Distal Biceps Injury: Surgery and Rehabilitation

Caroline Chebli, MDKennedy-White Orthopaedic Center

Distal Biceps Tears

Caused by the elbow being forced straight against resistance (eccentric load)

Most commonly seen in men 40-60 yrs old-86% in dominant arm

Incidence 1.2/100,000 people per year Rare in women 7.5x incidence in smokers

Distal Biceps Tear

Results in 30% loss of flexion strength

40% loss of supination strength

Best if done within a few weeks of injury

Hook Test

O’Driscoll et al Elbow flexed 90 degrees Forearm supinated Examiner hooks biceps

with finger from lateral side

100% sensitivity and specificity

Fixation Techniques

Repair needs to withstand 50N of force=force on biceps with elbow flexed to 90 degrees

1kg weight, force at 90 degrees is 112N Takes 204N to rupture a distal biceps

Fixation Techniques

Two-Incision (Boyd-Anderson)

One Incision

El-Hawary, et al. J Hand Surg Am. 2003;28:496-502.Mckee et al. J Shoulder Elbow Surg 2005;14:302-306.Kelly et al. JBJS Am. 2000;82:1575-1581

One-Incision Technique

Originally an S-shaped Henry approach – Extensile– High rate of nerve injuries

Now a smaller incision distal to the flexor crease is utilized– Lower complication

profile– Fixation techniques:

suture anchor repair, cortical button, interference screw, hybrid technique

One Incision Technique

Pros– Direct approach, avoids

PIN injury (?)– Lower risk of HO and

radioulnar synostosis

Cons– May injure radial nerve– LABC nerve injury

2-Incision Technique

Originally described by Boyd and Anderson

Modified by Kelley et al. Small transverse incision

antecubital fossa Retrieve tendon and palpate

radial tuberosity Curved clamp to identify dorsal

surface Split ECU Repair via bone tunnels

Two Incision Technique

Pros– Limits anterior

exposure/limits pain– Reduces injury to radial

nerve– Reduces injury to LABC

nerve

Cons– May have to detach

supinator– Radioulnar synostosis risk

My Preferred Technique

Tension Slide Technique Utilizing a Biceps Button

1-incision – 4cm incision 4cm distal to

flexor crease

Biceps Button

Fiberloop suture distal 2 cm of biceps tendon

Biceps Button

Exposure– Between brachioradialis

(radial) and pronator teres (ulnar)

– Limit traction on LABC nerve under BR

Biceps Button

Maximally supinate forearm

Expose radial tuberosity

Biceps Button

Bicortical Pin– 3.2 mm guide pin

bicortical through center of radial tuberosity

– Aim 30 degrees ulnar and proximal to avoid PIN

– 8mm unicortical hole– Irrigate

Biceps Button

Thread the Biceps Button

Biceps Button

Insert the Biceps Button– Hold all 4 strands and use

button inserter– Flip button and slide

tendon into 8mm unicortical hole

Biceps Button

Insert 7x10 tenodesis screw

Push tendon ulnar

Post Operative Care

Splint arm at 90 degrees for 10 days to 2 weeks

Place in removable elbow brace and lock at 90 degrees

2-6 Weeks

Hinged elbow brace at all times Remove for home exercises 3

times a day If not progressing well at 4 weeks

with HEP will send to PT for ROM Passive ROM

– Full flexion/extension/pronation/

supination

2-6 weeks

Shoulder ROM while in brace Hand and wrist ROM

6 Weeks-3 Months

Active and active assisted elbow ROM

Forearm strengthening Shoulder ROM Scapular stabilizer

strengthening 5 lb weight limit

3 Months

Elbow, wrist, hand, and shoulder strengthening

5 lb weight increase per week

5-6 Months

Return to full activity

Thank You