Distal Biceps Tendon Rupture: JBJS Summary

JBJS SUMMARY

Shoulder & Elbow

Distal Biceps Tendon Rupture

By: E. Scott Paxton, MD

Published: February 10, 2022

Distal biceps tendon ruptures typically affect middle-aged males, with rupture occurring during an eccentrically applied load into forced extension on the dominant extremity. Diagnosis is often clinical, and advanced imaging is rarely needed. Nonoperative treatment should be reserved for the elderly or low-demand patient because it results in significant loss of supination strength.‍^[1]

Multiple repair techniques have been described. Regardless of technique, operative treatment has a high success rate. A review of 190 cases reported a re-rupture rate of 1.5%, with most of those occurring within the first 3 weeks of index surgery and associated with a traumatic event or patient noncompliance.‍^[2]

Both single-incision and two-incision techniques have been described, with great success reported for both. A randomized controlled trial of a single-incision versus a two-incision technique found no difference in patient-reported outcome scores, although the two-incision technique resulted in a slightly lower complication rate and in 10% higher elbow flexion strength.‍^[3] Beks et al. found that a single-incision technique and obesity were associated with a higher rate of complications. ‍^[4]

Initial reports of the two-incision technique showed a high rate of synostosis secondary to the aggressive surgical dissection of both the proximal ulna as well as the radius. Newer techniques and the use of indomethacin postoperatively have reduced synostosis rates to <1%.‍^[5] The two-incision technique allows more anatomic placement of the insertion site, which improves supination strength but carries a risk of supinator muscle damage or denervation, both of which decrease supination strength.‍^[6] Hansen et al. performed postoperative CT scans and asserted that ideal suture anchor placement could not be performed through a single-incision technique, with suboptimal anchor placement leading to loss of supination strength in their patients.‍^[7]

Patients presenting in a delayed fashion may experience a higher rate of transient neurapraxia after surgical repair, although final functional outcomes have not been shown to differ compared to those of acute repairs.‍^[8] Therefore, repair of the ruptured tendon is an option for those presenting late.

Complications of distal biceps repair are usually minor and include transient neurapraxia of the lateral antebrachial cutaneous nerve, with consequent radial-sided forearm numbness. Posterior interosseus nerve palsies may also occur. Fortunately, these nerve palsies resolve over 3 to 7.5 months.

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References

[1]

Nonoperative Treatment of Distal Biceps Tendon Ruptures Compared with a Historical Control Group

Freeman, Carl R. MD; McCormick, Kelly R. MD; Mahoney, Donna CHT; Baratz, Mark MD; Lubahn, John D. MD

JBJS-Am, October 2009; 91(10); 2329–2334

http://dx.doi.org/10.2106/JBJS.H.01150

[2]

Re-rupture rate of primarily repaired distal biceps tendon injuries.

Hinchey JW, Aronowitz JG, Sanchez-Sotelo J, Morrey BF.

J Shoulder Elbow Surg., June 2014; 23(6); 850-4

https://www.ncbi.nlm.nih.gov/pubmed/24774620

[3]

Single Versus Double-Incision Technique for the Repair of Acute Distal Biceps Tendon Ruptures: A Randomized Clinical Trial

Grewal, Ruby MD, MSc, FRCSC; Athwal, George S. MD, FRCSC; MacDermid, Joy C. BScPT, MSc, PhD; Faber, Kenneth J. MD, MHPE, FRCSC; Drosdowech, Darren S. MD, FRCSC; El-Hawary, Ron MD, MSc, FRCSC; King, Graham J.W. MD, MSc, FRCSC

JBJS-Am, July 3, 2012; 94(13); 1166-1174

http://dx.doi.org/10.2106/JBJS.K.00436

[4]

Factors Associated With Adverse Events After Distal Biceps Tendon Repair or Reconstruction

Beks RB, Claessen FM, Oh LS, Ring D, Chen NC.

J Shoulder Elbow Surg. , August 2016; 25(8); 1229-34

https://www.ncbi.nlm.nih.gov/pubmed/27107731

[5]

The use of indomethacin in the prevention of postoperative radioulnar synostosis after distal biceps repair.

Costopoulos CL, Abboud JA, Ramsey ML, Getz CL, Sholder DS, Taras JP, Huttman D, Lazarus MD.

