Distal Biceps Repair
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What’s the Problem?
The biceps muscle is primarily responsible for rotating the forearm and secondarily for flexing the elbow. It inserts into the radius (the radial tuberosity) and sometimes can be pulled off or ruptures from its insertion there. The most common reason is overloading the elbow in a sudden movement – for instance starting to lift a heavy object. This causes pain, swelling and bruising to the front part of the elbow, as well as weakness with rotation and flexion. In the long term, this can lead to permanent weakness and fatigue with rotational actions like turning a screwdriver. There is also a cosmetic effect of a ruptured distal biceps, as the contour of the biceps will not be symmetric to the other side.
How can you treat it?
In some instances, non-surgical treatment is appropriate. This includes:
- Taking pain relief
- A sling for 2 weeks or so
- Physio to mobilise the elbow and surrounding muscles/tendons after the sling has been removed
Ultimately, surgery is only reserved for patients whose injury will significantly worsen their ability to work and function.
The Operation
A biceps repair involves an incision over the front of the forearm. The ruptured tendon is found and mobilised back to the radial tuberosity where it normally inserts. The bone is prepared and then the tendon anchored back to its original position.
The Anaesthetic
You will be asleep for the duration of the operation (ie a general anaesthetic). The anaesthetist may talk to you about a nerve block before the operation, which helps with pain relief and generally lasts 24-48 hours. Alternatively, Mr Lau can put local anaesthetic into the wound whilst you are asleep, which can also help reduce pain.
What are the Risks of this Operation?
- Infection:
Usually only a superficial wound infection to the top-most layer of the skin. In rarer cases a deep infection can develop and this is a serious complication that may require further surgery. Rare but serious, <1%. - Stiffness and ongoing pain:
It is common to have stiffness for a few months after the operation. This is because your elbow needs to be splinted to allow the tendon to heal. Physio after surgery will help with improving movement, but some elbow rehabilitation will be required. - Damage to the nerves and blood vessels around the elbow.
Rare but serious, <1% - Nerve irritation:
The Lateral Antebrachial Cutaneous Nerve is a sensory nerve to the outside half of your forearm. It can be stretched during this operation and ~20% of patients will develop some temporary numbness to this area, although almost all will resolve in a few months.
The Posterior Interosseous Nerve is another nerve that can be injured, and this controls the extension of the fingers and wrist. Because Mr Lau does not perform dual incision or bicortical fixation of his biceps tendons, this described complication is extremely unlikely to occur - <0.1% - Tendon Re-rupture:
This occurs infrequently but has been described in ~2.5% of cases. Adherence to the post-operative protocol is very important as it allows time for the tendon to re-attach itself to the bone. Excessive early lifting or loading of the tendon can increase the risk of failure.
Benefits
If Mr Lau recommends surgical repair of your ruptured distal biceps, it is because he feels you will have a better outcome with surgery. In particular, your elbow and forearm will have better rotational strength and elbow flexion as a consequence of surgery.
What can I expect?
You will wake up with your arm in a sling after your surgery and a half slab on the elbow. If you have had a nerve block, you shouldn’t feel any pain till the next day. The nurses will provide you pain relief and the next morning a physio will see you to go through some exercises you can do to mobilise the fingers and wrist to prevent excessive stiffness in these joints. These exercises will change over the next few weeks to months but you should try to do them regularly to maximise your rehabilitation.
Most patients spend 1 day in hospital after surgery, before going home. A number of allied health staff (physios, occupational therapists) will make sure you have adequate support at home before discharge. An appointment will be made for you for a wound check at 2 weeks. At this time, the plaster will be removed and you should just need to be in a sling. Another appointment with Mr Lau will be at 6 weeks.
What should I avoid doing?
- In the first 2 weeks:
Keep your wound/plaster dry. Try to mobilise your fingers and wrist as much as possible - Between 2 and 6 weeks:
Your arm will be in a sling, which you can gradually use less and less. Gentle flexion and extension of the elbow is possible passively, as well as continued wrist/finger exercises. You can pick up lighter objects such as a phone or cup with the affected side. You will have physio to help you with rehabilitation. - Between 6 and 12 weeks:
Full mobilisation of the wrist, fingers and elbow. The only restriction is no heavy lifting (weights, heavy pots/pans etc) till after 12 weeks. You shouldn’t need a sling any longer.
Return to…?
- Work
Depends what you do. Desk based work can be done from 2 weeks post operatively, if you can do these tasks single handedly. Otherwise generally 6 weeks before you can use both hands freely whilst seated.
For manual work, it depends on what kind of lifting/pushing you do, but generally not before 3 months - Drive
In Australia, you can’t drive unless you are in full control of both your arms. Therefore, whilst you’re in a sling, you cannot drive. Generally 6 weeks post operatively. - Sports/Hobbies:
- Swimming: water based exercise is very helpful after surgery. No swimming until the wounds have healed – usually 2 weeks post operatively. Active swimming from 12 weeks
- Golf: usually requires significant rehab and time before adequate protection of the biceps repair has occurred. Usually 4 to 6 months post op
- High Risk Sports (eg racquet sports, rock climbing, football, martial arts, skiing, horse riding). These sports are dependent on range of motion, control and strength. Improvement in elbow strength can be seen up to 2 years post operatively. Contact sports or those at risk of falls (skiing, horse riding) shouldn’t occur till 4-6 months post op
- Strength/Weight Training: training which loads the biceps tendon is the most risky weight resistance training for your repaired biceps tendon. Resisted biceps curls only from 12 weeks and heavy lifting/weight training only from 4-6 months. Stop if pain felt in the elbow during exercises.
Concerns or questions?
If you have any concerns post operatively, or you would like further information, please contact Mr Lau through the VBJS on 03 5752 5020 or via email at admin@vbjs.com.au
If you need urgent medical help, call 000 or go to your nearest emergency department.
Rehabilitation protocol
These notes have been prepared by Mr Simon Lau. They are general overviews and information aimed for use by his patients. They reflect Mr Lau’s views, opinions and recommendations. They do not constitute medical advice. The contents are provided for information and education purposes only. Please seek Mr Lau’s specific advice with any questions regarding medical conditions and treatment.