Score: 0%
ORTHOPEDIC MCQS OB 20 SHOULDER AND ELBOW 2
QUESTION 1
A 44-year-old male sustains the injury shown in Figures A and
1
Which of the following statements is true in regards to the treatment for the injury depicted?
1/. Non-surgical management results in improved strength and range of motion
2
The most common complication related to surgical management is an injury to the terminal branch of the musculocutaneous nerve
3/. Surgical fixation with bone tunnels offers the weakest repair
3
Surgical fixation with a cortical button offers the strongest repair
4
Synostosis is the most common complication following a single-incision surgical approach
He has suffered a distal biceps rupture as depicted in selected MRI slices (Figures A and B). The most common complication of this surgery is an injury to the lateral antebrachial cutaneous nerve (LABCN), which is the terminal branch of the musculocutaneous nerve.
Distal Biceps injuries are more common in males in their 40s. Non-operative management for complete ruptures is usually reserved for older and low demand individuals as there is a loss of sustained supination and flexion strength. Operative management is the mainstay of treatment through either a single or two-incision approach. The most common complication related to both the single and two-incision surgical technique is an injury to the LABCN. The two-incision surgical technique has an increased risk of synostosis and heterotopic ossification when compared to the single-incision surgical technique. The most biomechanical strong fixation is with use of both a cortical button and an interference screw.
Chavan et al. performed a systematic review that focused on distal biceps fixation, surgical approach, and complication profile. They found that the cortical button was biomechanically superior to all other methods of surgical fixation and there was not any significant difference in complications between single and two-incision techniques. However, the two-incision group had greater unsatisfactory clinical results that were defined by loss of range of motion of >30 degrees in any plane and/or loss of strength of <80% in flexion or supination.
Peeters et al. completed a retrospective case series with 26 patients that underwent distal biceps repair using cortical button fixation. At 16 months of average follow-up, patients had excellent function and improved pain, and the average flexion strength at the elbow was 80% and the average supination strength was 91%. Two patients had asymptomatic heterotopic ossification, three patients had their cortical button disengaged and one required removal. The authors concluded that the surgical fixation using a cortical button for distal biceps reattachment allows for excellent and reproducible clinical results.
McKee et al. reported their outcomes on 53 patients that completed a patient oriented outcome questionnaire following single-incision distal bicep repair using two suture anchors. This single surgeon population's mean Disabilities of the Arm, Shoulder, and Hand (DASH) score, 8.2, was similar to the mean DASH score in population controls, 6.2. Complications included one wound infection, two transient neuropraxic LABCN injuries and one posterior interosseous transient nerve palsy. There was not any loss of surgical fixation following repair and all patients had returned to within 5 degrees of their presurgical range of motion at the elbow.
Figures A and B are sagittal and axial T2 MRI slices, respectively, that demonstrate a complete distal biceps rupture with disruption of the tendon insertion to the radial tuberosity and the surrounding edema.
Incorrect Answers:
Answer 1: Non-surgical management of complete distal bicep ruptures does not result in improved strength and range of motion. Non-surgical management will lead to approximately a 50% loss of sustained forearm supination strength and approximately a 40% loss of sustained elbow flexion strength.
Answer 3: Distal biceps repair using bone tunnels is not the most biomechanically inferior technique. Surgical repair using a single interference screw is the most biomechanically inferior method.
Answer 4: Surgical repair using a cortical button alone does not result in the greatest time-zero biomechanical strength. The greatest time-zero biomechanical surgical fixation strength is obtained with the combination of the cortical button and interference screw.
Answer 5: The most common complication related to both the single and two incision surgical technique is an injury to the LABCN.
OrthoCash 2020
Distal Biceps injuries are more common in males in their 40s. Non-operative management for complete ruptures is usually reserved for older and low demand individuals as there is a loss of sustained supination and flexion strength. Operative management is the mainstay of treatment through either a single or two-incision approach. The most common complication related to both the single and two-incision surgical technique is an injury to the LABCN. The two-incision surgical technique has an increased risk of synostosis and heterotopic ossification when compared to the single-incision surgical technique. The most biomechanical strong fixation is with use of both a cortical button and an interference screw.
Chavan et al. performed a systematic review that focused on distal biceps fixation, surgical approach, and complication profile. They found that the cortical button was biomechanically superior to all other methods of surgical fixation and there was not any significant difference in complications between single and two-incision techniques. However, the two-incision group had greater unsatisfactory clinical results that were defined by loss of range of motion of >30 degrees in any plane and/or loss of strength of <80% in flexion or supination.
Peeters et al. completed a retrospective case series with 26 patients that underwent distal biceps repair using cortical button fixation. At 16 months of average follow-up, patients had excellent function and improved pain, and the average flexion strength at the elbow was 80% and the average supination strength was 91%. Two patients had asymptomatic heterotopic ossification, three patients had their cortical button disengaged and one required removal. The authors concluded that the surgical fixation using a cortical button for distal biceps reattachment allows for excellent and reproducible clinical results.
