Biceps Tendon Rupture With Post-operative Complications

Biceps Tendon Rupture With Post-operative Complications locomotive PBL Experiment WriteupIntroductionIn this PBL, we observe a case of biceps heftiness rupture with post-operative complication of heterotopic accord. We will first go finished the anatomy of the f number limb followed by a discussion of the ruptured biceps muscularity, heterotopic accordance and in the end mode of achieve of indomethacin.Learning Objectives1. Osteology of the upper limb with emphasis on the articulatio cubiti and carpus2. The neurovascular allow for to the upper limb3. Movements possible at correlatives of upper limb and the cheat of movements possible with regards to the jostle and wrist and the muscles that stimulate rough these actions.4. Rupture of distal biceps tendon5. Heterotopic accordance6. Mode of action of indomethacin1. Osteology of the upper limb with emphasis on the human shove and wristArmThe humerus is the largest and longest bone of the arm region connecting the s houlder to the forearm. Proximally, the inquiry of the humerus articulates with the glenoid cavity of the scapula forming the glenohumeral joint. Distally the humerus articulates with the 2 get up of the forearm, the ulna and radius. The humerus is shown in more detail in figure 1 below.Figure 1 Humerus (1)For anils case we will focus several magnanimous features on the distal region of the humerus which forms part of the elbow. There be two projections on either ramp of the distal end of the humerus which ar the mesial and askant epicondyle. The medial epicondyle protects the ulnar nerve which passes further posteriorly and also serves as the attachment site for the forearm sciolistic flexor muscles. The lateral epicondyle conversely is the attachment site for the forearm extensor muscles. Anteriorly in among these two epicondyles are two articulary surfaces the round surfaced lateral spike heel which articulates with the radius and the spool molded medial trochlea wh ich articulates with the ulna. Also precedingly, the radial tire nether region directly above the capitulum accommodates the tip of the radius during flexion of the elbow whereas the coronoid genus Fossa directly above the trochlea accommodates the coronoid crop of the ulna during flexion of the elbow. both the radial and coronoid fossa limit flexion of the elbow. Posteriorly, the olecranon fossa accommodates the olecranon process of the ulna during extension of the elbow. The olecranon fossa pr unconstipatedts hyperextension of the elbow.ForearmThe forearm is made up of two bones ulna and radius. Proximally both of these bones articulate with the humerus whereas distally only the radius directly articulates with the carpals of the wrist thereof connecting the arm to the wrist. The ulna and radius are shown in figure 2 below.Figure 2 Radius and Ulna (1)The ulnaThe ulna is the modify bone of the forearm and is medial and longer of the two bones. There is a projection anteri orly at the proximal end called the coronoid process which fits into the coronoid fossa during elbow extension. Posteriorly on the proximal end of the ulna is the olecranon process (which forms the prominence of the elbow) which fits into the olecranon fossa during elbow extension. The articular surface amidst the olecranon and the coronoid articulates with the trochlear of the humerus and gives the movements of elbow extension and flexion.The radiusThe radius is the lateral and shorter of the two bones. The head of the radius is a flat button shaped process that articulates with the capitulum of the humerus. The neck of the radius is a constriction just distal to the head which Anil has fractured. Due to the fact that no neurovascular problems were found, it is impregnable to conclude that the latterly branch of the radial nerve was non modify in this case. The radial tuberosity is distal to the neck on the anterior site which is the attachment point for the tendon of biceps.W ristThe ulna does not directly articulate with the carpal bones of the wrist distally. There is an articular disc between the smaller distal head of the ulna and the carpal bones. The radius directly articulates with the scaphoid and lunate carpal bones on its larger distal end. This is shown in figure 3 below.Figure 3 Wrist joint (1)2 The neurovascular supply of the upper limbarterial supplyThe upper limb is supplied by the subclavian artery which branches take away from the brachiocephalic trunk on the right and aortic arch on the left. The subclavian artery extends from its origin to the lateral border of the first rib. It and so changes its call forth to the axillary artery which extends to the lateral border of teres major later on which it becomes the brachial artery. The brachial artery extends to the cubital fossa of the elbow where it bifurcates into the radial and ulnar artery which run down the lateral and medial side of the forearm respectively. These two arteries an astomose in the palm of the hand forming the superficial ( principal(prenominal)ly supplied by ulnar artery) and deep (mainly supplied by radial artery) palmar arches. The fingers are supplied by the digital arteries branching from the palmar arches. The arterial supply is illustrated in figure 4 below.Figure 4 Arterial supply of upper limb (2)venous supplyThere are two main types of veins in the upper limb. Firstly, superficial veins which fag end be seen subcutaneously. There are troika main superficial veins which are the cephalic (laterally), basilic (medially) and median cubital (connection between cephalic and basilica at the cubital fossa) veins. The superficial veins are shown in figure 5 below.Figure 5 Venous supply to upper limb (3)Secondly, there are deep veins which usually accompanies the arteries in pairs and have the same name as the arteries. Perforating veins connect the superficial and deep veins to allow blood to always find a way tush to the heart. All the ve ins eventually drains