Distal Biceps Rupture
Biceps Tendon (Anatomy)
Biceps muscle and tendon.
In the shoulder it has two different origins, one from inside the shoulder joint and the other from a bone outside the joint.
These two tendons then join and form the main muscle mass in the front of your arm which you can easily palpate.
This muscle mass then becomes one single thick tendon (the distal biceps tendon) and attaches to the radial tuberosity which is a bone found around your elbow joint.
When you contract or flex your elbow you can easily palpate this tendon.
The distal biceps is important for flexing (or bending) your elbow and also for rotating your forearm outwards (supination). Therefore when this tendon ruptures you lose strength of flexion and supination.
How do patients present?
The injury usually occurs after a sudden lift or when your elbow is loaded in an unusual way (can be forced into extension). The patients are generally aged between 25 and 65 years of age and often the dominant arm is affected.
When the tear occurs you often hear or feel a snap and a tearing sensation. A lump can often be palpated in the lower arm as the tendon retracts around your elbow.
Photo showing a distal biceps rupture with swelling and the muscle belly sitting higher than normal.
How are Distal Biceps Ruptures diagnosed?
If one is unsure of the clinical diagnosis then a more definitive diagnosis can be made with imaging such as an ultrasound or the gold standard test of a MRI scan. Once the diagnosis is confirmed then treatment options can be considered.
How are Distal Biceps Tendon Ruptures treated?
For this reason surgery is generally recommended to restore function around the elbow. Conservative or non-operative treatment is generally recommended for those that have very low demands on their elbow with the understanding that there will always be an element of weakness.
How long after I rupture my tendon have I got to have it repaired?
Beyond 4 weeks after the injury it is very difficult to repair and the results are not as rewarding. After the rupture the tendon starts to retract up the arm and gets to a stage after 4 to 6 weeks where it cannot be brought down to its anatomical position of attachment.
How is the operation done?
The part of the radius it arises from is called the radial tuberosity. This part of the radius rotates around the other bone in the elbow called the ulna allowing the motion of rotation. The biceps tendon has to be surgically repaired to this anatomical part of the radius to allow full function to occur. The tendon can be repaired in two different ways – using either one or two incisions.
In my practice I prefer to use 1 small incision to allow the most anatomical repair – therefore restoring near to normal function.
Through this incision we dissect onto the bony attachment site for the tendon, a drill hole is made in this bony prominence for re-attachment of the tendon. The biceps is then pulled through the drill hole with an adjustable button and is secured with a screw in its anatomical position.
Image showing biceps tendon fixed to the radius with a drilled socket, a button to tension the repair and a screw for a more secure hold.
It is now up to the tendon to heal back to the bone and for your elbow to slowly regain function.
What happens after surgery for Distal Biceps Ruptures?
Your elbow is placed in a bandage and also a sling to protect the repair. No plaster is necessary. This operation can be performed as a day-only or sometimes an overnight procedure.
I get you to start moving your elbow the next day to prevent stiffness. The movement you start doing is called passive which means you use your other hand to hold your affected wrist as you move your arm. This prevents a load being placed on the repair.
I start with 2 exercises which are passive flexion and passive supination during the first 6 weeks as seen in these pictures.
During these 6 weeks you can take your arm out of the sling when sitting down or resting. One can generally do simple tasks such as using keyboards, eating and drinking. No weight heavier than a full coffee cup should be put through your elbow during this time of healing.
After 6 weeks a physiotherapy programme is started so you regain strength and function in your arm. It takes 4 to 6 months for your elbow to recover and feel reasonably normal. Heavy loads should not be put through your elbow in this time.
What is the success rate of surgery?
What complications can occur with this operation?
Firstly, if the tendon is of poor quality it maybe irreparable.
Some of the other complications include nerve damage as the tendon travels close to major nerves in your arm, blood vessel injury, and re-rupture of the tendon.
The other major complication that can occur is where your tendon repair heals rapidly causing extra bone to develop and subsequent loss of rotation of your forearm. If this occurs then a second operation is necessary to remove the bone so as to allow the rotation to recur.