McKee et al. reported their outcomes on 53 patients that completed a patient oriented outcome questionnaire following single-incision distal bicep repair using two suture anchors. This single surgeon population's mean Disabilities of the Arm, Shoulder, and Hand (DASH) score, 8.2, was similar to the mean DASH score in population controls, 6.2. Complications included one wound infection, two transient neuropraxic LABCN injuries and one posterior interosseous transient nerve palsy. There was not any loss of surgical fixation following repair and all patients had returned to within 5 degrees of their presurgical range of motion at the elbow.
Figures A and B are sagittal and axial T2 MRI slices, respectively, that demonstrate a complete distal biceps rupture with disruption of the tendon insertion to the radial tuberosity and the surrounding edema.
Incorrect Answers:
Answer 1: Non-surgical management of complete distal bicep ruptures does not result in improved strength and range of motion. Non-surgical management will lead to approximately a 50% loss of sustained forearm supination strength and approximately a 40% loss of sustained elbow flexion strength.
Answer 3: Distal biceps repair using bone tunnels is not the most biomechanically inferior technique. Surgical repair using a single interference screw is the most biomechanically inferior method.
Answer 4: Surgical repair using a cortical button alone does not result in the greatest time-zero biomechanical strength. The greatest time-zero biomechanical surgical fixation strength is obtained with the combination of the cortical button and interference screw.
Answer 5: The most common complication related to both the single and two incision surgical technique is an injury to the LABCN.
OrthoCash 2020
QUESTION 2
A 42-year-old man is performing his final deadlift at the annual CrossFit games when he suddenly experiences severe pain in his right arm and is unable to continue. Physical examination is significant for medial brachial ecchymosis, swelling and tenderness over the antecubital fossa, and significantly diminished supination strength. Radiographs are unremarkable and an MRI is shown in Figure
1
Given his age and activity level, he is taken for primary surgical repair utilizing a single-incision technique with combined cortical button and interference screw fixation. When the patient returns to clinic, he is found to have experienced the most common neurologic complication associated with this procedure. What is the course of the affected nerve?
1/. Branches distal to the elbow, passing between two heads of pronator teres, running along volar aspect of the flexor digitorum profundus
2
Dives through the supinator, coursing around the radial neck within the deep compartment of the forearm
3/. Pierces the fascia of the biceps brachii and lays lateral to biceps tendon, deep to the cephalic vein, until emerging and running superficially along the brachioradialis
4/. Runs deep to the brachioradialis and lateral to the radial artery, piercing the fascia of the brachioradialis and becoming superficial within the distal forearm
3
Runs with brachial artery where it enters the forearm between the pronator
teres and biceps tendon, traveling between the flexor digitorum superficialis and profundus
The most common neurologic complication and most common complication overall is neuropraxia of the lateral antebrachial cutaneous (LABCN). The LABCN pierces the fascia of the biceps brachii and lays lateral to the biceps tendon, deep to the cephalic vein, until emerging and running superficially along the brachioradialis.
Distal biceps tendon ruptures are uncommon but often debilitating injuries in younger active individuals. Surgical management is often recommended for patients with complete tears and chronic symptomatic partial tears due to
persistent deficits most notably in supination and to a lesser extent in elbow flexion strength. The two most commonly used approaches are the single- and dual-incision repair, with a gamut of repair techniques. The advantages and disadvantages of each approach are somewhat controversial, however, it is agreed upon that surgery reliably restores function with minimal risk of serious complications. The most common surgical complication is transient LABCN neuritis, cited in nearly one-quarter of cases and more common with the single-incision approach. Injury to the superficial branch of the radial nerve (SBRN), posterior interosseous nerve (PIN), median nerve, or anterior interosseous nerve (AIN) are increasingly rare, in that order. Heterotopic ossification is more common with a dual-incision approach, though the relative risk of PIN palsy remains disputed.
Cain et al. reviewed 198 consecutive cases of distal biceps tendon repair. The authors reported an overall 36% complication rate, with 3% requiring reoperation. The most common minor complications were LABRN neuritis (26%) and SBRN neuritis (6%), while major complications included PIN palsy (4%) and symptomatic heterotopic ossification (3%). The authors concluded that despite the high complication rate, most were transient neuropraxias, but cautioned about an increased rate of complications in surgeries performed over 28 days after injury.
Grewal et al. compared outcomes of the single- to the dual-incision technique for distal biceps repairs. The authors found that there were no significant differences at two-year follow-up in rate of recovery or any of the functional outcome scores, though dual-incision was associated with 10% greater isometric flexion strength. The authors concluded that the rate of complications was significantly greater in the single-incision group, but most often due to transient LABCN neuropraxia (40% vs 7%).
