Distal Biceps Rupture (Elbow) - James T. Mazzara, MD

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Jim Mazzara. Dr. Mazzara did his medical school training at New York Medical College. He then went on to complete an orthopaedic residency at St. Luke Roosevelt Hospital, which is a teaching hospital affiliate of Columbia University. Good morning, Dr. Mazzara.

Dr. Mazzara: Good morning.

Dr. Sechrest: Dr. Mazzara, let's change direction a bit and talk about another problem in the elbow which is actually an injury, and I think a lot of people injure their elbow and they're not really certain what happens. This is one of those. This condition is called distal biceps rupture, and what occurs is that you have a violent contraction of the biceps so much that you actually pull the end of the biceps tendon off at the elbow. So tell us a little bit about that injury. How does it occur and how do we treat that?

Dr. Mazzara: Well, I would say the majority of patients are males compared to females. They're generally in their 40s and 50s. They're lifting something heavy, either that something heavy is something that falls to the ground, and with the elbow near full extension they try to stop it from falling, and they feel a pop in the arm. Other times they'll be lifting something and forcefully push it up. Again, the elbow is basically in the same position in near full extension and they feel a little pop or strain in the arm, and what will happen is they may have some bruising or swelling or discoloration in that area. They may notice a little bit of pain, but not really a lot of pain, and over a period of time they may recognize that they may have some weakness in the hand in several different tasks. Initially, one of the weaknesses that patients will notice is elbow flexion, so they might not be able to bend the elbow as normally as they would otherwise. One of the issues that patients also note is weakness in supination. Supination is when the palm goes from palm down to palm up, and that is a weakness that tends to be noticeable when you're turning a key or screwdriver; and so it's generally males doing some kind of physical activity, have a pop in the arm not always as painful as one would think when you rupture a tendon, but have some swelling and aching and weakness shortly thereafter.

Dr. Sechrest: Now, a couple of questions. Is there any significance to the fact that the elbow is almost out straight when that occurs?

Dr. Mazzara: The tendon is almost maximally stretched at that point. It's draped over the edge of the bone and it's stretched as far as it could possibly be, and then what the patient does is pushing against the tendon when stretched as far as it could be. It's like taking a rubber band and pulling it just a little bit farther causing it to snap.

Dr. Sechrest: Okay. Where does that tendon snap? I've seen it snap in the middle of the tendon and pull off the bone. In your experience, where is the usual place of weakness?

Dr. Mazzara: The area from which the tendon snaps is generally going to be where it attaches to the bone in what's called the bicipital tuberosity. It's in the upper end of the bone called the radius which is this bone on this side of your forearm, here on the thumb side of the forearm there's a little bump or ridge on the bone. The biceps comes down, it attaches right to that area, there's a little raised spot like a little plateau, and in that area, when the tendon pulls away from the bone, many patients will actually see the tendon recoil up into the arm. Some patients however may not see that. They might feel and experience all the same symptoms, but for a number of reasons, may not see a change in the appearance of the arm. There are two reasons that may occur: 1) It may not have been a complete biceps tendon rupture. There might still be just a few fibers remaining although functionally it doesn't work normally. 2) There's also another anatomic structure that prevents the biceps tendon from recoiling all the way up the arm, so it might look the same despite the swelling and bruising. But chances are if they have that pop and have subsequent weakness, those patients have sustained a distal biceps tendon rupture.

Dr. Sechrest: It's always interesting to me that patients have a tendency to walk in 2 or 3 weeks later with this injury.

Dr. Mazzara: Yes.

Dr. Sechrest: And it's one of those injuries that they're not really certain whether they've hurt anything or just strained their elbow. It's not like a fracture or something where people say, "There's something wrong here." It's not like an injury where people say, "There's definitely something wrong to my elbow and I need to get it checked out." Sometimes it takes them a while to convince themselves that "I've done something wrong because my elbow is not functioning correctly." Has that been your experience?

Dr. Mazzara: That's very true. I do see a lot of patients who injure their elbow at work. Those people, if they have a work-related injury, generally come in a little bit earlier, but the person who injures it at home is generally going to say, "I think this will get better. It will go away." , and several weeks later it doesn't. It's when they have a complete rupture with retraction and they have a deformity that they come into the office early on. When you have that near complete rupture and it doesn't retract, it doesn't recoil all the way up into the upper arm, it may not look any different. It might not feel normal but it doesn't look different, and if it doesn't look different patients tend to delay a little longer. We know that the longer you wait to fix a biceps tendon rupture, the higher the risk of complication postoperatively.

Dr. Sechrest: Now, when that patient presents to your office, how do you go about making the diagnosis that they've actually ruptured their biceps tendon?

