Disclaimer This movie is an educational resource only and should not be used to manage Orthopaedic Health. All decisions about Biceps Tendon Rupture must be made in conjunction with your Physician or a licensed healthcare provider.
MULTIMEDIA HEALTH EDUCATION MANUAL TABLE OF CONTENTS SECTION CONTENT 1. Normal Shoulder Anatomy a. Introduction b. Normal Shoulder Anatomy 2. Bicep Rupture a. Causes b. Symptoms c. Immediate Treatment d. Diagnosis e. Conservative Treatment 3. Surgical Procedure a. Introduction b. Surgical Treatment c. Post Operative Care e. Risks and Complications
INTRODUCTION Tendons are strong, cord like structures in our bodies responsible for attaching muscles to bones. The biceps tendon attaches the biceps muscle in the upper arm to the shoulder and to the forearm.
Unit 1: Normal Shoulder Anatomy Introduction Biceps Tendon Rupture is a complete tearing away of the tendon from the bone. The majority of biceps tendon ruptures occur at the shoulder and is referred to as proximal biceps tendon rupture. The biceps tendon may also detach from the forearm distally, referred to as distal biceps tendon rupture, however this is less common. This learning module will focus primarily on proximal biceps tendon rupture as this constitutes over 90% of all biceps tendon ruptures. In order to understand more about Biceps Tendon Rupture, it is important to understand the normal anatomy of the shoulder. Normal Shoulder Anatomy There are three bones that come together to form the shoulder joint: the collarbone (clavicle), the shoulder blade (scapula), and the upper arm bone (humerus). The shoulder is a "ball-and-socket" joint. A "ball" at the top of the upper arm bone called the humerus fits neatly into a "socket" called the glenoid, a part of the shoulder blade or scapula. (Fig. 1) Cartilage cushions the joint and allows the bones to move on each other with smooth movements. The cartilage does not show up on X-ray, therefore you can see a joint space between the head of the upper arm bone (Humerus) and the glenoid socket of the shoulder blade (Scapula). (Refer fig. 1) Proximal end (Refer fig. 2) Proximal end (Fig. 2) Long head (Refer fig. 3) Long head (Fig. 3)
Short head (Refer fig. 4) Unit 1: Biceps Tendon Rupture Normal Shoulder Anatomy Short head (Fig. 4) Distal end (Refer fig. 5) Distal end (Fig. 5) Distal biceps tendon (Refer fig. 6) Distal biceps tendon (Fig. 6) Shoulder Bones Humerus The humerus provides attachment to muscles of the upper arm. The humeral head forms the ball of the ball-and-socket shoulder joint. (Refer fig. 7) Humerus (Fig. 7)
Scapula The scapula (shoulder blade) is a flat, triangular bone providing attachment to the muscles of the back and neck. (Refer fig. 8) Unit 1: Biceps Tendon Rupture Normal Shoulder Anatomy Scapula (Fig. 8) Clavicle The clavicle is an S-shaped bone that connects the shoulder girdle to the trunk. It maintains the shoulder in a functional position with the axial skeleton and allows varied arm positions in sports. Clavicle (Fig. 9) In addition to its structural function, the clavicle protects major underlying nerves and blood vessels as they pass from the neck to the axilla. (Refer fig. 9) Coracoid Process The coracoid process is the extension of the scapula or shoulder blade around the shoulder joint at the front (Refer fig. 10) Coracoid Process (Fig. 10) Acromion The acromion is the extension of the scapula or shoulder blade around the shoulder joint at the rear which forms a roof. This is also called the acromial process (Refer fig. 11) Acromion (Fig. 11)
Unit 1: Biceps Tendon Rupture Normal Shoulder Anatomy Glenoid The glenoid is the depression at the end of the scapula that forms the socket of the ball and socket joint. Glenoid (Refer fig. 12) (Fig. 12) Shoulder Soft Tissue Anatomy Rotator Cuff The rotator cuff refers to a group of four tendons that attach four shoulder muscles to the upper arm or humerus and hold it in the shoulder joint. Many shoulder problems are caused by injuries to the rotator cuff (Refer fig. 13) (Fig. 13) Biceps Tendons The biceps tendon is a long cord-like structure which attaches the biceps muscle to the shoulder and helps to stabilize the joint. (Refer fig. 14) (Fig. 14) Coracoclavicular Ligament Ligaments connect bone to bone, and coracoclavicular ligament connects the corocoid process of the scapula to the Clavicle. (Refer fig. 14) (Fig. 15)