Cohen reviewed the complications associated with distal biceps tendon repairs. The author highlighted the importance of surgical repair and noted that small differences between techniques were often clinically negligible as most patients returned to near full upper extremity function regardless. He noted that the single-incision repair was associated with less risk of heterotopic ossification, but carried a greater risk of neurologic injury, the most common being LABCN neuropraxia and to a much lesser extent PIN palsy.
Figure A is a sagittal T2 MRI cut demonstrating a complete distal biceps tendon rupture with proximal retraction.
Incorrect Answers:
Answer 1: The anterior interosseous nerve branches from the median nerve
within the forearm, 5-8cm distal to the lateral epicondyle, passes between two heads of pronator teres, runs along volar FDP, and ends in pronator quadratus at wrist.
Answer 2: The PIN branches from the radial nerve at the level of the radiocapitellar joint, dives through the supinator Arcade of Froshe, courses around the radial neck, emerges within the deep compartment of the forearm, and ends in the dorsal wrist capsule.
Answer 4: The SBRN branches from the radial nerve at the level of the radiocapitellar joint, runs deep to the brachioradialis and lateral to the radial artery, and pierces the fascia of the forearm 7-9cm proximal to the wrist where it courses to supply sensation over the snuffbox and dorso-radial hand. Answer 5: The median nerve runs with brachial artery where it enters the forearm between the pronator teres and biceps tendon, and travels between the flexor digitorum superficialis and profundus until emerging between flexor digitorum superficialis and flexor pollicis longus distally and entering the carpal tunnel.
OrthoCash 2020
The most common neurologic complication and most common complication overall is neuropraxia of the lateral antebrachial cutaneous (LABCN). The LABCN pierces the fascia of the biceps brachii and lays lateral to the biceps tendon, deep to the cephalic vein, until emerging and running superficially along the brachioradialis.
Distal biceps tendon ruptures are uncommon but often debilitating injuries in younger active individuals. Surgical management is often recommended for patients with complete tears and chronic symptomatic partial tears due to
persistent deficits most notably in supination and to a lesser extent in elbow flexion strength. The two most commonly used approaches are the single- and dual-incision repair, with a gamut of repair techniques. The advantages and disadvantages of each approach are somewhat controversial, however, it is agreed upon that surgery reliably restores function with minimal risk of serious complications. The most common surgical complication is transient LABCN neuritis, cited in nearly one-quarter of cases and more common with the single-incision approach. Injury to the superficial branch of the radial nerve (SBRN), posterior interosseous nerve (PIN), median nerve, or anterior interosseous nerve (AIN) are increasingly rare, in that order. Heterotopic ossification is more common with a dual-incision approach, though the relative risk of PIN palsy remains disputed.
Cain et al. reviewed 198 consecutive cases of distal biceps tendon repair. The authors reported an overall 36% complication rate, with 3% requiring reoperation. The most common minor complications were LABRN neuritis (26%) and SBRN neuritis (6%), while major complications included PIN palsy (4%) and symptomatic heterotopic ossification (3%). The authors concluded that despite the high complication rate, most were transient neuropraxias, but cautioned about an increased rate of complications in surgeries performed over 28 days after injury.
Grewal et al. compared outcomes of the single- to the dual-incision technique for distal biceps repairs. The authors found that there were no significant differences at two-year follow-up in rate of recovery or any of the functional outcome scores, though dual-incision was associated with 10% greater isometric flexion strength. The authors concluded that the rate of complications was significantly greater in the single-incision group, but most often due to transient LABCN neuropraxia (40% vs 7%).
Cohen reviewed the complications associated with distal biceps tendon repairs. The author highlighted the importance of surgical repair and noted that small differences between techniques were often clinically negligible as most patients returned to near full upper extremity function regardless. He noted that the single-incision repair was associated with less risk of heterotopic ossification, but carried a greater risk of neurologic injury, the most common being LABCN neuropraxia and to a much lesser extent PIN palsy.
Figure A is a sagittal T2 MRI cut demonstrating a complete distal biceps tendon rupture with proximal retraction.
Incorrect Answers:
Answer 1: The anterior interosseous nerve branches from the median nerve
within the forearm, 5-8cm distal to the lateral epicondyle, passes between two heads of pronator teres, runs along volar FDP, and ends in pronator quadratus at wrist.
Answer 2: The PIN branches from the radial nerve at the level of the radiocapitellar joint, dives through the supinator Arcade of Froshe, courses around the radial neck, emerges within the deep compartment of the forearm, and ends in the dorsal wrist capsule.
