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Ruptured biceps brachii short head muscle belly: A case report
Ruptured biceps brachii short head muscle belly: A case report Asit K. Shah, MD, PhD, and Mark E. Pruzansky, MD, New York, NY
R
upture of the biceps brachii is a well-documented injury. Most reports relate to rupture of the tendon of the long head of the biceps or the biceps insertion on the radius. Isolated rupture of the short head muscle belly is a rare occurrence and has been infrequently cited in the literature. Postacchini and Ricciardi-Pollini4 reviewed subcutaneous rupture of the short tendon of the biceps. Heckman and Levine3 reported a series of injuries to this region in military parachutists, involving transection of both heads of the biceps muscle, as a result of forced abduction of the involved extremity against the static line. Tobin et al5 reported a single case of biceps short head rupture with damage to the coracobrachialis. Gilcrest,2 in 1934, reviewed 100 patients with known rupture of the biceps. In his series, only 2 cases of isolated short head pathology were acknowledged, one partial and one complete. However, no record about the mechanism of injury was provided. The only other study on isolated involvement of the short head was done by DiChristina and Lustig1 in 1992. They reported a traumatic rupture of the short head in a young adult; however, no evidence of partial or complete rupture was documented. We present a case of complete, isolated, and traumatic rupture of the short head of the biceps muscle belly in a healthy 21-year-old man. The clinical and postoperative course is presented. This case would be the third documented occurrence of isolated complete rupture of the short head muscle of the biceps. In addition to a literature review, this report is unique in fully documenting and illustrating preoperative and intraoperative pathology.
injury had occurred 7 days earlier, while he was riding in the front passenger seat of a car with his right arm abducted and externally rotated out of the window, when his arm struck the open door of a parked car. Immediate pain and swelling of the right upper arm and elbow region ensued. On physical examination, there was soreness about the right shoulder and upper arm and weakness in elbow flexion. A large ecchymosis extended over the anteromedial aspect of the upper arm (Figure 1). With the patient’s right arm at his side, there was a medial depression in the coronal plane, transverse to the long axis of the upper arm. There was also a bulge in the anteromedial aspect of the mid– upper arm that became more conspicuous with active flexion of the supinated right forearm (Figure 2). During resisted elbow flexion, tension was palpable at the biceps tendons of origin and insertion. Radiographic evaluation of the right upper extremity showed no bony or soft-tissue abnormalities. Magnetic resonance imaging (MRI) of the right upper extremity revealed a complete tear of the short head of the biceps brachii muscle with surrounding edema approximately 15 cm from the coracoid process (Figure 3, A and B). As the patient was young and wanted to maximize strength and reduce deformity, surgical repair was performed 12 days after the injury. An extensile incision in the deltopectoral groove and extending medially and distally along the proximal two thirds of the upper arm was used. During exploration, the long head of the biceps tendon and the conjoined tendon were found to be intact. The short head of the biceps muscle was completely ruptured in its
CASE REPORT A 21-year-old, right hand– dominant man was seen for orthopaedic consultation with a chief complaint of pain, swelling, and weakness of the right upper extremity. His From the Department of Orthopaedic Surgery, Mount Sinai School of Medicine. Reprint requests: Mark E. Pruzansky, MD, 975 Park Ave, New York, NY 10028. J Shoulder Elbow Surg 2004;13:562–565. Copyright © 2004 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2004/$30.00 doi:10.1016/j.jse.2004.02.005
562
Figure 1 The spear indicates the longitudinal line of ecchymosis extending over the anteromedial aspect of the right upper arm, including a vertical indentation with the patient in the supine position, characteristic of short head biceps brachii muscle belly rupture.
J Shoulder Elbow Surg Volume 13, Number 5
Figure 2 Resisted active flexion and supination exaggerate bulging over the anteromedial aspect of the upper arm at the spear. The bulge is due to proximal and distal retraction of the muscle belly toward its origin and insertion sites.