Dr. Mazzara: You take a history. You do a good physical examination. The x-ray will probably look normal. If I have any question whatsoever if it's a biceps rupture that is not recoiled up into the upper arm, I'll do an MRI with special positioning on the elbow during the MRI. We have a very special protocol that we use when we send people for an MRI, it's called a FABS protocol, and basically patients need to be lying face down with their arm up above their head with their elbow in a certain position. The MRI needs to be taken in that position and you get a beautiful picture of the entire contour of the biceps tendon. We can even see even partial tears of biceps as well.

Dr. Sechrest: Once you've made the diagnosis of a biceps tendon rupture, what drives you to decision making? Is there any place for conservative care in a distal biceps tendon rupture?

Dr. Mazzara: I think it's going to depend on who the individual is. If it's a senior patient and they say, "It doesn't really matter to me that I'm going to lose elbow strength or strength in my hand and forearm", you don't have to operate on those people. Those people may do very well, but the vast majority of people who rupture the biceps are in their working years and really need good strength and good function of their arm and elbow and aren't going to tolerate those weaknesses, and many of these people are individuals who do physically demanding work and who need the ability to have good ability to supinate and flex their elbow.

Dr. Sechrest: Does it make any difference to you whether this is their dominant hand or their non-dominant hand?

Dr. Mazzara: Not in terms of recommendations, no.

Dr. Sechrest: So you're not any more prone to recommend surgery sooner for a right-handed person who's ruptured their right biceps as the left?

Dr. Mazzara: We treat them the same.

Dr. Sechrest: You treat them the same.

Dr. Mazzara: There's one other physical finding that I wanted to mention. When you take your elbow and you flex it about 90° and you put your palm up and you take your opposite hand, you can actually take your index finger and almost loop it around your biceps tendon. You can feel it as a very rigid cord right there. If you've had an injury and you don't feel that rigid cord right there with your arm in this position, chances are you've got some damage to the biceps. It may be partially torn, it may be complete, and if it's tender when you push on it, it could very well be just a partial tear, but partial tears of the distal biceps tend not to heal very well. So those are things that we tend to treat surgically as well.

Dr. Sechrest: Okay. So you're more apt to recommend surgery for a working person with this injury and not even consider any sort of conservative care.

Dr. Mazzara: I don't think there's really a role for conservative treatment. If somebody is going to notice a functional limitation and they're not going to be satisfied with functional limitations of their elbow because of a distal biceps tendon rupture, then really regardless of age, they'd be a good surgical candidate. Older patients tend to accept a little bit more impairment than a younger working patient might.

Dr. Sechrest: Okay. Well, describe the surgery for a ruptured biceps. Tell me a little bit about how this is done, and what the time of surgery looks like and how a patient should prepare.

Dr. Mazzara: Well, preoperatively, we want patients to get cleared medically. If I need an MRI, I'll do the MRI. In many cases, with complete retracted biceps tendon ruptures distally, we don't need the MRI. We get them to surgery and, under general anesthesia, my own technique, it's a two incision technique, we'll make a very small incision over here in the front of the elbow. It's a transverse incision. We retrieve and find the tendon, pull it out of the front part of the elbow. We have a special technique where we use sutures that we weave through the end of the tendon. Then we make a second incision on the outside of the elbow, about a 2 inch incision here, and through that second incision we make a little small bone tunnel in the bone, and then we pass the biceps tendon from one incision into the other, pass those stitches into the bone tunnel in the radius, and tie it back into the bone. We're just basically re-attaching the tendon into a bone tunnel, a little socket, that we've created. There are other techniques, however, where we can do a different type of repair. The incision is a little bit bigger in the upper part of the arm where either anchors are used or different kinds of security buttons are used where you can stabilize it in different ways. Those are perfectly acceptable approaches. My own technique is really based on years and years of experience. It's a procedure that's been established way before I got into practice. It's reliable and it works very well, and so I stick with the procedure that I know works well for me.

Dr. Sechrest: But the bottom line is what you're trying to do is put the tendon back where it belongs.

Dr. Mazzara: The tendon needs to go back, attach it to the bone, and how you do that is really going to be up to the individual surgeon, but to get the best function you want to re-attach it to the bone that it came from.

Dr. Sechrest: I'm assuming this is done as an outpatient? You don't have to stay in the hospital?

Dr. Mazzara: No, it's an outpatient. Postoperatively, I put people in a posterior splint, a little fiberglass splint on the back of the arm for about 7-10 days. I'll see them in the office, we'll take them out of the splint, I put them in a little hinged elbow brace, I teach them some exercises to do, and then send them to therapy. Generally, on some kind of postoperative restrictions for 3-4 months – you can't do any excessive physical lifting or stress the tendon repair for as long as 3 months minimum, sometimes more, and sometimes, in certain cases, we'll actually extend it to 6 months of restrictions depending on the kind of activity the individual wants to go back to.

