Traumatic Laceration of the Long Head of the Biceps Brachii From a Displaced Surgical Neck Fracture of the Humerus: A Case Report

Jaehon M. Kim MD
Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA

Jesse B. Jupiter MD
Hansjorg Wyss/AO Professor Orthopaedic Surgery at Harvard Medical School
Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA
Email: jjupiter1@partners.org


Abstract:

This case report identifies a traumatic laceration of the long head of the biceps brachii associated with a displaced surgical neck fracture of the humerus in a 37 year old woman who sustained a fall while skiing. At the time of surgery the tendon was found sharply divided and repaired primarily. The fracture was fixed with a proximal humeral blade plate. Follow-up revealed nearly full glenohumeral motion and a functional biceps muscle by 4 months.


Introduction:

Traumatic disruption of an otherwise normal tendon of the long head of the biceps brachii has been rarely reported (1-3). While personal correspondence has suggested that others have observed this same phenomenon with a proximal humeral fracture, a thorough search of the English literature has failed to identify this association. We report a clinical case of a lacaeration of the tendon of the long head of the biceps with an associated displaced surgical neck fracture in an otherwise healthy young woman.


Case Report:

A 37 year old healthy woman without prior history of shoulder pathology sustained a displaced surgical neck fracture of her right humerus from a fall while skiing (Figure 1). Upon presentation, the neurovascular status was intact and the upper arm exam was unremarkable with the exception of a large ecchymotic area just anterior to the axilla (Figure 2). The arm was held in a sling but there was no suggestion of contour deformity in the proximal or mid brachium to suggest injury to the biceps.

Figure 1: Surgical neck fracture of the humerus with significant displacement.

Figure 2: Clinical presentation of the patient notable for ecchymosis of anterior proximal arm.

Under general anesthesia, the fracture was exposed through a deltopectoral incision. The biceps tendon was found sharply divided at the fracture site and tagged for later repair (Figure 3). The fracture was reduced and fixed with a proximal humeral blade plate and screws (Figure 4). The biceps was then repaired with nonabsorbable suture in a modified 4-strand repair at the juncture and a second peripheral running suture.

Figure 3: Laceration of the proximal tendon of biceps bracchii at the level of the fracture site.

Figure 4: Reduction and surgical fixation of proximal humerus with fixed angle blade plate and screws.

Postoperatively, the patient was immobilized for 10 days in a sling and then permitted to begin shoulder motion. Fracture healing occurred without complications, and at the follow-up of 6 months, nearly full shoulder and elbow function had returned without cosmetic deformity of the brachium (Figure 5).

Figure 5: Uncomplicated postoperative course with almost full shoulder and elbow function.


Discussion:

Given the close proximity of the long head of the biceps as it runs through the bicipital groove, it is surprising that traumatic severance has not been well described in the literature. This is especially the case as more interest has now been developing for operative treatment of proximal humeral fractures (4, 5).
In this particular clinical case, the surgical neck fracture occurred in healthy bone while skiing at a high velocity suggesting that the fracture was widely displaced at impact. As the decision for surgery was based upon the displacement of the fracture, there was no clinical indication to suggest a need for preoperative MRI nor would it have influenced the surgical approach or decision making. One could suggest that the tenodesis of the biceps tendon would have been an alternative treatment for this injury; the fact that the tendon was easily retrieved, sharply lacerated, and repaired without tension allowed us to consider primary repair as a viable alternative.


Summary:

To our knowledge, this is the first reported case of proximal humerus fracture with laceration of the long head of the biceps. High-energy mechanism of injury and significant displacement at the fracture site are likely risks associated with this injury pattern. Both primary repair and tenodesis are viable surgical options.

Disclosure:

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. In support of their research fund, one or more of the authors received, in any one year, outside funding or grants of in excess of $10,000 from the AO Foundation, Smith and Nephew, Wright Medical, Small Bone Innovations, Joint Active Systems, Orthopaedic Trauma Association, and American Foundation for Surgery of the Hand/American Society for Surgery of the Hand.


References:

1. Ahrens, P. M., and Boileau, P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br 89B: 1001-1009, 2007.
2. Butler, E. F., and Buck, R. M. Rupture of the long head of the biceps brachii. South Med J 51: 1153-1156, 1958.
3. Mariani, E. M., Cofield, R. H., Askew, L. J., Li, G., and Chao, E. Y. S. Rupture of the tendon of the long head of the biceps brachii: Surgical versus nonsurgical treatment. Clin Orthop Rel Res 228: 233-239, 1988.
4. Robinson, C. M., and Page, R. S. Severely impacted valgus proximal humeral fractures. J Bone Joint Surg Am 85A: 1647-1655, 2003.
5. Drosdowech, D. S., Faber, K. J., and Athwal, G. S. Open reduction and internal fixation of proximal humerus fractures. Orthop Clin N Am 39: 429-439, 2008.

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