1,2 or
non-anatomic repair.3 However,
biome-chanical studies and clinical reports
highlighting the role of the biceps
muscle in elbow function have
raised questions about the success
of these methods.4-8 Today, most
would agree that anatomic repair
to the radial tuberosity is necessary
to obtain strength and endurance
in supination and flexion
Anatomy
The biceps muscle is the most superficial muscle in the anterior compartment of the arm The dis-tal tendon of the biceps muscle passes deep in the antecubital fossa
to insert at the radial tuberosity
The 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
It passes distally and medially across the antecubital fossa, blend-ing with the fascia overlyblend-ing the proximal flexor mass of the fore-arm, and inserts on the subcuta-neous border of the ulna
An appreciation of the local neuro-vascular anatomy is critical if injury to these structures is to be avoided at the time of surgical repair The lateral antebrachial cutaneous nerve is the terminal cutaneous branch of the musculo-cutaneous nerve, which supplies sensation to the volar-lateral aspect
of the forearm This nerve pierces the deep fascia of the arm near the musculotendinous junction of the distal biceps tendon between the biceps and brachialis muscles It exits the arm and lies in the subcu-taneous tissues of the antecubital fossa
Dr Ramsey is Assistant Professor of Ortho-paedic Surgery, University of Pennsylvania School of Medicine, Penn Musculoskeletal Institute, Presbyterian Medical Center, Philadelphia.
Reprint requests: Dr Ramsey, Penn Musculo-skeletal Institute, Presbyterian Medical Center, One Cupp Pavilion, 39th and Market Street, Philadelphia, PA 19104.
Copyright 1999 by the American Academy of Orthopaedic Surgeons.
Abstract
Rupture of the distal biceps tendon occurs most commonly in the dominant
extremity of men between 40 and 60 years of age when an unexpected extension
force is applied to the flexed arm Although previously thought to be an
uncom-mon injury, distal biceps tendon ruptures are being reported with increasing
frequency The rupture typically occurs at the tendon insertion into the radial
tuberosity in an area of preexisting tendon degeneration The diagnosis is made
on the basis of a history of a painful, tearing sensation in the antecubital region.
Physical examination demonstrates a palpable and visible deformity of the distal
biceps muscle belly with weakness in flexion and supination The ability to
pal-pate the tendon in the antecubital fossa may indicate partial tearing of the
biceps tendon Plain radiographs may show hypertrophic bone formation at the
radial tuberosity Magnetic resonance imaging is generally not required to
diagnose a complete rupture but may be useful in the case of a partial rupture.
Early surgical reattachment to the radial tuberosity is recommended for optimal
results A modified two-incision technique is the most widely used method of
repair, but anterior single-incision techniques may be equally effective provided
the radial nerve is protected The patient with a chronic rupture may benefit
from surgical reattachment, but proximal retraction and scarring of the muscle
belly can make tendon mobilization difficult, and inadequate length of the distal
biceps tendon may necessitate tendon augmentation Postoperative
rehabilita-tion must emphasize protected return of morehabilita-tion for the first 8 weeks after repair.
Formal strengthening may begin as early as 8 weeks, with a return to
unre-stricted activities, including lifting, by 5 months.
