Medicolegal Issues

Malpractice Counsel: Don’t Miss Popeye

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A 42-year-old man presented to the ED with left arm pain secondary to an injury he sustained at work. The patient stated that he had been helping to lift a heavy steel beam at a construction site when he experienced abrupt onset of pain in his left arm. He further noted that his left arm felt slightly weaker than normal after the injury.

The patient was left-hand dominant, denied any other injury, was otherwise in good health, and on no medications. With the exception of an appendectomy at age 12 years, his medical history was unremarkable. Regarding his social history, he admitted to smoking one pack of cigarettes per day, and to occasional alcohol consumption. He had no known drug allergies.

On physical examination, the patient’s vital signs were: blood pressure, 125/76 mm Hg; heart rate, 78 beats/min; respiratory rate, 16 breaths/min; and temperature, 98.6°F. Oxygen saturation was 99% on room air.

Examination of the patient’s left shoulder revealed no swelling or tenderness; he was able to fully internally/externally rotate the left shoulder, and lift his left hand above his head. The patient did have tenderness along the biceps area of the left arm, but no tenderness in the triceps area. The left elbow was tender in the antecubital fossa, but without swelling. He had full range of motion of the left elbow but with some pain. He likewise had full range of motion in his left wrist, but no tenderness or swelling. The left radial pulse was 2+. The patient had 5/5 grip strength with the left hand and good capillary refill.

The physician assistant (PA) evaluating the patient diagnosed an arm strain. At discharge, he referred the patient to an occupational health physician (OHP) for follow-up. He also instructed the patient to take ibuprofen 400 mg every 6 to 8 hours, and to limit use of his left arm for 3 days.

The patient followed up with the OHP approximately 3 weeks after discharge from the ED. The OHP was concerned the patient had experienced a distal biceps tendon rupture and referred the patient emergently to an orthopedic surgeon. The orthopedic surgeon saw the patient the next day, agreed with the diagnosis of a distal biceps tendon rupture, and attempted surgical repair the following day. The orthopedic surgeon informed the patient prior to the surgery that the delay in the referral and surgery could result in a poor functional outcome. The patient did have a difficult recovery period, and a second surgery was required, which did not result in any significant functional improvement.

The plaintiff sued the treating PA and supervising emergency physician (EP) for failure to properly diagnose the biceps tendon rupture, failure to appreciate the existence of a 3-week window of opportunity to repair the distal biceps tendon rupture, and failure to obtain an urgent orthopedic referral. The experts for the defense argued that the poor outcome was not a consequence of any delay in diagnosis or surgical repair. In addition, the defense disputed the existence of a 3-week window of opportunity for successful repair of a distal biceps tendon rupture. The jury returned a defense verdict.

Discussion

Proximal and Distal Biceps Tendon Ruptures

While both proximal and distal biceps tendon ruptures involve the biceps brachii, they are managed differently and have the potential for very different outcomes.1 At its proximal attachment, the biceps has two distinct tendinous insertions—the long head and the short head. For the distal attachment, the two muscle bellies unite at the midshaft of the humerus and attach as a single tendon on the radial tuberosity. In general, 96% of biceps tendon ruptures involve the long head, 1% involve the short head, and only 3% involve the distal tendon.1 Biceps tendon ruptures occur more commonly in men, patients who use anabolic steroids, cigarette smokers, patient history of tendinopathy, or patients who have a rotator cuff tear.1 Biceps tendon ruptures have not been found to be associated with statin use.2 The mechanism of injury includes heavy-lifting activities, such as weight lifting and rock climbing. However, when associated with a tendinopathy, minimal force may be involved.1

Signs and Symptoms

For proximal biceps tendon rupture, patients usually present with an acute or gradual onset of pain, swelling, and bruising of the upper arm and shoulder. Occasionally, if there is an inciting event, the patient may describe hearing or feeling a “popping” or “snapping” sound. On physical examination, the patient may exhibit a “Popeye” sign—a bulge in the distal biceps area due to the retracted biceps muscle belly. There is also tenderness along the biceps.

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