A forty-seven-year-old left-hand-dominant man injured his right
arm while playing rugby. The initial examination revealed ecchymosis
over the proximal aspect of the forearm, a proximally retracted
biceps brachii, and pain and weakness with resisted flexion and
supination. A diagnosis of a complete distal biceps tendon rupture
was made, and the patient elected to have operative treatment. The
tendon was reattached with use of the two-incision technique reported
by Boyd and Anderson4. Although
the original article described a curvilinear incision that begins
proximal to the antecubital fossa and ends just distal to the anterior
elbow-flexion crease, the incision used in this patient ended proximal
to the antecubital fossa.
Almost immediately after the operation, the patient noted decreased
sensation in the thumb and in the index, long, and ring fingers;
weakness of forearm pronation; and marked weakness of the flexor
pollicis longus and flexor digitorum profundus to the index and
long fingers. Initially, these findings were attributed to neurapraxia
of the median nerve caused by intraoperative retraction. At eight
weeks postoperatively, the patient continued to have dysesthesias
and flexor weakness in the thumb as well as in the index and long
fingers. Semmes-Weinstein monofilaments measuring 6.65 were undetectable on
the volar aspect of the thumb and the index finger; those measuring
4.31, 3.61, and 2.83 could be detected on the volar aspects of the
long, ring, and little fingers, respectively. There was no active
flexion of either the flexor pollicis longus or the flexor digitorum
profundus to the index finger. Median-nerve-conduction studies showed
an absent sensory potential on stimulation at the wrist and markedly reduced
evoked compound motor-unit action potentials on stimulation at or
proximal to the elbow. Electromyographic studies showed 2+ fibrillations and
increased insertional activity in the pronator teres, flexor pollicis
longus, and abductor pollicis brevis. These findings were consistent
with a severe compressive lesion of the right median nerve at the elbow.
On exploration of the original repair, the tendon was seen passing
over the median nerve proximally, between the median and ulnar nerves
just distal to the antecubital fossa, and then curving posterior
to the median nerve before attaching to the bicipital tuberosity
(Fig. 1).
The course of the biceps tendon created a high median neuropathy.
The repair was detached, and the median nerve was released. Examination
of the nerve revealed a proximal thickening consistent with a pseudoneuroma.
An epineurotomy was performed; the fascicles appeared to be intact.
The distal biceps tendon was then reattached with use of an anterior
approach. A trough was created in the bicipital tuberosity, and
heavy sutures that had been previously secured to the biceps tendon
were passed through two drill-holes in the posterior cortex and
tied posteriorly through a small dorsal incision5,6.
At four weeks postoperatively, the patient had a positive Tinel
sign without tenderness in the area of the distal volar wrist crease.
At eight weeks, he began to have nonfunctional contraction of the flexor
digitorum profundus to the index finger and improved sensation in
the thumb and in the index and long fingers. By three months, he
had weak active flexion of the interphalangeal joint of the thumb
and a nontender Tinel sign in the palm.
The patient had continued improvement until two years postoperatively.
At that time, function of the biceps was excellent and
the range of motion of the elbow was good, with flexion-extension
of 135° to 0° and pronation-supination of 60° to 60°. The strength
of the flexor pollicis longus was 5 of 5, and that of the flexor
digitorum profundus of the index finger was 4+ of 5. Semmes-Weinstein
monofilaments measuring 2.83, 3.22, and 2.83 were detectable on
the volar aspects of the thumb, index finger, and long finger, respectively
(compared with 2.44, 2.83, and 2.36 for the volar aspects of the
uninvolved thumb, index finger, and long finger).
Complications following the surgical repair of distal biceps
tendon ruptures have been reported infrequently. There may be decreased
strength in elbow flexion and supination, particularly with insertion of
the distal biceps tendon into the brachialis muscle1. Heterotopic bone formation with
radioulnar synostosis has been reported following the two-incision approach7. Nerve injury is the most frequently
reported complication, and several authors have reported cases of transient
radial nerve neurapraxia3,8-11.
Katzman et al.12 described a case
of delayed palsy of the posterior interosseous nerve four months
after the operation; exploration revealed a 3-cm section of the
nerve entrapped in scar tissue. Release of the scar tissue led to
eventual recovery of nerve function one year later. Persistent radial
and posterior interosseous nerve injuries have also been reported,
by Dobbie13 and by Meherin and
Kilgore10. Ulnar nerve injuries,
both transient and permanent, were reported by Boucher and Morton3.
Median nerve injuries have been reported as well3,10. Strauch et al.11 described
a patient in whom persistent subjective median nerve paresthesias
developed several months after surgery; the symptoms, which prevented
the patient from returning to work but not from participating in
sports activity, could not be documented on physical examination
or on electrodiagnostic studies. In a review of thirteen distal biceps
tendon ruptures, Boucher and Morton3 stated
that one patient had "prolonged median nerve paresthesias" associated
with myositis ossificans.
In the current report, we objectively documented a persistent
high median nerve palsy following repair of a distal biceps tendon
rupture. The palsy occurred when the distal biceps tendon was incorrectly
placed between the median and ulnar nerves rather than in its anatomic
position lateral to the median nerve, thus compressing it. The palsy
was relieved by rerouting of the distal biceps tendon along its
normal anatomic course.
This report is not a criticism of the two-incision technique
but rather a description of the problems associated with inadequate
exposure. The original article by Boyd and Anderson4 described an extensile incision that
extended just distal to the antecubital fossa. Agins et al.14 modified the anterior incision to
a more cosmetically acceptable transverse incision. Either incision allows
the tendon to be passed posteriorly. It is crucial, however, to
pass the biceps tendon along its anatomic course. Boyd and Anderson
alluded to this obvious fact when they described how to pass the
blunt instrument from the anterior incision posteriorly between
the radius and the ulna. This can be accomplished safely if the
bicipital tendon sheath can be identified. If the sheath cannot
be identified, the tendon should be passed radial (lateral) to the
median nerve.
Although the literature suggests that the exposure obtained with
use of a two-incision technique may help to decrease the prevalence
of nerve injury, especially that of the posterior interosseous nerve,
a single anterior incision has also been shown to be safe5,6,15-18. This case illustrates the
need for careful dissection and precise surgical technique regardless
of the approach that is used.