J Am Acad Orthop Surg 1999;7:199-207
Diagnosis and Management
Matthew L Ramsey, MD
Trang 2The median nerve, brachial
artery, and brachial vein lie medial
to the biceps tendon beneath the
bicipital aponeurosis The brachial
artery bifurcates at the level of the
ra-dial head into its terminal branches,
the radial and ulnar arteries The
radial recurrent artery branches
from the radial artery and passes
laterally and proximally across the
antecubital fossa
The radial nerve enters the
ante-cubital fossa laterally between the
brachialis and brachioradialis
mus-cles Anterior to the humeral
epi-condyle, the nerve divides into a
superficial branch and a deep
branch The superficial branch of
the radial nerve continues into the
forearm under the brachioradialis
and lateral to the radial artery and
supplies sensation to the middorsal
aspect of the forearm The deep
branch of the radial nerve (posterior
interosseous nerve) courses around
the lateral side of the radius and
enters the supinator muscle
be-tween its humeral and radial heads
Functional Biomechanics
The biceps muscle is the strongest
supinator of the forearm and assists
the brachialis in elbow flexion The
ability of the biceps to perform
these functions depends on the
position of the arm The biceps
muscle is more active in flexion of
the supinated forearm than in
flex-ion of the pronated forearm There
is little, if any, electrical activity in
the biceps muscle when flexion of
the pronated forearm is attempted,
unless there is a substantial
pronat-ing force resistpronat-ing supination.9
Contraction of the biceps muscle
tends to supinate the pronated
fore-arm and may therefore be inhibited
when the forearm is in pronation
The contribution of the biceps to
forearm supination increases with
elbow flexion, reaching a maximum
at about 90 degrees of flexion
Beyond 90 degrees, there is no sub-stantial increase in biceps activity as the muscle-tendon unit shortens.10
Etiology
Rupture of the distal biceps tendon
is most likely to occur in the domi-nant extremity of men between the fourth and sixth decades of life The average age at the time of rupture is approximately 50 years (range, 18
to 72 years).3,5-7,11-18 All reported cases of complete distal biceps ten-don rupture have occurred in men
However, partial rupture of the dis-tal biceps tendon has been reported
in women.19
The mechanism of injury is usu-ally a single traumatic event in which an unexpected extension force is applied to an arm flexed to
90 degrees The tendon typically avulses from the radial tuberosity, although ruptures within the ten-don substance and at the musculo-tendinous junction have been reported The bicipital aponeurosis may or may not rupture acutely
Some authors have described the rupture as occurring in stages, such that the insertion to the radial tuberosity is disrupted initially and the bicipital aponeurosis tears later, completing the rupture.19,20 How-ever, the bicipital aponeurosis may
be intact in some instances, pre-venting proximal migration of the ruptured tendon into the arm
The pathogenesis of distal biceps tendon ruptures is poorly under-stood Degenerative and mechani-cal processes have been implicated
as the cause of rupture It is gener-ally accepted that normal tendons
do not rupture.18,21,22 The contribu-tion of a degenerative process to tendon rupture is supported by intraoperative observations of a thickened, bulbous distal end of the tendon Microscopic characteriza-tion of spontaneously ruptured ten-dons, including the distal biceps
tendon, has demonstrated an array
of degenerative changes.21 Interest-ingly, similar changes were present
in control specimens from patients with no history of symptoms
relat-ed to the distal biceps tendon The degenerative process may continue unrecognized, compromising the structural integrity of the tendon, until sufficient trauma causes com-plete rupture
Hypovascularity of the tendon may play a role in tendon rupture
in some patients Vascular injection studies of the distal biceps tendon demonstrate two consistent sources
of extratendinous blood supply, one distally at the tendon insertion from the posterior recurrent artery and one proximally from the brachial artery A hypovascular zone has been identified between the proximal and distal zones.23
The fact that most ruptures occur at the tendon insertion, as opposed to
a more proximal location, would seem to eliminate hypovascularity
as the sole cause of rupture
