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Acute distal biceps tendon rupture — MSRA MCQ

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HardSoft Tissue InjuryAcute distal biceps tendon ruptureMSRA

A 46-year-old right-hand-dominant self-employed builder attends a GP-led urgent treatment centre 4 hours after trying to stop a loaded wheelbarrow rolling downhill. His right elbow was forcibly extended while he was actively flexing it. He felt a painful snap in the antecubital fossa and stopped work immediately. There is local swelling and tenderness in the antecubital fossa but no wound or deformity. Elbow flexion is preserved but weaker than on the left. Forearm supination against resistance is markedly weak and painful compared with the left. The proximal biceps contour is normal. With the elbow flexed to 90 degrees and the forearm supinated, the distal biceps tendon cannot be hooked from the lateral side of the antecubital fossa. Distal neurovascular examination is normal. Elbow radiographs show no fracture or avulsion injury. What is the most appropriate management today?

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

Reveal the answer and explanation

Correct answer: A — Arrange an urgent direct orthopaedic referral today for suspected acute distal biceps rupture.

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

This is a suspected acute distal biceps tendon rupture and requires urgent orthopaedic assessment. The discriminating features are an eccentric loading mechanism with forced elbow extension, acute antecubital pain, disproportionate loss of resisted supination, and a positive Hook test (inability to hook the distal tendon). Preserved elbow flexion does not exclude rupture because brachialis and other elbow flexors remain functional. A normal proximal biceps contour also helps distinguish this from the more visible deformity of a proximal long-head biceps rupture. A is inappropriate because physiotherapy is suitable for many non-urgent upper-limb soft-tissue conditions but not a suspected acute distal biceps rupture. B and E risk delaying specialist assessment while awaiting imaging; imaging may be arranged by the specialist service when needed, but it should not postpone urgent referral where clinical suspicion is high. C is also insufficient: a sling may be used for comfort, but routine MSK management is not the appropriate pathway. Urgent orthopaedic assessment is needed because active, working patients with distal biceps rupture may be considered for operative repair, and delay can make repair more difficult.

Reference: Upper limb — Borders Ref Help Toolkit, NHS Borders (2025) — https://www.rightdecisions.scot.nhs.uk/borders-ref-help-toolkit/physiotherapy/msk-physiotherapy/upper-limb/ Shoulder and Elbow — NHS Tayside RefGuide (Accessed August 2026) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/shoulder-and-elbow/?organization=nhs-tayside&useNavigation=true