Unit 1: Biceps Tendon Rupture Normal Shoulder Anatomy Acromioclavicular Ligament Ligaments connect bone to bone, and acromioclavicular ligament connects the Acromion process to the clavicle. (Refer fig. 16) (Fig. 16) Glenoid Labrum The Glenoid labrum is a ring of fibrous cartilage surrounding the glenoid for stabilization of the shoulder joint. (Refer fig. 17) (Fig. 17) Capsula The capsule that surrounds the shoulder joint consists of very strong ligaments that helps to keep the ball and socket normally aligned. (Refer fig. 18) (Fig. 18)
Unit 2: Bicep Rupture Causes Biceps tendon ruptures occur most often to people over 60 who have developed chronic micro tears from degenerative changes and overuse. These micro tears weaken the tendon making it more susceptible to rupturing. The tendon can eventually pull away from the bone, often during a simple maneuver. Patients usually have a history of shoulder problems such as impingement or rotator cuff problems prior to the rupture. Occasionally, biceps tendon ruptures occur in younger patients who lift weights or engage in heavy manual labor occupations. This usually causes the rupture to occur at the distal end near the elbow but can occur at the proximal end, although this is rare in this patient population. Signs and Symptoms Symptoms of a biceps tendon rupture are different depending on the location of the rupture. For proximal biceps tendon ruptures occurring at the shoulder, symptoms can include the following: Sudden, sharp pain to the shoulder and upper arm Snapping sound may be heard at time of injury A bulging biceps muscle near the elbow, referred to as a positive Popeye sign Bruising to the upper arm Pain relief after rupture occurs No initial pain at all For distal biceps tendon ruptures occurring at the elbow, symptoms can include: Sudden, sharp pain at the elbow Snapping sound may be heard at time of injury Swelling and bruising around the elbow Loss of strength with certain movements Immediate Treatment Immediately following an injury and before being evaluated by a medical doctor, you should initiate the R.I.C.E. Method of treatment: Rest: Rest the arm as more damage could result from putting pressure on the injury. Ice: Ice packs applied to the injury will help diminish swelling and pain. Ice should be applied over a towel to the affected area for 15-20 minutes four times a day for several days. Never place ice directly over the skin. Compression: Wrapping the arm with an elastic bandage or compression stocking can help to minimize the swelling and provide support. Elevation: Elevating the affected arm above heart level will also help with swelling and pain.
Unit 2: Bicep Rupture Diagnosis Orthopaedic injuries should be evaluated by an Orthopaedic surgeon for proper diagnosis and treatment. Your surgeon will perform the following: Medical History Physical Examination The physical examination performed by your orthopedist is usually definitive enough to diagnose biceps tendon rupture. However, in some cases, further diagnostic studies may be required to rule out other conditions and confirm the diagnosis. Diagnostic Studies may include: X-rays A form of electromagnetic radiation that is used to take pictures of bones. Ultrasound A non-invasive medical imaging test that utilizes sound waves and their echoes to create 2 dimensional images. MRI Magnetic and radio waves are used to create a computer image of soft tissue such as nerves and ligaments. Conservative Treatment The goal of conservative treatment for Biceps Tendon Rupture is to restore stability, strength, and full range of motion. Conservative treatment measures may include the following: Closed Reduction Following a dislocation, your Orthopaedist can often manipulate the shoulder joint, usually under anesthesia, realigning it into proper position. Surgery may still be necessary to restore normal function depending on your situation. Medications Over the counter pain meds such as aspirin and NSAID s (non-steroidal anti-inflammatory drugs) such as ibuprofen can help with the pain and swelling. Cortisone injections may also be administered to decrease swelling.
Unit 2: Bicep Rupture Rest Rest the injured shoulder as much as possible and avoid activities that require overhead motion. A sling may be ordered for 1-2 weeks to facilitate healing. Ice Ice packs applied to the injury will help diminish swelling and pain. Ice should be applied over a towel to the affected area for 20 minutes every hour. Never place ice directly over the skin. Therapy Your physician may refer you to a therapist for instruction in strengthening and stretching exercises.
