Distal Biceps Rupture

Dr. Randale Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today we’ll be talking remotely again with Dr. William Seeds. Dr. Seeds is an orthopedic surgeon that practices in Ashtabula, Ohio. Dr. Seeds also is a Sports Medicine provider for the GaReat Center in Geneva, Ohio. Thanks for joining us today Dr. Seeds.

Dr. William Seeds: Randy, thanks for having me. I'm happy to be here.

Dr. Randale Sechrest: Well, Dr. Seeds, what I thought we would discuss today is a fairly common problem, but one that people get confused with another problem that occurs at the shoulder, and that's distal biceps tendon rupture. I think people are familiar with biceps tendon rupture and some people may not understand that it can occur at both ends of the biceps – one at the shoulder, which is probably more common than the more violent injury of a distal biceps rupture. But, lets start out by sort of describing what this injury is and what causes this injury.

Dr. William Seeds: Well, typically Randy this injury occurs when the elbow is in a flexed position and it's trying to stop a weight from progressing. It's what we would call an eccentric contraction of the muscle. So there is a slight bend in the elbow and you're trying to resist something or you're falling and resisting something in a flexed position of the elbow. And that is most typically how we see that injury. In most people at the time of injury when they do disrupt that tendon they know they've done it – they've either heard a pop or felt a pop, and have a pretty significant amount of pain at that time. Other presenting symptoms would be immediate swelling, some black and blue bruising around the area which would indicate bleeding. But most people at the time of the injury can recall those specific type of events happening.

Dr. Randale Sechrest: Lets talk a little bit about the anatomy of the biceps, and especially the distal biceps tendon. Where is this rupture and why does it occur at that area.

Dr. William Seeds: Typically what it is is the muscle attaching to tendon than attaches to bone. It attaches to the proximal part of the radius to what we call the tubercle of the radius. The proximal tubercle. And what happens is that tendon will rupture usually off of that area of the tubercle and it's a tendon – more than likely it's usually a tendon injury where the tendon disrupts. And usually the problems with that are when it's a complete disruption, the likelihood of that repairing itself is very unlikely that that can occur.

Dr. Randale Sechrest: Now, in terms of the type of patient that normally suffers this type of injury – is this something we see in young, active adults? Children? Or older adults?

Dr. William Seeds: That's a good questions Randy, We tend to see that usually in the population of 30 years and older. We believe it may be more secondary to the fact that the tendon Is a long tendon, the blood supply is very tenuous to that area. A lot of these injuries can be related to just repetitive use of that tendon and it weakens and then finally disrupts from a specific activity. But no, we don't usually see these in younger people, we usually see these in middle-aged and older people.

Dr. Randale Sechrest: And how does a patient know that they have actually ruptured this tendon. You mentioned that sometimes they feel a pop, they have a lot of pain. But what would drive them to either see an orthopedic surgeon or feel that this was a pretty serious injury that they should go to the emergency room and actually have it evaluated.

Dr. William Seeds: Well, again, usually it's – they've felt something pop or pull, they've heard a noise or pop. And they've not only got pain associated with the use of their elbow, but they also have a disruption in the strength of the muscle, in the amount of flexion strength they have and also in what we call supination, where they have difficulty twisting their palm up. And that is an indication of an injury to that distal biceps and usually that combination of factors is what will bring a patient into the emergency room or to our office. And, sometimes, sometimes we will see these delayed in presentation and that, as we'll discuss can bring a whole other group of problems associated with it.

Dr. Randale Sechrest: Well, when the patient finally does make it to your office, and you begin to evaluate the patient, how do you try to figure out what is going on?

