Working Diagnosis:
Bilateral distal biceps tendon ruptures

Treatment:
Treatment options were discussed including simultaneous bilateral surgery versus a staged operation. A staged operation was preferred to allow use of one arm for activities of daily living. The left biceps was addressed first due to the extent of tendon retraction. A single transverse incision was made 4cm distal to the elbow flexion crease. The tendon was found to be completely avulsed and retracted. A fiber loop suture was placed in the distal stump. Using a tension slide technique, the tendon was advanced into the radial tuberosity and secured with a button. The elbow was immobilized in a posterior splint for 1 week and then transitioned to a sling. 6 weeks later, surgery was performed on the right in a similar fashion.

Outcome:
Satisfactory subjective and objective outcomes for both elbows were obtained.

Author's Comments:
Rupture of the distal biceps tendon is uncommon with an incidence of 1.2 per 100,000. Forceful eccentric contractions are frequently the cause of injury. Non operative management can result in 30% loss of flexion strength and 40-50% of supination. Surgical planning is crucial to achieve optimal outcome as chronic cases require reconstruction which have variable recovery compared to primary repair. This patient had staged primary repair to allow use of one arm for ADLs

Editor's Comments:
While simultaneous bilateral biceps tendon ruptures are exceedingly rare, this case highlights a classic presentation of biceps tendon rupture. Ruptures of the distal biceps tendon occur in males between the ages 40-60 and frequently affect the dominant arm. The mechanism of injury is usually an eccentric contraction. Timely recognition and intervention is vital. This case illustrates the challenge of balancing early surgical repair given complications associated with delayed surgical intervention, while also allowing the patient to maintain functional upper extremity use.

References:
Rokito AS, lofin I. Simultaneous bilateral distal biceps tendon rupture during a preacher curl exercise: a case report. Bull NYU Hosp Jt Dis. 2008;66(1):68-71.

Green JB, Skaife TL, Leslie BM. Bilateral distal biceps tendon ruptures. J Hand Surg Am. 2012;37(1):120-3.

Strauch RJ. Biceps and triceps injuries of the elbow. Orthop Clin North Am. 1999;30(1):95-107.

Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii. A biomechanical study. J Bone Joint Surg Am. 1985;67(3):418-21.

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