Unit 3: Surgical Procedure Introduction to Surgery Your surgeon may recommend surgical repair for proximal biceps tendon rupture in order to regain maximum upper arm strength in the following patients: Younger patients Athletic patients Patients concerned about the cosmetic appearance of the bulging bicep muscle, also referred to as popeye sign. Distal biceps tendon ruptures at the elbow are almost always treated surgically. Surgery to repair a ruptured biceps tendon may be performed arthroscopically. Arthroscopy is a surgical procedure in which an arthroscope is inserted into a joint. The arthroscope is a small fiber-optic viewing instrument made up of a tiny lens, light source and video camera. The surgical instruments used in arthroscopic surgery are very small (only 3 or 4 mm in diameter) but appear much larger when viewed through an arthroscope. The television camera attached to the arthroscope displays the image of the joint on a television screen, allowing the surgeon to look throughout the shoulder or elbow at cartilage, ligaments, and tendons. The surgeon can determine the amount or type of injury, and then repair or correct the problem as necessary. Arthroscopic surgical procedures are often performed on an outpatient basis and the patient is able to return home on the same day. The benefits of arthroscopy compared to the alternative, open shoulder or open elbow surgery, include: Smaller incisions Minimal soft tissue trauma Less pain Faster healing time Lower infection rate Less scarring Earlier mobilization Usually performed as outpatient day surgery Surgical Treatment Arthroscopy to repair a proximal ruptured biceps tendon is performed in a hospital operating room under general anesthesia. The surgery is referred to as Arthroscopic Biceps Tenodesis. The surgeon will make several small incisions, about ¼ inch each, to the shoulder area. (Refer fig. 19 to 24) (Fig. 19)
Unit 3: Biceps Tendon Rupture Surgical Procedure Surgical Treatment These incisions result in very small scars, which in many cases are unnoticeable. In one portal, the arthroscope is inserted to view the shoulder joint. Along with the arthroscope, a sterile solution is pumped into the joint which expands the shoulder joint, giving the surgeon a clear view and room to work. The other portal is used for the insertion of surgical instruments. A surgical instrument is used to probe various parts within the joint to determine the extent of the problem. Any bone spurs present that may have contributed to the rupture will be shaved with an instrument called a burr. The surgeon will locate the biceps tendon and debride (remove) any frayed edges that occurred from the rupture. The biceps tendon will then be attached to the humerus bone, the upper arm bone, as opposed to its original location on the labrum within the shoulder. The tendon is secured to the humerus with a special screw. After treating the problem, the portals (incisions) are closed by suturing or by tape. Arthroscopy is much less traumatic to the muscles, ligaments, and tissues than the traditional method of surgically opening the shoulder with long incisions (open technique). (Fig. 20) (Fig. 21) (Fig. 22) (Fig. 23) (Refer fig. 19 to 24) (Fig. 24)
Post Operative Care Unit 3: Biceps Tendon Rupture Surgical Procedure You will wake up in the recovery room and then be transferred back to the ward. A bandage will be around the operated shoulder and the shoulder placed in a soft sling. Once you are recovered your IV will be removed and you will be shown a number of exercises to do. You will be encouraged to move your fingers and wrist often. Your surgeon will see you prior to discharge and explain the findings of the operation and what was done during surgery. Pain medication will be provided and should be taken as directed. You can remove the bandage in 24-72 hours to shower, depending on your surgeon s preference, and place dressings provided by your surgeon over the area. It is NORMAL for the shoulder to swell after the surgery. Placing ice-packs on the shoulder will help to reduce swelling. (Ice packs on for 20 min 3-4 times a day until swelling has reduced) Physical therapy will be ordered to restore normal upper arm function and strength. It is imperative that you follow your therapist s instructions to prevent complications. You will be able to drive when you are off pain medications and no longer in a sling, usually about 3 weeks. You should make an appointment with your surgeon 7-10 days after surgery to monitor your progress. Eating a healthy diet and not smoking will promote healing. Risks and Complications As with any surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. Complications can be medical (general) or specific to Biceps Tendon Rupture surgery. Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include: Allergic reactions to medications Blood loss requiring transfusion with its low risk of disease transmission Heart attacks, strokes, kidney failure, pneumonia, bladder infections Complications from nerve blocks such as infection or nerve damage Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.
Risks and Complications Unit 3: Biceps Tendon Rupture Surgical Procedure The majority of patients suffer no complications following Biceps Tendon Rupture, however, complications can occur and include: Infection Infections can occur superficially at the portal insertion sites or in the joint space of the shoulder, a more serious infection. Nerve damage Trauma to the nerves can cause numbness, tingling, pain, and weakness. Hemarthrosis A condition caused by excess bleeding into the joint after the surgery is completed. This may require additional arthroscopic surgery to irrigate the joint and evacuate the blood. Reflex Sympathetic Dystrophy This is an extremely rare condition that is not entirely understood, which can cause unexplained and excessive pain. Risk factors that can negatively affect adequate healing after surgery include: (Fig. 25)
Unit 3: Disclaimer Summary A good knowledge of this procedure will make the stress of undertaking the procedure easier for you to bear. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery. Disclaimer Although every effort is made to educate you on Biceps Tendon Rupture, there will be specific information that will not be discussed. Talk to your doctor or health care provider about any questions you may have. You must not proceed until you are confident that you understand this procedure, particularly, the complications.
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