You are in: eMedicine Specialties > Orthopedic Surgery > HAND AND UPPER EXTREMITY Bicipital Tendon InjuriesArticle Last Updated: May 18, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: John P Salvo, Jr, MD, Assistant Director, Sports Medicine, Assistant Professor of Surgery, UMDNJ, Cooper Bone and Joint Institute, Cooper University Hospital John P Salvo Jr is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, Pennsylvania Medical Society, and Pennsylvania Orthopaedic Society Editors: Michael S Clarke, MD, Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Thomas R Hunt III, MD, John D Sherrill Professor of Surgery, Director, Division of Orthopedic Surgery, Surgeon in Chief, UAB Upper Extremity Fellowship, UAB Highlands Hospital, University of Alabama at Birmingham School of Medicine; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: biceps tendon, distal biceps tendon, elbow tendon, bicipital tendonitis, bicipital tear, bicipital injury, elbow pain, elbow deformity, modified Boyd-Anderson incision INTRODUCTIONSection 2 of 11
  Bicipital tendon injuries of the elbow most commonly occur in the dominant extremity of men aged 40-60 years. Injuries range from tendonitis to partial tears to complete ruptures. A rupture usually occurs at the insertion of the tendon to the radial tuberosity, resulting in pain and deformity about the elbow, as well as weakness, especially with supination. Most surgeons agree that the best results are obtained with early surgical intervention and reattachment of the tendon to the radial tuberosity. History of the ProcedureBoyd and Anderson first described a modified 2-incision approach for repair of a distal biceps tendon in 1961. The original approach involved subperiosteal dissection on the ulna. This led to an increased incidence of synostosis and heterotopic bone formation. A modified approach with muscle-splitting rather than subperiosteal dissection decreases the incidence of synostosis and heterotopic bone formation. The biceps tendon is secured after the tuberosity is excavated. The tendon is fixed through 3 drill holes in the tuberosity. The advent of suture anchors has increased the popularity of the single-incision approach. This approach has the theoretical advantage of a low risk of synostosis. The originally described anterior single-incision extensile approach was associated with radial nerve injury. Today's limited anterior approach has been has been associated with neurapraxic injuries only. ProblemThe biceps brachii is the most powerful supinator of the forearm, and along with the brachialis, it provides elbow flexion. Rupture of the distal biceps tendon results in loss of supination power and deformity, as well as pain in the elbow. Without early surgical repair, chronic weakness and deformity persist. Pain typically resolves in time. Because this injury is most common in the dominant extremity of active middle-aged men, it may lead to significant impairment of their daily activities. FrequencyThe overall frequency of bicipital tendon injuries is not truly known but has been reported to occur in 1.2 patients per 100,000 population. It has been reported with increasing frequency, but generally is considered to represent only 3% of biceps tendon injuries as a whole. This injury is more common in men and rarely reported in women. EtiologyBicipital tendon injuries most commonly occur when an extension force is applied with the elbow in flexed position. This force overpowers the tendon and causes its rupture. It is believed that a degenerative process occurs in the tendon prior to the rupture. This process is evident clinically at the time of surgery with the finding of a bulbous, degenerated end of the tendon. Histologic studies have confirmed the degenerative process. Exactly how partial ruptures are related to this process is unknown. In addition, mechanical and vascular issues contribute. ClinicalBicipital tendon ruptures most commonly occur in the dominant extremity in men aged 40-60 years, with an average patient age of about 50 years. They often have a history of acute pain in the antecubital fossa, and patients typically give a history of either lifting or holding something heavy with their elbow flexed immediately prior to the injury. Patients may or may not have a history of previous elbow pain. This pain, if present, may be related to tendon degeneration or a previous partial tear. The acute pain is accompanied by deformity in the antecubital fossa due to tendon retraction. An obvious deformity indicates rupture of the tendon and the lacertus