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SplintER Series: A Fateful FOOSH

Posted by Peter Mitchell Martin, DO on

A 66 year-old man presents with right anterior elbow pain, ecchymosis, and a “lump” in his right upper extremity after a ground level fall (Figure 1). What is your suspected diagnosis? What physical exam maneuver(s) can help you confirm your diagnosis? What is your initial workup in the ED? What imaging confirms the diagnosis? What is your management and disposition?

Figure 1: Case Courtesy of Dr. Peter M. Martin

What is your suspected diagnosis?

Distal biceps tendon rupture.

  • Pearl: In a patient following a traumatic event with elbow ecchymoses and an appreciable deformity near the upper extremity, in this case reported as a “lump”, a distal biceps rupture must be in the differential.

What physical exam maneuver(s) can help you confirm your diagnosis?

  • Hook Test: With the patient at rest, you should be able to hook your finger around the patient’s distal biceps tendon near insertion at the antecubital fossa. If not, a tear should be suspected.
  • Yergason’s Test: Resisted elbow flexion and supination to evaluate strength of biceps tendon/muscle and for reproduction of pain.

What is your initial workup in the ED?

A complete distal biceps rupture is largely a clinical diagnosis based on the mechanism of injury (strong, mechanical overload during eccentric muscle contraction of the biceps) as well as a positive hook test and Yergason’s test. However, X-ray of the elbow can help rule out fracture, especially given an atypical mechanism of injury, such as in our patient.

  • Pearl: Bedside ultrasound is helpful in the hands of a skilled operator, as imaging of the distal biceps with other modalities can be difficult (Figure 2).

Figure 2: Image A: Ultrasound distal biceps (tendon rupture with appreciated tendon incongruity and retraction towards left part of image), Case Courtesy of Dr. Maulik S. Patel, Radiopaedia.org, rID: 61870; Image B: Ultrasound Distal Biceps (Normal evaluation with intact, compact distal biceps tendon), Case Courtesy of Dr. Maulik S. Patel, Radiopaedia.org, rID: 61870; Image C: Probe placement for evaluation distal biceps in long-axis view (Case Courtesy of Dr. Peter M. Martin)

What imaging confirms the diagnosis?

Imaging is not necessary to confirm a distal biceps rupture [1]. If needed however, such as in preoperative evaluation, this can be performed by diagnostic ultrasound or MRI (Figure 3). MRI is usually obtained on an outpatient basis. When performed, it should be done soon after discharge from the ED, ideally within 1-2 weeks, as best surgical outcomes are obtained when surgery is performed within 2-3 weeks of injury occurrence [2,3].

Figure 3: Proton Density Fat-Saturated (PD FS) sequence at the level of the radial tuberosity (Insertion point of the conjoint distal biceps tendon shows hemorrhage and edema at the insertion, and lack of visualization of the tendon). There is also edema and hemorrhage between the fascial planes of the brachioradialis and pronator teres, and edema within the superficial soft tissues (Case courtesy of Dr. Peter M. Martin).

What is your management and disposition?

While proximal biceps injuries and tears may be managed conservatively initially, complete distal biceps tears warrant timely surgical intervention for most patients (except for the most low demand and sedentary patients). These injuries need to be operated on within 2-3 weeks of the injury for best outcomes with regards to strength and appreciable muscle deformity [4]. Therefore, patients should have urgent follow up with orthopedic surgery. No bracing or casting is needed.

Check out ALiEM’s Paucis Verbis cards to brush up on other can’t miss orthopedic injuries, and SplintER Series for more elbow cases.

References

  1. Srinivasan RC, Pederson WC, Morrey BF. Distal Biceps Tendon Repair and Reconstruction. J Hand Surg Am. 2020 Jan;45(1):48-56. doi: 10.1016/j.jhsa.2019.09.014. PMID: 31901332.
  2. Tarallo, L., Lombardi, M., Zambianchi, F. et al. Distal biceps tendon rupture: advantages and drawbacks of the anatomical reinsertion with a modified double incision approach. BMC Musculoskelet Disord 19, 364 (2018). PMID: 30305070.
  3. García Rodríguez C, García-Polín López C, Del Olmo Hernández T, Moros Marco S, Jacobo Edo O, Ávila Lafuente JL. Distal biceps tendon rupture: diagnostic strength of ultrasonography and magnetic resonance. Rev Esp Cir Ortop Traumatol (Engl Ed). 2020 Mar-Apr;64(2):77-82. English, Spanish. doi: 10.1016/j.recot.2019.11.004. Epub 2020 Jan 27. PMID: 32001186.
  4. Logan CA, Shahien A, Haber D, Foster Z, Farrington A, Provencher MT. REHABILITATION FOLLOWING DISTAL BICEPS REPAIR. Int J Sports Phys Ther. 2019 Apr;14(2):308-317. PMID: 30997282; PMCID: PMC6449020.

Author information

Peter Mitchell Martin, DO

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