Review Question - QID 219930

The patient has undergone a distal biceps tendon repair with a suspensory button and supplemental biotenodesis screw fixation. Increasingly ulnar position of the distal biceps insertion and theoretically improving the lever arm for forearm rotation/supination (Answer 4).

Distal biceps rupture is a common injury to the elbow most commonly sustained to the dominant elbow in men. The injury most commonly occurs during eccentric load, and patients present typically with pain, swelling, and possibly a reverse "popeye" deformity as the muscle retracts proximally. Patients treated nonoperatively lose approximately 30% of elbow flexion and 40% of forearm supination strength. Operative management focuses on the anatomic fixation of the distal biceps tendon to the radial tuberosity. Repair can be performed through a single or dual incision technique. Fixation can be achieved with bone tunnels, suture anchors, endobuttons, suspensory buttons, and biotenodesis screws. Care is taken to position the insertion of the tendon as ulnar on the radial tuberosity as safely feasible to optimize the windlass effect of the distal biceps tendon and increase forearm supination strength.

Baratz et al. perform a review of the surgical treatment options for distal biceps tendon repair. They discuss the consequences of nonoperative management and quote an average of 40% loss of supination strength and 30% loss of flexion strength in one study. They review the surgical approach options, fixation strategies, and most common complications after distal biceps tendon repair.

Sutton et al. provide a narrative review of the surgical management of distal biceps tendon rupture. Single-incision techniques exploit the interval between pronator teres and brachioradialis, with care to ligate the recurrent radial vessels and protect the lateral antebrachial cutaneous nerve. Fixation strategies include bone tunnels, suture buttons, endobuttons, and interference screw fixation. The most common complication after distal biceps repair is lateral antebrachial cutaneous nerve dysesthesia.

Figure A: Fluoroscopic image demonstrating suspensory button fixation of distal biceps tendon repair through the radial tuberosity

Incorrect Answers:
Answer 1: Although distal biceps repair does restore elbow flexion strength, ulnar positioning of the insertion does not confer a biomechanical advantage regarding flexion.
Answers 2, 3, and 5: Distal biceps tendon repair does not affect elbow extension, forearm pronation, or finger flexion strength.