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Distal Biceps Tendon Rupture: part one

- Discussion:
    - distal biceps may rupture off the radial tuberosity;
    - presents w/ painful swollen elbow usually in a 50-60 yo active male, most often in the dominant side (uncommon in women); 
    - incidence of distal biceps rupture is 1.2 per 100,000 persons per year;
    - single traumatic event involving flexion against resistance, w/ elbow at a right angle results in a sudden sharp tearing sensation
             (eccentric loading);
    - consequences of loss of strength:
             - 30 % decrease in flexion strength;
             - 40 % loss of supination strength;
    - partial biceps tendon rupture:
             - biceps tendon will still be palpable in the antecubital fossa;
             - biceps tendonitis and median nerve compression may be common following this injury;
             - ref: Partial rupture of the distal biceps tendon.
    - diff dx:
Spontaneous bacterial seeding of a biceps hematoma

- Exam:
    - weakness of flexion and supination;
    - carefully palpate for a residual biceps tendon in the antecubital fossa noting the partial rupture may be common; 
    - hook test:
           - patient actively supinates the flexed elbow;
           - intact hook test permits the examiner to hook his or her index finger under the intact biceps tendon from the lateral side;
           - w/ an abnormal hook test (distal avulsion), there is no cord-like structure to palpate or hook;
    - references:
           - The Hook Test for Distal Biceps Tendon Avulsion
           - The Biceps Crease Interval for Diagnosing Complete Distal Biceps Tendon Ruptures.

- MRI:
    - MRI may be useful if the diagnosis is in question;
    - MRI may show a gap between the tendon and its insertion site on the tuberosity;

- Treatment:
     - non operative treatment:
            - supination decreases by 50% where as flexion strength will decrease by 35-40% & patients complain of prolonged pain;
            - patients will note that loss of supination strength is more significant than loss of flexion strength;
            - all pts rx'ed nonsurgically remain weak, esp in supination;
            - decrease in endurance strength averages 40%. 
            - references:
                     - Rupture of the distal tendon of the biceps brachi. Operative versus non-operative treatment
                     - Avulsion of the distal biceps brachii tendon in middle-aged population: is surgical repair advisable? A comparative study of 22 patients treated with either nonoperative management or early anatomical repair.

     - surgical treatment:
            - surgery must be performed early to avoid scarring down of biceps;
            - w/ inadequate mobilization of the biceps, the elbow will have to be left in flexion (up to 70 deg flexion);
            - if flexion beyond 70 deg is required for tendon opposition to the radial tuberosity, consider the need for a
                     semitendinosus autograft;
            - one incision (modified Henry approach): 
            - two incision approach (Boyd and Anderson)
                    - references:
                           - A method for reinsertion of the distal biceps brachii tendon.  
                           - Clinical, functional, and radiographic assessments of Boyd-Anderson surgical procedures for repair of distal biceps ruptures.

                           - Proximal radioulnar synostosis after repair of distal biceps brachii rupture by 2-incision technique. Report of 4 cases
                           - Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial.
                           - Radiological and Clinical Evaluation of the Transosseous Cortical Button Technique in Distal Biceps Tendon Repair

            - tenodesis:
                    - w/ delayed treatment, the biceps may be attached to brachialis;
                    - this does not improve supination strength, but does improve flexion strength;
                    - alternatively, consider use of a tendon autograft;
                    - ref: Rupture of distal biceps: power analysis and complications after anatomic reinsertion compared with fixation to brachialis.

Rupture of the distal insertion of the biceps brachii tendon.

Rupture of the distal tendon of the biceps brachii. A biomechanical study.

Distal biceps brachii tendon avulsion: a simplified method of operative repair.  

Distal biceps brachii repair. Results in dominant and nondominant extremities.

Repair of avulsion of insertion of biceps brachii tendon

Surgical Repair of Distal Biceps Tendon Ruptures. A Biomechanical Comparison of Two Techniques

Distal biceps tendon repair: Comparison of surgical techniques.

Failure Strengths in Distal Biceps Tendon Repair

The Importance of Preserving the Radial Tuberosity During Distal Biceps Repair

Distal Biceps Brachii Tendon Rupture Resulting in Acute Compartment Syndrome