The space available for the bi-ceps tendon between the radius and the ulna changes depending on forearm position The distance between the radius and the ulna is maximal in supination and de-creases progressively with forearm pronation In full pronation, the bi-ceps tendon occupies 85% of the available space23; therefore, any-thing that encroaches on this space may result in mechanical impinge-ment Davis and Yassine22 theo-rized that hypertrophic bone on the anterior margin of the radial tuber-osity contributes to tendon failure because of repetitive impingement with forearm rotation
Clinical Evaluation History and Physical Examination
Patients with complete distal biceps tendon ruptures usually
Trang 3report an unexpected extension
force applied to the flexed arm
The most common symptom
asso-ciated with distal biceps tendon
rupture is a sudden, sharp, painful
tearing sensation in the antecubital
region of the elbow and
occasional-ly in the posterolateral aspect of the
elbow The intense pain subsides
in a few hours and is replaced by a
dull ache, which can last for weeks
and may become chronic
activity-related pain Subjective weakness
in supination is a variable
com-plaint, which may depend on the
functional demands placed on the
extremity Weakness in flexion is
profound immediately after
rup-ture because of pain but tends to
diminish with time
Physical examination
demon-strates tenderness in the
bital fossa A defect in the
antecu-bital fossa can usually be palpated
If the biceps tendon is palpated in
the antecubital fossa, a partial
rup-ture of the distal biceps tendon
must be considered If the bicipital
aponeurosis is intact, the deformity
is not as pronounced but is usually
easy to appreciate on comparison
with the opposite extremity With
active flexion of the elbow, the
biceps muscle belly retracts
proxi-mally, accentuating the defect in
the antecubital fossa (Fig 1)
Ecchymosis and swelling appear in
the antecubital fossa and along the
medial aspect of the arm and
proxi-mal forearm
Weakness in supination, as well
as some weakness in flexion, can
usually be demonstrated In the
acute phase, weakness may be
related to pain in addition to the
functional deficits of the detached
biceps tendon
Radiologic Evaluation
Radiographic studies can aid in
the diagnosis of ruptures of the
dis-tal biceps tendon but are not a
sub-stitute for a thorough history and
physical examination Plain
radio-graphs generally do not demon-strate any osseous changes How-ever, irregularity and enlargement
of the radial tuberosity22 and avul-sion of a portion of the radial tuberosity3have been reported in patients with complete ruptures of the distal biceps tendon
Inability to palpate the distal biceps tendon in the antecubital fossa is indicative of a complete rupture If the history and symp-toms suggest a biceps tendon injury and the tendon can be pal-pated in the antecubital fossa, other causes of antecubital pain, includ-ing cubital bursitis, bicipital tendi-nosis (tendon degeneration), partial biceps tendon rupture, and entrap-ment of the lateral antebrachial cutaneous nerve, must be investi-gated Cubital bursitis (enlargement
of the bursal sac that lies between the biceps tendon and the anterior aspect of the radial tuberosity) may exist in isolation or in association with a distal biceps tendon lesion
Tendon degeneration (bicipital tendinosis) without rupture may occur in isolation or in association with cubital bursitis or partial rup-ture In this circumstance,
magnet-ic resonance (MR) imaging of the elbow may provide useful informa-tion about the integrity of the distal biceps tendon and any intrasub-stance degeneration (Fig 2) How-ever, the distinction between bicip-ital tendinosis and partial ruptures
is not always apparent on MR imaging.24
Classification
There is no widely accepted classi-fication for distal biceps tendon injuries Partial ruptures of the dis-tal biceps tendon have been
report-ed only in case reports and small series.19,24,25 Partial tendon failure can occur at the tendon insertion to bone19,22,24or within the substance
of the tendon, which can be
elon-gated.25 Because so few cases of partial rupture have been reported, any classification that aspires to guide treatment is subject to error Complete ruptures are arbitrar-ily classified on the basis of the amount of time between rupture and diagnosis In chronic tears, the integrity of the bicipital aponeuro-sis is also important because of its role as a tether to proximal retrac-tion The value of defining the chronicity of the rupture and the integrity of the bicipital aponeuro-sis lies in its usefulness in predict-ing the ease of repair (Table 1) Distal biceps tendon ruptures diagnosed early are easily reat-tached to the tuberosity with pre-dictably good results regardless of whether the bicipital aponeurosis
is intact or ruptured.4,6-8,11,13,17,18
Fig 1 Proximal retraction of the biceps muscle belly with attempted flexion of the elbow.
