Learning Point of the Article:
Learning Point of the Article:
Closed traumatic ruptures of the biceps brachii muscle belly are rare injuries, despite the intra-muscular nature of the tear they can be successfully treated with appropriate operative timing and technique.
Case Report | Volume 9 | Issue 1 | JOCR January – February 2019 | Page 15-18| Ryan S Selley, Matthew J Hartwell, Richard W Nicolay, Vehniah K Tjong, Stephen M Gryzlo. DOI: 10.13107/jocr.2250-0685.1288
Authors: Ryan S Selley, Matthew J Hartwell, Richard W Nicolay, Vehniah K Tjong, Stephen M Gryzlo
Department of Orthopedic Surgery, Northwestern Memorial Hospital, Chicago, Illinois, USA.
Address of Correspondence:
Dr. Ryan S Selley,
Department of Orthopedic Surgery,Northwestern Memorial Hospital – 676 North Saint Clair Street,Chicago, IL 60611.
Introduction: Intrasubstance biceps brachii rupture is a rare injury. Non-operative management of this injury has demonstrated worse outcomes than early operative intervention.
Case Report: We report a case of a traumatic long head of the biceps brachii muscle belly rupture repaired primarily through the Kragh technique augmented with human dermal collagen matrix. The patient demonstrated full strength, an intact repair through clinical exam and magnetic resonance imaging at 6-year follow-up. Dash scoring demonstrated 0 (no disability) out of 100 at this time.
Conclusion: Repair of acute traumatic closed transection of the biceps brachii can be successfully repaired utilizing this technique with excellent post-operative function.
Keywords: Intrasubstance biceps rupture, Kraghtechnique, muscle repair.
Intrasubstance biceps brachii rupture is a rare injury most commonly seen in young males in their late teens to early 20’s [1, 2, 3, 4]. There are 91 reported cases in the literature, with the majority occurring in military parachutists and water sports with varied traumatic mechanisms [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12]. Military parachutists experience the injury secondary to a direct impact from a static ripcord line while exiting the aircraft [1, 2]. Other case reports describe indirect injury during forced eccentric loading of the biceps from a tow rope [3, 5, 6, 7]. One case report detailed a biceps rupture in a passenger’s arm that was hanging out of a window and was forcefully abducted and externally rotated when it struck a parked vehicle . Clinical descriptions of intrasubstance biceps rupture include pain, tenderness, and a palpable gap along the biceps muscle belly. These features can mimic a distal biceps tendon rupture and can be distinguished either with ultrasonography or magnetic resonance imaging (MRI) [3, 8]. The decision to consider operative versus non-operative management is multifactorial. Important considerations include age, activity level, injury chronicity, concomitant injury, and the quality of the residual muscle. Two studies in the military describe improved clinical outcomes in terms of strength, cosmesis, and satisfaction with early primary operative repair [1, 2]. We report successful long-term functional and MRI results of an individual who sustained a complete long head of the biceps muscle belly rupture treated with primary repair.
Consent for publication was obtained from the patient. A healthy, 24-year-old, right-hand dominant male was riding his motorcycle traveling approximately 25 miles per hour when he was struck by a motor vehicle. The mechanism of fall is unclear secondary to amnesia, but he was ejected from the motorcycle as reported by bystanders. The patient subsequently presented to the clinic4 days after the injury with complaints of left arm pain and swelling. On physical examination, the patient had swelling and tenderness to palpation over the mid aspect of the left humerus, and an obvious defect was noted with an associated popeye deformity, ecchymosis was present distally though not at the rupture site (Fig. 1). He could achieve full range of motion in his shoulder and elbow but had reduced strength with elbow flexion (4/5) and forearm supination (3/5). Radiographs revealed no fractures or other abnormalities. MRI revealed the following: (a) Sagittal short TI inversion recovery (STIR) image of the injured arm demonstrating the long head muscle belly rupture with an intact short head and partially ruptured brachialis, (b) coronal STIR image centered over the distal anterior upper arm demonstrating complete rupture of the long head biceps muscle belly with a 9 cm gap and intervening hematoma, and (c) axial T2 fat suppression image of the midshaft humerus at the level of the biceps rupture demonstrating an intact short head biceps muscle belly, partially ruptured brachialis and hematoma within the biceps compartment (Fig. 2). As the patient was young and wished to maximize strength and minimize deformity, he elected for surgical repair 8days after the injury. An anterior midline incision was performed starting at the deltopectoral interval proximally and extending distally 12 cm. Subcutaneous edema was encountered immediately; the biceps fascia was incised, and the biceps brachii was noted to be transected with preservation of the short head deep fibers (Fig. 3). The musculocutaneous nerve was not encountered. Intervening hematoma was evacuated, and muscle edges were debrided. An absorbable suture was then used to whip stitch the proximal and distal segments of muscle, and four modified Mason-Allen stitches using non absorbable suture were used to capture each quadrant as described by Kragh and Basamania . The deep internal muscle stitches were closed primarily followed by the superficial stitches (Fig. 4). To augment the strength of repair, a human dermal collagen matrix was placed over the repair anteromedially (Fig. 5). The elbow was subsequently taken through a range of flexion, extension, pronation, and supination with no blocks to motion or repair site gapping. Subsequently, fascial and skin closure was performed, and a posterior mold splint was placed in 90° of flexion. The patient’s post-operative rehabilitation protocol consisted of a 6 weeks period of progressive splinting from 90° of flexion to full extension. He was allowed to begin active pronation and supination in the splint at 3 weeks. From 6 to 12 weeks, the patient remained in a hinged elbow brace with an allowable arc of motion from 30 to 90° of flexion. He progressed 10°per week until full extension and flexion were achieved. From 3 months to 1 year the patient began a slow progressive strengthening program. The patient notably had achieved 5/5 flexion and 5/5 supination strength and retained full range of motion at his 1year follow-up appointment. A small divot was noted at the repair site but was acceptable cosmetically to the patient and similar to the contralateral arm (Fig. 6). The patient subsequently presented to clinic 6 years following the initial injury for evaluation of a palpable suture over the proximal end of the incision. On physical examination, he had retained full range of motion and had 5/5 strength with elbow flexion and supination. A disability of arm, shoulder, and hand (DASH) score was obtained at this time and was rated a 0 (no disability) out of 100. In addition, a score of 0 (no difficulty) was reported for the work and sport modules. A follow-up MRI at this time demonstrated reconstitution of the biceps brachii muscle belly with minimal residual intrasubstance scarring (Fig. 7).
