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Distal biceps ruptures – a ticking time bomb? · MSKMag OutLoud

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  SPEAKER_00: Distal biceps ruptures, a ticking time bomb by Val Jones.
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  SPEAKER_00: Working in a regional trauma center,
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  SPEAKER_00: we're used to seeing lots of soft tissue injuries on a regular basis.
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  But the one that was considered more unusual when I first
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  started working at the
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  shoulder and elbow unit in Sheffield over 20 years ago was the
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  acute distal biceps
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  SPEAKER_00: rupture.
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  Previous literature both on UK and US populations describe it
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  as a rare injury,
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  SPEAKER_00: with an incidence of 1.2 to 2.6 per 100,000 person years.
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  This equated to seeing and operating upon about 10 and 12
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  patients per annum from
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  the Sheffield population of approximately 750,000 during the
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  first few years of the
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  SPEAKER_00: millennium.
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  SPEAKER_00: However,
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  SPEAKER_00: in the last decade there has been an explosion,
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  SPEAKER_00: quite literally,
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  SPEAKER_00: in the number of patients attending our unit with distal biceps rupture.
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  SPEAKER_00: Our team now on average sees up to 40 cases per year,
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  SPEAKER_00: over a 300% increase over a 20-year period.
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  These figures made me question what was driving this increase
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  and was this just a
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  SPEAKER_00: regional trend or something that other orthopaedic units were seeing?
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  SPEAKER_00: Also,
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  what are the implications for an already struggling healthcare
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  system to cope with
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  SPEAKER_00: an increased demand for surgery,
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  SPEAKER_00: imaging,
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  SPEAKER_00: resources and post-operative rehabilitation?
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  SPEAKER_00: Trawling through recent literature,
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  SPEAKER_00: there is very little written on the incidence of these injuries,
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  SPEAKER_00: apart from one study looking at Swedish and Finnish registries,
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  which found a 6-7 fold increase in this type of injury and a
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  28-fold increase in
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  SPEAKER_00: distal biceps repair surgery.
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  SPEAKER_00: Staggering numbers with a huge implication for resource allocation,
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  SPEAKER_00: with figures that echoed our own experience in Sheffield.
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  SPEAKER_00: In the general population,
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  full thickness tears are most encountered in active middle-aged
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  men between 40 and
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  SPEAKER_00: 60 years of age.
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  Often when questioned,
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  these patients have had no warning signs before their tendon
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  tear.
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  The incidence in women is extremely low and clinically I've
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  only met one female
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  SPEAKER_00: with this injury during my 23 year tenure in Sheffield.
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  An evaluation of distal biceps tendon ruptures in women sees
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  them describe a more
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  gradual onset of symptoms and a higher incidence of partial
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  tears rather than full
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  SPEAKER_00: thickness ones.
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  Other predisposing factors to injury may include an elevated
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  body mass index ,
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  SPEAKER_00: smoking and medication use,
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  SPEAKER_00: elevated BMI,
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  SPEAKER_00: possibly secondary to greater muscle mass,
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  SPEAKER_00: would increase the load on the tendon and may predispose to rupture.
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  Furthermore,
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  obesity has been shown to decrease immune responses to acute
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  tendon injury.
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  SPEAKER_00: Of patients with a distal biceps tendon rupture,
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  SPEAKER_00: 36 to 66% are reported to be obese,
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  SPEAKER_00: compared with the general UK population obesity rate,
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  SPEAKER_00: which is approximately 30%.
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  The exact instance of smoking in patients with distal biceps
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  tendon ruptures is
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  SPEAKER_00: unknown,
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  but it is widely accepted that smoking is a predisposing factor
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  in tendon injuries.
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  One study quotes a seven-fold increase in distal biceps
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  ruptures in smokers
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  SPEAKER_00: compared with non-smokers.
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  Smoking rates have increased in the adult population of those
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  aged 45 and above,
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  SPEAKER_00: which is the peak age for these injuries to occur.
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  A possible effect of smoking involves an increased zone of
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  hypovascularity in the
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  SPEAKER_00: tendon between the proximal and distal blood supply.
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  SPEAKER_00: Patients often ask if vaping carries the same risk as cigarette smoking,
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  but I have to be honest and tell patients that I just don't
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  have that answer
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  SPEAKER_00: currently.
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  Maybe the correlation between musculoskeletal injury risk and
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  vaping will become
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  SPEAKER_00: more evident over time.
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  SPEAKER_00: The image and performance enhancement drug market,
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  SPEAKER_00: including anabolic steroids,
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  SPEAKER_00: has become increasingly accessible through online sellers,
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  SPEAKER_00: which has broadened their appeal to a wider market.
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  Their usage has become semi-normalised and socially acceptable,
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  coining the term gym and tonic.
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  SPEAKER_00: Weightlifters are the primary user group of IPEDs,
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  SPEAKER_00: with increase in usage seen in both males and females.
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  Anabolic steroid use combined with exercise may lead to
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  dysplasia of collagen
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  SPEAKER_00: fibrils,
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  which can decrease the tensile strength of the tendon with an
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  associated increase
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  SPEAKER_00: in muscle strength.
