Distal biceps tendon injuries: A clinically relevant current concepts review

Abstract

Distal biceps tendon (DBT) conditions comprise a spectrum of disorders including bicipitoradial bursitis, partial tears, acute and chronic complete tears.In low-demand patients with complete DBT tears, non-operative treatment may be entertained provided the patient understands the potential for residual weakness, particularly in forearm supination.Most acute tears are best treated by primary repair using either single-incision or double-incision techniques with good clinical outcomes.Single-incision techniques may carry a higher risk of nerve-related complications, whereas double-incision techniques have historically been considered to carry a higher risk of heterotopic ossification, particularly if the ulna is exposed.Various fixation techniques, including bone tunnels, cortical buttons, suture anchors, interference screws or a combination seem to provide different fixation strength but similar clinical outcomes.Some chronic tears may be repaired primarily, provided tendon tissue can be identified; alternatively, autograft or allograft reconstruction can be considered, and good outcomes have been reported with both techniques. Cite this article: Alentorn-Geli E, Assenmacher AT, Sanchez-Sotelo J. Distal biceps tendon injuries: a clinically relevant current concepts review. EFORT Open Rev 2016;1:316-324. DOI: 10.1302/2058-5241.1.000053.

Keywords: distal biceps tendon; elbow; repair; tendon tear.

Fig. 1

The hook test for distal biceps tendon, as described by O’Driscoll. a) The normal test in which the examiner’s finger to can be hooked under the biceps tendon. (Used with permission of the Mayo Foundation for Medical Education and Research. All rights reserved). b) The abnormal test, in which the examiner is unable to hook the distal biceps tendon. (Used with permission of the Mayo Foundation for Medical Education and Research. All rights reserved). c) Demonstration of a normal hook test. As shown, a cord-like structure is felt under the index finger. d) Clinical picture demonstrating an abnormal hook test. The examiner is unable to feel the cord-like structure corresponding to the distal biceps tendon.

Fig. 2

Clinical and imaging demonstration of the FABS test as described by Giuffrè and Moss. (Used with permission of the Mayo Foundation for Medical Education and Research. All rights reserved). a) Clinical image of the FABS position with the patient lying supine, the shoulder fully abducted and the elbow and supinated. b) MRI appearance of the FABS position. Note the normal distal biceps tendon (white arrows and arrow heads).

Fig. 3

Representation of the two-incision technique for repair of acute distal biceps tendon ruptures. (Used with permission of the Mayo Foundation for Medical Education and Research All rights reserved). a) Location of the transverse anterior incision at the level of the distal humerus-anterior elbow, and the longitudinal posterior incision at the level of the posterior and proximal forearm. b) Trimming of the tendon, and creation of the passing plane with a blunt instrument from the anterior incision to the posterior aspect of the proximal forearm following the tract of the biceps tendon. The skin is indented and a knife is used to create the second incision over the instrument. c) Demonstration of the relevant anatomy to create the passing plane for the distal biceps tendon. Note that the common extensor and supinator muscles are split to expose the radial tuberosity, avoiding exposure of the ulna. d) Passing of the distal biceps tendon (with the Krakow suture) from the anterior-proximal incision to the posterior-distal incision.

Fig. 4

Surgical photographs demonstrating the two-incision distal biceps reconstruction technique for chronic tears using an Achilles tendon allograft. a) A double Krakow suture is placed in the distal Achilles allograft. The Achilles allograft is then brought through the anterior incision and passed to the posterior-distal incision. b) Detail of the attachment of the Achilles allograft into the native remnant of the distal biceps tendon (white arrow). The remaining allograft tissue (black arrow) will be attached to the remaining distal biceps muscle (black arrow head). c) The graft is typically tensioned in approximately 45° of flexion, but the position varies depending on the shape of the biceps as compared with the opposite, normal side. d) Final demonstration of the reconstruction. The distal biceps tendon has been reconstructed with the Achilles tendon allograft (black arrow).