Overview
Distal biceps rupture typically occurs in middle-aged men during heavy lifting with the elbow flexed 90 degrees or with sudden contraction against resistance (Campbell). Patients report a pop, followed by antecubital pain, swelling and ecchymosis, proximal migration of the muscle, a palpable defect and weakness of flexion and supination. With the elbow extended the biceps is twice as powerful as the supinator, and more so in flexion, so most authors reattach the tendon anatomically to the radial tuberosity (Campbell).
Diagnosis (Campbell)
Test | Method | Positive result |
|---|---|---|
Biceps squeeze test | Patient seated, elbow 60-80 degrees; squeeze the biceps firmly at the myotendinous junction and belly | No forearm supination (PPV 95%, sensitivity 100%) |
Hook test | Elbow flexed and supinated; hook the index finger under the lateral edge of the tendon in the antecubital fossa | Unable to hook a cordlike structure (100% sensitivity and specificity when done correctly). Hooking the medial edge may mistake the lacertus fibrosus for an intact tendon |
Partial ruptures cause pain and weakness of flexion and supination but the tendon remains palpable; they may compress the median nerve in the proximal forearm.
MRI distinguishes complete from partial tears and shows tendinosis, tenosynovitis, hematoma and brachialis contusion; the FABS position (elbow 90 degrees flexion, shoulder 180 degrees abduction, forearm supination) gives a true longitudinal view. Ultrasound is faster and cheaper but user dependent; in one comparison MRI accuracy, sensitivity and specificity were 86%, 76% and 50% versus 45%, 62% and 20% for ultrasound.
Treatment Considerations (Campbell)
Timing: delayed repair has higher complication rates (retraction, atrophy, scar). Early repair gives better outcomes, although recent reports show delayed reconstruction (more than 21 days, e.g., semitendinosus autograft) achieves similar strength and motion with somewhat lower scores.
Single- versus two-incision: most studies report similar outcomes. Nerve injuries are more frequent with single-incision techniques; heterotopic ossification and radioulnar synostosis are more common after two-incision techniques. In one series of 784 repairs, the double-incision technique had more posterior interosseous nerve palsy, heterotopic bone and reoperations; another of 970 repairs found more synostosis and neuritis with two incisions.
Single-incision advantages: limited tuberosity exposure, better cosmesis, less heterotopic ossification. Disadvantages: expensive hardware, possibly less secure fixation, no bony trough for revascularization.
Fixation: biomechanical results conflict (buttons strongest in some studies; transosseous sutures stronger than anchors in others; all-suture and titanium anchors similar). Interference screws have a higher risk of anatomic failure than anchors, without functional difference.
Campbell's Concepts: Avoiding Heterotopic Ossification and Synostosis (Two-Incision Technique)
Make the trapdoor with an osteotome rather than a drill, to avoid scattering bone particles into the interosseous space; or substitute a trough.
Minimize disruption of the interosseous membrane; pass a curved clamp around the radial neck without touching the ulna.
Use a small transverse anterior incision instead of a curvilinear one.
Technique 53.32: Two-Incision Repair (Boyd and Anderson) (Campbell)
Make a 2-cm transverse anterior incision and a 6- to 8-cm posterolateral incision along the ulnar border.
Open the deep fascia and identify the biceps tendon by palpation.
Locate the original tunnel through the interosseous membrane.
Place Krakow locking stitches in the tendon end, keeping each throw close to the previous one so the end does not bunch and can seat in the trough.
Deliver the tendon with a long curved hemostat from the anterior to the posterolateral incision, avoiding multiple passes through the membrane.
Deepen the posterolateral incision, identify the anconeus and dissect it sharply off bone; pronate the forearm to protect the posterior interosseous nerve.
Make a trough ("trapdoor") in the tuberosity with a small curved 1/4-inch osteotome.
Drill two holes in the dorsal aspect of the trough, leaving a 10-mm bone bridge.
Pass the sutures, and with them the tendon, through the interosseous membrane.
Pass each suture through the trough and out its drill hole with a suture passer.
Pull the tendon into the trough and tie the sutures securely over bone.
Close the anterior incision with the elbow flexed about 60 degrees; release the tourniquet and close the posterolateral incision.
Postoperative care: posterior plaster splint with the elbow at 110 degrees and the forearm in moderate supination; at 2 weeks remove splint and sutures and fit a hinged brace for 4 weeks with passive flexion and active extension progressing 15-20 degrees per week; add pronation-supination at 4-6 weeks; full motion by 6-8 weeks; return to full activity at 12-16 weeks.
Technique 53.33: Single-Incision Repair (Campbell)
Make a 3- to 4-cm anterior longitudinal incision (Henry approach). Ligate superficial antecubital veins as needed and identify and preserve the lateral antebrachial cutaneous nerve.
Retrieve the torn tendon and keep it in a moist sponge.
Ligate the radial recurrent vessels.
Use deep retractors to expose the radial tuberosity; debride the tendon remnant and elevate the periosteum with a curette.
Fix the tendon to the tuberosity with bone tunnels, suture anchors, a cortical button, or tenodesis/interference screws.
Move the forearm through full pronation and supination to confirm smooth tracking.
Postoperative care: immobilize at 90 degrees for 2 weeks (suture removal), then a hinged brace with an 80-degree extension stop, full passive flexion and passive pronation-supination to 90 degrees; from 6 weeks progressive extension of 20 degrees per week; active flexion at 8 weeks; strengthening at 12 weeks; unrestricted use at 16 weeks. An early-motion protocol in a sling as tolerated has been shown to be safe with no clinical difference.
Complications (Campbell)
Nerve injury: lateral antebrachial cutaneous and posterior interosseous nerves (more common with single-incision repair).
Heterotopic ossification and radioulnar synostosis (more common with two-incision repair).
Re-rupture or fixation failure (higher anatomic failure with interference screws).
References
Bernholt DL, Azar FM. Traumatic disorders. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 53, Techniques 53.32-53.33.