Trang 4However, the results of repair of
chronic ruptures vary and are not
predictable solely on the basis of
the time between rupture and
re-pair If the bicipital aponeurosis
remains intact, the tendon is
pre-vented from retracting proximally
into the arm Rupture of the distal
biceps tendon and the bicipital
aponeurosis allows the tendon to
retract proximally Over time,
scar-ring to the brachialis and retraction
of the tendon into the biceps
mus-cle belly may limit the ability to
obtain sufficient length for
anatom-ic repair
Treatment
Partial Rupture
The difficulty in treating
pa-tients with partial tears of the distal
biceps tendon lies in proper
diag-nosis Cubital bursitis, with or
without concomitant bicipital
tendinosis, and partial ruptures can
both present with pain in the
ante-cubital fossa; furthermore, both
conditions may be present at the
same time.26 The advent of MR
imaging has allowed direct
assess-ment of pathologic changes within
soft tissue that previously could
only be inferred from the history and physical examination.27,28 This has helped define the pathology of the distal biceps tendon
Partial distal biceps tendon rup-tures that fail to respond to nonop-erative treatment are best managed surgically Most partial ruptures occur at the insertion into the radial tuberosity.19,22,24 The most success-ful surgical results for symptomatic partial ruptures have been achieved
by releasing the remaining portion
of the biceps tendon from the tuberosity, debriding the frayed tendon end, and anatomically reat-taching the tendon to the radial tuberosity as if there were a com-plete rupture.19,24 Foxworthy and Kinninmonth29 reported a case of median nerve compression from an enlarged synovial bursa associated with a partial rupture of less than 50% of the distal biceps tendon, which was treated with median nerve decompression and debride-ment of the biceps tendon Whether debridement of the distal biceps tendon contributed anything to the improvement in the patientÕs symp-toms is unclear from this report
Other authors have not reported success with debridement of partial tears of the distal biceps tendon.19
Elongation of the biceps tendon without failure at the tuberosity is
an unusual form of partial tearing reported by Nielsen.25 The thin, elongated tendon does not possess the mechanical integrity of the intact tendon and behaves
clinical-ly like a complete rupture Nielsen used Z-plasty shortening of the biceps tendon with suture rein-forcement to reestablish the length-tension relationship of the biceps muscle Postoperatively, flexion strength and supination strength were equivalent to those in the noninjured arm
Complete Rupture
The superiority of early
anatom-ic repair in returning flexion and supination strength is well estab-lished.4,6-8,11,13,17,18 Although some patients may choose nonoperative management of complete ruptures, they should be told of the possibility
of activity-related pain in the arm and forearm, as well as decreased strength and endurance in flexion and supination Nonoperative management should be considered only for elderly, sedentary patients who do not require strength and endurance in flexion and supina-tion and for patients who are too ill
to undergo surgery
Single-incision and two-incision techniques to treat these injuries have been described Recently, with the availability of suture
Fig 2 Fast spin-echo T2-weighted MR images of two patients A, Normal distal biceps
tendon insertion (arrowhead) B, Partial insertional rupture (arrowhead) with
degenera-tion of the distal biceps inserdegenera-tion (arrow).
Table 1 Classification of Distal Biceps Tendon Ruptures
Partial rupture Insertional Intrasubstance (elongation) Complete rupture
Acute (<4 weeks) Chronic (>4 weeks) Intact aponeurosis Ruptured aponeurosis
Trang 5anchors, the use of an anterior
approach has increased in
populari-ty.16,30,31 When using suture
an-chors and a single-incision
tech-nique for acute distal biceps tendon
ruptures, the radial nerve should be
protected but does not need to be
formally identified and dissected.31
In chronic cases, the surgeon should
consider identifying the superficial
and deep branches of the radial
nerve to avoid injury if a single
anterior incision is to be utilized In
this situation, a pullout suture tied
over a bolster or soft-tissue button
or suture anchors are used.7,13,16,17
Before suture anchors became
avail-able, radial nerve injuries were
reported with single-incision
tech-niques,3,5,7,12 which prompted the
development of two-incision
tech-niques.8,14,32
Most authors favor a modified
Boyd-Anderson two-incision
tech-nique for complete ruptures The
original technique involves
subpe-riosteal exposure of the ulna.32 This
