Treatment of Distal Biceps Tendon Ruptures Benjamin J
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(aspects of trauma • a review paper) Treatment of Distal Biceps Tendon Ruptures Benjamin J. Widmer, MD, and Robert Z. Tashjian, MD ABSTRACT n 1925, Biancheri1 examined nates at the supraglenoid tubercle Distal biceps tendon rupture is the incidence of biceps ten- and traverses the shoulder joint an injury typically reported in the don ruptures and found that before exiting through the later- dominant extremity of middle- 96% ruptured at the long head, al rotator cuff interval. It then aged men. Clinical findings are I 1% proximally at the short head, passes through the intertubercular the mainstay of diagnosis, but 2 magnetic resonance imaging or and 3% distally. In 1941, Dobbie groove into the proximal arm. The ultrasound imaging can provide specifically examined distal biceps short head takes origin from the additional diagnostic information. injuries and made an early attempt coracoid. The distal biceps ten- Anterior 1- or 2-incision repairs are at a meta-analysis. He reviewed the don inserts into the radial tuberos- commonly used. Various fixation 24 surgically treated cases of distal ity and supinates the forearm and techniques have been reported, biceps injuries previously reported assists with elbow flexion.8 It also all with comparable biomechani- in the literature and sent a ques- functions as a secondary elevator cal results and clinical outcomes. tionnaire to almost 500 active sur- and abductor of the shoulder.9 Complication rates are lower in patients treated closer to time of injury. Tendon retraction associat- ed with chronic ruptures can pre- sent a difficult surgical problem. “Partial ruptures should be treated Advanced soft-tissue imaging adds helpful information about the without surgery initially..” level of biceps tendon retraction Protected and possible reparability. When the tendon can be reapproximated geons. From their replies, he identi- Elbow and forearm position safely at less than 45° to 90° fied 51 new cases of distal biceps has been determined to affect the of elbow flexion, then primary repair may be performed. When injuries repaired with a variety of function of the biceps muscle. reapproximation is not possible, techniques and noted that the “end Electromyograms have demon- options are reconstruction and results as reported are equally satis- strated that the flexion activity of tenodesis. Reconstruction per- factory” independent of technique the biceps is inhibited by forearm formed through 1 or 2 incisions and are “for the most part excel- pronation.10 Maximum supination with either allograft or autograft lent.” He identified only 3 reported strength is achieved with forearm has successfully restored both complications. flexion, and maximum flexion motion and power. Interest in the surgical treatment strength is achieved with forearm of distal biceps injuries has continued supination.11 to grow with the 1961 description by The blood supply to the distal Dr. Widmer is Resident, and Dr. Tashjian Boyd and Anderson3 of a 2-incision biceps tendon is somewhat tenuous. is Assistant Professor, Department of repair technique and more recently The brachial artery provides proxi- Orthopaedics, University of Utah School with several reports4-7 of promis- mal perfusion, and the distal blood of Medicine, Salt Lake City, Utah. ing results with 1-incision repairs. supply stems from the posterior This increased interest is reflected radial recurrent artery and the bra- Address correspondence to: Robert in a “distal biceps tendon ruptures” chial artery. This leaves a watershed Z. Tashjian, MD, University of Utah PubMed search that yielded 46 cita- area approximately 2 cm in length Orthopaedic Center, 590 Wakara Way, tions for calendar year 2007. 1 to 2 cm proximal to the insertion.12 Salt LakeCopyright City, UT 84108 (tel, 801-587- 5457; fax, 801-587-5411; e-mail, robert. More details about the distal [email protected]). DISTAL BICEPS TENDON biceps footprint have been revealed ANATOMY in recent years. The biceps ten- Am J Orthop. 2010;39(6):288-296. The biceps muscle has 2 tendinous don occupies 85% of the proximal Copyright Quadrant HealthCom Inc. origins and 1 tendinous insertion. radioulnar joint at the level of the 2010. All rights reserved. The long head of the biceps origi- tuberosity in full pronation and 288 The American Journal of Orthopedics® B. J. Widmer and R.Z. Tashjian tinct distal tendons (distal exten- sions of the long- and short-head muscle bellies) were easily identi- fied as receiving equal musculocu- taneous innervation and attaching separately to the radial tuberosity. The long-head distal tendon was noted to be crescentic and deep and to insert proximally, whereas the short-head distal tendon was con- sistently oval and superficial and inserted distally14 (Figure 1). The tendon insertion is a mean Figure 3. Lateral antebrachial cutaneous 23 mm distal to the articular mar- nerve just lateral to distal biceps tendon gin, is located on the posterior/ during anterior approach for repair. ulnar aspect of the tuberosity, and is oriented 