What is the management of a ruptured biceps tendon in the Emergency Room (ER), including placement in a sling, pain control with medication, and referral to orthopedics?

From the Guidelines

For a ruptured bicep in the ER, the initial management should include placing the patient in a sling for comfort and immobilization, providing appropriate pain control, and referring the patient to orthopedics for definitive management, with a focus on minimizing morbidity, mortality, and improving quality of life. The most recent and highest quality study 1 emphasizes the importance of effective pain management, suggesting the use of medications such as acetaminophen (1000mg every 6 hours) or NSAIDs (ibuprofen 400-600mg every 6 hours or naproxen 500mg twice daily) for pain control. Opioids like hydrocodone/acetaminophen 5/325mg every 6 hours as needed may be considered for severe pain, but with caution due to potential adverse effects, particularly in elderly patients. Ice application for 20 minutes every 2-3 hours can help reduce swelling and pain. The patient should be advised to avoid activities that stress the injured arm, particularly lifting and pulling movements.

Key Considerations

• Prompt orthopedic referral is crucial, ideally within 1-2 weeks, as surgical repair may be necessary, especially for complete tears of the distal biceps tendon.
• Early surgical intervention (within 2-3 weeks of injury) typically yields better functional outcomes than delayed repair, as suggested by the principles of managing acute injuries.
• The decision between conservative and surgical management depends on the location of the rupture, degree of functional impairment, and patient factors such as age and activity level.

Pain Management

• The choice of analgesics should consider the type of injury, pain severity, and patient’s clinical features, with a preference for medications that have minimal side effects and do not compromise the patient's hemodynamic status.
• Regular intravenous administration of acetaminophen every 6 hours, unless contraindicated, is effective in traumatic pain relief, according to 1.
• NSAIDs need to be used with caution in elderly patients due to their potential adverse events, such as acute kidney injury and gastrointestinal complications, and should be co-prescribed with a proton pump inhibitor if used.

From the Research

Initial Treatment in the ER

• Place patient in a sling to immobilize the affected arm and reduce discomfort 2
• Provide pain control, which may include administration of intravenous acetaminophen and ibuprofen, as this combination has been shown to be safe and effective for postoperative pain management 3
• Refer the patient to orthopedics for further evaluation and treatment, as some cases may require surgical intervention, such as reinsertion of the ruptured distal biceps tendon 4

Considerations for Referral to Orthopedics

• The decision to refer to orthopedics may depend on the patient's occupation, lifestyle, and the severity of the injury, as well as the location of the rupture (proximal or distal) 2, 4
• Orthopedic evaluation may involve discussion of treatment options, including conservative management, physical therapy, or surgical intervention 4, 5

Physical Therapy Interventions

• For patients with biceps tendinopathy, physical therapy interventions may include exercise, manual therapy, and patient education, as recommended by international experts in the field 5
• A multimodal approach to physical therapy may be effective in managing biceps tendinopathy and promoting recovery 5