approach has caused radioulnar
synostosis,8,12,33prompting
modifi-cation of the technique Currently, a
muscle-splitting approach through
the common extensor and supinator
muscles is preferred Although this
may reduce the incidence of
proxi-mal radioulnar synostosis, it has not
eliminated it entirely.15
Technique for Immediate
Repair
The patient is placed supine on
the operating room table with the
affected arm extended on an arm
board A tourniquet can be used if
desired An anterolateral incision
beginning 5 cm above the flexion
crease along the lateral border of
the biceps is the standard
ap-proach The incision should curve
medially at the flexion crease of the
elbow to avoid crossing the elbow
at a 90-degree angle to the flexion
crease This extensive exposure is
unnecessary in acute ruptures; a
transverse incision in the flexion
crease with distal extension pro-vides adequate exposure and a cos-metically acceptable incision The lateral antebrachial cutaneous nerve is identified as it pierces the deep fascia and is retracted
lateral-ly The deep fascia is incised, and the distal biceps tendon is identi-fied If the bicipital aponeurosis is intact, the tendon will remain in the tendon sheath or will retract proximally and turn back on itself
in the antecubital fossa If the bicipital aponeurosis is ruptured, the tendon will retract proximally into the anterior compartment of the arm The tendon is retrieved and minimally debrided Two No 5 nonabsorbable Bunnell sutures are passed through the tendon
If the rupture is acute or the ten-don remains in the tenten-don sheath distally, an extensive soft-tissue dis-section, including identification of the radial nerve, is not necessary
The sheath previously occupied by the biceps tendon can be easily identified by blunt finger dissection down to the radial tuberosity With the forearm in supination, a blunt hemostat is advanced along the medial border of the radial tuberos-ity to the dorsolateral aspect of the
proximal forearm; care must be taken not to violate the periosteum
of the ulna (Fig 3)
A second incision is made over the hemostat down to the fascia overlying the common extensor muscle mass The common exten-sor muscle mass and supinator muscles are split down to the radial tuberosity with the forearm in max-imal pronation A high-speed burr
is used to create a cavity in the
radi-al tuberosity large enough to accept the distal biceps tendon Three small drill holes are placed along the margin of the cavitated tuberos-ity The sutures are passed from the anterior incision through to the second incision (Fig 4) The tendon
is passed deep and medial to the lat-eral antebrachial cutaneous nerve The sutures are passed through the drill holes and tied The wounds are closed in layers, and the elbow
is immobilized in 90 degrees of flex-ion with the forearm in supinatflex-ion
Technique for Delayed Repair
The need to repair chronic rup-tures of the distal biceps remains questionable Chronic ruptures are more difficult to repair than acute ruptures However, the disability
Fig 3 A,The ulnar periosteum is not exposed in the modified muscle-splitting
two-inci-sion technique (dotted line shows correct direction of incitwo-inci-sion) B, Care must be taken not
to violate the ulnar periosteum when passing the hemostat to the dorsolateral aspect of the forearm or when making an incision on that surface (dotted line shows incorrect direction
of incision).
Trang 6associated with a chronic rupture
often justifies the attempt at repair
even though the results are not as
predictable as those after
immedi-ate repairs
Anatomic repair of the ruptured
tendon to the tuberosity is the goal
of delayed repair if improved
strength and endurance are
neces-sary If surgery is being performed
because of activity-related pain in
the arm and forearm, tenodesis to
the brachialis can be considered,
with the understanding that
supi-nation strength and endurance will
not improve
Proximal retraction of the
rup-tured tendon may preclude
ana-tomic reattachment because of a loss
of tendon length An intact bicipital
aponeurosis will limit proximal
retraction of the tendon, making
repair somewhat easier Inadequate tendon length should be anticipated preoperatively and discussed with the patient so that an alternative source of graft to extend the tendon can be planned Autogenous tissue
is preferred to synthetic materials
Rolled fascia lata or semitendinosus autograft are acceptable graft mate-rials The semitendinosus tendon is similar in caliber to the native biceps tendon and has performed well in clinical use.34
In cases of chronic rupture, the distal biceps tendon sheath is scarred, necessitating a more exten-sive dissection Identification and protection of the radial nerve are warranted in this situation
