Case Study

Rupture of the biceps brachii is a well-documented injury. Most reports relate to rupture of the tendon of the
long head of the biceps or the biceps insertion on the radius, latter being called as Popeye biceps but Isolated rupture of the short head muscle belly is a rare occurrence and has been not documented or researched upon. Statistics indicate 90-96% of all biceps brachii ruptures occur in the long head and 3-7% in the distal tendon. Postacchini and Ricciardi-Pollini4 reviewed subcutaneous rupture of the short tendon of the biceps. Heckman and Levine3 reported a series of injuries to this region in military parachutists, involving transaction of both heads of the biceps muscle, as a result of forced abduction of the involved extremity against the static line. Tobin et al5 reported a single case of biceps short head rupture with damage to the coracobrachialis. Gilcrest,2 in 1934, reviewed 100 patients with known rupture of the biceps but out of the 100cases, only 2 had documented short head biceps rupture.Along with the major drawback was that the mechanism of injury was not described. We present a case of a 26 yr old male presented to us with a swelling over his left mid arm and complains of the weakness of his left arm The clinical and postoperative course is presented. This case would be the rare documented occurrence of isolated rupture through the muscle belly of the short head of biceps. In addition to a literature review, this report is unique in fully documenting and illustrating preoperative and intraoperative pathology.

26 yr old right hand dominated male presented to orthopedics department presented to us with chief complains of swelling over his left mid and weakness of his left arm after suffering an injury when his bike slipped and while falling down in order to break the fall he tried to hold onto a metal post and his was subjected to abduction and external rotation force 10 days back, Immediate pain and swelling of the left upper arm and elbow region ensued
Physical examination showed a linear sulcus like deformity over medial and mid-portion of the patient’s upper arm and when the patient contracted his biceps, we observed that the long head tendon remained intact and that a clearly defined bulge had developed (FIGURE 1 AND 1.1). Patient had retained its full motion in flexion and extension and supination and pronation of the arm.HOOK test was performed and distal bicep tendon was found intact.Sign of decreased muscle power was present but no signs of neurological or vascular injury was seen.

Magnetic resonance image (MRI) studies suggested a partial muscle belly rupture through the short head of the biceps with edematous fluid collection, leaving the long head intact. (Fig 2.1,2.2)
Since the patient was a young patient and is actively involved in sports and patient wanted to maximize strength and reduce deformity and the injury had occurred at his dominant side we selected a course of operative treatment that would restore strength and functions to a greater extent than might be projected with conservative treatment.

An extensile incision in the deltopectoral groove and extending medially and distally along the proximal two thirds of the upper arm was used. During exploration, the long head of the biceps tendon and the conjoined tendon were found to be intact. The short head of the biceps muscle was found to be partially torn with the lateral aspect of the muscle belly intact. The musculocutaneous nerve was identified entering the proximal part of the ruptured muscle and was isolated. The proximal and distal ends of the muscle belly were debrided.We repaired the defect with Two No. 2 nonabsorbable sutures that were woven through the muscle belly. The elbow was taken gently into full extension, and no separation was observed at the repair site. Postoperatively, the extremity was placed in a broad arm sling.

More than 90% of biceps ruptures involve the long head tendon. These injuries are especially common in the elderly. Ruptures in the muscle belly of the biceps are rare. the literature describes only 4 cases of complete rupture through the muscle belly isolated to the short head.In the earliest document, Gilcreest analyzes 100 cases of lesion in the biceps alone, reporting 2 ruptures of short head: 1 partial and 1 complete.But the circumstances of the injury are undocumented. In the case described by DiChristina and Lustig, the rupture occurred during water skiing when a sudden traction against flexion and adduction of the arm was applied with the elbow extended. Postacchini and Ricciardi-Pollini report a case of rupture of the short head tendon, writing that the short head is most vulnerable to flexion and adduction of the arm with the elbow extended. In a case reported by Shahand Pruzansky, the patient’s arm was forced to extend while his arm was abducted and externally rotated. Reviewing such cases of muscle belly ruptures of the biceps, we can draw an association with circumstances involving a rapid or sudden extending force against an eccentrically contracting muscle or a blunt localized blow to the muscle during contraction. In the following case report we suspect violent abduction of the arm with elbow in extension when the patient held onto a pole to break the fall lead to increase load on the short head of biceps leading to its tear .The position of the limb and force of action coupled together to produce the injury. There are no set methods for the repair of muscle belly of biceps brachii a study by Heckman and Levine3 of nearly 50 parachutists with biceps muscle ruptures (both heads) lend support for immediate treatment with aspiration and splinting or early surgical repair. This course of therapy appears to lead to the best functional and cosmetic results. Similarly, Kragh and Basamania5 analyze 12 traumatic injuries in paratroopers and express support for surgical treatment. Heckman and Levine point out that restoring normal functional length appears to be impossible if the gap in the muscle persists for more than 3 days. In a study on the recovery of lacerated skeletal muscles, Terada8 concludes that muscle fibers are able to recover through a regenerative gap of under 1.0 mm. Terada also reports necrotic change 0.6mmfrom the lacerated muscle ends within 2 days after an injury. This observation supports Heckman and Levine’s suggestion: that a gap persisting longer than 3 days cannot be reattached by regenerating muscle fibers, making surgical reattachment necessary. Another issue is whether surgical reattachment can lead to muscle fiber recovery at the lacerated ends. Numerous studies show that lacerated muscles do not recover their original function and exhibit atrophic and fibrous change in the lacerated distal muscle. However, Urabe9 and Ichikawa4 suggest the potential for recovery in the fibers of the lacerated muscle after suturing if the suture site is kept free of traction stress. However, we were unable to confirm apparent scar-like changes during intraoperative exploration or pathological studies. We observed no significant decline in muscle strength. Nevertheless, we chose surgical treatment for 2 reasons: 1) the patient was a young athlete, and 2) prospects for recovery are slim after conservative treatment in cases involving a persistent gap after 10 days post-injury. The procedure resulted in satisfactory functional and cosmetic outcomes .

Isolated ruptures in the short head muscle belly are rare,with a mere handful of documented cases in the literature. Based on reported cases of ruptures in the biceps muscle belly, surgical treatment or aspiration may be preferable to conservative treatment, especially in younger patients and those who are physically active.and patients undergoing surgical repair have a better outcome provided we follow the above pre and post-surgical repair guidelines.