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Hand Surgery, Vol. 20, No. 1 (2015) 141–143 © World Scientific Publishing Company DOI: 10.1142/S0218810415720028

COMPLETE CLOSED BRACHIORADIALIS TENDON RUPTURE: A CASE REPORT Ifrah Afreen Khan,* Luke Joseph Bonato* and Ash Chehata† *Monash

School of Medicine, Faculty of Medicine Nursing and Health Sciences Monash University, Melbourne, Australia †Cabrini

Hospital Malvern Epworth Hospital, Richmond Melbourne, Australia Received 6 March 2014; Revised 12 June 2014; Accepted 13 June 2014; Published 20 January 2015 ABSTRACT A complete brachioradialis tendon rupture, as an isolated incident, is extremely rare. Consequently, there is little to no literature on how this can occur and how to treat it. We present the case of a 44-year-old male with a complete, closed brachioradialis tendon rupture following a waterskiing accident. The clinical, imagining and operative findings are outlined alongside management and final outcomes. Our case highlights the effectiveness of a combined surgical and staged physiotherapy approach, for the management of a complete, closed brachioradialis tendon rupture, in an otherwise healthy man. Keywords: Brachioradialis; Tendon; Rupture.

INTRODUCTION

CASE REPORT

Anatomically, the brachioradialis muscle originates from the lateral supracondylar ridge of the distal humerus and its tendon inserts on the lateral aspect of the radial styloid process. Brachioradialis primarily assists in elbow flexion and has also been shown to have a secondary function as a pronator, more than a supinator.1 The distal insertion of the tendon fans upon the radial styloid process to form a rigid bone-tendon junction preventing any mobility at the point of insertion.2 The tendon itself consists of strong fibrous connective tissue which transmits the forces generated to the radius, producing movement. To our knowledge, we present the first reported case of a complete, closed brachioradialis tendon rupture.

A 44-year-old right-handed male presented to our clinic with weakened right elbow flexion, associated with a mid forearm mass and mild tenderness. This was following a waterskiing accident 11 days earlier. The injury was sustained while attempting to rise out of the water. Our patient had been grasping a rope handle and flexing his elbow at approximately 30  while resisting the forward pull of the boat. Consequently, the patient felt a snap and instantaneous weakness in his right arm. A mildly localised tenderness was also reported. Significant past surgical and medical history includes a left knee reconstruction and gout in 2006. Our patient was not

Correspondence to: Mr. Ash Chehata, Orthopaedic Surgeon, Suite 31, Cabrini Hospital, Isabella Street Malvern, VIC, 3144, Australia. Tel: (þ61) 3-9509-7499, E-mail: [email protected] 141

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taking any regular medication and had not previously suffered from a chronic inflammatory arthropathy or tendinosis, which could have predisposed to tendon rupture. A non-smoker and non-steroid user, our patient also had no relevant family history. His exercise regime pre-accident consisted of cardiovascular and weight training at the gym, 2–3 times per week. Clinical examination revealed a large mass in the proximal forearm associated with weakness when the elbow was flexed and the forearm was in neutral rotation. Power was identified as 3/5 in the manual muscle test (MMT) and neurological examination was normal. Magnetic resonance imaging (MRI) was conducted and showed a complete distal brachioradialis insertion rupture with tendon retraction and muscle belly bunching (Fig. 1). Neurovascular bundles were normal and no intramuscular signal abnormalities were detected. Intraoperative findings revealed a complete tendon rupture like a delamination tear (Fig. 2). Once mobilised, the tendon was weaved through the distal tendon segment still attached, using a modified pulvertaft weave3 (Fig. 3). Post operatively the forearm was immobilised in a backslab and a sling for 2 weeks, after which gentle passive stretching exercises were commenced. At 12 weeks our patient was

Fig. 2

Fig. 3

Intraoperative findings of complete brachioradialis tendon rupture.

Successful modified pulvertaft weave for tendon reattachment.

performing unrestricted strengthening exercises. At 4 months our patient was back at work and at 9 months he had returned to normal sporting activities. Follow up at 18 months showed normal muscle contour and strength.

DISCUSSION

Fig. 1 Sagittal section MRI of right forearm. Abnormal brachioradialis muscle and tendon retraction shown on the left of the film.

A complete rupture of the brachioradialis tendon is extremely rare, with no other cases reported in the literature. Our patient’s pathology occurred during pronation and 30  of elbow flexion, in resistance to the high force generated by the motorboat. Due to the rigid and wide tethering of

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Complete Closed Brachioradialis Tendon Rupture

the tendon at its insertion upon the radial styloid process, the tendon ruptured rather than detaching at its insertion. Diagnostically, clinical weakness in elbow flexion and pronation with an associated forearm mass is suggestive of brachioradialis pathology. Confirmation with MRI should be performed. The closest reported case in the literature involves a closed partial rupture of the brachioradialis tendon during exercise.4 A 42-year-old, right hand dominant male presented with weakness and pain in his right forearm after exercising on a reclining leg press at the gym. Prior to symptom onset, the patient had been reclining at a 45  angle with his elbows fully extended and parallel to his trunk axis. His forearm had been in a neutral position while gripping the machine handles. Clinical examination elicited pain on resisted pronation and elbow flexion. Relevant medical history included asthma treated with becotide and ventolin inhalers. In contrast to our patient, this case utilised conservative treatment. Follow up at 9 months with strength testing showed a significant reduction in power and endurance in the right forearm compared to the left. Had surgical tendon repair been performed, a greater restoration of strength and functionality may have been achieved. Surgical repair restored our patient’s power from a 3/5 in the MMT to a level of functionality where he could resume his pre-accident exercises and work with normal strength.

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CONCLUSION A complete, closed brachioradialis tendon rupture has never been reported in the literature until now. A partial brachioradialis tendon tear however has shown a significant reduction in strength and endurance when conservatively managed. This contrasts to the return of normal strength displayed by our patient who was surgically managed with a modified pulvertaft weave. Our case demonstrates the effectiveness of a delayed operative treatment with a staged physiotherapy rehabilitation program in restoring the patient’s anatomy and function, as well as enabling a successful return to work.

References 1. Boland MR, Spigelman T, Uhl TL, The function of brachioradialis, J Hand Surgery [Am] 33(10):1853–1859, 2008. 2. Friden J, Albrecht D, Lieber R, Biomechanical analysis of the brachioradialis as a donor in tendon transfer, Clin Orthop Relat Res 383:152– 161, 2001. 3. Pulvertaft RG, Tendon grafts for flexor tendon injuries in the fingers and thumb; A study of technique and results, J. Bone Joint Surg [Br] 38B(1):175–194, 1956. 4. Armstrong D, Arrowsmith J, Burke F, Closed rupture of brachioradialis during exercise, J Hand Surg [Eur] 36:704–705, 2011.

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Complete closed brachioradialis tendon rupture: a case report.

A complete brachioradialis tendon rupture, as an isolated incident, is extremely rare. Consequently, there is little to no literature on how this can ...
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