A 76-year-old woman presents with five days of progressive right upper extremity, axillary, and lateral chest wall bruising. She takes warfarin for atrial fibrillation, and claims her last “Coumadin check” a week earlier was normal.
She denies paresthesias, weakness, itching, plethora, shortness of breath, chest pain, and trauma. She is concerned because the bruising is spreading from the upper arm down, with some mild swelling and pain in the arm. She is retired, but had helped move some boxes at her church a week earlier. Distally she is neurovascularly intact. What injury do you suspect is the cause of her symptoms?
Diagnosis: Biceps Tendon Rupture
The biceps muscle is responsible for shoulder and elbow flexion, forearm supination, and grip strength. The biceps muscle fixes to the shoulder girdle by two tendinous attachments. The proximal long head attaches to the supraglenoid tubercle, and the proximal short head attaches to the coracoid process of the scapula. The solo distal biceps tendon attaches to the elbow (radial tubrical). Biceps tendon tears occur 95 percent of the time at the proximal heads (nearly all in long head), and often are associated with rotator cuff tears. They typically occur in middle-aged men with a history of chronic shoulder pain secondary to chronic wear of the tendon after lifting a heavy object in the dominant arm. (Physician Sportsmed 1999;27:95.) Biceps rupture can also occur in young athletes after a traumatic injury or heavy lifting. (J Shoulder Elbow Surg 2004;13:580.)
Patients with suspected biceps tendon rupture warrant a complete physical examination of the shoulder and elbow. Acute anterior shoulder pain is the most common feature of a tendon rupture, often with radiation down the bicep, and may be associated with a pop. A history of persistent shoulder “soreness” is not uncommon. Pain is exacerbated with range-of-motion movements at the shoulder and possibly elbow depending on the location of the tear. Patients with complete long head proximal biceps tendon rupture will have a palpable mass (contracted muscle belly) near the elbow. Function will remain largely intact because of the integrity of the short head. (Wheeless’ Textbook of Orthopaedics; http://bit.ly/bicepsrupture.) Ecchymosis and swelling in the biceps area may also occur.
Those with distal biceps rupture will have decreased strength with supination and flexion at the forearm and acute pain in the anticubital fossa. (Clin Orthop Relat Res 1991 Oct;:143.) If the rupture is complete, the biceps tendon will not be palpable in the anticubital fossa via the hook test (patient flexes elbow to 90°; intact biceps tendon should be a palpable cordlike structure with examiner's hooked index finder when pulling medial to lateral). (Am J Sports Med 2007;35:1865.) This test may be of limited use in patients with anticubital fossa adipose. The Speed's and Yergason's tests have been shown unreliable as isolated maneuvers to diagnose bicep tendon injury. (Arthroscopy 2004 Mar;20:231.)
The differential diagnosis of tendon rupture is fairly circumscribed and includes pathology of the shoulder and elbow, including osteo and septic arthritis, gout, fracture, and muscle and ligamentous injury.
Musculoskeletal tendinous injuries are typically best characterized anato-mically by MRI. (Comput Med Imaging Grap 1992;16:345.) The diagnosis also can be made clinically using radiographs to rule out bony injury in trauma and verify bony shoulder changes consistent with chronic inflammation (hypertrophic spurring). Arthrography has fallen out of favor because the procedure is invasive, and requires radiation exposure to the patient. Ultrasound has been noted to be diagnostically helpful in complete ruptures or dislocations, but has limited ability to detect partial ruptures. (Clin Orthop Relat Res 1986 Jan;:184; Acta Orthop 2005;76:503.)
In the ED, treating isolated proximal biceps tendon rupture is typically supportive with orthopedic follow-up. Rest, ice, compression, and anti--inflammatory medications are recommended. Physical therapy is helpful to direct early exercise therapies to improve shoulder and elbow mobility outcomes and strength.
No consensus exists on operative vs. nonoperative treatment of biceps tendon ruptures; most recommend treatment based on the individual. Operative repair (tenodesis) is recommended for cosmesis or when other comorbid shoulder injuries exist that require operative repair. Patients with nonoperative repair may be expected to have persistent weakness in the affected extremity, which rarely affects daily activities but may be unacceptable for some. Weakness is less likely in those patients who receive operative repair. (Clin Orthop Relat Res 1988 Mar;:233.)
All patients with nonoperative distal tendon rupture are expected to have persistent weakness, but typically have acceptable outcomes. (www.wheelessonline.com.) Patients with high pre-injury function (recreational sports enthusiast) may be good candidates for operative repair to maintain function, but the decision of operative vs. non operative repair must be based on the patient's injury, pre-injury function and post-treatment expectation. (Injury 2008;39:753.) Early operative repair can also decrease the risk of persistent pain. (Laeknabladid 2009;95:19.)
This patient was diagnosed with a complete short head biceps tendon rupture with hematoma formation on CT scan, which was performed because of the concern for vascular injury given the impressive expanding ecchymosis and swelling.
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