Distal biceps ruptures: open and endoscopic techniques

Abstract

Distal biceps tendon ruptures are relatively rare. Patients are usually middle-aged men involved in heavy labor. Patients usually present with the history of a pop and a proximal migration of the biceps muscle belly. Clinical exam should be sufficient to diagnose a complete rupture. Several specific tests have been described. Ultrasound scanning or MRI can help confirm the diagnosis. Radiographs are not needed to diagnose distal biceps tendon rupture but may show typical findings. Imaging, more specifically the flexion-abduction-supination (FABS) view MRI, is particularly helpful in the case of a partial rupture or chronic rupture of the distal biceps tendon. Results of surgical reinsertion of the distal biceps have been shown to be superior to conservative treatment. Different techniques and approaches have been described with specific advantages and disadvantages. Primary repair of the tendon is preferred. If this is no longer possible in chronic tears, an augmentation can be done using tendon graft. Results of surgical treatment are good in the vast majority of patients. Reruptures are rare but minor complications are common. Major complications may include posterior interosseous nerve palsy or radioulnar synostosis, but the risk of these complications may be decreased by meticulous attention to detail during surgery.

Keywords: Avulsion; Biceps endoscopy; Biceps tendon; Double incision; Rupture; Single incision.

Fig. 1

Proximal retraction of the biceps muscle belly can occur with a complete distal biceps tendon rupture. Reprinted with Permission from MoRe Foundation

Fig. 2

Lateral radiograph of a patient with a complete distal biceps tendon rupture showing flattening and degenerative changes of the bicipital tuberosity. Reprinted with Permission from MoRe Foundation

Fig. 3

The diagnosis of a complete rupture of the distal biceps tendon can easily be confirmed with ultrasound scanning. Reprinted with Permission from MoRe Foundation

Fig. 4

Magnetic resonance image showing a complete distal biceps tendon avulsion. Reprinted with Permission from MoRe Foundation

Fig. 5

A FABS view MRI is particularly helpful in partial or chronic tendon ruptures. It allows for a clear view of both the insertion and the course of the tendon. Reprinted with Permission from MoRe Foundation

Fig. 6

The lateral antebrachial cutaneous nerve (asterisk) is located just radial to the incision superficial to the brachioradialis muscle. It is vulnerable during the approach but can also be injured by excessive retraction. Reprinted with Permission from MoRe Foundation

Fig. 7

The scope is entered into the bicipital bursa, between the tendon and the tuberosity. Reprinted with Permission from MoRe Foundation

Fig. 8

Endoscopic view of a bone anchor repair of a partially torn distal biceps tendon. Reprinted with Permission from MoRe Foundation

Fig. 9

The tendon is sutured to a cortical button. The stump will be debrided, leaving a 2-mm gap between the tendon and the button. Reprinted with Permission from MoRe Foundation

Fig. 10

Both the 8-mm drill hole in the near cortex and the 4.5-mm drill hole in the far cortex are seen. The cortical button will be pulled past the second cortex and flipped, thereby securing the tendon in the intramedullary canal of the proximal radius. Reprinted with Permission from MoRe Foundation

Fig. 11

Postoperative radiograph showing correct position of the cortical button and ingrowth of the tendon in the canal. Reprinted with Permission from MoRe Foundation

Fig. 12

Postoperative CT scan, showing a significant amount of heterotopic ossification following a cortical button repair of the distal biceps. Although rotation was limited, this did not bother the patient and he declined revision surgery. Reprinted with Permission from MoRe Foundation