fibrosis. Some patients have swelling and/or ecchymosis in the antecubital fossa as well, typically over the medial proximal forearm. Initially, they may have weakness with flexion due to pain. This symptom may subside in a few days as the swelling decreases, but weakness with supination does not subside. If the tendon is completely ruptured but the lacertus fibrosis is intact, little deformity may be present. On examination, tenderness may be noted in the antecubital fossa, as well as deformity due to the tendon retraction. If the lacertus fibrosis is not ruptured, the deformity is not as pronounced, but it can still be appreciated on comparison with the opposite extremity. The deformity is accentuated with resisted supination with the elbow in flexion. INDICATIONSSection 3 of 11
Most surgeons agree that the vast majority of bicipital tendon ruptures benefit from early surgical repair. Indications for surgical intervention include a complete tendon rupture, with or without lacertus fibrosis rupture, in an otherwise healthy, cooperative, and active individual. Acute ruptures are best treated early, within 8 weeks of the injury. Chronic injuries may require reconstruction or augmentation of the tendon and is a much more complicated procedure. RELEVANT ANATOMYSection 4 of 11
The biceps brachii travels in the anterior compartment of the arm and is innervated by the musculocutaneous nerve. It is the most powerful supinator of the forearm and also acts as a flexor of the elbow. It has 2 separate, proximal origins: the coracoid process and the bicipital tuberosity of the superior glenoid. Distally, a single tendon inserts on the radial tuberosity after passing through the antecubital fossa. The lacertus fibrosis, an aponeurotic expansion, originates at the musculotendinous junction medially and blends distally with the fascia of the superficial flexor mass and inserts on the proximal ulna. The lateral antebrachial cutaneous nerve travels between the brachialis and biceps brachii and exits the arm in the subcutaneous tissue laterally. It supplies sensation to the lateral aspect of the forearm. The median nerve courses with the brachial artery and vein medial to the biceps tendon in the antecubital fossa. The artery bifurcates into the radial and ulnar arteries at the level of the radial head. A recurrent branch from the radial artery travels lateral and proximal across the antecubital fossa. The radial nerve travels laterally between the brachialis and brachioradialis to enter the antecubital fossa. The superficial branch travels deep to the brachioradialis in the forearm. The deep branch enters the supinator muscle lateral to the radius and becomes the posterior interosseous nerve. CONTRAINDICATIONSSection 5 of 11
Surgical repair of a bicipital tendon rupture has few contraindications. Contraindications include the presence of little functional impairment from the injury, medical contraindications to a surgical procedure, and a sedentary or uncooperative patient. A relative contraindication is chronic disruption. Because of tendon retraction and muscle contraction, it is difficult or impossible to anatomically reattach the tendon to the radial tuberosity. In these situations, delayed reconstruction using autograft or allograft tissue is required and the outcome is less dependable. WORKUPSection 6 of 11
Imaging Studies
TREATMENTSection 7 of 11
Surgical therapyEarly surgical intervention for complete ruptures provides the best results. Two techniques are commonly used: the 2-incision (modified Boyd-Anderson) technique and the single-incision technique. The 2-incision technique, which Boyd and Anderson described in 1961, is the more common technique. However, with the advent of suture anchors, the single incision is becoming more popular. Advantages of the 2-incision technique includes potentially stronger fixation to the radial tuberosity. The most common complication is heterotopic bone, which can create a mechanical block to motion. As a result, this bone may need to be surgically removed. Another reported complication is injury to the posterior interosseous branch of the radial nerve. The single-incision technique has the obvious advantage of 1 incision versus 2 incisions. Fixation is usually achieved with suture anchors placed into the radial tuberosity. The most common complication with the current single-incision technique is lateral antebrachial nerve neurapraxia. Preoperative detailsA thorough history, physical examination, and radiographic workup should be completed prior to surgery. Range of motion (ROM) and