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Now let's talk a bit about

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complete tendon disruption of the biceps.

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It's not a, uh, common injury

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to find this tendon disruption at the level of the elbow.

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It occurs in, in about 5% of all, uh, injuries

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to the biceps tendon.

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Typically, it is a problem seen more often in men than in

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women and generally in middle age or elderly persons.

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Much more frequent in my experience,

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involving the dominant extremity as opposed

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to the non-dominant extremity.

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We see it when people are using steroids

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to build up their musculature.

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One of the sports in which I have seen this regularly is

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weightlifting and in common

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with other tendons around the body.

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Often it is the vascular supply

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that is questioned in these, uh, injuries.

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In that there are regions

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of tendons in which the vascular supply tends

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to be not as profuse.

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These are called kind of vulnerable regions of the tendon.

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We discussed them earlier in this course when we talked

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about the rotator cuff.

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Same thing for the tendons about the ankle and foot.

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The achilles for example,

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and it may be true for the biceps tendon as well,

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but there's variable literature on this subject.

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The typical mechanism is hyperextension

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with flexion again in a supinated forearm.

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So here's an example, fairly simple.

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It's an old, uh, image,

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but it shows nicely the amount of fluid that may occur

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acutely following a distal rupture of the biceps tendon.

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Your job in these cases is the obviously to identify

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that you're dealing with an abnormality to determine

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in fact, how much is the proximal retraction

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of the torn tendon.

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What is the status of the end of the torn tendon?

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Those are things that you need to describe

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typically on clinical, uh, examination

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and on questioning the patient pain

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and often a popping sensation

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resulting in a soft tissue mass.

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Uh, the Popeye sign, particularly when dealing

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with a complete tear of the biceps tendon,

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I'm showing you on the right, uh, on the right,

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a picture taken from the literature of the hook test

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where the examiner tries to hook his finger, his

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or her finger beneath the biceps.

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And you can do it, I don't know if you can see my

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arm, but you can do it.

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And typically if you do it, you can feel your biceps.

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You want to in fact place that in fact laterally

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and come in from the lateral side to confirm

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that the tendon is torn or intact.

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If you do the same thing coming in from the medial side

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trying to hook your finger beneath the tendon,

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you may be fooled because an intact ERUs fibrosis can

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simulate a normal biceps tendon.

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Clinical diagnosis is not very difficult

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with a complete tear, particularly a retracted tear.

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And there are some other, other abnormalities.

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I'll show you a few.

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We'll discuss a few of these, including cubital bursitis

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and irregular radial tuberosity.

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Uh, that can accompany tearing of the, uh, distal byte.

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So here is another example shown in sagittal

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and axial

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and fabs views of a distal tear

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of both tendons of the biceps brachii muscle

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with significant retraction.

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You can see the soft tissue edema,

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the fabs view showing you, in fact, perhaps the degree

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of retraction the best.

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Uh, although it can look for shortened in the fab's view.

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Again, your report when you describe this, the site of tear,

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the degree of retraction, you wanna measure that.

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I find it easiest in the sagittal plane to measure that,

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but you have to go from the radial tuberosity

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to the torn tendon.

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It may take several sagittal images to do that.

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I like to discuss with all tendon there is the quality

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of the torn tendon, is it frayed and irregular?

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All right, or is it smooth?

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And I like to at least indicate the status of the

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ERUs fibrosis.

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Of course, there may be other injuries also about the elbow.

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One more case. They all pretty much look the same.

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You'll note the bare radial tuberosity here,

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the tendon retracted considerably here, somewhat irregular,

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but not too bad.

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The erti fibrosis, it's as abnormal.

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We can see that on the transverse view with edema

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and inability to identify clearly the entire

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erti fibrosis.

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And one other point you may see,

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and it may distract you from looking at the distal portion

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of the biceps tendon, is that this tendon may rupture

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acutely and like a slingshot, it will injure

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through its retraction, the distal myo tendon, its junction.

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So you can end up with a lot

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of edema about the myo tendonous junction.

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The white arrow is showing you some in this case,

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and your attention may indicate

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because of that finding that you're dealing

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with a myo tendonous injury.

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But a myo tendonous injury can accompany a distal pi biceps

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tendon rupture with a lot of proximal retraction.

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Now let me, uh, go back to what I said earlier, that some

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tendon disruptions are not complete, but they are partial

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and they may include, uh, include a full thickness tear,

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but of only one limb of this bifurcated tendon.

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So remember, we have the long head

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and the short head that may attach separately at the

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radial tuberosity.

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So let me show you two or three cases of that.

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And in my experience,

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although I've seen this maybe 20 times now

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with one exception, it's been the short head tendon

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that has been torn and retracted with an intact long head.

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So here in this case, indeed is that short head.

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You can see that it is uh, um, retracted.

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You can see the long head tendon here,

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I'm showing you with the arrows.

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It is attaching normally to the radius.

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So this is a full thickness partial with tear

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and incomplete tear that it is a full thickness of one,

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but not of both tendons.

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Here's the same thing, and again, I've labeled this

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for you on all of these images, the sagittal image, the, uh,

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transverse images.

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And so you can see the short head is torn and retracted.

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You can't follow it all the way down.

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That's the white arrows.

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Whereas the yellow arrow is showing you a pretty intact

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tendon of the long head, which you can follow down

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to its radial attachment.

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And here, in fact is the single exception in my experience,

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where the, it is the long head tendon that is disrupted

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and retracted approximately.

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This score turned out as I trace the tendons

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to be the short head tendon still attached

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to the radial tuberosity.

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Now, there are some associated findings that we,

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uh, uh, look for.

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Basically we are looking for irregularity

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of the radial tuberosity shown in this example.

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I think that these occur together.

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You get some irregularity, you get partial tearing,

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and then with friction,

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the irregularity increases the tear progresses.

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The other finding that is associated with tearing of the,

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uh, uh, of these uh, biceps uh,

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tendon is bicipital radial burs bursa fluid.

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We call this cubital bursitis.

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And the position of this bursa intimate with the distal

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biceps tendon depends upon whether

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the elbow is pronated or supinated

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because it will be on one side in the pronated position,

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but on both sides of the biceps tendon in the supinated.

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Just to show you an example here,

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the fluid sensitive sequence at the bottom,

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a gadolinium enhanced sequence at the top, this was done

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with the arm pronated, and you can see that the inflamed

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Complex bursa is lying mainly to the radial side

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of that biceps tendon, which was abnormal

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and torn in this case.

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One further example, similar findings, torn biceps tendon.

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This was almost a complete tear

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and you can see the fluid within

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this particular bicipital radial bursa.

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There is another bursa that, uh, we, uh, have

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around the elbow at Ous bursa.

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There are a couple of reports I believe

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that have associated this with

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biceps tendon pathology as well.

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This bursa is located more distally between the radius and.