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Biceps rupture in a patient on long-term anticoagulation leading to compartment syndrome and nerve palsies
BICEPS RUPTURE IN A PATIENT ON LONG-TERM ANTICOAGULATION LEADING TO COMPARTMENT SYNDROME AND NERVE PALSIES A. M. RICHARDS and A. L. H. MOSS
From the Department of Plastic and Reconstructive Surgery, St George's Hospital, London, UK We report the case of a man on long term anticoagulation who presented with a rupture of the long head of the biceps resulting in a compartment syndrome and nerve palsies.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 3:411-412 months after injury showed significant impairment of both radial and median conduction in the upper arm with some evidence of reinervation of the median and radially innervated muscles of the forearm. This situation was unchanged 1 year after injury. The ulnar nerve function was almost completely recovered, but radial and median function remained diminished in the forearm and absent in the hand.
Rupture of the biceps has been well described, and occurs most commonly in the long head (Dobbie, 1941). There has been one previous report of biceps rupture leading to transient neurological deficit (Foxworthy and Kinninmonth, 1992). Anticoagulation is known to increase the incidence of compartment syndromes (Hay et al, 1992). We report a case in which a partial rupture of the biceps, together with anticoagulation combined to produce a severe compartment syndrome which resulted in a long-term neurological deficit.
DISCUSSION
Rupture of the biceps tendon is relatively common and affects the long head in 96% of cases. The short head and distal tendon are less commonly affected: 3% and 1% respectively (Dobbie, 1941). The condition is most commonly found in the dominant arm of middle-aged men involved in strenuous activities of a repetitive nature (Morrey et al, 1985). It is well recognized that there is an increased incidence of compartment syndromes in patients on longterm anticoagulation (Ebraheim et al, 1991; Graham and Loomer, 1985; Griffiths and Jones, 1993). There has been one previous report of neurological problems as a consequence of biceps rupture (Foxworthy and Kinninmonth, 1992). However there have been no previous reports of biceps rupture in an anticoagulated patient leading to prolonged neurological deficit. Trauma, particularly when associated with haematoma, is known to upset anticoagulant therapy (Hay et al, 1992). The biceps rupture and consequent haematoma deplete the stores of clotting factors. The
CASE R E P O R T
A 67-year-old right-handed man was referred with a 1 week history of increasing swelling and tenseness of his left upper arm. He attributed this to an episode 1 week earlier when he had sustained trauma to the arm when carrying a heavy bucket. He was on 4 mg warfarin daily following an aortic valve replacement in 1987. His I N R on admission was 7.1 (therapeutic range 3-4). On examination he was noted to have an extremely tender and tense upper arm associated with a significant amount of bruising (Fig 1). He had no active movement at the elbow and complete radial, ulnar and median nerve palsies from below the mid-arm (Fig 2). A provisional diagnosis of compartment syndrome following biceps rupture was made and the arm was explored. At operation the long head of the biceps was found to be partially ruptured and ischaemic. The brachial plexus and axillary vessels were surrounded and compressed by a large haematoma. The haematoma was evacuated and the area drained; no attempt was made to repair the partially ruptured biceps tendon. Following delayed primary closure the upper arm healed uneventfully, however the nerve palsies persisted. Studies 5
Fig 1
Fig 2
Tense, swollen and bruised upper arm at presentation 1 week after presumed biceps rupture. 411
Bruising extending down arm at presentation with complete triple nerve palsy and wrist drop.
412
situation is then compounded by the administration of warfarin which acts by decreasing the formation of clotting factors. A vicious circle is thus set up in which large bleeds in anticoagulated patients can disturb the normal equilibrium with clotting proceeding out of control. Compartment syndrome of the upper arm is relatively rare in comparison to the more common sites of forearm and lower leg. It has been reported after venepuncture in haemophiliacs (Nixon and Brindley, 1989), as a complication of prolonged tourniquet time (Greene and Louis, 1983), after trauma (Palumbo and Abrams, 1994), and after rupture of the long head of the biceps (McHale et al, 1991) or triceps (Brumback, 1987). The rarity of upper arm compartment syndrome may be because the brachial fascia is comparatively distensible allowing a greater capacity for swelling prior to an increase in compartmental pressure (Leguit, 1982). Studies have shown that whilst muscle undergoes irreversible functional loss after 2 to 4 hours of ischaemia, nerves show abnormal function after 30 minutes of ischaemia and suffer irreversible functional loss after 12 to 24 hours (Matsen, 1975). This case illustrates the importance of early compartmental decompression. In order to avoid possible crippling sequelae it is important to be aware of the possibility of a compartment syndrome developing after biceps rupture and the index of suspicion should be increased further in the anticoagulated patient.