30° anterior to the coro- Andover, Mass), and so forth—is Figure 1. Anatomy of radial tuberosity nal plane with the arm fully supi- directed slightly radial during inser- insertion of distal biceps tendon. nated.15 With the arm in full supi- tion (Figure 2). nation, the center of the tuberosity 35% in full supination. This repre- is a mean 45° anterior to horizontal SURGICAL ANATOMY sents a 50% reduction in the space in the plane of the forearm, and the An understanding of the relevant available for the tendon during posterior margin of the tuberosity surgical anatomy is essential to safe transition from supination to pro- is a mean 15° anterior to horizontal and efficient distal biceps repair. nation.12 The radial tuberosity has in the plane of the forearm. These The musculocutaneous nerve been found to have 2 distinct por- anatomical properties result in the innervates the biceps and brachialis tions—a rough posterior portion tendon inserting approximately 30° and then continues in the interval for tendon insertion and a smooth, anterior to horizontal in the plane between these 2 muscles as the bursa-covered anterior portion.12 of the forearm (halfway between lateral antebrachial cutaneous The tuberosity is 24 mm proximal the posterior margin andProtected the tuber- (LABC) nerve. This nerve provides to distal and 12 mm medial to lat- osity center) in full supination. sensation to the lateral forearm. eral. The tendon footprint is 19 mm When there is a rotational deficit It should be carefully identified proximal to distal and 4 mm medial limiting full supination, this loca- and protected during distal biceps to lateral.13 Therefore, the tendon tion can make a 1-incision repair repair, as a traction injury can attaches to only approximately one difficult. Similarly, with the 1-inci- result in numbness or paresthe- third of the overall width of the sion technique, a more anatomi- sias along the forearm. The LABC tuberosity (Figure 1). In addition, cal repair can be achieved when nerve is superficial and just lateral an anatomical study demonstrated the fixation instrument—anchors, to the biceps tendon and is easily that, in 10 of 17 specimens, 2 dis- EndoButton (Smith & Nephew, identified during initial exposure (Figure 3). Care should be taken during repair to not reroute the distal biceps anterior to the nerve. The radial nerve runs between the brachialis and the brachiora- dialis and is usually out of the surgical field during dissection. It bifurcates just anterior to the lat- eral epicondyle, and the posterior interosseous nerve courses radially to enter the supinator while the Copyright superficial radial nerve continues distally beneath the brachiora- dialis. Although the nerve is not routinely exposed during surgery, constant awareness of it and its dis- tal posterior interosseous branch is Figure 2. Angulation of radial tuberosity insertion of distal biceps tendon. needed while retractors are being June 2010 289 Treatment of Distal Biceps Tendon Ruptures and age-matched cadaveric controls of a variety of ruptured tendons, including the distal biceps. All ruptured tendons were abnormal: 97% demonstrated degenerative changes, and inflammatory find- ings accounted for the other 3%. In the age-matched cadaveric controls, however, degenerative changes were found in only 34% of specimens. Finally, a relatively hypovascular zone of the distal tendon has been Figure 4. Hook test. Patient’s arm is abducted and elbow flexed to 90° with forearm in proposed as a possible predispos- supination; examiner hooks index finger behind distal biceps tendon. ing factor leading to distal biceps tendon ruptures. The hypovascular placed posterolateral to the radial to 39, 0.5 in ages 40 to 49, and 0.7 zone is located within the tendon tuberosity. We prefer to not hook in ages 50 to 59. Ninety-three per- substance distally, not directly at instruments, like Hohman retrac- cent of patients were men, and 50% the tendon insertion. Most ruptures tors, posterior to the radius but of cases were in patients 30 to 39 are tuberosity avulsions, not mid- rather to use several deep right- years old. The dominant extremity substance ruptures, though muscu- angle retractors for exposure. The was involved in 86% of cases, and lotendinous injuries have also been median nerve courses ulnarly to an eccentric contraction preceded described.12,20 Therefore, given the the brachial artery and along the all injuries. Smokers had more than common location of tendon rup- radial aspect of the pronator teres 7-fold increased risk for rupture. tures, the zone of limited vascular- before diving deep to the flexor ity is unlikely to have a significant digitorum superficialis. Finally, the ETIOLOGY effect on the rate of ruptures. lacertus fibrosis extends from the The etiology of distal biceps ten- biceps tendon ulnarly and overlies don injuries is multifactorial and Clinical Evaluation the brachial artery, the bifurca- includes mechanical failure, tendon Distal biceps tendon injuries rep- tion of the brachial artery, and the degeneration, and limitedProtected vascu- resent a spectrum of disease from median nerve.