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midsubstance (Figure 4, A). The musculocutaneous nerve was identified entering the proximal part of the ruptured muscle and was isolated. The median nerve was in the depth of the wound and was carefully freed from adherent tissues. The hematoma was evacuated, and the proximal and distal ends of the muscle belly were debrided. Two No. 2 nonabsorbable sutures were woven through the muscle belly and fascia in Kessler- and Bunnell-type patterns. A No. 1 nonabsorbable suture was run marginally around the rupture site in a continuous manner (Figure 4, B). The elbow was taken gently into full extension, and no separation was observed at the repair site. Postoperatively, the extremity was placed in a long arm splint at night at 90° of flexion and full forearm supination. At 4 weeks, a hinged brace was permitted for full flexion and increases in extension over the next 6 weeks. After a brief period of rehabilitation, which included range-of-motion and strengthening exercises, the patient regained full strength of his right arm and returned to all activities 5 months after surgery. He was
Figure 3 A, Evidence of focal rupture of the short head of the biceps muscle with hematoma formation at the rupture site, measuring approximately 4 cm ⫻ 2 cm ⫻ 4 cm, at the open rectangle. There is surrounding edema within the intact muscle, proximally and distally, as marked by the open square. The brachialis is identified by the closed rectangle. The triceps is under the closed cross, and the trochlea is under the open cross. B, There is hematoma (indicated by the square) between the long head of the biceps muscle and the humerus. The long head is indicated by the closed arrow and the hematoma within the short head by the rectangle. The triceps is denoted by the open arrow.
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Figure 4 Complete rupture of the short head of the muscle belly of the biceps brachii before (A) and after (B) surgical repair. In A, the spear indicates the hematoma and tear between the right proximal and left distal parts of the short head and the box represents the long head. In B, the spear is at the short head and the box is at the long head of the biceps muscle.
satisfied with the appearance of his arm despite the scar, a small concavity, and mild atrophy of the biceps brachii.
DISCUSSION Rupture through the substance of the biceps brachii muscle is unusual, and isolated short head muscle transection has been infrequently cited. Although ruptures of both heads have occurred, the tendinous areas appear to be the most vulnerable to injury. This case further establishes the entity of isolated rupture through the muscle of the short head of the biceps and introduces the role of MRI in diagnosing muscle rupture. During physical examination with the arm at the side, telltale signs of this particular ruptured muscle include a sizeable bulge in the medial and middle third of the arm and a transverse depression in the sagittal plane at the site normally filled by the short head of the biceps muscle belly. The bulge is due to the proximal and distal retraction of the muscle belly toward its origin and insertion sites, respectively. The large hematoma invades this traumatic space, limiting the depth of the surface concavity. Contraction of the muscle by active elbow flexion and resisted forearm
supination allows the mass to become more conspicuous. Differential diagnosis of short head rupture includes involvement of the long head of the biceps and coracobrachialis. Review of the mechanism of injury and clinical examination may aid in distinguishing among these entities. Ecchymosis and deformity involving long head pathology are located more anteriorly. Focal depression is more subtle and medial in short head ruptures. MRI has proved to be a useful aid in diagnosing softtissue injuries. We report the first case of MRI diagnosis of complete short head biceps muscle belly rupture. On imaging, the long head was found to be intact, as was the musculotendinous junction of the short head. Edema and soft-tissue swelling were confined to adjacent muscle of the short head and soft tissues. Treatment of complete biceps muscle and distal tendon tears in athletes is primarily surgical, as this is usually the best way to restore both flexion and supination strength. Treatment of partial ruptures is controversial. Some authors advocate nonsurgical treatment, with protection during the acute phase and slow return to function. In the 4 reported cases of surgical repair of partial or complete tears in the
Shah and Pruzansky
J Shoulder Elbow Surg Volume 13, Number 5
short head muscle belly, return to function and patient satisfaction were considered to be good. Poor function was found in delayed repair of intramuscular substance tears. Although we performed early surgical repair of an intramuscular substance tear of the short head of the biceps brachii muscle, the data available are inadequate to support treatment recommendations. In conclusion, isolated rupture of the short head of the biceps brachii muscle belly is a rare injury. Careful physical examination and MRI accurately map the location and magnitude of muscle tear. Consideration should be given to this clinical entity in any case of blunt trauma to the brachium.
565
REFERENCES
1. DiChristina DG, Lustig KA. Rupture through short head of the biceps muscle belly: a case report. Clin Orthop 1992;277:139-41. 2. Gilcrest EI. The common syndrome of rupture, dislocation and elongation of the long head of the biceps brachii. Analysis of 100 cases. Surg Gynecol Obstet 1934;58:322-40. 3. Heckman JD, Levine MI. Traumatic closed transection of the biceps brachii in military parachutists. J Bone Joint Surg Am 1978;60: 369-72. 4. Postacchini F, Ricciardi-Pollini PT. Rupture of the short head tendon of the biceps brachii. Clin Orthop 1977;124:229-32. 5. Tobin WJ, Cohen LD, Vandover JT. Parachute injuries. JAMA 1941;117:1318-21.