THE JOURNAL OF HAND SURGERY VOL. 22B No. 3 JUNE 1997 Dobbie RP (1941). Avulsion of the lower biceps brachii tendon: analysis of fiftyone previously unreported cases. American Journal of Surgery, 51: 66~683. Ebraheim NA, Hoeflinger MJ, Savolaine ER, Jackson WT (1991). Anterior compartment syndrome of the thigh as a complication of blunt trauma in a patient on prolonged anticoagulation therapy. Clinical Orthopaedics and Related Research, 263: 180-184. Foxworthy M, Kinuinmonth AW (1992). Median nerve compression in the proximal forearm as a complication of partial rupture of the distal biceps brachii tendon. Journal of Hand Surgery 17B: 515 517. Graham B, Loomer RL (1985). Anterior compartment syndrome in a patient with fracture of the tibial plateau treated by continuous passive motion and anticoagulants: report of a case. Clinical Orthopaedics and Related Research, 195:197 199. Greene TA, Louis DS (1983). Compartment syndrome of the arm. A complication of the pneumatic tourniquet. Journal of Bone and Joint Surgery, 65A: 270-273. Griffiths D, Jones DH (1993). Spontaneous compartment syndrome in a patient on long-term anticoagulation, Journal of Hand Surgery 18B: 4142. Hay SM, Allen MJ, Barnes MR (1992). Acute compartment syndromes resulting from anticoagulant treatment. British Medical Journal, 305: 1474-1475. Leguit P (1982). Compartment syndromes of the upper arm. Netherlands Journal of Surgery, 34: 123-126. McHale KA, Geissele A, Perlik PD (1991). Compartment syndrome of the biceps brachii compartment following rupture of the long head of the biceps. Orthopedics, 14: 787-788. Matsen FA (1975). Compartmental of syndrome. A unified concept, Clinical Orthopaedics and Related Research, 113: 8-14. Morrey BF, Askew LJ, An KN, Dobyns JB (1985). Rupture of the distal tendon of the biceps brachii. Journal of Bone and Joint Surgery, 67A: 418421. Nixon RG, Brindley GW (1989). Hemophilia presenting as compartment syndrome in the arm following venipuncture. Clinical Orthopaedics and Related Research, 244:176 181. Palumbo RC, Abrams JS (1994). Compartment syndrome of the upper arm. Orthopedics, 17:1144-1147.
References
Received: 19 March 1996 Accepted after revision: 9 December 1996 Mr A. M. Riehards, 2 The Sidings,Downton, Salisbury,WiltshireSP5 3QZ, UK.
Brumback RJ (1987). Compartment syndrome complicating avulsion of the origin of the triceps. Journal of Bone and Joint Surgery, 69A: 1445-1446.
© 1997The British Societyfor Surgeryof the Hand
From the Department of Plastic and Reconstructive Surgery, St George's Hospital, London, UK We report the case of a man on long term anticoagulation who presented with a rupture of the long head of the biceps resulting in a compartment syndrome and nerve palsies.
Journal of Hand Surgery (British and European Volume, 1997) 22B: 3:411-412 months after injury showed significant impairment of both radial and median conduction in the upper arm with some evidence of reinervation of the median and radially innervated muscles of the forearm. This situation was unchanged 1 year after injury. The ulnar nerve function was almost completely recovered, but radial and median function remained diminished in the forearm and absent in the hand.
Rupture of the biceps has been well described, and occurs most commonly in the long head (Dobbie, 1941). There has been one previous report of biceps rupture leading to transient neurological deficit (Foxworthy and Kinninmonth, 1992). Anticoagulation is known to increase the incidence of compartment syndromes (Hay et al, 1992). We report a case in which a partial rupture of the biceps, together with anticoagulation combined to produce a severe compartment syndrome which resulted in a long-term neurological deficit.
DISCUSSION
Rupture of the biceps tendon is relatively common and affects the long head in 96% of cases. The short head and distal tendon are less commonly affected: 3% and 1% respectively (Dobbie, 1941). The condition is most commonly found in the dominant arm of middle-aged men involved in strenuous activities of a repetitive nature (Morrey et al, 1985). It is well recognized that there is an increased incidence of compartment syndromes in patients on longterm anticoagulation (Ebraheim et al, 1991; Graham and Loomer, 1985; Griffiths and Jones, 1993). There has been one previous report of neurological problems as a consequence of biceps rupture (Foxworthy and Kinninmonth, 1992). However there have been no previous reports of biceps rupture in an anticoagulated patient leading to prolonged neurological deficit. Trauma, particularly when associated with haematoma, is known to upset anticoagulant therapy (Hay et al, 1992). The biceps rupture and consequent haematoma deplete the stores of clotting factors. The
CASE R E P O R T
A 67-year-old right-handed man was referred with a 1 week history of increasing swelling and tenseness of his left upper arm. He attributed this to an episode 1 week earlier when he had sustained trauma to the arm when carrying a heavy bucket. He was on 4 mg warfarin daily following an aortic valve replacement in 1987. His I N R on admission was 7.1 (therapeutic range 3-4). On examination he was noted to have an extremely tender and tense upper arm associated with a significant amount of bruising (Fig 1). He had no active movement at the elbow and complete radial, ulnar and median nerve palsies from below the mid-arm (Fig 2). A provisional diagnosis of compartment syndrome following biceps rupture was made and the arm was explored. At operation the long head of the biceps was found to be partially ruptured and ischaemic. The brachial plexus and axillary vessels were surrounded and compressed by a large haematoma. The haematoma was evacuated and the area drained; no attempt was made to repair the partially ruptured biceps tendon. Following delayed primary closure the upper arm healed uneventfully, however the nerve palsies persisted. Studies 5
Fig 1
Fig 2
Tense, swollen and bruised upper arm at presentation 1 week after presumed biceps rupture. 411
Bruising extending down arm at presentation with complete triple nerve palsy and wrist drop.
