DISTAL BICEPS TENDON RUPTURE

57 year old male gymnast presents with clinical biceps rupture
MRI Right Elbow (Standard protocol PD and PD fat-sat sequences + Coronal PD FS FABS sequence):

  • Complete avulsion of distal biceps brachii tendon from the radial tuberosity (buckled and retracted 8 cm) with minimal tendon stump remaining at the tuberosity
  • Lacertus fibrosus is torn
  • No avulsed bone fragment or subcortical marrow oedema signal

 

Bicep1

 

FABS – accurately demonstrates stump margins and retraction             Sag PD SPAIR – stump at radial tuberosity and haematoma occupying defect / bicipitoradial bursa

Discussion

  • Most commonly – dominant arm males > 40 lifting heavy object (background tendinopathy)
  • 2nd most common group is athletes undertaking strength/conditioning training or athletic trauma
  • Mechanism often eccentric contraction of biceps with heavy load
  • Tear most commonly at/near radial tuberosity tendinous insertion
  • Pain and popping sensation antecubital fossa
  • Pop-eye defect on clinical exam (retracted tendon with distal defect)
  • Limited flexion and supination
  • Can fibrose and scar down to brachialis if left untreated
  • In complete tear – early surgical repair is often warranted and has been shown to result in superior supination and flexion strength and pain relief compared to conservative management.

Bicep2

Axial PD SPAIR images at proximal and distal stump levels with haematoma in the defect and diffuse soft tissue oedema

 

MR Imaging

  • Imaging test of choice
    • Routing Tri-planar
    • FABS sequence (elbow Flexed, arm ABducted, wrist Supinated)
      • Slices oriented parallel to long axis of tendon – accurate assess retraction and tuberosity
    • Demonstrates
      • Location and extent (partial or complete) of tear
      • Retraction (degree) and integrity of Lacertus Fibrosus can influence surgical approach
      • Bony avulsions / subjacent marrow oedema
      • Condition of tendon stumps
    • Classifies tear
      • Complete
      • Partial (can delineate morphology such as bifurcate biceps tendon head anatomy)
      • Tendinopathy
      • Chronic tearing with fibrosis

US Imaging

  • Can assess discontinuity and retraction
  • Long and short head components can often be delineated

 

Differential Diagnoses                                                                 

  • Partial v complete tear
  • Brachialis tear

 

 

Further Reading:

L Chew, M & Giuffre, B. Disorders of the Distal Biceps Brachii Tendon1. Radiographics : a review publication of the RSNA, Inc. 25. 1227-37 (2005).
Koulouris G et al: Bifid insertion distal biceps brachii tendon with isolated rupture: magnetic resonance findings. J Shoulder Elbow Surg. 18(6):e22-5, (2009).
Giuffre, B. & Moss, M. Optimal positioning for MRI of the distal biceps brachii tendon: flexed abducted supinated view. Am. J. Roentgenol. 944–946 (2004).
Stadnick, ME. Distal Biceps Tendon Rupture Elbow. MRI Web Clinic — Jan 2015.