The majority of intrasubstance ruptures of the biceps brachii have been reported to occur in either military parachutists or those engaging in water sports [3, 5, 6]. We present a previously unreported mechanism of injury, as this patient experienced an intrasubstance biceps rupture during a motorcycle accident. The described mechanisms of injury in military parachutists and water sport athletes were related to either a direct, blunt force to the biceps muscle belly from a static line or forced eccentric elbow loading [3, 5, 6]. In the currently presented case, we suspect the patient may have experienced an indirect injury to the biceps muscle belly given the lack of ecchymosis at the biceps rupture site during the initial evaluation in the emergency room and the high energy nature of a motorcycle collision that could result in forcible eccentric loading of the biceps. There remains no standardized operative treatment for intrasubstance biceps ruptures. Case reports of short head muscle belly ruptures have been repaired with a variety of techniques ranging from suturing the muscle cores with interrupted stitches and the periphery with double Kessler stitches to repairing the muscle belly and fascia with Kessler and Bunnell type patterns and running nonabsorbable suture around the margin of the ruptured site[9, 10, 11, 12]. These repairs were all associated with adequate clinical outcomes from 2 to 5 months follow-up. Other repair techniques for complete biceps brachii muscle belly ruptures have been reported inmilitary parachutists at the Womack Army Medical Center by Heckman and Levine and Kragh and Basamania [1, 2]. Heckman described re-approximating the muscle bellies with double right-angle sutures of heavy catgut and reinforcing the repair with a U-shaped flap of biceps fascia. Kraghlater illustrated an updated surgical repair that incorporated different techniques. This included modified Mason-Allen stitches in each of the four muscle quadrants along with a running interlocked perimeter stitch in the muscle fibers and epimysium. We utilized the Kragh repair method for this patient with one modification, a human dermal collagen matrix was placed over the repair site to offload the muscle suture interface and minimize the risk of suture pull through. Reported outcomes after primary repair of intrasubstance ruptures of the biceps brachii have highlighted satisfactory clinical and cosmetic outcomes with minimal complications. The typical clinical follow-up after the primary surgical repair was <1 year; however, Kragh reported adequate clinical outcomes at an average follow-up of 2.2 years. [1, 2, 3, 6, 9, 10, 11, 12] A single study was identified that reported MRI results at 2 months following repair of an isolated short head muscle belly rupture, which demonstrated muscle continuity . We now present 6-year follow-up evaluation after primary repair of an intrasubstance long head biceps brachii rupture utilizing the Kragh repair technique with excellent clinical and radiographic outcomes. The patient regained full strength, is satisfied with the cosmetic outcome, reports no disability on DASH questionnaire, and has MRI results that demonstrated complete reconstitution of the biceps brachii muscle belly.
We report a case of traumatic intrasubstance biceps brachii muscle belly rupture that was repaired using the Kragh technique and augmented with human dermal collagen matrix. Post-operative follow-up demonstrated an intact repair through clinical exam and MRI, full strength and no disability on DASH scoring at 6 years. Repair of acute traumatic closed transection of the biceps brachii can be successfully repaired utilizing this technique with excellent post-operative function.
Closed traumatic ruptures of the biceps brachii muscle belly are rare injuries. Despite the intramuscular nature of the tear they can be successfully treated with operative repair.
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|Dr. Ryan S Selley||Dr. Matthew J Hartwell||Dr. Richard W Nicolay||Dr. Vehniah K Tjong||Dr. Stephen M Gryzlo|
|How to Cite This Article: Selley R S, Hartwell M J, Nicolay R W, Tjong V K, Gryzlo S M. Complete Intrasubstance Long Head Biceps Brachii Rupture with Successful Repair: A Case Report. Journal of Orthopaedic Case Reports 2019 Jan-Feb; 9(1): 15-18.
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