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  SPEAKER_00: Changes in tendons' crimp morphology have been shown to occur as well,
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  SPEAKER_00: which again may alter the tensile strength of the tendon.
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  Less commonly,
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  tendon rupture can also be linked with statin or
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  fluoroquinolone antibiotic use.
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  SPEAKER_00: High-risk sports for distal bicep tendon ruptures are weightlifting,
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  SPEAKER_00: American football,
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  SPEAKER_00: judo and other contact sports,
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  and usually occur with an eccentric force is applied to a
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  flexed or supinated
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  SPEAKER_00: elbow,
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  with most patients describing an audible pop followed by pain
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  and weakness.
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  SPEAKER_00: Not all are sporting injuries, though.
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  SPEAKER_00: In Sheffield,
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  we've seen it in patients who've tried to stop their dog
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  running off by hanging
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  onto their collar or by trying to catch a wardrobe falling down
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  the stairs.
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  SPEAKER_00: That was never going to work out well.
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  After discussion with the surgical team,
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  most medically well patients opt for an acute repair.
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  SPEAKER_00: An acute repair is deemed less risky for patients with less chance of
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  SPEAKER_00: post-operative complications.
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  SPEAKER_00: However,
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  one note of caution is there is the lack of clinical consensus
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  on the role of
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  SPEAKER_00: operative treatment.
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  Support for surgery has largely been driven by biomechanical
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  studies that report a
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  SPEAKER_00: reduction in supination and elbow flexion strength,
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  SPEAKER_00: as well as impaired endurance seen in injuries managed non-operatively.
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  There is a lack of robust evidence comparing non-operative
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  versus operative treatment.
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  SPEAKER_00: Public perception towards surgical treatment is often positive,
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  although the evidence of its superiority over other treatments
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  is lacking.
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  SPEAKER_00: When considering surgery,
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  SPEAKER_00: there is often a disregard for the associated risks,
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  SPEAKER_00: with individuals often taking a it-will-never-happen-to-me stance.
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  SPEAKER_00: But distal biceps repairs carry a huge 25% complication rate,
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  with 1 in 20 patients suffering a serious adverse event such as
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  vascular or nerve
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  SPEAKER_00: injury,
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  SPEAKER_00: heterotopic ossification,
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  SPEAKER_00: or re-rupture.
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  Given the real risks involved with surgery,
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  what's driving the increase in this procedure?
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  SPEAKER_00: Firstly,
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  the recognition of the injury and accuracy of diagnosis by
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  healthcare professionals
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  SPEAKER_00: may have improved.
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  SPEAKER_00: Physical examination techniques,
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  SPEAKER_00: such as the commonly used hook test,
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  SPEAKER_00: combined with a careful history,
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  SPEAKER_00: make swifter diagnosis more likely.
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  SPEAKER_00: Historically,
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  patients with a delayed presentation were often advised against
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  surgery as delayed
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  SPEAKER_00: repairs are associated with higher complication rates.
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  So faster diagnosis probably leads to an increase in surgical
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  conversion rates.
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  The availability of modern imaging technologies such as MRI and
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  ultrasound scans
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  may have made confirming the diagnosis easier and again will
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  decrease any delay
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  SPEAKER_00: between injury and diagnosis,
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  SPEAKER_00: once again leading to an increased possibility of surgery.
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  Other reasons may be that with increasing sporting
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  participation and more active
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  SPEAKER_00: older populations,
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  the incidence and age at presentation of this injury would be
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  expected to rise.
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  This group of patients may be more interested in full recovery
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  and therefore
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  surgical options are more likely to be explored as patients are
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  unwilling to live
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  with a lifelong strength deficit and cosmetic deformity often
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  seen following
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  SPEAKER_00: conservative management.
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  Recent advances in surgical techniques such as the use of
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  button techniques allow
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  SPEAKER_00: for strong initial fixation which allows early active mobilization.
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  SPEAKER_00: Music to most physios' ears.
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  SPEAKER_00: There is little consensus on the optimal post-op rehabilitation program,
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  but our own in-house experience of immediate active post-op
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  mobilization resulted
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  in a faster return to function with less physiotherapy
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  intervention compared to
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  SPEAKER_00: delayed mobilization.
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  SPEAKER_00: There was no increase in complication rates,
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  SPEAKER_00: such as re-rupture following accelerated mobilisation.
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  Loading above 10kg is avoided for 3 months post-op because of
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  the pull-out strain
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  SPEAKER_00: of the button devices used,
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  SPEAKER_00: but otherwise there is no other restriction placed on our patients.
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  SPEAKER_00: In conclusion,
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  distal biceps ruptures are becoming increasingly prevalent for
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  a variety of
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  SPEAKER_00: reasons.
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  Healthcare practitioners should remain vigilant in diagnosing
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  the injury and
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  SPEAKER_00: swiftly refer on for urgent surgical opinion.
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  SPEAKER_00: Despite the lack of robust evidence,
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  surgery in the medically well is considered the current optimal
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  treatment approach,
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  with early mobilisation following surgery appearing to be
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  beneficial both in terms
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  SPEAKER_00: of speed of recovery and use of physiotherapy resources.