stability of the elbow should be assessed. Intraoperative detailsExamination with the patient under anesthesia is essential to surgery in any extremity. Surgery should be performed by using a tourniquet placed as high on the arm as possible. After standard sterile preparation and draping, the limb is exsanguinated and the tourniquet inflated. With the 2-incision technique, a small incision in the antecubital fossa (approximately 3-4 cm) is made in the flexion crease. Dissection is taken through the fascia, and the biceps tendon is easily identified. Sometimes, a "milking" maneuver must be performed to deliver the tendon into the wound. Once the tendon is identified, it is prepared for fixation. The tendon invariably has bulbous degeneration at the rupture site. Once the bulbous degeneration is resected, 2 nonabsorbable braided 5-0 sutures are placed in a Bunnell or Krakow fashion to secure the tendon. A curved Kocher or Kelly clamp is used to mark the second incision. The clamp is placed through the sheath of the biceps tendon and curved toward the radius with the forearm in supination. Great care is taken not to disturb the periosteum of the ulna to prevent synostosis. The clamp is used to tent the skin dorsally after it passes by the radial tuberosity. Once the clamp is past the tuberosity, the forearm is placed in pronation. Pronation of the forearm protects the radial nerve. A 4- to 6-cm incision is made over the tip of the clamp. The dissection is taken down through the fascia of the common extensor and supinator and down to the radial tuberosity, which is cleared of overlying soft tissue. The tuberosity can be excavated with a high-speed burr. D'Arco et al described a better technique in 1998. In their method, the radial tuberosity is prepared with multiple drill holes in an oval fashion and then excavated with small curved curettes. This approach avoids creating the bone dust from the burr that may lead to synostosis. After the tuberosity is prepared, 3 drill holes are made along the lateral margin of the tuberosity. The tendon is then delivered from the anterior wound to the tuberosity. This step can be expedited by placing a passing stitch when the curved clamp is removed from the biceps tendon sheath. The tendon is delivered into the tuberosity, and the sutures are tied securing the tendon. Lastly, the wound is closed in layers. Postoperative detailsWhether the 2-incision or the 1-incision technique is used, the elbow should be immobilized in 90° of flexion and slight supination for 7-10 days for the patient's comfort. Outpatient physical therapy begins with gentle ROM. A hinged ROM brace can help initially block the terminal 30° of flexion to protect the repair. This angle is gradually increased to full extension. Pronation and supination should be initiated early in therapy. Follow-upUnrestricted motion can usually be achieved by 6-8 weeks after surgery. Full, unrestricted resistance activities should be delayed at least 4 months. COMPLICATIONSSection 8 of 11
The most common complication from a 2-incision approach is heterotopic bone formation. This complication can be minimized by avoiding use of a burr to excavate the radial tuberosity, decreasing the amount of bone dust created. In addition, by avoiding disruption of the ulnar periosteum, the risk of synostosis can be minimized. The most common complication from a 1-incision approach is nerve palsy. Most of these palsies are transient in nature and completely resolve. They are best avoided by minimizing traction on the nerve. OUTCOME AND PROGNOSISSection 9 of 11
Excellent results can be obtained with early surgical intervention. Early direct repair of the tendon to the radial tuberosity gives the best opportunity for full functional recovery. Both the 2-incision and the 1-incision techniques provide excellent results. The choice of technique depends on the surgeon's preference. Delayed repair or reconstruction is more difficult than early treatment. Late repair may result in long-term weakness and loss of motion due to the chronicity of the injury. FUTURE AND CONTROVERSIESSection 10 of 11
With early repair, success rates with either the 2-incision or the 1-incision technique are great. The 1-incision technique will continue to advance with the development of better suture anchors. The use of multiple drill holes instead of a high-speed burr to excavate the radial tuberosity should also improve outcomes by decreasing the incidence of synostosis. REFERENCESSection 11 of 11
Bicipital Tendon Injuries excerpt Article Last Updated: May 18, 2006 |
