Distal Biceps Tendon Rupture: A Historical Perspective and Current Concepts
Abstract & Commentary
Synopsis: Distal biceps tendon ruptures require repair, through a one- or two-incision approach, to restore proper function.
Source: Bernstein AD, et al. Distal biceps tendon ruptures: A historical perspective and current concepts. Am J Orthop. 2001;(3):193-200.
This study by Bernstein and colleagues is a nice review of the etiology, clinical evaluation, and treatment of ruptures of the distal insertion of the biceps brachii. An overview of the anatomy of this muscle is also included.
The biceps is the most powerful supinator of the forearm but also aids the brachialis in forearm flexion. Most distal ruptures are traumatic in origin, although pre-existing degenerative changes in the tendon, as well as chronic inflammation, have been suggested as contributing factors. This injury is typically seen in the dominant arm in men, 40-50 years of age. It is not commonly seen in athletes. Patients typically report hearing a pop and having pain and swelling following forced extension of the flexed elbow. On physical examination, diagnosis is confirmed by the absence of the palpable biceps tendon in the anticubital fossa. Supination weakness is also evident.
Operative correction is recommended, although complications following the procedure are not uncommon and include paresthesias, heterotopic ossification, and the development of radioulnar synostosis.
Comment by Letha Y. Griffin, MD, PhD
Distal biceps tendon ruptures are not as commonly encountered as proximal ruptures of the long head of the biceps. However, unlike proximal ruptures where, except in a select group of young athletes, conservative management is the rule, distal tendon ruptures necessitate operative correction with reattachment of tendon to the radial tuberosity. This is because there are 2 proximal origins but just 1 distal insertion for the biceps.
Various techniques for this repair have been described. Some investigators recommend using a 1-incision technique, whereas others have recommended 2 incisions in an attempt to avoid complications secondary to injury to the median or radial nerves during the dissection. In the 1-incision technique, exposure is by an anterior incision, through which not only is the biceps tendon found but the radial tuberosity is also exposed. In the 2-incision technique, exposure of the radial tuberosity is through a posterior-lateral approach. Recently, with the development of suture anchors, which decrease the need for extensive exposure of the radial tuberosity, there has been renewed interest in repairing the tendon through a single anterior incision.
The only large series of this injury occurring in athletes (primarily weight lifters) was reported by D’Alassandro and colleagues. In that study, all patients were able to return to full unrestricted activity, although there was an average loss of flexion endurance of 20%. As with other procedures around the joint, postoperative rehabilitation is important in restoring full function to the extremity.