Review Question - QID 214099

This patient has a classic history and exam for a ruptured distal biceps tendon. During the volar approach, the recurrent radial artery is encountered crossing near the biceps tuberosity and is often ligated during the procedure.

Distal biceps ruptures are common athletic injuries frequently occurring during eccentric muscle contraction. The biceps' primary function is to supinate the forearm, with lesser contributions to elbow flexion. Though non-operative treatment is sometimes tolerated in less-active individuals, most require surgical repair, or in chronic cases, tendinous reconstruction. With the volar antecubital approach, the lateral antebrachial cutaneous nerve is immediately encountered, exiting laterally between the biceps and brachialis muscles. During the deep dissection, the recurrent radial artery is found near the tuberosity. This should either be dissected and carefully retracted from the field or ligated to prevent disruption and hematoma formation. The posterior interosseous nerve is located more lateral and dorsal at this level, and avoiding forceful retraction limits the risk of injury.

Sutton et al. provided an overview on distal biceps rupture management. They discussed the advantages and disadvantages of single- or dual-incisions techniques, and the various fixation devices available for repair. They concluded both techniques are safe and effective but the surgeon should be mindful of the pertinent nearby neurovascular structures.

Lin et al. reviewed the clinical utility of ultrasound in the upper extremity. Thought the ultrasound is user-dependent, it is immediately available at the point of care, and can aid in both diagnosing common tendinopathies and for injection-guidance. Given these benefits, they advocated for the implementation of ultrasound into the orthopedic residency curriculum.

Illustration A demonstrates the classic "reverse popeye" sign from the bunching of the biceps muscle belly proximally. Illustration B shows the method of visualizing the distal biceps tendon (DBT) and muscle belly (DBM) with the ultrasound probe, creating an image analogous to a sagittal MRi sequence. Illustration C reveals the radial recurrent artery crossing the distal biceps tendon.

Incorrect Answers:
Answer 1: The anterior interosseous artery branches from the ulnar artery and courses along the interosseous membrane.
Answer 2: The anterior recurrent artery branches from the ulnar artery and courses proximal and superficial to the brachialis insertion.
Answer 4: The recurrent interosseous artery branches from the posterior interosseous and is located in the posterior forearm.
Answer 5: The ulnar artery is far medial to the biceps tuberosity and runs between the FDS and FDP muscle bellies.