J Shoulder Elbow Surg. , February 2017; 26(2); 295-298

https://www.ncbi.nlm.nih.gov/pubmed/28104092

[6]

Factors That Determine Supination Strength Following Distal Biceps Repair

Schmidt, Christopher C. MD; Brown, Brandon T. MMEng; Qvick, Lars M. MD; Stacowicz, Rafal Z. MD; Latona, Carmen R. MD; Miller, Mark Carl PhD

JBJS-Am, July 20, 2016; 98(14); 1153-11600

http://dx.doi.org/10.2106/JBJS.15.01025

[7]

Anatomic repair of the distal biceps tendon cannot be consistently performed through a classic single-incision suture anchor technique.

Hansen G, Smith A, Pollock JW, Werier J, Nairn R, Rakhra KS, Benoit D, Papp S.

J Shoulder Elbow Surg., December 2014; 23(12); 1898-904

https://www.ncbi.nlm.nih.gov/pubmed/25219473

[8]

Delayed repair of distal biceps tendon ruptures is successful: a case-control study.

Haverstock J, Grewal R, King GJW, Athwal GS.

J Shoulder Elbow Surg., June 2017; 26(26); 1031-1036

https://www.ncbi.nlm.nih.gov/pubmed/28526421

Related Images from JBJS

Preoperative images. Fig. 1-A An anteroposterior radiograph showing a hypertrophic change in the radial tuberosity. Fig. 1-B A sagittal T2-weighted magnetic resonance image showed complete rupture of the distal biceps tendon associated with 65 mm of proximal retraction.

A Novel Reconstruction Technique for Chronic Distal Biceps Tendon Rupture

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Skin incision made before right distal biceps reconstruction.

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Fig. 1-A T2-weighted sagittal magnetic resonance image through the medial portion of the biceps, showing that the distal tendon (arrow) is detached and retracted. Fig. 1-B T2-weighted sagittal magnetic resonance image through the lateral portion of the biceps, showing an intact muscle-tendon unit (arrow).

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Active ROM of the elbow and forearm 2 years 10 months after surgery. ROM = range of motion.

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Coronal view of the elbow demonstrating the neurovascular anatomy. BT = biceps tendon, LHA = long head of the biceps tendon attachment, SHA = short head of the biceps tendon attachment, R = radius, U = ulna, H = humerus, B = brachioradialis, BA = brachial artery, MN = median nerve, LABCN = lateral antebrachial cutaneous nerve, RRA = recurrent radial artery, RN = radial nerve, BECRL = branch to the extensor carpi radialis longus, BECRB = branch to the extensor carpi radialis brevis, DBRN = deep branch of the radial nerve, and SFBR = superficial branch of the radial nerve.

Surgical Management of Acute Distal Biceps Tendon Ruptures

Savin, David D.; Watson, Jonathan; Youderian, Ari R.; Lee, Simon; Hammarstedt, Jon E.; Hutchinson, Mark R.; Goldberg, Benjamin A.

J Bone Joint Surg Am, 99(9):785-796 | Current Concepts Review | May 03, 2017

CT obtained at the 2-year-10-month follow-up. Bony union of the grafted iliac crest and continuity of the reconstructed distal biceps tendon (arrow) were confirmed. CT = computed tomography.

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Deep exposure. The scarred tendinous portion of the distal biceps is held with a clamp (arrowhead). The mosquito clamp is on the radial tuberosity (arrow).

A Novel Reconstruction Technique for Chronic Distal Biceps Tendon Rupture

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JBJS Case Connect, 13(3):e23.00184 | Case Reports | August 09, 2023

T2-weighted sagittal MRI showing LHB retraction.

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Coronal T1-weighted magnetic resonance imaging (MRI) of the shoulder showing bicep tendinopathy. Coronal T1-weighted magnetic resonance imaging (MRI) of the shoulder showing bicep tendinopathy.

Rupture of the Proximal Long Head of Biceps Tendon Presenting as a Pectoralis Major Tear

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The incision is in the right antecubital fossa, and the retractors are distal. The distal biceps tendon (arrow) courses from lateral to medial, superficial to the median nerve (asterisks). The tendon compresses the nerve proximally and then spirals posterior to the nerve as it courses to the radial tuberosity. The tendon should have been placed lateral to the median nerve.

Surgical Repair of Distal Biceps Tendon Rupture Complicated by Median Nerve Entrapment

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J Bone Joint Surg Am, 83(5):741-743 | Case Report | May, 2001