Answer 4: The SBRN branches from the radial nerve at the level of the radiocapitellar joint, runs deep to the brachioradialis and lateral to the radial artery, and pierces the fascia of the forearm 7-9cm proximal to the wrist where it courses to supply sensation over the snuffbox and dorso-radial hand. Answer 5: The median nerve runs with brachial artery where it enters the forearm between the pronator teres and biceps tendon, and travels between the flexor digitorum superficialis and profundus until emerging between flexor digitorum superficialis and flexor pollicis longus distally and entering the carpal tunnel.
OrthoCash 2020
QUESTION 3
A 55-year-old male presents to your clinic after a fall off a ladder and landing on his left shoulder. On examination, he has a positive drop arm sign but full passive, but painful, range of motion of the left shoulder. Radiographs are shown in Figures A and
1
MRI studies are obtained and shown in Figures C through
2
The patient elects to undergo operative intervention. Which of the following is true with respect to a double-row rotator cuff repair compared to a single-row repair?
1/. Increased time to healing with double-row repair compared to single-row repair
2/. Decreased functional outcome scores with single-row repair compared to double-row repair
3/. Decreased re-tear rate with double-row repair compared to single-row repair
4/. Increased post-operative pain with double-row repair compared to single row repair
5/. Less anatomic footprint restoration with a double-row repair compared to a single-row repair
The patient in the vignette has a large left rotator cuff tear. There is a lower retear rate associated with double-row rotator cuff repair (RCR) versus a single-row RCR.
There are many important and controversial topics with respect to arthroscopic rotator cuff repair. One important concept is the restoration of the rotator cuff footprint during the repair. It has been cited that a larger footprint will improve healing and the mechanical strength of the rotator cuff repair. A double-row suture technique (with mattress sutures in the medial row and simple sutures in the lateral row) has been shown to create a more anatomic repair of the footprint leading to a lower incidence of retears compared to a single-row repair (medial row mattress sutures only). However, there has been no difference noted between the techniques with respect to functional outcome scores, pain scores, or time to healing.
DeHaan et al. performed a systematic review of prosepective level I or II studies that compared the efficacy of single-row RCR versus double-row RCR. The authors found that the functional ASES, Constant, and UCLA outcome scores revealed no difference between the 2 groups. The authors did note that the total retear rate, which included both complete and partial re-rears, was 43.1% for the single-row RCR and 27.2% for the double-row RCR (P = .057). The authors concluded that double-row RCR revealed a trend toward a lower radiographic proven re-tear rate, although the data did not reach statistical significance.
Millett et al. performed a systematic review and meta-analysis of level 1 randomized trials comparing single-row with double-row RCRs to compare clinical outcomes and imaging-diagnosed re-tear rates. The authors reviewed 7 studies that met their inclusion criteria and noted there were no significant differences in ASES, UCLA, or Constant scores between the single-row and double-row groups. They did note that there was a statistically significant increased risk of sustaining an imaging-proven re-tear of any type in the single-row group compared to the double-row group. The authors concluded that single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs, especially with regard to partial-thickness re-tears.
Figures A and B are the Grashey and axillary lateral radiographs of the left shoulder without any definitive pathology. Figures C, D, and E are the sagittal T2 weighted MRI sequences showing a full-thickness left superior rotator cuff tear.
Incorrect Answers:
Answer 1: There is no difference between the time to healing of a double-row RCR versus a single-row RCR.
Answer 2: There is no difference between the postoperative functional scores of a patient who has undergone a double-row RCR versus a single-row RCR. Answer 4: There is no difference between the postoperative pain scores of a patient who has undergone a double-row RCR versus a single-row RCR. Answer 5: A MORE anatomic restoration of the footprint is often cited with a double-row RCR compared to a single-row RCR.
OrthoCash 2020
2/. Decreased functional outcome scores with single-row repair compared to double-row repair
3/. Decreased re-tear rate with double-row repair compared to single-row repair
4/. Increased post-operative pain with double-row repair compared to single row repair
5/. Less anatomic footprint restoration with a double-row repair compared to a single-row repair
The patient in the vignette has a large left rotator cuff tear. There is a lower retear rate associated with double-row rotator cuff repair (RCR) versus a single-row RCR.
There are many important and controversial topics with respect to arthroscopic rotator cuff repair. One important concept is the restoration of the rotator cuff footprint during the repair. It has been cited that a larger footprint will improve healing and the mechanical strength of the rotator cuff repair. A double-row suture technique (with mattress sutures in the medial row and simple sutures in the lateral row) has been shown to create a more anatomic repair of the footprint leading to a lower incidence of retears compared to a single-row repair (medial row mattress sutures only). However, there has been no difference noted between the techniques with respect to functional outcome scores, pain scores, or time to healing.
