Etiology and injury mechanisms
Biceps injuries are generally divided into open and closed, each having its own causes and contributing factors.
- Open injuries. These occur in chop or stab wounds. They are typically characterized by combined tissue damage: in addition to the biceps muscle, adjacent muscle groups, bone structures, as well as blood vessels and nerves are injured.
- Closed injuries. Most often, these result from sudden and powerful muscle strain. A direct blow to the segment is an extremely rare cause.
There are distinct age-related features. In young people, avulsion usually occurs at the anatomical attachment site of the tendon to the supraglenoid tubercle of the scapula. In older patients, the injury develops on the background of long-standing degenerative processes of the tendon directly within the projection of the intertubercular sulcus of the humerus. It should be noted that ruptures of the distal tendon (at the elbow joint) are recorded significantly less often.
Clinical presentation and diagnostics
In subcutaneous (closed) rupture, the patient experiences sudden sharp pain at the moment of injury. Within the first 48 hours, an extensive hematoma forms in the injury zone. Despite the injury, active flexion of the forearm remains possible, although in the early stages it is accompanied by pronounced pain syndrome.
The main visual sign is deformity of the shoulder contour. Deprived of one of its fixation points, the biceps muscle contracts and shifts toward the remaining attachment site, forming a tumor-like bulge beneath the skin.
To confirm the diagnosis, the physician uses a provocative test: the patient is asked to actively flex the forearm against the resistance of the examiner's hand. In this case, the deformity and muscle bulge become as clearly contoured as possible.
Topographic diagnosis of the rupture level:
- Long head injury: the muscle belly shifts downward. The tumor-like bulge is localized in the lower half of the arm, and a soft-tissue depression is palpated directly above it.
- Distal tendon injury: the muscle contracts upward. The bulge is clearly defined in the upper half of the segment, with a characteristic tissue depression beneath it.
Instrumental studies
The clinical diagnosis of a biceps rupture is usually unambiguous. Nevertheless, radiography is a mandatory primary imaging method. Its purpose is not to visualize the tendon, but to rule out concomitant injuries to bone structures.
If the clinical picture remains inconclusive (e.g., in partial ruptures or pronounced edema), modern soft-tissue imaging methods are used — ultrasound and MRI. They allow accurate determination of the defect level and the degree of muscle belly retraction.
Surgical treatment and rehabilitation
The baseline standard of care for biceps ruptures is surgical intervention. Conservative management is permitted only as an exception — in elderly patients whose daily physical activity is minimal.
In open wounds, the tendon is repaired during primary surgical debridement using a non-absorbable adapting suture, followed by the application of a plaster splint or Velpeau bandage for 3–4 weeks.
In closed injuries, surgical tactics depend on the level of rupture:
- Long head injury: The simplest method is fixation of the tendon to the bone in the intertubercular sulcus zone. For young and active patients, I.N. Lavrov's method is more justified, in which the damaged tendon is sutured to the acromion of the scapula. Immobilization: Desault bandage for 4 weeks, then transitioning to a sling for 2 weeks.
- Distal tendon injury: Surgeons repair the ruptured ends with interrupted sutures or fix the central tendon fragment to the radius. Immobilization: plaster splint from the shoulder to the wrist joint with the elbow flexed at 90°. Fixation period — from 4 to 6 weeks.
Briefly: answers to topical questions
What specific clinical tests are used to diagnose a rupture of the biceps brachii tendon?
A specific provocative test is used to diagnose a rupture of the biceps brachii tendon.
- Provocative test — muscle contour deformity is revealed more clearly during active forearm flexion against resistance.
When performing this test, the contracted muscle shifts toward the remaining attachment site, forming a characteristic tumor-like bulge beneath the skin. Topographic diagnostics are based on the localization of this formation: in a long head rupture, it is located in the lower half of the arm, while in a distal tendon rupture, it is in the upper half.
What types of tendon sutures are used to repair the distal tendon of the biceps brachii?
Interrupted sutures are used to repair the distal tendon of the biceps brachii.
Surgical tactics for this injury consist of suturing the ruptured ends of the tendon with interrupted sutures. Alternatively, the central segment of the tendon is sutured directly to the radius. In general, conventional interrupted and mattress sutures are also acceptable during surgical tendon repair if they firmly hold the ends in the position of adaptation.
Which anatomical structures form the intertubercular sulcus of the humerus?
The intertubercular sulcus (sulcus intertubercularis) of the humerus is formed by the muscular tubercles and bone crests extending from them.
The following structures of the proximal epiphysis participate in the formation of the sulcus:
- Greater tubercle (tuberculum majus) — located laterally.
- Lesser tubercle (tuberculum minus) — located medially and slightly anteriorly to the greater one.
- Crest of the greater tubercle (crista tuberculi majoris) — extends downward from the greater tubercle.
- Crest of the lesser tubercle (crista tuberculi minoris) — extends downward from the lesser tubercle.
The sulcus itself is located directly between these tubercles and crests.
For topographic diagnosis, use the rule «Where it tore is where it drifted»: if the tendon tore from above (long head), the muscle slides down, forming a lump in the lower third of the arm. If the avulsion occurred from below (distally), the belly contracts upward, and a lump appears in the upper third.
Class and exam questions
Why is elbow flexion preserved in a biceps rupture?
Forearm flexion is not completely lost, as other flexor muscles (e.g., brachialis and brachioradialis muscles) actively participate in this movement. However, immediately after the injury, an attempt to bend the arm is accompanied by severe pain.
Why order an X-ray if muscle deformation is obvious?
Radiography is performed primarily to rule out concomitant bone trauma, such as avulsion fractures. The tendon itself is not visible on an X-ray, so ultrasound or MRI is used when in doubt.
How are combined open injuries of the biceps managed?
Treatment is carried out during primary surgical debridement of the wound. The ends of the ruptured tendon are sutured with a non-absorbable adapting suture, after which the arm is immobilized with a plaster splint or Velpeau bandage for 3–4 weeks.
What else to study on this topic
- Clinical diagnostics of rotator cuff injuries of the shoulder
- «Falling flag» sign (Krasnov–Miroshnichenko technique)
- Subacromial impingement syndrome: mechanism of development and consequences
- Low-invasive arthroscopic reconstruction of the shoulder joint
- Surgical fixation of the biceps according to I.N. Lavrov's method
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