What is this?
Distal biceps rupture is when the tendon attaching the biceps muscle to the elbow is torn from the bone. This injury most commonly occurs in middle-aged men during an episode of heavy lifting.
What are the symptoms?
When the distal biceps tendon ruptures, it usually feels like a painful pop directly in front of the elbow. The initial pain often subsides quickly with the subsequent development of swelling and bruising in front of the elbow. The arm often feels weak with attempts to flex (bend) the elbow or rotate the forearm into the palm up position.
Do I need any further investigations?
Rupture of the distal biceps can usually be diagnosed on examination of the elbow. The findings include absence of the tendon on the front of the elbow and loss of strength in both flexion and supination. Tests such as ultrasound or magnetic resonance imaging (MRI) scans can helpful in certain cases where there is significant swelling or body habitus makes the identification of the tendon difficult.
What are the non-surgical treatment options?
Distal biceps ruptures can be treated without surgery but this will result in permanent loss of strength in elbow flexion and supination. Generally therefore most patients opt to proceed with surgery and nonsurgical treatments are usually only used for people who do minimal activities and require minimal arm strength.
What does surgery involve?
Surgery should ideally be performed within 2-3 weeks of the injury. Beyond this point the tendon recoils further up the arm and scars into the abnormal position making the procedure more difficult and the results less predictable. A small incision is made over the front of the elbow. The ruptured free end of the biceps tendon is retrieved and the damaged and degenerated end is trimmed. Sutures are then crisscrossed through the bottom inch of the tendon, which is attached to an Endobutton (a small metal button). The original attachment on the radius (radial tuberosity) is drilled to create a hole for the tendon end. The button is then passed through the hole and flipped so that it is secured on the back of the bone.
What is the success of surgery?
Generally, this is a safe and reliable operation to reattach the tendon to the bone, restore the contour of the biceps and the strength in the elbow.
What are the potential risks of surgery?
Any surgical procedure carries risks, however every effort is made to minimise these to ensure the best possible outcome from your surgery. The commonest risks of surgery include infection, nerve injury, elbow stiffness and failure of tendon healing. A stretch to the nerve supplying sensation to the thumb side of the forearm is very common and generally resolves by 3 months post surgery.
What is the recovery after surgery?
You will be given a sling to wear for the first couple of weeks after surgery. You can begin moving the elbow gently from day 1. You will usually be seen in clinic two weeks after surgery to check the wound and be given some general advice about recovery. There are no sutures to be removed as they are buried under the skin. For the first 6 weeks after surgery you can gently work on regaining range of elbow motion. During this period the arm can be used for simple activities of daily living but avoid any heavy lifting. At 2-3 months, the tendon repair is strong enough to begin strengthening and resistance exercises and your physiotherapist will guide this.
When can I return to normal activities?
Return to work depends on the nature of the job. You can return to desk and computer work when you feel comfortable to do so. If you have a heavy manual job then it will be at least 3 months before you can safely return to work. You may return to driving when you feel safe to control the vehicle, which will usually be a few weeks after surgery.