Electrodiagnostic / Neuromuscular Medicine
Becky Cox, MD
Resident
MedStar National Rehabilitation Hospital
WASHINGTON DC, District of Columbia, United States
Michael Blatt, MD
Resident
Washington Hospital Center
Washington, DC, District of Columbia, United States
Brandon Kase, MD
Attending
MedStar National Rehabilitation Hospital
Washington, DC, District of Columbia, United States
Laura Malmut, MD, MEd
Medical Director of Transplant Rehabilitation; Clerkship Director; Associate Professor
MedStar National Rehabilitation Hospital and Georgetown University School of Medicine
Washington, District of Columbia, United States
Becky Cox, MD
Emory University School of Medicine
WASHINGTON DC, District of Columbia, United States
A 41-year-old male with history of DVT (on apixaban) was admitted to the hospital with acute pancreatitis. His hospital course was complicated by syncope and fall onto his left upper extremity. CT demonstrated a 260 cm3 left biceps brachii hematoma with proximal biceps tendon rupture. Pain was uncontrolled on high-dose opioids. He was subsequently admitted to an inpatient rehabilitation facility. Further history was significant for burning left hand pain with paresthesias. Exam revealed patchy weakness and sensory impairment throughout the left hand and forearm. MRI of the left brachial plexus was unremarkable. Electrodiagnostic studies demonstrated multifocal peripheral nerve injuries affecting the median, ulnar, and radial nerves. Pharmacologic pain management was optimized to address the neuropathic pain. Following inpatient rehabilitation discharge, the patient was referred for musculoskeletal ultrasound to evaluate peripheral nerves distal to the level of the plexus and plastic surgical evaluation.
This case presents an atypical collection of nerve injuries following proximal biceps muscle rupture. Possible etiologies include primary neural trauma during the fall and secondary compression from the hematoma. The most commonly affected nerve following biceps muscle rupture is the musculocutaneous nerve due to tensile and shearing forces during avulsion of the long head of the biceps. In addition to therapy and pain management, additional treatment modalities can include edema management and referral to plastic surgery for possible nerve grafting. Traumatic injuries to derivatives of the brachial plexus are at risk of developing complex regional pain syndrome and this should be monitored.
This case highlights the need to assess patients with biceps muscle ruptures for concomitant nerve injury. Early identification of somatic and neuropathic defects following such injuries can improve symptom management, time to surgical evaluation and functional outcomes.