412
situation is then compounded by the administration of warfarin which acts by decreasing the formation of clotting factors. A vicious circle is thus set up in which large bleeds in anticoagulated patients can disturb the normal equilibrium with clotting proceeding out of control. Compartment syndrome of the upper arm is relatively rare in comparison to the more common sites of forearm and lower leg. It has been reported after venepuncture in haemophiliacs (Nixon and Brindley, 1989), as a complication of prolonged tourniquet time (Greene and Louis, 1983), after trauma (Palumbo and Abrams, 1994), and after rupture of the long head of the biceps (McHale et al, 1991) or triceps (Brumback, 1987). The rarity of upper arm compartment syndrome may be because the brachial fascia is comparatively distensible allowing a greater capacity for swelling prior to an increase in compartmental pressure (Leguit, 1982). Studies have shown that whilst muscle undergoes irreversible functional loss after 2 to 4 hours of ischaemia, nerves show abnormal function after 30 minutes of ischaemia and suffer irreversible functional loss after 12 to 24 hours (Matsen, 1975). This case illustrates the importance of early compartmental decompression. In order to avoid possible crippling sequelae it is important to be aware of the possibility of a compartment syndrome developing after biceps rupture and the index of suspicion should be increased further in the anticoagulated patient.
THE JOURNAL OF HAND SURGERY VOL. 22B No. 3 JUNE 1997 Dobbie RP (1941). Avulsion of the lower biceps brachii tendon: analysis of fiftyone previously unreported cases. American Journal of Surgery, 51: 66~683. Ebraheim NA, Hoeflinger MJ, Savolaine ER, Jackson WT (1991). Anterior compartment syndrome of the thigh as a complication of blunt trauma in a patient on prolonged anticoagulation therapy. Clinical Orthopaedics and Related Research, 263: 180-184. Foxworthy M, Kinuinmonth AW (1992). Median nerve compression in the proximal forearm as a complication of partial rupture of the distal biceps brachii tendon. Journal of Hand Surgery 17B: 515 517. Graham B, Loomer RL (1985). Anterior compartment syndrome in a patient with fracture of the tibial plateau treated by continuous passive motion and anticoagulants: report of a case. Clinical Orthopaedics and Related Research, 195:197 199. Greene TA, Louis DS (1983). Compartment syndrome of the arm. A complication of the pneumatic tourniquet. Journal of Bone and Joint Surgery, 65A: 270-273. Griffiths D, Jones DH (1993). Spontaneous compartment syndrome in a patient on long-term anticoagulation, Journal of Hand Surgery 18B: 4142. Hay SM, Allen MJ, Barnes MR (1992). Acute compartment syndromes resulting from anticoagulant treatment. British Medical Journal, 305: 1474-1475. Leguit P (1982). Compartment syndromes of the upper arm. Netherlands Journal of Surgery, 34: 123-126. McHale KA, Geissele A, Perlik PD (1991). Compartment syndrome of the biceps brachii compartment following rupture of the long head of the biceps. Orthopedics, 14: 787-788. Matsen FA (1975). Compartmental of syndrome. A unified concept, Clinical Orthopaedics and Related Research, 113: 8-14. Morrey BF, Askew LJ, An KN, Dobyns JB (1985). Rupture of the distal tendon of the biceps brachii. Journal of Bone and Joint Surgery, 67A: 418421. Nixon RG, Brindley GW (1989). Hemophilia presenting as compartment syndrome in the arm following venipuncture. Clinical Orthopaedics and Related Research, 244:176 181. Palumbo RC, Abrams JS (1994). Compartment syndrome of the upper arm. Orthopedics, 17:1144-1147.
References
Received: 19 March 1996 Accepted after revision: 9 December 1996 Mr A. M. Riehards, 2 The Sidings,Downton, Salisbury,WiltshireSP5 3QZ, UK.
Brumback RJ (1987). Compartment syndrome complicating avulsion of the origin of the triceps. Journal of Bone and Joint Surgery, 69A: 1445-1446.
© 1997The British Societyfor Surgeryof the Hand