into the axillary vein, then to the subclavian vein, then brachiocephalic vein and finally into the heart via superior vena cava.Nervous supplyThe brachial plexus serves as the nerve supply for the upper limb arising from spinal anaesthesia nerve roots from C5, 6, 7, 8 and T1. There are 5 pole branches of the brachial plexus in the arm. Table 1 below shows the five-spot terminal nerves with their corresponding roots, get supply, sensory supply and clinical test.Table 1 Nerves, corresponding roots, motor supply, sensory supply and clinical test (4)3 Movements possible at joints of upper limb and the range of movements possible with regards to the elbow and wrist and the muscles that bring about these actions.The elbow consists of three joints the humeroulnar joint from the trochlear notch of the ulnar to trochlear of humerus, the humeroradial joint from the head of the radius to the capitulum of humerus and the superior radioulnar joint from the head of the r adius to the radial notch of the ulna. The humeroulnar and humeroradial joints allow for flexion and extension of the elbow whereas the superior radioulnar joint allows for pronation and supination. This happens when the head of the radius which is enclosed in annular ligament crosses over the persistent ulna bone.The muscles that move the elbow are shown in table 2 belowTable 2 Main muscles of elbow (5)Movements and ranges for the elbow and wrist are shown in table 3 belowTable 3 Movements and ranges for elbow and wrist (6)4 Rupture of distal biceps tendonSymptomsSymptoms allow s welling in the front of the elbow, severe pain at the elbow and a bulge in the upper arm because of the shortened biceps brachii muscle. Since Anil shows no biceps tendon reflex upon assessment, this is likely to be a effected rupture of the tendon.CauseIn this case, Anil is diagnosed to have ruptured his distal biceps tendon which attaches to the radial tuberosity. Distal biceps tendon rupture tends to be caused by a single traumatic event involving flexion of the elbow at a right angle against resistance. For Anil, the snapping of the rope caused his elbow to straighten suddenly. His biceps contracted superfluous hard to prevent this from happening but the extreme tension in his biceps and tendon led to the rupture of the distal biceps tendon. intercessionSince Anil is pacify relatively young at 38 years old and stock-still needs full use of his upper limb, the surgical treatment filling is most preferred. Sometimes the tendon is attached by stitching through holes made in the bone. However the military operation for Anil was done by attaching the tendon to the bone using a small metal house and screws into the radius to secure the plate usually called the endobutton technique (7, 8) which has a really good prognosis of regaining full mobility in the elbow.ComplicationsComplications after the surgery include nerve damage and heterotopic ossification. After eight weeks Ani l returned with stiffness, worry in turning his hand over and wrist pain which the mend diagnosed as heterotopic ossification after palpation of a firm plug along the biceps tendon. Direct intervention was not taken as the biceps tendon needed time to fully heal.5 Heterotopic ossificationHeterotopic ossification is the outgrowth of bone in abnormal places such as soft tissue. Heterotopic ossification is a notable complication of distal biceps tendon repair. The current proposed pathogenesis of how heterotopic ossification arises is the transformation of pluripotential mesenchymal cells which are recruited to the fracture healing site into osteoblasts that results in ectopic bone formation. (9) Bone, tendons and ligaments which are all connective tissue all grant the same mesenchymal stem cell origin (shown in figure 6) and and then mesenchymal stem cells recruited to promote tendon repair cease differentiate into osteoblasts. Osteoblasts skunk also be pulled out of the bone when the tendon ruptures and therefore can unfold to bone certification. Hence great attention has been given to change and irrigating the surgical zone. (10)Figure 6 Mesenchymal stem cells differentiation (11)The heterotopic ossification at the biceps tendon led to Anil having reduced supination to just 20 payable to the biceps being the main supinator muscle. After twenty weeks, the heterotopic ossification was surgically removed. radioactivity therapy has been an established supplement in treatment of heterotopic ossification. (10, 12, 13) The mechanism of how radiation therapy workings is still unclear but is thought to inhibit pluripotential mesenchymal stem cells from differentiating. (14) However, even though radiation therapy is effective, there has been concerns about malignancy from the radiation. Low doses (6 Mode of action of IndomethacinNon-steroidal anti-inflammatory drugs (NSAID) such as Indomethacin are also commonly used to supplement surgical deracination of heterotopic ossifications. (10, 13) Indomethacin non-selectively inhibits cyclooxygenase (COX1 and COX 2) which are involved in the merchandise of prostaglandins from arachidonic acid. During the healing of a fracture, mesenchymal stem cells differentiate into chondrocytes which is independent of COX-2. COX-2 then produces prostaglandins which cause the chondrocytes to hypertrophy. These hypertrophic cells secrete growth factors which cause angiogenesis, osteoclast recruitment, osteogenesis and fracture bridging which leads to bone deposition shown in figure 7 below. However NSAIDs have to be guardedly prescribed especially with patients who have reflux diseases as NSAIDs can lead to ulcer formation. (19)Figure 7 Formation of bone via COX-2 and prostaglandins (20)In conclusion, more research has to be done into the pathophysiology of heterotopic ossification as well as selective drugs that only inhibit COX-2 so that NSAIDs can be safely prescribed even for patients who have reflux diseases.Bibliography1.N. 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