R
upture of the biceps brachii is a well-documented injury. Most reports relate to rupture of the tendon of the long head of the biceps or the biceps insertion on the radius. Isolated rupture of the short head muscle belly is a rare occurrence and has been infrequently cited in the literature. Postacchini and Ricciardi-Pollini4 reviewed subcutaneous rupture of the short tendon of the biceps. Heckman and Levine3 reported a series of injuries to this region in military parachutists, involving transection of both heads of the biceps muscle, as a result of forced abduction of the involved extremity against the static line. Tobin et al5 reported a single case of biceps short head rupture with damage to the coracobrachialis. Gilcrest,2 in 1934, reviewed 100 patients with known rupture of the biceps. In his series, only 2 cases of isolated short head pathology were acknowledged, one partial and one complete. However, no record about the mechanism of injury was provided. The only other study on isolated involvement of the short head was done by DiChristina and Lustig1 in 1992. They reported a traumatic rupture of the short head in a young adult; however, no evidence of partial or complete rupture was documented. We present a case of complete, isolated, and traumatic rupture of the short head of the biceps muscle belly in a healthy 21-year-old man. The clinical and postoperative course is presented. This case would be the third documented occurrence of isolated complete rupture of the short head muscle of the biceps. In addition to a literature review, this report is unique in fully documenting and illustrating preoperative and intraoperative pathology.
injury had occurred 7 days earlier, while he was riding in the front passenger seat of a car with his right arm abducted and externally rotated out of the window, when his arm struck the open door of a parked car. Immediate pain and swelling of the right upper arm and elbow region ensued. On physical examination, there was soreness about the right shoulder and upper arm and weakness in elbow flexion. A large ecchymosis extended over the anteromedial aspect of the upper arm (Figure 1). With the patient’s right arm at his side, there was a medial depression in the coronal plane, transverse to the long axis of the upper arm. There was also a bulge in the anteromedial aspect of the mid– upper arm that became more conspicuous with active flexion of the supinated right forearm (Figure 2). During resisted elbow flexion, tension was palpable at the biceps tendons of origin and insertion. Radiographic evaluation of the right upper extremity showed no bony or soft-tissue abnormalities. Magnetic resonance imaging (MRI) of the right upper extremity revealed a complete tear of the short head of the biceps brachii muscle with surrounding edema approximately 15 cm from the coracoid process (Figure 3, A and B). As the patient was young and wanted to maximize strength and reduce deformity, surgical repair was performed 12 days after the injury. An extensile incision in the deltopectoral groove and extending medially and distally along the proximal two thirds of the upper arm was used. During exploration, the long head of the biceps tendon and the conjoined tendon were found to be intact. The short head of the biceps muscle was completely ruptured in its
CASE REPORT A 21-year-old, right hand– dominant man was seen for orthopaedic consultation with a chief complaint of pain, swelling, and weakness of the right upper extremity. His From the Department of Orthopaedic Surgery, Mount Sinai School of Medicine. Reprint requests: Mark E. Pruzansky, MD, 975 Park Ave, New York, NY 10028. J Shoulder Elbow Surg 2004;13:562–565. Copyright © 2004 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2004/$30.00 doi:10.1016/j.jse.2004.02.005
562
Figure 1 The spear indicates the longitudinal line of ecchymosis extending over the anteromedial aspect of the right upper arm, including a vertical indentation with the patient in the supine position, characteristic of short head biceps brachii muscle belly rupture.
J Shoulder Elbow Surg Volume 13, Number 5
Figure 2 Resisted active flexion and supination exaggerate bulging over the anteromedial aspect of the upper arm at the spear. The bulge is due to proximal and distal retraction of the muscle belly toward its origin and insertion sites.
