In this case example, treatment of a distal biceps rupture is discussed. Questions answered include: 1) Can this heal by itself? 2) What happens if no treatment is provided? and 3) When should surgery be done? The optimal timing, best way to operate, and postoperative care are also discussed.
The patient was a 47-year-old man who was lifting something heavy. There was a “pop” sensation along the front of the elbow. Less than 24 hours later, there was swelling and bruising in that area. His job performance was compromised because he didn’t have the strength to turn his hand in the palm up position (called supination).
An MRI showed a complete rupture of the biceps where it attaches to the elbow. For the patient who is self-employed and without insurance or paid time off, the question became: will it heal on its own? The patient wanted to know, “Will I get back to ‘normal'”?
Most orthopedic experts agree that surgery is needed. And the best time to repair a biceps tendon that has retracted (snapped back up into the upper arm) is within the first six weeks after injury. In fact, the best results with fewest complications occur when surgery is done in the first two weeks after injury. After six weeks, reconstruction with a graft (rather than a repair procedure) is more likely.
But back to the question whether surgery restores supination strength. The answer is “Yes.” Without surgical repair, the patient can expect about a 40 per cent loss of supination motion. There can be another 30 per cent loss of strength. And there could still be other complications such as nerve injury, bone fracture, and even re-rupture of the biceps. It’s not likely the arm will get back to normal without intervention.
Surgeons are more concerned than patients about the most effective surgical approach. One decision surgeons face is the best way to reattach the tendon, referred to as the fixation method. There is concern about possible nerve damage and the effect of treatment on the strength of supination and/or flexion.
The surgeon also decides on the number, type, and location of incisions. If an incision technique doesn’t improve overall results, then why use it? Surgeon and patient both keep in mind that any surgery always comes with its own risks and potential for complications.
What happened with this patient? The gentleman was told at the time of his initial exam that he could expect continued weakness whenever trying to turn or twist (supinate) the forearm. This type of motion is important for his job as a self-employed contractor. Easy fatigue of the injured arm was another likely event. Some people can adapt to these changes while others cannot.
The authors did not reveal this patient’s decision or the final outcome. But in the process of presenting the case, they offered their philosophy, approaches, and expected results.