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MRI Web Clinic - November 2004
Biceps Tendon Rupture Elbow
By Michael E. Stadnick, M.D.
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Clinical History: 45 year-old male experienced a "pop" and acute onset pain while lifting a heavy bucket. What are the findings? What is your diagnosis?
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A
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B
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Answer
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A
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B
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Findings
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(A) A fat-suppressed proton density-weighted axial image through the proximal forearm at the level of the bicipital tuberosity demonstrates fluid-signal intensity (arrow) adjacent to the bicipital tuberosity and absence of the biceps tendon. (B) A proton-density weighted image through the distal humerus demonstrates hemorrhage and edema (arrows) surrounding a retracted biceps tendon (arrowhead).
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Diagnosis
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Distal Biceps Tendon Rupture.
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Discussion
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Ruptures of the distal biceps tendon are seen most commonly in the dominant arm of males greater than 40 years of age. The injury also affects athletes involved in strength training or who have sustained athletic related trauma. The mechanism of injury is forced extension of a flexed and supinated forearm. Distal biceps tendon ruptures most commonly present after a single traumatic event. However, evidence suggests that tendon hypovascularity and mechanical impingement are contributory factors, increasing tendon susceptibility to rupture.1
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C
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D
The distal biceps tendon attachment to the bicipital tuberosity of the proximal radius is best demonstrated on axial images. A normal tendon (arrows) demonstrates low signal on (C) T1-weighted - and (D) fat-suppressed T2 weighted - images.
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E
The lacertus fibrosus (LF) fans out over the flexor pronator group (FP). An intact lacertus fibrosus tethers the biceps tendon (BT), limiting the retraction of a complete distal biceps rupture.
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The typical clinical presentation of a complete biceps tendon rupture is one of swelling, ecchymosis, and a retraction of the tendon leading to a palpable "mass" in the antecubital fossa (F). Retraction of the ruptured distal biceps tendon is prevented if the bicipital aponeurosis (lacertus fibrosus) remains intact (E). In such cases the typical "mass" of retracted tendon in the antecubital fossa is absent, and an accurate clinical diagnosis may be difficult (G,H). Partial tears of the distal biceps tendon are rarely diagnosed. The clinical presentation for this entity is typically more insidious in onset with the patient complaining of chronic pain, often without significant loss of strength (I).
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F
T2 weighted sagittal image of the elbow demonstrates a retracted and coiled biceps tendon (arrows) in the antecubital fossa anterior to the brachialis muscle. The tendon is surrounded by hemorrhage and edema (arrowheads). These findings account for the palpable abnormality typical on physical exam.
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G
T2 weighted fat-suppressed sagittal image of the elbow of a patient with a complete distal biceps rupture demonstrates an edematous but non-retracted biceps tendon (arrows).
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H
Proton density fat-suppressed axial image of the patient in (G) demonstrates mild fluid-signal intensity outlining an intact lacertus fibrosus (arrows), seen attaching to the edematous biceps tendon (arrowhead).
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I
Fat-suppressed proton density axial image of the proximal forearm demonstrates abnormally increased signal intensity and an increased diameter of the distal biceps tendon (arrow) compatible with a partial tear. Avulsive marrow edema is present within the bicipital tuberosity of the radius (arrowheads) and distension of the bicipitoradial bursa is present (short arrow).
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MR allows the diagnosis of distal biceps rupture by demonstrating an abnormal tendon diameter, altered tendon signal intensity, and tendon retraction. Peritendinous fluid resulting from hemorrhage and edema is typically present with acute ruptures. Partial tears of the tendon are diagnosed by abnormal intra-tendinous signal and alterations in tendon caliber. Avulsive marrow edema in the bicipital tuberosity and bicipital bursitis are frequent accompanying findings (I).2
Surgical repair of distal biceps rupture results in superior supination and flexion strength and pain relief compared to conservative management.3 Early surgical repair is most desirable, especially if the lacertus fibrosus is torn with tendon retraction. Treatment of partial tears often begins conservatively. However, many of these patients will eventually require surgical repair for pain relief and to regain strength.4
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Conclusion
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The diagnosis of distal biceps tendon rupture may be difficult if tendon retraction is absent or if a partial rupture is present. MRI provides an accurate diagnosis of this entity and is able to differentiate a complete from partial tendon rupture. The integrity of the lacertus fibrosus can also be assessed, which is often important in surgical planning.
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References
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1 Seiler III JG, Parker LM, Chamberland PD, Sherbourne GM, Carpenter WA. The Distal Biceps Tendon. Two Potential Mechanisms Involved in its Rupture: Arterial Supply and Mechanical Impingement. J Shoulder Elbow Surg 4:149-156,1995.
2 Williams BD, Schweitzer ME, Weihaupt D, Lerman J, Rubenstein DL, Eosenberg ZS. Partial tears of the distal biceps tendon: MR appearance and associated clinical findings. Skeletal Radiol.2001 Oct;30(10):560-4.
3 Davison BL, Engler WD, Tigert LJ. Long Term Evaluation of Repaired Distal Biceps Brachii Tendon Ruptures. Clin Orthop 333: 186-191, 1996.
4 Vardakas DG, Musgrave DS, Varitimidis SE, Goebel F, Sotereanos DG. Partial rupture of the distal biceps tendon. J Shoulder Elbow Surg 10:377-379, 2001.
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