DeHaan et al. performed a systematic review of prosepective level I or II studies that compared the efficacy of single-row RCR versus double-row RCR. The authors found that the functional ASES, Constant, and UCLA outcome scores revealed no difference between the 2 groups. The authors did note that the total retear rate, which included both complete and partial re-rears, was 43.1% for the single-row RCR and 27.2% for the double-row RCR (P = .057). The authors concluded that double-row RCR revealed a trend toward a lower radiographic proven re-tear rate, although the data did not reach statistical significance.
Millett et al. performed a systematic review and meta-analysis of level 1 randomized trials comparing single-row with double-row RCRs to compare clinical outcomes and imaging-diagnosed re-tear rates. The authors reviewed 7 studies that met their inclusion criteria and noted there were no significant differences in ASES, UCLA, or Constant scores between the single-row and double-row groups. They did note that there was a statistically significant increased risk of sustaining an imaging-proven re-tear of any type in the single-row group compared to the double-row group. The authors concluded that single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs, especially with regard to partial-thickness re-tears.
Figures A and B are the Grashey and axillary lateral radiographs of the left shoulder without any definitive pathology. Figures C, D, and E are the sagittal T2 weighted MRI sequences showing a full-thickness left superior rotator cuff tear.
Incorrect Answers:
Answer 1: There is no difference between the time to healing of a double-row RCR versus a single-row RCR.
Answer 2: There is no difference between the postoperative functional scores of a patient who has undergone a double-row RCR versus a single-row RCR. Answer 4: There is no difference between the postoperative pain scores of a patient who has undergone a double-row RCR versus a single-row RCR. Answer 5: A MORE anatomic restoration of the footprint is often cited with a double-row RCR compared to a single-row RCR.
OrthoCash 2020
QUESTION 4
A 52-year-old male presents to your clinic after injuring his left arm while moving apartments 2 weeks prior. He was helping lift a heavy piano across the floor and suddenly felt a pop in his left elbow. He has mild pain and swelling around the antecubital fossa.
Radiographs are shown in Figures A and B and MRI studies are shown in Figures C and
Radiographs are shown in Figures A and B and MRI studies are shown in Figures C and
1
Non-operative management will likely lead to which of the following clinical outcomes?
 
1/. Chronic elbow instability
2/. Chronic elbow pain
3/. Decreased supination strength
4/. A relative loss of elbow flexion compared to supination
2
Persistent lateral elbow pain with resisted wrist extension.
The patient has a left partial distal biceps tendon tear based on the MRI and clinical history. Non-operative management is most likely to lead to decreased supination strength.
A distal biceps tendon rupture generally occurs due to a sudden excessive eccentric tension as the arm is forced from a flexed to an extended position. These injuries comprise of 10% of all biceps injuries. Partial tears occur primarily on the radial side of the tuberosity footprint. Management is generally operative but patients who are low demand or who have partial injuries can be managed non-operatively. The most common sequela of non operative management is a decrease in supination strength compared to the uninjured side.
Bisson et al. performed a retrospective review of 45 consecutive cases of dual incision distal biceps tendon repairs to assess for the incidence of complications. They noted that 12 of 45 patients (27%) experienced a total of 14 postoperative complications, including nerve dysfunction in 7, functional radioulnar synostosis in 3, loss of motion unrelated to heterotopic ossification in 2, early re-rupture in 1, and reflex sympathetic dystrophy in 1. They also noted that complications were significantly more common when the repair was performed 2 weeks after the day of injury.
Watson et al. performed a systematic review comparing the results of the various surgical approaches and repair techniques for acute distal biceps tendon ruptures. The authors found 22 studies looking at 494 patients and cited a 24.5% complication rate with no difference between the single and dual incision approach. The most common complication was lateral antebrachial cutaneous nerve neurapraxia (9.6% across all studies, 11.6% for one incision, and 5.8% for two incisions). The authors conclude that the complication rate does not differ significantly between one and two-incision distal biceps repairs.
Schmidt et al. performed a study to evaluate the pain, disability, and isometric supination torque at 3 forearm positions in a prospective cohort of biceps deficient arms to assess the potential for functional return with nonoperative treatment. They studied 23 men with complete unilateral distal biceps avulsion who underwent isometric supination strength testing of both limbs at 60° of supination, 0° (neutral), and 60° of pronation. They found that the uninjured arm was stronger (P < .001), and peak torque varied with forearm position. They concluded that distal biceps tendon rupture led to a 60% decrease in supination strength in the neutrally oriented forearm.
Cusick et al. performed a retrospective review of 170 distal biceps ruptures treated using a cortical button in conjunction with an interference screw to evaluate for possible complications. They noted a failure rate of 1.2% with 2 patients requiring a repeat operation. The authors concluded that the use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate of failure.
