Distal Biceps Tendon Rupture - Wheeless' Textbook of Orthopaedics

- Discussion:
- distal biceps may rupture off the radial tuberosity;
- presents w/ painful swollen elbow usually in a 50-60 yo active male;
- single traumatic event involving flexion against resistance, w/ elbow at a right angle results in a sudden sharp tearing sensation;
- consequences of loss of strength:
- 30 % decrease in flexion strength;
- 40 % loss of supination strength;
- partial biceps tendon rupture:
- biceps tendon will still be palpable in the antecubital fossa;
- biceps tendonitis and median nerve compression may be common following this injury;
             - ref Partial rupture of the distal biceps tendon.

- Exam:
- weakness of flexion and supination;
- carefully palpate for a residual biceps tendon in the antecubital fossa noting the partial rupture may be common;
    - hook test:
           - patient actively supinates the flexed elbow;
           - intact hook test permits the examinerto hook his or her index finger under the intact biceps tendonfrom the lateral side;
           - w/ an abnormal hook test (distal avulsion), there is no cord-like structure to palpate or hook;
    - references:
           - The Hook Test for Distal Biceps Tendon Avulsion
           - The Biceps Crease Interval for Diagnosing Complete Distal Biceps Tendon Ruptures.

- MRI:
- MRI may be useful if the diagnosis is in question;
- MRI may show a gap between the tendon and its insertion site on the tuberosity;

- Treatment:
- non operative treatment:
- supination decreases by 50% where as flexion strength will decrease by 35-40% & patients complain of prolonged pain;
- patients will note that loss of supination strength is more significant than loss of flexion strength;
- all pts rx'ed nonsurgically remain weak, esp in supination;
- decrease in endurance strength averages 40%.
            - references:
                     - Rupture of the distal tendon of the biceps brachi, Operative versus non-operative treatment.
                     - Avulsion of the distal biceps brachii tendon in middle-aged population: Is surgical repair advisable? A comparative study of 22 patients treated w/ either nonop management or early anatomical repair.
     - surgical treatment:
- surgery must be performed early to avoid scarring down of biceps;
- w/ inadequate mobilization of the biceps, the elbow will have to be left in flexion (up to 70 deg flexion);
- if flexion beyond 70 deg is required for tendon opposition to the radial tuberosity, consider the need for
a semitendinosus autograft;
- one incision (modified Henry approach):
            - two incision approach (Boyd and Anderson)
- references:
- A method for reinsertion of the distal biceps brachii tendon. HB Boyd et al. JBJS. 43-A. 1961. p 1041.
- Clinical, Functional, and X-ray of Conventional and Boyd-Anderson Surgical Procedures for Repair of Distal Biceps Tendon Ruptures.
                                    Patrick D'Arco MEd, ATC. American Journal of Sports Medicine Vol 26 No 2 March - April 1998
- Proximal radioulnar synostosis after repair of distal biceps brachi rupture by the two-incision technique. Report of four cases.
JM Failla et al. CORR. Vol 253.. p 133. 1990.
- tenodesis:
- w/ delayed treatment, the biceps may be attached to brachialis;
- this does not improve supination strength, but does improve flexion strength;
- alternatively, consider use of a tendon autograft;
- ref: Rupture of distal biceps tendon: Isokinetic power analysis and complications after anatomic reinsertion compared w/ fixation to brachialis muscle.

Rupture of the distal insertion of the biceps brachi tendon.

Rupture of the distal tendon of the biceps brachi. A biomechanical study.

Distal biceps brachii tendon avulsion: a simplified method of operative repair. DS Louis et al. Am J. Sports Med. Vol 14. 1986. p 234.

Distal biceps brachii repair. Results in dominant and nondominant extremities.

Rupture of the distal biceps tendon: biomechanical assessment of different treatment options. WH Norman. CORR. Vol 193. 1985. p 189.

Surgical Repair of Distal Biceps Tendon Ruptures. A Biomechanical Comparison of Two Techniques

Distal biceps tendon repair: Comparison of surgical techniques.

Radioulnar synostosis after the two-incision biceps repair: A standardized treatment protocol.

Failure Strengths in Distal Biceps Tendon Repair