Case study: Biceps tendon rupture
A 41-year-old man presented persistent left shoulder pain, weakness, and limited range of motion, especially during elbow flexion, linked to overuse and repetitive lifting at work. Despite conservative treatments like physical therapy and pain medications, his symptoms persisted, impacting daily life. The patient was diagnosed with a chronic, complete rupture of the long head of the biceps tendon at its insertion in the bicipital groove (distal biceps tendon rupture). Elective surgical repair was planned due to the injury’s chronic nature and the patient’s preference. An ultrasound-guided axillary brachial plexus block was scheduled for effective pain control during and after surgery.
Nerve block technique
The patient was positioned in a supine manner with the left arm abducted and externally rotated to optimize access to the axillary region. Subsequently, a high-frequency linear ultrasound transducer was used to visualize the axillary artery and vein in the transverse plane. The axillary brachial plexus, comprising the radial, median, and ulnar nerves, and the musculocutaneous nerve, were identified by utilizing proximal-distal movements. Under ultrasound guidance, a 22-gauge, 50 mm needle was inserted in-plane to inject 20 mL of 0.5% ropivacaine.
- 8 mL below the axillary artery.
- 8 mL above the axillary artery.
- 4 mL for the musculocutaneous nerve, essential for this surgery to allow relaxation of the biceps muscle.
Axillary brachial plexus block; Reverse Ultrasound Anatomy with needle insertion in-plane and local anesthetic spread (blue). AA, axillary artery; AV, axillary vein; McN, musculocutaneous nerve; MN, median nerve; UN, ulnar nerve; RN, radial nerve; MbCN, medial brachial cutaneous nerve.
The axillary brachial plexus block provided excellent intraoperative and postoperative analgesia. The surgical procedure, which involved reattaching the ruptured biceps tendon to its anatomical insertion, proceeded seamlessly without any complications. The patient began a structured rehabilitation program under the guidance of a physical therapist to gradually restore function to the shoulder and elbow.
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