Abrams. et al. performed a cadaveric study to evaluate radial nerve motor branch anatomy within the forearm. The authors looked at 20 normal fresh cadaver arms and noted that the innervation order from proximal to distal (based on mean shortest branch lengths) was brachioradialis, ECRL, supinator, ECRB, EDC, ECU, EDQ, APL, EPL, EPB, and lastly EIP. They also noted that the mean distances from a point 100 mm proximal to the lateral epicondyle to the muscle measured along the shortest nerve branch ranged from 97.2 mm for the brachioradialis to 299.8 mm for the EIP.
Figures A and B are AP and lateral radiographs of the left elbow which show no findings. Figures C is a T2-weighted axial MRI image that reveals a partial tear of the distal biceps tendon off of the radial tuberosity. Figure D is the T2- weighted coronal MRI image also showing a partial tear of the distal biceps tendon with associated fluid around the distal biceps tendon. Illustration A is the labeled version of Figure C which shows the partial biceps tendon tear (red arrow)
Incorrect Answers:
Answer 1: Chronic elbow instability would be seen in the event of non operative management of a terrible triad injury or anteromedial facet coronoid fracture.
Answer 2: Non-operative management of distal biceps tendon tears are generally not associated with chronic elbow pain.
Answer 4: Non-operative management of distal biceps tendon tears lead to a relative loss of supination compared to elbow flexion.
Answer 5: Persistent lateral elbow pain with resisted wrist extension would be seen with lateral epicondylitis.
OrthoCash 2020
A distal biceps tendon rupture generally occurs due to a sudden excessive eccentric tension as the arm is forced from a flexed to an extended position. These injuries comprise of 10% of all biceps injuries. Partial tears occur primarily on the radial side of the tuberosity footprint. Management is generally operative but patients who are low demand or who have partial injuries can be managed non-operatively. The most common sequela of non operative management is a decrease in supination strength compared to the uninjured side.
Bisson et al. performed a retrospective review of 45 consecutive cases of dual incision distal biceps tendon repairs to assess for the incidence of complications. They noted that 12 of 45 patients (27%) experienced a total of 14 postoperative complications, including nerve dysfunction in 7, functional radioulnar synostosis in 3, loss of motion unrelated to heterotopic ossification in 2, early re-rupture in 1, and reflex sympathetic dystrophy in 1. They also noted that complications were significantly more common when the repair was performed 2 weeks after the day of injury.
Watson et al. performed a systematic review comparing the results of the various surgical approaches and repair techniques for acute distal biceps tendon ruptures. The authors found 22 studies looking at 494 patients and cited a 24.5% complication rate with no difference between the single and dual incision approach. The most common complication was lateral antebrachial cutaneous nerve neurapraxia (9.6% across all studies, 11.6% for one incision, and 5.8% for two incisions). The authors conclude that the complication rate does not differ significantly between one and two-incision distal biceps repairs.
Schmidt et al. performed a study to evaluate the pain, disability, and isometric supination torque at 3 forearm positions in a prospective cohort of biceps deficient arms to assess the potential for functional return with nonoperative treatment. They studied 23 men with complete unilateral distal biceps avulsion who underwent isometric supination strength testing of both limbs at 60° of supination, 0° (neutral), and 60° of pronation. They found that the uninjured arm was stronger (P < .001), and peak torque varied with forearm position. They concluded that distal biceps tendon rupture led to a 60% decrease in supination strength in the neutrally oriented forearm.
Cusick et al. performed a retrospective review of 170 distal biceps ruptures treated using a cortical button in conjunction with an interference screw to evaluate for possible complications. They noted a failure rate of 1.2% with 2 patients requiring a repeat operation. The authors concluded that the use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate of failure.
Abrams. et al. performed a cadaveric study to evaluate radial nerve motor branch anatomy within the forearm. The authors looked at 20 normal fresh cadaver arms and noted that the innervation order from proximal to distal (based on mean shortest branch lengths) was brachioradialis, ECRL, supinator, ECRB, EDC, ECU, EDQ, APL, EPL, EPB, and lastly EIP. They also noted that the mean distances from a point 100 mm proximal to the lateral epicondyle to the muscle measured along the shortest nerve branch ranged from 97.2 mm for the brachioradialis to 299.8 mm for the EIP.
Figures A and B are AP and lateral radiographs of the left elbow which show no findings. Figures C is a T2-weighted axial MRI image that reveals a partial tear of the distal biceps tendon off of the radial tuberosity. Figure D is the T2- weighted coronal MRI image also showing a partial tear of the distal biceps tendon with associated fluid around the distal biceps tendon. Illustration A is the labeled version of Figure C which shows the partial biceps tendon tear (red arrow)
Incorrect Answers:
Answer 1: Chronic elbow instability would be seen in the event of non operative management of a terrible triad injury or anteromedial facet coronoid fracture.
Answer 2: Non-operative management of distal biceps tendon tears are generally not associated with chronic elbow pain.