Shah and Pruzansky
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midsubstance (Figure 4, A). The musculocutaneous nerve was identified entering the proximal part of the ruptured muscle and was isolated. The median nerve was in the depth of the wound and was carefully freed from adherent tissues. The hematoma was evacuated, and the proximal and distal ends of the muscle belly were debrided. Two No. 2 nonabsorbable sutures were woven through the muscle belly and fascia in Kessler- and Bunnell-type patterns. A No. 1 nonabsorbable suture was run marginally around the rupture site in a continuous manner (Figure 4, B). The elbow was taken gently into full extension, and no separation was observed at the repair site. Postoperatively, the extremity was placed in a long arm splint at night at 90° of flexion and full forearm supination. At 4 weeks, a hinged brace was permitted for full flexion and increases in extension over the next 6 weeks. After a brief period of rehabilitation, which included range-of-motion and strengthening exercises, the patient regained full strength of his right arm and returned to all activities 5 months after surgery. He was
Figure 3 A, Evidence of focal rupture of the short head of the biceps muscle with hematoma formation at the rupture site, measuring approximately 4 cm ⫻ 2 cm ⫻ 4 cm, at the open rectangle. There is surrounding edema within the intact muscle, proximally and distally, as marked by the open square. The brachialis is identified by the closed rectangle. The triceps is under the closed cross, and the trochlea is under the open cross. B, There is hematoma (indicated by the square) between the long head of the biceps muscle and the humerus. The long head is indicated by the closed arrow and the hematoma within the short head by the rectangle. The triceps is denoted by the open arrow.
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Shah and Pruzansky
J Shoulder Elbow Surg September/October 2004
Figure 4 Complete rupture of the short head of the muscle belly of the biceps brachii before (A) and after (B) surgical repair. In A, the spear indicates the hematoma and tear between the right proximal and left distal parts of the short head and the box represents the long head. In B, the spear is at the short head and the box is at the long head of the biceps muscle.
satisfied with the appearance of his arm despite the scar, a small concavity, and mild atrophy of the biceps brachii.
DISCUSSION Rupture through the substance of the biceps brachii muscle is unusual, and isolated short head muscle transection has been infrequently cited. Although ruptures of both heads have occurred, the tendinous areas appear to be the most vulnerable to injury. This case further establishes the entity of isolated rupture through the muscle of the short head of the biceps and introduces the role of MRI in diagnosing muscle rupture. During physical examination with the arm at the side, telltale signs of this particular ruptured muscle include a sizeable bulge in the medial and middle third of the arm and a transverse depression in the sagittal plane at the site normally filled by the short head of the biceps muscle belly. The bulge is due to the proximal and distal retraction of the muscle belly toward its origin and insertion sites, respectively. The large hematoma invades this traumatic space, limiting the depth of the surface concavity. Contraction of the muscle by active elbow flexion and resisted forearm
supination allows the mass to become more conspicuous. Differential diagnosis of short head rupture includes involvement of the long head of the biceps and coracobrachialis. Review of the mechanism of injury and clinical examination may aid in distinguishing among these entities. Ecchymosis and deformity involving long head pathology are located more anteriorly. Focal depression is more subtle and medial in short head ruptures. MRI has proved to be a useful aid in diagnosing softtissue injuries. We report the first case of MRI diagnosis of complete short head biceps muscle belly rupture. On imaging, the long head was found to be intact, as was the musculotendinous junction of the short head. Edema and soft-tissue swelling were confined to adjacent muscle of the short head and soft tissues. Treatment of complete biceps muscle and distal tendon tears in athletes is primarily surgical, as this is usually the best way to restore both flexion and supination strength. Treatment of partial ruptures is controversial. Some authors advocate nonsurgical treatment, with protection during the acute phase and slow return to function. In the 4 reported cases of surgical repair of partial or complete tears in the
Shah and Pruzansky
J Shoulder Elbow Surg Volume 13, Number 5
short head muscle belly, return to function and patient satisfaction were considered to be good. Poor function was found in delayed repair of intramuscular substance tears. Although we performed early surgical repair of an intramuscular substance tear of the short head of the biceps brachii muscle, the data available are inadequate to support treatment recommendations. In conclusion, isolated rupture of the short head of the biceps brachii muscle belly is a rare injury. Careful physical examination and MRI accurately map the location and magnitude of muscle tear. Consideration should be given to this clinical entity in any case of blunt trauma to the brachium.
565
REFERENCES
1. DiChristina DG, Lustig KA. Rupture through short head of the biceps muscle belly: a case report. Clin Orthop 1992;277:139-41. 2. Gilcrest EI. The common syndrome of rupture, dislocation and elongation of the long head of the biceps brachii. Analysis of 100 cases. Surg Gynecol Obstet 1934;58:322-40. 3. Heckman JD, Levine MI. Traumatic closed transection of the biceps brachii in military parachutists. J Bone Joint Surg Am 1978;60: 369-72. 4. Postacchini F, Ricciardi-Pollini PT. Rupture of the short head tendon of the biceps brachii. Clin Orthop 1977;124:229-32. 5. Tobin WJ, Cohen LD, Vandover JT. Parachute injuries. JAMA 1941;117:1318-21.