Original Report

Sonography of Tears of the Distal Biceps Tendon

Theodore T. Miller & Ronald S. Adler

Distal biceps tendon rupture :

- rare, only 3% of all biceps tendon tears
- is easily diagnosed on physical examination as a palpable
defect in the antecubital fossa, a palpable mass in the anterior aspect of arm, and a weakness of flexion & supination
- clinical diagnose is more difficult, in cases of partial tear
that are not retracted tendon because of intact aponeurosis

With MR imaging, a complete tear diagnosed by :

- absence of the tendon at its insertion
- tendon retraction
- edema or hemorrhage in the tendon sheath
MR imaging is the gold standard, but sonography is less expensive, more rapidly performed, and the contralateral elbow
is readily available for comparison

MATERIALS AND METHODES

Sonographic examination of 7 men :
* 5 recreational athletes
* 1 competitive amateur power lifter
* 1 manual laborer
Mechanism of injury was eccentric contraction of the elbow
All patients described a popping sensation at the time of injury,
pain, weakness of flexion, and swelling

They were referred by orthopedist of suspected tears of the distal

biceps tendon for imaging :
* 5 patients for sonography ( 1 with MRI )
* 2 patients for MRI ( 2 with sonography )
The forearm was maximally supinated to bring the tendinous insertion on the radial tuberosity into view
For longitudinal images, the transducer is on oblique plane slightly inferolaterally to the long axis of forearm. For transverse images, the transducer is perpendicular to the long axis of forearm

The imaging criteria for rupture :

- tendinous discontinuity with or without retraction
- surrounding hypoechoic fluid on sonography
- high-signal-intensity fluid on T2-weighted images
The imaging criteria for partial tear :
- thickening or thinning of the tendon
- contour irregularity or waviness

RESULTS

4 patients had complete

rupture
of the distal biceps tendon, manifest as tendinous discontinuity, retraction, and hypoechoic
fluid in the gap
Tendinous discontinuity and
retraction were best appreciated on longitudinal images

1 patient had almost retraction the entire tendon, but a thin strand
of tendon appeared to remain attached to the radial tuberosity

2 patients had thickened and wavy of the distal biceps tendon, but
could be traced to their attachment on the radial
tuberosity

Sonography altered treatment of 2 patients :

In one patient :
In another patient :
- initially clinical impression
- initially clinical impression
was a partial tear
suspected high-grade partial
tear
- sonography showed complete
rupture

- sonography showed a partial

tear with most of the tendon
intact

- treatment was changed from

conservative to operative

- treatment was changed from

planned operative to conservative with NSAID

DISCUSSION
MR imaging :
-accuracy is 100% in 24 patients combined from two
series

Sonography :
-accuracy cannot be addressed because of retrospective nature, nonblinded
examinations in two
instances, and small number of
patients

MR imaging :
-alters treatment in 8 of 21
patients (Fitzgerald)

Sonography :
-alters treatment in 2 of 7
patients

MR imaging :
-in 10 patients, tendon retraction <8cm correlated
with an intact aponeurosis
and >8cm correlated with a
torn aponeurosis (Le Huec)

Sonography :
-in 2 patients, tendon
retraction <8cm had a torn aponeurosis

MR imaging :
-in partial tears, abnormal
intratendinous signal intensity and thinning or thickening of the tendon are best
assessed in axial plane

Sonography :
-in partial tears, thickening
and altered echogenicity of
the tendon were appreciated in axial and longitudinal planes, and irregular
contour was appreciated in
longitudinal plane only

MR imaging :
-assessment of tendon
thickness is based on the
experience of viewer with
normal biceps tendon
(Fitzgerald)

Sonography :
-assessment of tendon
thickness is based on the
comparison with the normal contralateral elbow

The advantage of sonography is its ability to optimize the

imaging plane with real-time scanning to best display tendon abnormality
The limitation of sonography is its dependence on the skill
and experience of the operator
Larger series investigating the accuracy of sonography of
this rare injury are necessary to determine if sonography
can be used for screening of suspected distal biceps tendon
injury and for people who cannot undergo MR imaging