Answer 4: Non-operative management of distal biceps tendon tears lead to a relative loss of supination compared to elbow flexion.
Answer 5: Persistent lateral elbow pain with resisted wrist extension would be seen with lateral epicondylitis.
OrthoCash 2020
QUESTION 5
A 25-year-old bodybuilder presents to your clinic 3 days after injuring his left arm while weight lifting. He presents with pain and ecchymosis around his antecubital fossa. On examination, his hook test is abnormal. MRI studies are shown in Figures A through
1
He inquiries about the risks of surgical repair. With respect to the most common sensory nerve and most common motor nerve that are injured during surgery, which of the following would be the expected post-operative neuro deficits?
 
1/. Decreased sensation over lateral forearm and weakness in finger abduction
2
Decreased sensation over dorsal hand and weakness in wrist extension
3
Decreased sensation over lateral forearm and weakness in wrist extension
4
Decreased sensation over dorsal hand and weakness in thumb IP joint flexion
5/. Decreased sensation over lateral forearm and weakness in thumb IP joint flexion
The patient in the vignette has sustained a complete distal biceps rupture and is inquiring about surgical repair. During repair, the most commonly injured sensory nerve is the lateral antebrachial cutaneous (LABC) and the most commonly injured motor nerve is the posterior interosseous nerve (PIN). Injury to the LABC would lead to decreased sensation over the lateral forearm and injury to the PIN would result in weakness in wrist extension.
There are many complications that can occur after surgical repair of a distal biceps tendon rupture. These include both relatively minor complications (20% risk) as well as major complications (4% risk). The most common minor complications are neuropraxia to the LABC (9%), heterotopic ossification (3- 4%), superficial radial nerve (SRN) palsy (2-3%), superficial infection (1%), and stiffness (1%). The most common major complications are PIN
neuropraxia (1-2%), re-rupture (1-2%), deep infection (1%) and radioulnar synostosis (1%). Regarding injury to the PIN, there had been data that suggested it was more common with a limited single incision approach but recent meta-analysis suggests the rate is similar to the dual incision approach. The most commonly discussed mechanisms of PIN injury are direct injury from radially based retractors and prolonged traction during the procedure. PIN entrapment by the cortical button may also occur.
Bisson et al. performed a retrospective review of 45 consecutive cases of dual incision distal biceps tendon repairs to assess for the incidence of complications. They noted that 12 of 45 patients (27%) experienced a total of 14 postoperative complications, including nerve dysfunction in 7, functional radioulnar synostosis in 3, loss of motion unrelated to heterotopic ossification in 2, early re-rupture in 1, and reflex sympathetic dystrophy in 1. They also noted that complications were significantly more common when the repair was performed 2 weeks after the day of injury.
Watson et al. performed a systematic review comparing the results of the various surgical approaches and repair techniques for acute distal biceps tendon ruptures. The authors found 22 studies looking at 494 patients and cited a 24.5% complication rate with no difference between the single and dual incision approach. The most common complication was lateral antebrachial cutaneous nerve neurapraxia (9.6% across all studies, 11.6% for one incision, and 5.8% for two incisions). The authors conclude that the complication rate does not differ significantly between one and two-incision distal biceps repairs.
Schmidt et al. performed a study to evaluate the pain, disability, and isometric supination torque at 3 forearm positions in a prospective cohort of biceps deficient arms to assess the potential for functional return with nonoperative treatment. They studied 23 men with complete unilateral distal biceps avulsion who underwent isometric supination strength testing of both limbs at 60° of supination, 0° (neutral), and 60° of pronation. They found that the uninjured arm was stronger (P < .001), and peak torque varied with forearm position. They concluded that distal biceps tendon rupture led to a 60% decrease in supination strength in the neutrally oriented forearm.
Cusick et al. performed a retrospective review of 170 distal biceps ruptures treated using a cortical button in conjunction with an interference screw to evaluate for possible complications. They noted a failure rate of 1.2% with 2 patients requiring a repeat operation. The authors concluded that the use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate
of failure.
Abrams. et al. performed a cadaveric study to evaluate radial nerve motor branch anatomy within the forearm. The authors looked at 20 normal fresh cadaver arms and noted that the innervation order from proximal to distal (based on mean shortest branch lengths) was brachioradialis, ECRL, supinator, ECRB, EDC, ECU, EDQ, APL, EPL, EPB, and lastly EIP. They also noted that the mean distances from a point 100 mm proximal to the lateral epicondyle to the muscle measured along the shortest nerve branch ranged from 97.2 mm for the brachioradialis to 299.8 mm for the EIP.
Figures A through C are T2-weighted axial and coronal MRI cuts that show a complete distal biceps tendon rupture off the radial tuberosity with proximal retraction of the tendon.
