01Approach to the Critical Patient/attcp32

Triage and limb threat screen

›Immediate threats

›Open injury over shoulder or elbow

›Rapidly expanding hematoma

›Hard signs of vascular injury

›Pulsatile bleeding

›Absent distal pulses

›Distal ischemia

›Audible bruit or palpable thrill

›Progressive neurologic deficit

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive stretch

›Tense compartments

›Escalation triggers

›If hard signs of vascular injury, immediate vascular surgery and orthopedics

›If suspected compartment syndrome, immediate orthopedics

›If open tendon injury, antibiotics and urgent orthopedics

›Immediate monitoring and support

›Hemodynamic instability evaluation for significant bleeding risk

›Analgesia escalation pathway

›If severe pain, parenteral analgesia titration

›If procedural sedation required, PSA pathway with monitoring

Key concepts

›Injury patterns

›Proximal long head biceps tendon rupture

›Commonly degenerative

›Often coexists with rotator cuff pathology

02History/hx36

Injury context

›History elements

›Onset

›Sudden pain with pop

›Gradual pain with acute worsening

›Mechanism

›Eccentric load with elbow flexed and forearm supinated

›Heavy lift with extended elbow

›Fall onto outstretched arm

›Timing

›Time since injury

›Prior evaluation or delayed presentation

›Dominance and function

›Hand dominance

›Occupational demands

›Athletic demands

›Symptoms

›Weakness pattern

›Supination weakness

›Elbow flexion weakness

›Shoulder pain and cramping

›Deformity

›Upper arm bulge

›Bruising distribution

›Prior shoulder or elbow pathology

›Rotator cuff disease

›Prior biceps symptoms

›Prior tendon rupture

03Physical Exam/exam53

Inspection and functional exam

›Exam domains

›Inspection

›Ecchymosis

›Antecubital fossa ecchymosis

›Upper arm ecchymosis

›Deformity

›Popeye deformity

›Proximal migration of muscle belly

›Swelling

›Anterior elbow swelling

›Shoulder groove tenderness

›Palpation

›Distal tendon palpability

›Tendon gap in antecubital fossa

›Bicipital groove tenderness

›Radial tuberosity region tenderness

›Strength testing

›Elbow flexion strength comparison

›Forearm supination strength comparison

›Pain-limited effort documentation

›Range of motion

›Elbow flexion and extension

›Forearm pronation and supination

›Shoulder ROM if proximal symptoms

›Neurovascular exam

›Radial pulse

›Ulnar pulse

04Differential Diagnosis/ddx23

Shoulder and elbow acute pain mimics

›Mimics and co-injuries

›Rotator cuff tear (ICD-10 M75.1)

›Weakness in abduction and external rotation

›SLAP lesion (SNOMED CT concept)

›Clicking and deep shoulder pain

›Proximal humerus fracture (ICD-10 S42.2)

›Bony tenderness and limited ROM

›Elbow dislocation (ICD-10 S53.1)

›Deformity and loss of joint congruity

›Radial head fracture (ICD-10 S52.12)

›Lateral elbow pain and effusion

›Brachialis muscle injury (SNOMED CT concept)

›Pain with flexion without distal tendon gap

›Distal biceps tendinopathy without rupture (SNOMED CT concept)

›Pain predominant without strength loss

›Medial epicondylitis (ICD-10 M77.0)

›Pain with wrist flexion and pronation

›Lateral epicondylitis (ICD-10 M77.1)

›Pain with wrist extension and gripping

›Distal biceps avulsion fracture fragment (SNOMED CT concept)

›Radiographic fleck near radial tuberosity

›Acute compartment syndrome forearm (ICD-10 T79.A1)

