Injury to the long head of the biceps brachii
Treatment strategy depends on the patient's functional demands.
Conservative approach Refraining from surgery is acceptable if the resulting decrease in muscle strength does not interfere with the patient's activities of daily living. In this case, a sling is used for limb immobilization during the period of acute pain (on average, one and a half to two weeks). Physical therapy is mandatory, and an early return to functional loads is encouraged.
Surgical treatment The primary method is I. N. Lavrov's procedure. The essence of the intervention is the fixation of the avulsed end to the acromion of the scapula. The procedure involves a strict sequence of steps:
- Performing a surgical approach to the injury site.
- Locating and pulling down the retracted tendon.
- Secure fixation of the tendon to the bone structure of the acromion.
Finger flexor injuries: biomechanics and diagnostics
Such injuries are most often open in nature, occurring, for example, from slash wounds. A critical aspect is understanding the biomechanics of fragment displacement.
Displacement of ends The proximal (central) segment inevitably retracts toward the palm under the influence of muscle traction. The location of the distal end is variable and depends on the position of the finger at the moment of the cut:
- If the finger was fully extended, the distal fragment remains right in the projection of the wound.
- If the finger was flexed, subsequent straightening causes the distal segment to shift significantly distal to the level of the injury.
Topical clinical diagnosis Assessment of motor function allows for the precise determination of which structures are damaged:
- Isolated injury to the flexor digitorum profundus: active flexion of the distal phalanx is completely absent. Meanwhile, the middle phalanx flexes normally because the flexor digitorum superficialis remains intact.
- Simultaneous injury to both flexors: the patient cannot flex either the distal or the middle phalanx. Flexion at the metacarpophalangeal joint (proximal phalanx) is preserved because the interosseous and lumbrical muscles are responsible for this movement.
- Isolated injury to the flexor digitorum superficialis: flexion of both phalanxes (middle and distal) is preserved; the intact flexor digitorum profundus takes over the function.
Surgical repair of flexors
Treatment of hand flexor tendon injuries is strictly surgical. The greatest challenge is operating in the so-called «critical» or «no man's land» zone (within the tendon sheath), which requires refined surgical technique.
Access and technique features
- Any incisions on the palmar surface of the fingers themselves are permitted only in a transverse direction.
- To find the retracted proximal fragment, the surgeon makes an additional incision in the area of the palmar crease.
- The found end is grasped and carefully pulled back through the tendon sheath to the site of the injury on the finger using a special tendon passer.
Tactics for various injury levels
- Near the distal phalanx (flexor digitorum profundus): suturing the ends together is pointless. The distal fragment is completely excised, and the central end is reattached directly to the bone of the distal phalanx. Alternatively, arthrodesis of the distal interphalangeal joint or tenodesis (fixation to the middle phalanx bone in a slight flexion position) can be performed.
- Within the sheath (both flexors): the damaged superficial flexor is removed, and only the deep flexor is repaired (sutured). Important: this rule does not apply to the forearm, wrist, and palm — there, in case of a double injury, both tendons are sutured.
Postoperative management and extensor injuries
After suturing the flexors, a dorsal splint (extending to the elbow joint) is applied, and the hand is fixed in a position of moderate flexion. Passive joint mobilization is initiated on the 7th day, and active movements are permitted only after 3 weeks. Before starting active exercises, the blocking suture (if one was applied) must be removed.
Extensor injuries Extensors are frequently injured in a closed manner: from a direct blow to the dorsum of the finger or axial loading (typical for volleyball players). There are two main types of deformities:
- Mallet finger: occurs with a complete rupture at the level of the distal interphalangeal joint. The terminal phalanx droops in a flexed position, and active extension is lost (though passive extension is possible).
- Boutonnière deformity (Weinstein's double contracture): the consequence of an injury to the middle slip of the tendon at the level of the proximal joint. In this case, the lateral bands of the extensor slip to the lateral surfaces of the phalanx. A specialized Rozov splint is used to immobilize the finger in such injuries.
Briefly: answers to topical questions
What is the typical mechanism of injury in a quadriceps tendon rupture?
The typical injury mechanism involves direct and indirect impact to the knee joint area.
- Direct mechanism — a blow above or below the patella during leg extension, as well as a fall onto a flexed knee joint.
- Indirect mechanism — an energetic, sharp, uncoordinated contraction of the quadriceps muscle during forced knee flexion under body weight (e.g., during a sudden stop in running, loss of balance, or landing after a jump).
Where is the tissue defect palpated in a complete quadriceps tendon rupture?
The tissue defect in a complete quadriceps tendon rupture is palpated directly above the patella. In this area, a painful depression is defined, which increases when attempting to tense the muscle. Meanwhile, the avulsed end of the rectus femoris muscle is palpated in the lower third of the thigh, and at later stages after the injury — in its middle third.
How does the patella displace in a complete rupture of its patellar ligament?
In a complete rupture of the patellar ligament, the patella easily displaces upward and to the sides. High-riding patella (patella alta) is formed, where its lower pole lies above the normal level of the joint line. Hypermobility of the patella upward in both directions is noted, and upon contraction of the quadriceps femoris muscle, its upward displacement further increases.
Which clinical test reveals a complete loss of the knee extensor mechanism function?
To detect a complete loss of function of the extensor apparatus, the ability for active knee extension is tested. The test is performed with the patient in a sitting position: in a complete rupture, active extension of the lower leg is entirely absent (impossible or sharply limited and painful), whereas passive extension is preserved. Additionally, with complete disruption of the supporting ligamentous apparatus, the «heel-drop test» (or inability to lift the straightened leg) is revealed.
What instrumental diagnostic methods are optimal for confirming a patellar tendon rupture?
Optimal instrumental diagnostic methods to confirm a patellar ligament rupture are radiography, ultrasound, and MRI.
- Radiography — performed in two standard projections to assess the height of the patella and rule out bone damage.
- Lateral stress radiographs — performed while tensing the quadriceps muscle (with a rupture, the upward displacement of the patella increases).
- Ultrasound and MRI — the most informative and non-invasive methods used in doubtful cases.
What is the difference between high-riding patella (patella alta) and low-riding patella (patella baja) in knee injuries?
High (patella alta) and low (patella baja) patellar height differ in its position relative to the knee joint. A symmetrical high or low position is most likely an anatomical variant. An asymmetrical position suggests a rupture of the quadriceps tendon or patellar ligament and requires ruling out these injuries. High patellar height may contribute to abnormal tracking and cartilage damage; the specific impact of low patellar height is not described in the literature.
To diagnose the flexors: "Deep flexes the end, superficial flexes the middle." If the fingertip does not flex, the deep flexor is ruptured.
Class and exam questions
Can a biceps tendon rupture be treated without surgery?
Yes, conservative treatment is permissible. It is applied if the decrease in upper extremity strength does not interfere with the patient's daily life and self-care.
In which direction are incisions made on the palmar aspect of the finger?
Incisions on the palmar aspect of the fingers for tendon exposure must be made exclusively in a transverse direction.
What to do if both flexors are ruptured within the tendon sheath?
In this situation, the superficial flexor is completely excised and removed, while only the deep flexor is subject to surgical repair.
What else to study on this topic
- Detailed analysis of the surgical steps according to I. N. Lavrov's method
- Anatomical borders and features of the "dead zone" of the hand
- Techniques for placing tendon sutures on the deep flexor
- Rules for applying and removing the locking suture after tenorrhaphies
- Design and principles of applying the Rozov splint for extensor injuries
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