Incorrect Answers:
Answer 1: While an injury to the LABC is the most common sensory nerve complication, injury to the ulnar nerve (interosseous muscles) is a relatively rare motor nerve complications (< 0.1%) during distal biceps tendon repair. Answer 2 and 4: Injury to the SRN is the 2nd most common sensory nerve complication after an injury to the LABC.
Answer 5: While an injury to the LABC is the most common sensory nerve complication, injury to the AIN nerve (FPL) is a relatively rare motor nerve complications (< 0.1%) during distal biceps tendon repair.
OrthoCash 2020
The patient in the vignette has sustained a complete distal biceps rupture and is inquiring about surgical repair. During repair, the most commonly injured sensory nerve is the lateral antebrachial cutaneous (LABC) and the most commonly injured motor nerve is the posterior interosseous nerve (PIN). Injury to the LABC would lead to decreased sensation over the lateral forearm and injury to the PIN would result in weakness in wrist extension.
There are many complications that can occur after surgical repair of a distal biceps tendon rupture. These include both relatively minor complications (20% risk) as well as major complications (4% risk). The most common minor complications are neuropraxia to the LABC (9%), heterotopic ossification (3- 4%), superficial radial nerve (SRN) palsy (2-3%), superficial infection (1%), and stiffness (1%). The most common major complications are PIN
neuropraxia (1-2%), re-rupture (1-2%), deep infection (1%) and radioulnar synostosis (1%). Regarding injury to the PIN, there had been data that suggested it was more common with a limited single incision approach but recent meta-analysis suggests the rate is similar to the dual incision approach. The most commonly discussed mechanisms of PIN injury are direct injury from radially based retractors and prolonged traction during the procedure. PIN entrapment by the cortical button may also occur.
Bisson et al. performed a retrospective review of 45 consecutive cases of dual incision distal biceps tendon repairs to assess for the incidence of complications. They noted that 12 of 45 patients (27%) experienced a total of 14 postoperative complications, including nerve dysfunction in 7, functional radioulnar synostosis in 3, loss of motion unrelated to heterotopic ossification in 2, early re-rupture in 1, and reflex sympathetic dystrophy in 1. They also noted that complications were significantly more common when the repair was performed 2 weeks after the day of injury.
Watson et al. performed a systematic review comparing the results of the various surgical approaches and repair techniques for acute distal biceps tendon ruptures. The authors found 22 studies looking at 494 patients and cited a 24.5% complication rate with no difference between the single and dual incision approach. The most common complication was lateral antebrachial cutaneous nerve neurapraxia (9.6% across all studies, 11.6% for one incision, and 5.8% for two incisions). The authors conclude that the complication rate does not differ significantly between one and two-incision distal biceps repairs.
Schmidt et al. performed a study to evaluate the pain, disability, and isometric supination torque at 3 forearm positions in a prospective cohort of biceps deficient arms to assess the potential for functional return with nonoperative treatment. They studied 23 men with complete unilateral distal biceps avulsion who underwent isometric supination strength testing of both limbs at 60° of supination, 0° (neutral), and 60° of pronation. They found that the uninjured arm was stronger (P < .001), and peak torque varied with forearm position. They concluded that distal biceps tendon rupture led to a 60% decrease in supination strength in the neutrally oriented forearm.
Cusick et al. performed a retrospective review of 170 distal biceps ruptures treated using a cortical button in conjunction with an interference screw to evaluate for possible complications. They noted a failure rate of 1.2% with 2 patients requiring a repeat operation. The authors concluded that the use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate
of failure.
Abrams. et al. performed a cadaveric study to evaluate radial nerve motor branch anatomy within the forearm. The authors looked at 20 normal fresh cadaver arms and noted that the innervation order from proximal to distal (based on mean shortest branch lengths) was brachioradialis, ECRL, supinator, ECRB, EDC, ECU, EDQ, APL, EPL, EPB, and lastly EIP. They also noted that the mean distances from a point 100 mm proximal to the lateral epicondyle to the muscle measured along the shortest nerve branch ranged from 97.2 mm for the brachioradialis to 299.8 mm for the EIP.
Figures A through C are T2-weighted axial and coronal MRI cuts that show a complete distal biceps tendon rupture off the radial tuberosity with proximal retraction of the tendon.
Incorrect Answers:
Answer 1: While an injury to the LABC is the most common sensory nerve complication, injury to the ulnar nerve (interosseous muscles) is a relatively rare motor nerve complications (< 0.1%) during distal biceps tendon repair. Answer 2 and 4: Injury to the SRN is the 2nd most common sensory nerve complication after an injury to the LABC.
Answer 5: While an injury to the LABC is the most common sensory nerve complication, injury to the AIN nerve (FPL) is a relatively rare motor nerve complications (< 0.1%) during distal biceps tendon repair.
OrthoCash 2020