›Pain out of proportion with tense compartments

05Laboratory Tests/lt16

Routine ED labs

›Lab strategy

›No routine labs for isolated closed tendon rupture with stable vitals

›Indications for labs

›Procedural sedation plan

›Point-of-care glucose if altered mentation risk

›Significant hematoma with anticoagulation

›Hemoglobin for symptomatic anemia concern

›INR for warfarin use

›Operative pathway or admission

›CBC

›Electrolytes and creatinine

›Type and screen if major bleeding concern

Interpretation and pitfalls

›Lab limitations

›Normal hemoglobin does not exclude expanding hematoma early

›INR does not reflect DOAC intensity reliably

›CK not routinely helpful for isolated biceps rupture

06Diagnostic Tests/dt39

Scoring Systems

›Clinical test performance framing

›Hook test for distal rupture

›Positive test supports diagnosis

›Negative test does not exclude rupture

›Lower sensitivity in partial tears

›Clinical suspicion escalation

›If exam equivocal and functional loss present, ultrasound or MRI

Radiographs

›X-ray role

›Elbow radiographs

›AP view

›Lateral view

›Indications

›Traumatic mechanism with bony tenderness

›Concern for radial head fracture

›Concern for elbow dislocation

›Shoulder radiographs

›AP view

›Scapular Y view

›Axillary view when tolerated

›Indications

›Traumatic mechanism with shoulder pain

›Concern for proximal humerus fracture

›Expected findings

›Often normal in isolated tendon rupture

›Avulsion fleck possible near radial tuberosity in distal injuries

07Disposition/dispo22

ED disposition planning

›Discharge criteria

›Hemodynamic stability

›No neurovascular compromise

›Pain controlled with oral regimen

›Immobilization tolerated

›Reliable follow-up plan

›Admission criteria

›Uncontrolled pain despite ED management

›Progressive neurologic deficit

›Vascular compromise concern

›Compartment syndrome concern

›Associated fracture requiring admission pathway

›Urgent consultation and follow-up timing

›Distal biceps rupture

›Orthopedics or hand and upper limb surgery referral urgent

›Early surgical discussion for active patients

›Proximal long head rupture

›Outpatient orthopedics or sports medicine referral

›Earlier referral if high-demand patient or cosmetic concern

›Work restrictions documentation

›No lifting with affected arm until reassessed

›Sling use guidance

08Treatment/t38

Immediate life-saving interventions

›Immediate threats management

›If hard signs of vascular injury, direct pressure and immediate surgical pathway

›If impending compartment syndrome, remove constriction and immediate orthopedics

›If open injury, sterile dressing and antibiotics pathway

Immobilization and Splinting

›Immobilization options

›Distal rupture immobilization

›Sling for comfort

›Posterior long arm splint if severe pain with motion

›Proximal rupture immobilization

›Sling for comfort

›Immobilization principles

›Neutral forearm position as tolerated

›Avoid heavy lifting and resisted supination

›Neurovascular reassessment after splint

›Adjunct measures

›Ice application schedule

›Elevation for swelling control

Definitive management pathways

›Distal biceps rupture

›Surgical repair discussion

›Higher demand patients

›Dominant arm involvement

›Significant supination weakness

›Nonoperative pathway

›Low-demand patients

›Significant comorbidity or anesthesia risk

09Special Populations/sp27

Pregnancy

›Pregnancy considerations

›Analgesia selection

›Acetaminophen preferred

›NSAID avoidance in third trimester

›Imaging minimization

›Ultrasound preference when diagnostic uncertainty exists

›Thromboembolism risk context

›Individualized assessment if immobilization prolonged

Geriatric

›Geriatric considerations

›Degenerative proximal rupture prevalence

›Rotator cuff disease coexisting likelihood

›Medication safety

›NSAID renal and GI risk

›Opioid delirium risk

›Functional planning

›Early PT to prevent stiffness

›Higher threshold for independence concerns

Pediatrics

›Pediatric considerations

›True biceps tendon rupture rarity

›Alternative diagnoses prioritization

›Apophyseal injury

›Elbow fracture patterns

›Imaging

›Low threshold for radiographs with trauma

›Weight-based analgesia

10Background/b37

Epidemiology

›Epidemiology overview

›Proximal long head rupture

›More common than distal rupture

›Older age predominance

›Distal rupture

›Less common

›Middle-aged active adult predominance

›Risk factors

›Smoking association with tendon degeneration

›Anabolic steroid association with tendon rupture risk

›Fluoroquinolone exposure association with tendinopathy risk

Pathophysiology

›Anatomic concepts

›Proximal long head course

›Intra-articular origin

›Bicipital groove segment

›Distal insertion

›Radial tuberosity attachment

›Lacertus fibrosus contribution to tendon stability

›Injury mechanics

›Eccentric overload as typical distal rupture mechanism

›Degenerative attrition as common proximal mechanism

›Functional consequences

›Supination torque reduction with distal rupture

›Cosmetic deformity prominence with proximal rupture

Therapeutic Considerations

›Operative versus nonoperative rationale

11Patient Discharge Instructions/pdi31

Copy discharge instructions

›Discharge instructions

›Diagnosis summary

›Suspected biceps tendon rupture

›Location

›Proximal long head

›Distal near elbow

›Activity

›Sling use for comfort

›No lifting with affected arm

›Avoid resisted elbow flexion

›Avoid resisted forearm supination

›Swelling care

›Ice 15 minutes at a time

›Repeat every 2 to 3 hours while awake for 48 hours

›Elevation above heart when possible

›Pain medicines

›Acetaminophen dosing as prescribed

›NSAID dosing as prescribed

›Opioid only if needed

›No driving after opioid use

›Follow-up

›Orthopedics or sports medicine appointment

›Distal rupture urgency

›Contact within 24 to 72 hours if possible

›Return to ED immediately

›Hand or forearm numbness

›New weakness in wrist or finger extension

12References/r24

Clinical guidelines and evidence sources

›Evidence sources

›ACEP Clinical Policy

›Procedural sedation and analgesia in the emergency department

›Capnography adjunct recommendation

›Level B

›Fasting time not a reason to delay urgent PSA

›Level B

›Ketamine and propofol safety for ED PSA

›Level A

›Orthopedic references

›Distal biceps rupture repair timing and outcomes literature

›Proximal long head biceps rupture management reviews

›Point-of-care references

›Ultrasound and MRI diagnostic descriptions for distal and proximal rupture

›Clinical test performance studies for hook test and partial tears

Coding references

›ICD-10 and SNOMED CT mapping

›ICD-10 S46.1

›Injury of muscle and tendon of long head of biceps

›ICD-10 S46.2

›Injury of muscle, fascia and tendon of other parts of biceps

›SNOMED CT concepts

›Rupture of biceps tendon

›Distal biceps tendon rupture

›Proximal biceps tendon rupture

Evidence & Review

Evidence & Review