Dr. William Seeds: Well, typically we'll listened to what the history of what the patient has described as the injury. Where most of them can recall hearing a pop or feeling a pop of that area. We'll do the normal exam, looking for swelling around the elbow, looking for black and blue - meaning bleeding, what we would call ecchymosis, or bleeding around that tendon, which would be more indicative of a potential tear. We'd be checking their muscle strength, specifically in supination and flexion to look for weakness. And also a test that we do in flexion, it's called a hook test. Where we can specifically palpate that distal biceps tendon and we can put our finger around that tendon and have the patient supinate the wrist and we'll be able to feel that tendon kind of move over the elbow– or move over the finger, and we'll be able to extend it and feel that tendon. So we have a couple a pretty I think select tests to be able to help us in discerning if there is a true rupture of the tendon or not.

Dr. Randale Sechrest: And what about imaging studies? Is this an injury that you feel like you need to get an x-ray on or need to get some sort of an advanced imaging like an MRI scan to really figure out what's going on?

Dr. William Seeds: Yes, all patients will initially have an x-ray when they present with this elbow injury. We will be looking for any bony avulsion, where sometimes it will pull a piece of the bone. We will be looking for other possible associated injuries around the elbow where there may be actually a radial head fracture and not an actual tendon injury. So, the x-ray is there to determine if there is any true bone injury, but also to look for the possibility of avulsion. I have a very low threshold, I am really quick to recommend MRI evaluation of the tendon, of these injuries, because how significant they are and how important they are in what I believe in repairing and restoring that function – or giving that patient the option to make that decision. I believe the MRI is very important in helping to give you an indication of how significant the tear is, if it's a full tear – which most of the time you can tell by exam, sometimes you can be fooled by too much blood in the area where that can be deceiving. But the MRI is, I think, very important in giving you the information that you need to make some very early decisions for this injury.

Dr. Randale Sechrest: Now you mentioned that you like to see these early. Do you have any advice for patients who may think that they may have suffered a distal biceps rupture in terms of trying to seek care – if they're given an appointment lets say three weeks later in an orthopedic surgeon's office after being seen in the emergency room – do you think that's too late to wait? Do you think they should try to move this appointment up somewhat?

Dr. William Seeds: Yes, Randy, I absolutely think that this is something that needs to be seen by a, in our hands as soon as we can. In fact my office is instructed to ask specific questions where they – if we're seeing someone for an elbow problem, we try to do the best we can to ascertain the information to make a decision if they possibly could have had a biceps injury because they know how important it is to get those people in immediately. And I think the patients should insist, if they feel that they have anything of that degree of an injury that they should insist in the emergency room that they get seen immediately in an orthopedists office or do a better job of communicating to the office that they believe they have a biceps injury because they will be seen very quickly.

Dr. Randale Sechrest: And what is the purpose of that. I mean what are we talking about here in terms of the risks if you let it wait?

Dr. William Seeds: The problem with this if it's a full rupture of the distal biceps, you want to be able to offer that patient the decision making of potentially restoring that function back to the elbow where you can repair that tendon back to the bone. And that is a surgical procedure that we would like to get to within the first couple weeks, if not sooner, with this type of an injury. And when we have that discussion with the patient, we are letting them know that this type of an injury has a very good success rate in getting people back to full function, where potentially where they decide not to do something with it, or they're not able to get to it soon enough, you can compromise a significant amount of strength where they can lose up to 50% of their ability to rotate, in supinating the wrist, they fatigue very quickly where they don't have an endurance to be able to turn a screwdriver or things like that. And they lose about 30-40% of their flexion strength too. So those are some real things that you have to have a discussion with the patients that they understand that that is a very significant possibility if they choose not to undertake repair of that tendon.

Dr. Randale Sechrest: Well, it sound like in most cases you are going to recommend surgical intervention if you evaluate the patient and find they have a complete rupture of the tendon. Are there instances where you might suggest to the patient that they may do okay without surgery?

Dr. William Seeds: Yes, Randy, I certainly do. For instance if the MRI shows a partial tear, then we take a more conservative route of physical therapy and just an understanding with the patient that it's a long time to restoring that arm back to functional use. Which could very well, easily 3-4 months before they can start really using that extremity against any really forceful type of stresses, but we definitely take a conservative route with most of the partial tears of the distal tendon, but the full ruptures I'm aggressive in recommending full reconstruction.

