Acute complete and partial distal biceps tendon ruptures: what have we learned? A review

Abstract

Acute distal biceps tendon (DBT) pathology includes bicipitoradial bursitis, tendinosis, partial and complete tears.Diagnosis of complete DBT tears is mainly clinical, whereas in partial tears medical imaging is a valuable addition to the clinical diagnosis.New insights in clinical and medical imaging of partial tears may reduce time to diagnosis and may guide the treatment plan.Most complete tears are best treated with primary repair using either a single-incision or double-incision approach with good clinical outcome.The double-incision technique has a higher risk of heterotopic ossification, whereas a single-incision technique carries a higher risk of nerve-related complications.Intramedullary fixation may be a viable solution to negate the risk of posterior interosseus nerve lesions in single-incision repairs.DBT endoscopy can be used to treat low-grade partial tears and tendinosis. Cite this article: EFORT Open Rev 2021;6:956-965. DOI: 10.1302/2058-5241.6.200145.

Keywords: complete; distal biceps tendon; elbow; intramedullary; partial; review; rupture; test.

Fig. 1

The short and long head of the distal biceps tendon have distinct insertion areas. Note. Copyright MoRe Foundation.

Fig. 2

Localization of the lateral antebrachial cutaneous nerve (LACN), the superficial branch of radial nerve (SBRN), the median nerve (MN), the ulnar artery (UA), radial and recurrent radial arteries (RA), and their bifurcation. Biceps flagged with white arrow. Note. Copyright MoRe Foundation.

Fig. 3

The posterior interosseous nerve runs in close contact with the radius, circling the bone from anterior to posterior. The exact position with regard to the distal biceps tendon and radial tuberosity depends on the position of the forearm in supination or pronation. Position shown in relation to a bicortical button. Note. Copyright MoRe Foundation.

Fig. 4

A reverse Popeye sign can be seen in complete distal biceps tendon ruptures. Note. Copyright MoRe Foundation.

Fig. 5

(A) The biceps provocation test is a two-part test. The patient is standing, with the elbow supported by the examiner and flexed to 70 degrees. The examiner’s hands are placed on the patient’s forearm and the patient is asked to flex the elbow against resistance with the forearm supinated (ABTs). The forearm is then pronated, and the test is repeated (ABTp). Care is taken not to place the hands on the hand or wrist, as resisted wrist flexion or extension might elicit pain in other elbow pathologies. (B) On the left, the position of the biceps tendon with the forearm supinated (tear in green). On the right, the position of the biceps tendon with the forearm pronated (tear in red). As the distal biceps tendon wraps around the radial tuberosity when the arm is pronated, the tendon is stretched and compressed when the biceps is activated. Note. Copyright MoRe Foundation.

Fig. 6

(A) Flexion-abduction-supination view positioning with shoulder abduction and elbow flexion-supination. (B) Flexion-abduction-supination magnetic resonance imaging view (three-dimensional double-echo steady state with water excitation) showing normal distal biceps tendon. The entire tendon can be viewed from the insertion to the musculotendinous junction on a single image. Note. Copyright MoRe Foundation.

Fig. 7

Image of the intramedullary button. The pedals of the button span over the radial tuberosity with a fixation on the strong anterior cortex. Note. Copyright ORF Foundation.

Fig. 8

(A) Flexion abduction supination view of a partial distal biceps tendon tear. (B) Endoscopic view of the same distal biceps tendon insertion. Endoscopic debridement is a viable solution for low-grade partial tears. Note. Copyright MoRe Foundation.