SHORT REPORT
Upper Limb Ischaemia Secondary to a Bifurcated Distal Biceps Tendon: A Case Report T. Aherne a b
a,*
, F.M. Shaikh a, P. Naughton a, H. Mullett b, D. Moneley
a
Department of Vascular Surgery, Beaumont Hospital, Dublin, Ireland Department of Orthopaedic Surgery, Beaumont Hospital, Dublin, Ireland
Introduction: Clinical manifestations of hypertrophic bifurcated distal biceps tendons are rarely described. We report the first known case of brachial arterial entrapment resulting from this unusual anatomical variable. Report: A 24-year-old gentleman presented with positional upper limb ischaemic symptoms. Initial investigation was unremarkable. Operative exposure of the ante-cubital fossa revealed compression of the brachial artery by a hypertrophic bifurcated distal biceps tendon. Partial division of the tendon led to resolution of symptoms. Discussion: In challenging cases of upper limb ischaemia surgical, intervention may be justified for both diagnostic and therapeutic purposes. Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Article history: Received 10 February 2014, Accepted 1 May 2014, Keywords: Upper limb, Ischaemia, Chronic, Bifurcated biceps tendon INTRODUCTION We report the first known case of upper limb ischaemia related to compression of the brachial artery secondary to hypertrophic bifurcated distal biceps tendons. Report A 24-year-old gentleman with no significant medical background presented to the Emergency Room with a short history of dependent upper limb (UL) ischaemic symptoms. He reported a gradual onset of pain, paraesthesia, and a cold sensation affecting both hands, particularly the left. Of note, symptoms only arose with the UL at his side with resolution upon elevation of the limb to a level greater than 90 degrees. Further questioning revealed a recent uptake of employment involving manual labour. Examination showed bilateral cold, cyanosed hands most marked on the left. Dynamic examination of the upper limb pulses, formal pressure testing, and autoimmune screens were unremarkable. Magnetic resonance imaging (MRI) of the left UL vasculature and anatomy were normal. Conversely, Doppler ultrasound and formal left UL digital subtraction angiography with provocation identified impaired forearm arterial blood flow in the dependent position (Fig. 1). Subsequent symptomatic progression markedly impacted patient quality of life. Given this deterioration and the potential for brachial arterial compression surgical exploration of the left antecubital fossa (ACF) was deemed the most appropriate diagnostic/treatment option. DOI of original article: http://dx.doi.org/10.1016/j.ejvs.2014.05.005 * Corresponding author. T. Aherne, Department of Vascular Surgery, Beaumont Hospital, Beaumont Rd, Dublin 9, Ireland. E-mail address:
[email protected] (T. Aherne). 1533-3167/$ e see front matter Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvsextra.2014.05.003
A 6-cm lazy S incision was performed overlying the left ACF. Upon anterior exposure of the fossa, a hypertrophic bifurcated distal biceps tendon was identified (Fig. 2). Dissection revealed a common insertion point at the radial tuberosity with divergent tendons inserting proximally into two separate biceps muscle bellies. A bruised brachial artery underlay the convergence point of the tendon with partial compression of the vessel in the extended position. Following complete anatomical inspection the medial aspect of the common insertion was partially divided allowing for the maintenance of function while relieving the underlying artery from tension. This was confirmed using dynamic intraoperative Doppler imaging (Fig. 3). Immediate symptomatic response was noted postoperatively with resolution of left side symptoms at monthly follow-up. Unfortunately, right UL symptoms persisted for which he underwent subsequent diagnostic imaging. Exploration revealed comparable anatomy. Partial division of the tendon again resulted in an excellent symptomatic outcome. DISCUSSION UL ischaemia is rare and often underdiagnosed. Most commonly, acute processes such as athero-embolic disease or underlying trauma are the cause, with chronic ischaemia accounting for a minority of cases. Reports have described atypical distal upper limb musculoskeletal anatomy chronically disrupting arterial function.1,2 Classically, the long and short heads of biceps brachii originate from the supra-glenoid tubercule and the coracoid process inserting distally as a common tendon into the radial tuberosity. A bifurcated distal biceps tendon was first reported by Sassmannshausen et al.3 and has subsequently been noted in 48% of cadaveric specimens.4 It does not, however, commonly present clinically and has never been reported to compress the brachial artery.
Please cite this article in press as: Aherne T, et al., Upper Limb Ischaemia Secondary to a Bifurcated Distal Biceps Tendon: A Case Report, EJVES Extra (2014), http://dx.doi.org/10.1016/j.ejvsextra.2014.05.003
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Figure 3. Partial tendon division with release of the brachial artery. Figure 1. Left upper limb angiography revealed impaired forearm arterial flow.
Symptomatic improvement was seen with partial division of the lacertus in all cases. In this case, diagnosis of the underlying process was challenging as no atypical anatomy was evident radiologically. Furthermore, retrospective review of preoperative imaging offered no indication of operative findings. Our initial goal had been to attain symptomatic relief via noninvasive means. However, symptomatic deterioration dictated surgical exploration was required for both diagnostic and therapeutic purposes. FUNDING None. CONFLICTS OF INTEREST None. REFERENCES
Figure 2. Anterior exposure of the hypertrophic bifurcated biceps tendon.
While both popliteal arterial entrapment and thoracic outlet syndrome are well documented, forearm arterial entrapment remains rare. Brachial arterial entrapment was first reported by Biemans2 in 1977. He noted ischaemic upper limb symptoms in a muscular 39-year-old gentleman secondary to muscular hypertrophy. Complete symptomatic relief was achieved with division of the lacertus fibrosus.2 Similarly, transient upper limb symptoms were described by Bassett5 in a case series of five muscular athletes. They noted patients to have both exertional and positional ischaemic symptoms due to brachial artery compression secondary to hypertrophy of the lacertus fibrosus.
1 Chemla ES, Raynaud A, Mongredien B, Combes MA, D’Attellis N, Cardon CF, et al. Forearm arteries entrapment syndrome: a rare cause of recurrent angioaccess thrombosis. J Vasc Surg 2001;34: 743e7. 2 Biermans RG. Brachial artery entrapment syndrome. Intermittent arterial compression as a result of muscular hypertrophy. J Cardiovasc Surg 1977;4:367e71. 3 Sassmannshausen G, Mair SD, Blazar PE. Rupture of a bifurcated distal biceps tendon. A case report. J Bone Joint Surg Am 2004;86-A(12):2737e40. 4 Cho CH, Song KS, Choi IJ, Kim DK, Lee JH, Kim HT, et al. Insertional anatomy and clinical relevance of the distal biceps tendon. Knee Surg Sports Traumatol Arthrosc 2011;19(11): 1930e5. 5 Bassett 3rd FH, Spinner RJ, Schroeter TA. Brachial artery compression by the lacertus fibrosus. Clin Orthop Relat Res 1994;307:110e6.
Please cite this article in press as: Aherne T, et al., Upper Limb Ischaemia Secondary to a Bifurcated Distal Biceps Tendon: A Case Report, EJVES Extra (2014), http://dx.doi.org/10.1016/j.ejvsextra.2014.05.003