Dr. Randale Sechrest: Now what about if it's the patients non-dominant arm. For example if they're right handed and this occurs on the left, do you still feel very strongly that that patient still would do better with surgery?

Dr. William Seeds: Yes, well, I guess I should take a step back and say, with my patients I really give them the information to make the decision. I give them the information of the potential weakness of both the supination and rotation of the wrist and flexion of the wrist and some and the possibility of a potential pain with that type of a process if you don't repair it. And I let them make that decision, with the non-dominant extremity, depending on the age, I'm still a believer that I can restore that elbow back to function that they had before, it's got a good track record and so I'm there to give them the information to help them in making that decision that's best for them.

Dr. Randale Sechrest: Well, lets talk a little bit about the surgery. Tell me a little bit about how you perform this surgery. Is it out patient surgery or is this something that you keep the patient over night?

Dr. William Seeds: It's typically something that can be done in an outpatient setting. Again it depends on the patient, and how early you're able to get to this injury, but usually these are people that you can send home as an out patient type of surgery and there are some certain neurovascular parameters that will follow in evaluating that extremity and we like to see the patients the next day. And typically with these outpatient procedures, we will see the patient next day in physical therapy, so we have the ability to follow that extremity pretty quickly after a surgical repair.

Dr. Randale Sechrest: Lets talk a little bit about the surgery itself- how do you perform the surgery?

Dr. William Seeds: Well, usually as far as performing this type of surgery. We will approach it either as a one incision or two incisions. I will go over that with the patient, and it really has to do with the anatomy of the forearm and how difficult it is to get to where we need to repair it. I utilize both approaches and I can tell you that sometimes I will go in with the thought that I might be using two incisions, and I only have to use one, and sometimes I go in thinking I's going to use one and I end up using two. In my hands I find that there is really no difference as far as the rehabilitation or the healing time of either approach, and also the post operative pain, I don't find really a difference with either approach of one or two incisions. So, I discuss that with the patient, and I use that really to my discretion as to how easy it is to do the repair.

Dr. Randale Sechrest: Well, lets talk a little bit about the rehab. What sort of a brace or a cast or bandage do you utilize after the surgery?

Dr. William Seeds: Usually I will put these patients in braces, where again we're not doing anything to disrupt the soft tissue. We can follow the swelling of the extremity and it locks their arm in a position where they're not going to do any damage to that tendon repair and we'll keep them in a flexed position so that the tendon is not in a stretched or compromised position. And then we will take them out of that brace in therapy where we start doing some passive type of range of motion to just get the range back into the elbow. And I tend to find that we don't lose, we can get peoples range of motion pretty much back to normal on most of these cases. So we can be pretty aggressive with the rehabilitation, but we need to protect it, and will usually use that brace for about the first 6 weeks. I also do that with my partial tears that I treat non-operatively. I will keep them in a brace for about the same amount of time also.

Dr. Randale Sechrest: And how long does it take someone to really get over this injury, to the point where you release them to essentially do anything that they want to do?

Dr. William Seeds: Well, I think back to normal daily activities, with no significant stress – lets say they are not a weight lifter or a water skier, or something like that – within three months they can be back I think to some normal activities. As far as getting back to where they can start working on restoring significant strength if they're a weight lifter or as I said if they're doing significant stress – if they're a heavy laborer, that could be anywhere from 4-6 months before they have that function or they're able to stress that tendon to that degree.

Dr. Randale Sechrest: And do you actually restrict these patients once they've healed? Do you give them any advice about things to avoid? Or do you pretty much expect them to get back to any activity that they desire.

Dr. William Seeds: No, I tell all the patients that our objective in repairing this tendon is to get them back to full activity with no restrictions. And the literature has shown that we can do that with these patients and we can restore them back to function without any further bracing or anything like that. And the re-rupture rate is pretty low with these types of injuries

Dr. Randale Sechrest: Well, lets talk a little bit about the complications, or potential complications that you worry about as an orthopedic surgeon. And I guess we probably ought to divide that into things that you're worried about right at the time of surgery, things that your worried about in the post operative period, and then maybe things that you're worried about long term – that can occur even several weeks down the road. So, give us some ideas about what you worry about.