Dr. Sechrest: So you're trying to allow that tendon not only to heal to the bone, but to regain its strength, because that's a very, very strong tendon.

Dr. Mazzara: Absolutely. We want it to become stronger. Healing takes about 6-8 weeks, but to strengthen to the point where you can do anything you want with it can take somewhat longer.

Dr. Sechrest: How long of a postoperative recovery until that person is what we would consider normal and do they ever get back absolutely normal strength?

Dr. Mazzara: Yeah, I would say the vast majority of people can get a great result – full motion, normal strength – at the 4-6 month mark. It depends on the individual and what we're dealing with in terms of preoperative status and function, and the age of the patient really has a strong influence on that, but most patients are doing very well and have minimal to no pain. It can feel normal for those patients.

Dr. Sechrest: And are they at any higher risk of re-rupturing that tendon down the road since they've have one rupture?

Dr. Mazzara: Not necessarily. We're not making those individuals indestructible, but at the same time they're not at higher risk for re-tearing. They could basically go back and do whatever they did before once the tendon is healed. This is one of those operations where once you're healed, you're healed, and you're probably as good as you were before.

Dr. Sechrest: Now let's talk a little bit about the downsides of a biceps rupture and the potential complications. We're there near some vascular structures, we're there near some nerve structures. What are the downsides and the possible risk of having surgery for a biceps tendon rupture?

Dr. Mazzara: Well, any surgery can be associated with the risk of nerve damage, bleeding and infection. In terms of nerve damage, there's actually a very substantial nerve, called the radial nerve that's there, that is at risk and if it's injured either by traction or other kind of injury, you can actually develop weakness of the hand and wrist and inability to extend the hand and risk. Fortunately, that's very uncommon and the two incision technique tends to reduce the chances of nerve injury. It never quite eliminates potential nerve injury risk, but it reduces it substantially. Bleeding and infection – low chance of that happening – but it's always a theoretical risk. There's one other risk when you operate on the elbow which is kind of special to the elbow. You can see it in the knee, but while we're talking about biceps ruptures, it's a condition called heterotopic bone or heterotopic ossification. What will happen is: because of trauma to the tendon and the adjacent bone, your body responds to the healing process of this, sometimes to the surgery, by making exuberant amounts of extra bone. That extra bone can actually become a mechanical obstacle to range-of-motion. Under very unusual circumstances, patients can make so much bone where they can't move the elbow. What we do to minimize the chances of that happening, is to place patients on oral anti-inflammatories. I personally use Indocin, give patients Indocin, 25 milligrams, three times a day, after a distal biceps tendon repair, and we get them moving fairly quickly. I'm not certain of any studies that look at radiation for the purpose of reducing heterotopic bone, but we us radiation for other joints when we're trying to reduce heterotopic bone formation there, and in the elbow I find Indocin to be very satisfactory.

Dr. Sechrest: How long should the patient expect to take Indocin generally?

Dr. Mazzara: Generally, 6 weeks in my practice.

Dr. Sechrest: So a full 6 weeks as long as their stomachs tolerate that medication without any problems?

Dr. Mazzara: Yes. They have to be able to take the medicine and tolerate at the same time.

Dr. Sechrest: This has been a great discussion about, I think, a more common injury than people really realize. Any final comments about things we haven't discussed, or any sort of pearls that you would have for patients who may think they have had a biceps rupture?

Dr. Mazzara: Well, I think if there is an injury in the front of the elbow, you have some kind of ache or pain, it certainly warrants evaluation. You should be evaluated by somebody who has some experience in treating this condition. You may or may not need to have an MRI to look at the condition of the tendon. Some people will have a condition called a bicipital radial bursitis. It's not a surgical problem, it can be treated non-operatively, but you don't know that unless you've had that thorough evaluation. Also, if you think you have an injury, I think the concern is, you don't want to wait long because if the tendon retracts, the normal tunnel or path through which the tendon courses, down to the radius becomes filled with scar tissue increasing the risk of complications after surgery, increasing the difficulty of the surgery and also may, at some point in time, be unable to fix that biceps tendon because it's been retracted for so long it can't be retrieved and repaired. There are other ways around that are more complicated and not quite as easy to recover from though, so delay in treatment is not always to the patient's advantage.

Dr. Sechrest: So, if I can paraphrase, the working person who relies on their arms probably is better off to having this injury repaired, and the sooner the better.

Dr. Mazzara: Absolutely.

Dr. Sechrest: Thank you very much. Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.