The graft should be passed from anterior to the posterolateral incision and fixed to the tuberosity, as
de-scribed for an immediate repair With the elbow in 45 to 60 degrees of flexion, the graft is woven through the distal end of the native biceps tendon and secured to itself (Fig 5) Postoperative care is similar to that for immediate repairs
Postoperative Rehabilitation
The extremity is immobilized with the elbow in 90 degrees of flex-ion and the forearm in supinatflex-ion for 7 to 10 days A hinged flexion-assist splint with a 30-degree exten-sion block is used to protect the re-pair until 8 weeks postoperatively The splint is then removed, and un-restricted motion and progressive strengthening are begun Unre-stricted activities, including strenu-ous lifting, are not allowed until 5 months after repair
The rehabilitation program for patients with delayed repairs is similar to that for patients with acute repairs The limit of active extension in the early postoperative period is dictated by the tension in the biceps tendon
Results
As mentioned previously, numer-ous early reports on the treatment of distal biceps tendon ruptures indi-cated that satisfactory results could
be obtained, with return of normal
or near-normal strength and func-tion, regardless of the method of treatment Some authors advocated nonoperative management of these injuries, citing normal return of strength and function and docu-menting the ability to return to work earlier than after surgical treatment.1,2 Other authors sup-ported attachment of the biceps ten-don to the brachialis muscle.4,12
This position was historically advo-cated in 1941 by Dobbie,12who was Òimpressed with the numerous important structures identified and contained in this anatomic region
Fig 4 The exposed tuberosity is excavated with a high-speed burr, taking care to leave
the thicker cortical bone along the radial border of the tuberosity intact Three drill holes
are made along the radial side of the tuberosity The sutures are passed through the drill
holes and tied with the forearm in neutral position to prevent the sutures from pulling out
of the drill holes (Adapted with permission from the Mayo Clinic, Rochester, Minn.)
Biceps tendon
Trang 7and was thoroughly convinced that
exposure of the tubercle was
impractical and unwise.Ó
Reattach-ment of the biceps tendon to the
brachialis muscle simplified the
sur-gical procedure considerably and
avoided the potential complication
of radial nerve injury.3,12 However,
objective strength data demonstrate
no improvement in supination
strength.8
As the role of the biceps muscle
in elbow strength and function
became known, support for early
anatomic repair grew In 1985,
Morrey et al8reported loss of flexion
and supination strength by as much
as 50% with nonoperative treatment
Similarly, Baker and Bierwagen4
documented objective deficiencies in flexion and supination strength of 21% and 27%, respectively Equally impressive were the losses of flexion and supination endurance,
estimat-ed at 21% and 47%, respectively
While this degree of loss of strength may not be incapacitating for many activities of daily living, activities that require sustained strength and endurance can be severely limited
When one considers that this injury occurs most frequently in the domi-nant extremity in heavy laborers, it
is not surprising that these deficits can be disabling
Surgical repair is the more re-cently accepted approach Nu-merous studies have reported ex-cellent results with early anatomic repair of the distal biceps ten-don.4,6-8,11,13,17,18 Morrey et al8
reported 97% flexion strength and 95% supination strength compared with the uninvolved extremity
Other authors have demonstrated similar return of strength and en-durance but have reported differ-ences based on hand dominance
Repaired nondominant extremities demonstrated mild weakness and lack of endurance compared with the uninvolved dominant extremi-ty; however, strength and endur-ance of the repaired dominant ex-tremity were equivalent to those in the unrepaired nondominant ex-tremity.4,11,15
Patients with chronic ruptures (>4 weeks) present a difficult chal-lenge Proximal retraction of the biceps muscle and scarring to the brachialis can occasionally make anatomic repair impossible Fascia lata autograft,3,13a semitendinosus autograft,34and a ligament aug-mentation device wrapped with fascia lata20 have all been used to extend a shortened biceps muscle
Strength in flexion and supination
is improved in comparison to rup-tured tendons treated
nonopera-tively, but the degree of improve-ment varies.5,8,34 Boucher and Mor-ton5reported 50% residual flexion weakness in a patient treated 4.5 months after injury Hang et al34