Dr. William Seeds: Well, potentially as I discussed with making the decision of 1 versus 2 incisions, that's more focused on what the anatomy is around that repair site as far as the neurovascular structures, more of the significant veinous drainage and the arterial supply around that area, I tend to do, when I do this surgery, I tend not to ligate a lot of the veins around the forearm because I don't want to, I try to keep that trauma to the veinous structures limited. And so if I feel I am doing too significant amount of the dissection I'll go to the two incision where I don't have to worry as much about that. And also we worry about the nerve injuries that can happen and more specifically to the superficial radial nerve where we can have injuries with that. And again it depends on the incision, that's with the two incision. The single incision we're worried a little bit more about the anterior aspects of the median nerve. And so it really just depends – you're trying to be as conservative as you can and to be very knowledgeable of not having any nerve or vascular injury. That's acutely, and those things we'll actually watch for post operatively also to make sure there is no increased swelling aspect after the surgery, we'll continue to follow neurovascular exam. And then I think our concern after that is as with any surgery to make sure we're looking for infection. We're always worried about the possibility of and that's why we brace them about the possibility of re-rupture of the tendon too soon because of some activity when they weren't able to protect themselves from. And then as time goes on one aspect that we're a little more concerned with, I think more with the two incision than the single incision, is the possibility of some bone growth, some herterotopic bone that can grow between the bones in the muscle, in the interosseous membrane there between the two bones. That sometimes can have an effect on rotation of the wrist and uh, that's really it. That is what we look for and I I said the complication rate is significantly low with this procedure, so I think that with the experience of with these injuries and knowing you can use one versus two incisions and be able to be pretty versatile in that aspect, I think you can make some good decisions and do a good job.

Dr. Randale Sechrest: You know you mention that most of these cases were done as an outpatient, what about the anesthesia? Is this something that you typically prefer to put the patient completely to sleep with a general anesthetic or do you use some type of a block just to numb up the arm so that you can work on the arm?

Dr. William Seeds: Well, I usually will, I usually don't want to disrupt the arm in the neurovascular exam, so if for any reason I'd have to wake the patient up, or do anything to examine the patient immediately I want to be able to have that ability to do that so most of the patients I'll do under a general anesthesia on an outpatient basis where I don't have to just block the arm and be concerned about following the nerve post operatively. So, that's why I make that decision.

Dr. Randale Sechrest: Well, this has been an excellent and I think a comprehensive discussion about this injury. I think we ought to clarify once again that this is an injury that were talking about called a distal biceps tendon rupture. And that differs from the shoulder problem that some people may be familiar with where the long head of the biceps is ruptures from the top end of the humerus, or the shoulder, and that gives you a completely different sort of injury, it also gives you a completely different sort of choices to make. But I want to clarify that what we're really talking about is a very specific injury at the elbow that involves the distal end of the biceps. So, as we close this discussion, is there anything that you feel like patients should know that we haven't discussed during this conversation?

Dr. William Seeds: Well, I think that it's just important for people to understand that we take these injuries, we consider all elbow injuries around this area significant. And we make sure, we try to rule out the fact that there is any type of tendon injury. We, a lot if us will use the MRI to help get this diagnosis quickly. We'll act very conservatively initially as far as bracing you initially to protect you, but we're trying to get all these things done to help to make a decision as quickly as we can to give the patient the right choices in making the best decision for them. So, I think it's just important to get to your orthopedic physician as soon as you can when you feel that there is a potential of this type of injury.

Dr. Randale Sechrest: Well, I want to thank you for joining us today. I think this has been a great discussion, and thanks for sharing this information.

Dr. William Seeds: Thanks for having me Randy. I look forward to talking with you again soon.