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Acute complete distal biceps tendon rupture — MSRA MCQ

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HardSoft Tissue InjuryAcute complete distal biceps tendon ruptureMSRA

A 46-year-old right-hand-dominant self-employed plumber attends a GP-led urgent treatment centre 4 hours after trying to stop a heavy boiler from falling. His left elbow was flexed and forearm supinated when he felt a sudden painful pop in the antecubital fossa. He has developed swelling and bruising over the proximal volar forearm. Elbow radiographs show no fracture or dislocation. He has full passive elbow movement and can actively flex the elbow, but resisted forearm supination is markedly weaker and painful compared with the right. The distal biceps contour is proximally retracted. With the elbow flexed to 90 degrees and the forearm supinated, the examiner cannot hook a finger beneath the distal biceps tendon from the lateral side. The biceps crease interval is increased compared with the unaffected arm. Distal pulses, sensation, wrist and finger extension are normal. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Apply a sling and arrange same-day assessment through the orthopaedic on-call or acute fracture pathway

Explanation lettering: E = shown as A · A = shown as B · D = shown as C · B = shown as D · C = shown as E

This presentation is highly suggestive of an acute complete distal biceps tendon rupture: an eccentric load on a flexed, supinated elbow, an antecubital pop with bruising, proximal retraction of the muscle contour, and disproportionate loss of supination strength. The combination of an abnormal Hook test and increased biceps crease interval is highly accurate for acute complete rupture. Normal plain radiographs do not exclude tendon rupture. Suspected acute distal biceps rupture requires urgent orthopaedic assessment through an acute pathway. This is particularly important in this high-demand manual worker, because complete rupture can cause important persistent supination weakness and delay may complicate repair. A sling is appropriate pending specialist assessment, but should not substitute for referral. A is inappropriate because imaging should not delay urgent referral when the clinical diagnosis is compelling; the orthopaedic service can determine whether ultrasound or MRI is needed. B, D and E incorrectly treat this as a minor soft-tissue injury or a partial tear. Conservative management may be considered for selected low-demand patients after specialist discussion, but is not the initial primary-care disposition for a clinically suspected acute complete rupture.

Reference: Upper limb | Right Decisions (Reviewed 2025) — https://www.rightdecisions.scot.nhs.uk/borders-ref-help-toolkit/physiotherapy/msk-physiotherapy/upper-limb/ Distal Biceps Tendon Ruptures: Diagnostic Strategy Through Physical Examination (2022) — https://pubmed.ncbi.nlm.nih.gov/36349931/