found only 13% flexion and 14% supination deficits in a patient treated with semitendinosus aug-mentation 1 year after injury Al-though late repairs carry a greater risk of providing no improvement
in strength, surgery should be con-sidered for patients with consider-able disability
When partial rupture of the dis-tal insertion has been successfully managed by releasing the remain-ing tendinous insertion to the tuberosity and reattaching the ten-don as if it were completely rup-tured, patients have been able to return to normal work activities without difficulty.19,24 Bourne and Morrey19 evaluated postoperative strength data after release and repair of partially ruptured ten-dons and found normal values in one patient and a decrease by 33%
in supination with normal flexion strength in a second patient Nielsen25has reported a case of biceps tendon elongation with mechanical insufficiency of the biceps muscle After nonoperative treatment failed to improve the patientÕs symptoms, a Z-plasty shortening of the tendon was per-formed, which restored power to the extremity
Complications
Many authors have reported radial nerve injury after repair with the use of a single-incision anterior approach.3,5,7,18 Fortunately, when
a radial nerve palsy occurs, it typi-cally resolves completely, although permanent radial nerve injury has been reported.3
Although a two-incision repair decreases the incidence of radial nerve injury, proximal radioulnar
Fig 5 The semitendinosus graft is
secured to the radial tuberosity through
drill holes With the arm in 45 to 60
degrees of flexion, the graft is woven
through the distal biceps tendon stump
and secured to itself (Adapted with
per-mission from Hang DW, Bach BR Jr,
Bojchuk J: Repair of chronic distal biceps
brachii tendon rupture using free
autoge-nous semitendinosus tendon Clin Orthop
1996;323:188-191.)
Trang 8synostosis has been reported as a
potential complication of this
ap-proach.8,12,15,33 Use of a
muscle-splitting approach instead of the
original technique of subperiosteal
ulnar dissection may reduce the
incidence of this complication
Summary
Rupture of the distal biceps tendon
can be disabling for individuals who
require upper extremity strength for
vocational and recreational
activi-ties It occurs when an unexpected
extension force is applied against a
contracting biceps muscle Rupture
probably occurs through a tendon
weakened by intrasubstance
degen-eration or external mechanical
im-pingement
The history and physical
exami-nation are usually sufficient to
make the diagnosis The hallmark
is a palpable defect in the distal
biceps, which is accentuated by
attempted elbow flexion Weak-ness on supination is easily demon-strated; flexion weakness is more subtle Radiologic evaluation, including plain radiographs and
MR images, is generally not neces-sary to make the diagnosis Mag-netic resonance imaging may occa-sionally be useful in differentiating among biceps tendon degeneration (tendinosis), cubital bursitis, and partial distal tendon ruptures
Immediate surgical repair of the ruptured biceps tendon is advocated for optimal return of function Use
of a two-incision muscle-splitting approach and nonabsorbable su-tures is recommended for secure repair Techniques that utilize a single anterior incision are ade-quate but require protection of the radial nerve to avoid nerve injury
The use of suture anchors may sim-plify the procedure In the case of a chronic rupture, there may be inad-equate tendon length to reach the radial tuberosity Autogenous
tis-sue or an augmentation device can
be considered in this situation The results of late repair are less pre-dictable for return of strength, but activity-related pain is diminished Symptomatic partial tendon ruptures are rare Failure of non-operative management may be treated by release and repair of the partially torn tendon However, experience with surgical treatment
is limited
Postoperative rehabilitation involves protection of the repair against any lifting force for 6 to 8 weeks Initially, the arm is immo-bilized in a splint with the elbow in
90 degrees of flexion and the fore-arm in supination for 7 to 10 days
A flexion-assist splint with a 30-degree extension block is utilized for 6 to 8 weeks postoperatively Unrestricted range-of-motion exer-cises and gentle strengthening are begun at 8 weeks Return to unre-stricted activity is allowed by 5 months after surgery
References
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3 Meherin JM, Kilgore ES Jr: The
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4 Baker BE, Bierwagen D: Rupture of
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