Question
A 45 year old man felt a sudden pop in the front of his elbow while lifting a heavy object. He has bruising and weakness of supination.
- What is the diagnosis and how do you confirm it?
- What are the management options?
- What are the complications of surgery?
Answer
Diagnosis
- Distal biceps tendon rupture, typically in men aged 40 to 60, with smoking and steroids as risk factors
- Reverse Popeye sign with proximal retraction of the muscle belly
- Positive hook test, with no tendon felt in the antecubital fossa
- Weak supination more than weak flexion
- MRI in the flexed abducted supinated (FABS) position or ultrasound for partial tears and retraction
Management
- Non-operative care in low demand patients, with loss of about 40% supination and 30% flexion strength
- Early repair within 2 to 3 weeks in active patients
- Single incision repair with cortical button, suture anchors or interference screw
- Two incision (Boyd-Anderson) technique through a posterolateral approach
- Chronic retracted ruptures may need tendon graft reconstruction
Complications
- Lateral antebrachial cutaneous nerve neurapraxia, the most common, with single incision repairs
- Posterior interosseous nerve injury
- Heterotopic ossification and radioulnar synostosis, more often with the two incision approach
- Rerupture
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.