open access

Vol 82, No 2 (2023)
Original article
Submitted: 2021-10-02
Accepted: 2022-01-17
Published online: 2022-02-28
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Anatomical variations of the biceps brachii insertion: a proposal for a new classification

B. Szewczyk1, F. Paulsen23, R. F. LaPrade4, A. Borowski5, N. Zielinska1, Ł. Olewnik1
·
Pubmed: 35239179
·
Folia Morphol 2023;82(2):359-367.
Affiliations
  1. Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
  2. Institute of Functional and Clinical Anatomy, Erlangen, Germany
  3. Department of Topographic Anatomy and Operative Surgery, Sechenov University, Moscow, Russia
  4. Twin Cities Orthopaedics, Edina, Minnesota, United States
  5. Clinic of Orthopaedic and Paediatric Orthopaedics, Medical University of Lodz, Poland

open access

Vol 82, No 2 (2023)
ORIGINAL ARTICLES
Submitted: 2021-10-02
Accepted: 2022-01-17
Published online: 2022-02-28

Abstract

Background: The biceps brachii (BB) muscle is one of the three muscles located
in the anterior compartment of the arm. Its insertion consists of two parts. The
first part — main tendon — attached in the radial tuberosity and the second part
— lacertus fibrosus (LF) — in the fascia of the forearm flexors. The intention of
research was to reveal the morphological diversity of the insertion of this muscle.
Thanks to the results of this work, have been created a classification of the distal
attachment of BB. The results of that research can be used to further develop
surgical procedures in the given region.
Materials and methods: Eighty (40 left, and 40 right, 42 female, 38 male) upper
limbs fixed in 10% formalin solution were examined.
Results: We observed three types of the insertion of the BB. Type I was characterised
by a single tendon and occurred most frequently in 78.75% of the examined
limbs. The second most common type was type II which was characterised by
a double tendon and was observed in 13.75% of all the limbs. The last and least
common was type III which was characterised by three tendons and occurred
in 7.5% of the examined limbs. Additionally, the type of LF was analysed. In
8 (10%) specimens it was absent, i.e. in 2 specimens with type II insertion and
6 specimens with type III (p = 0.0001). Therefore, it may be deduced that type
III BB insertion tendon predisposes to LF deficiency.
Conclusions: The BB tendon is characterised by high morphological variability.
The new classification proposes three types of distal attachment: type I — one
tendon; type II — two separated band-shaped tendons; type III — three separated
band-shaped tendons. The presence of type III BB tendon predisposes to a lack
of LF.

Abstract

Background: The biceps brachii (BB) muscle is one of the three muscles located
in the anterior compartment of the arm. Its insertion consists of two parts. The
first part — main tendon — attached in the radial tuberosity and the second part
— lacertus fibrosus (LF) — in the fascia of the forearm flexors. The intention of
research was to reveal the morphological diversity of the insertion of this muscle.
Thanks to the results of this work, have been created a classification of the distal
attachment of BB. The results of that research can be used to further develop
surgical procedures in the given region.
Materials and methods: Eighty (40 left, and 40 right, 42 female, 38 male) upper
limbs fixed in 10% formalin solution were examined.
Results: We observed three types of the insertion of the BB. Type I was characterised
by a single tendon and occurred most frequently in 78.75% of the examined
limbs. The second most common type was type II which was characterised by
a double tendon and was observed in 13.75% of all the limbs. The last and least
common was type III which was characterised by three tendons and occurred
in 7.5% of the examined limbs. Additionally, the type of LF was analysed. In
8 (10%) specimens it was absent, i.e. in 2 specimens with type II insertion and
6 specimens with type III (p = 0.0001). Therefore, it may be deduced that type
III BB insertion tendon predisposes to LF deficiency.
Conclusions: The BB tendon is characterised by high morphological variability.
The new classification proposes three types of distal attachment: type I — one
tendon; type II — two separated band-shaped tendons; type III — three separated
band-shaped tendons. The presence of type III BB tendon predisposes to a lack
of LF.

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Keywords

biceps brachii, biceps brachii tendon, lacertus fibrosus, bicipital aponeurosis, new classification

About this article
Title

Anatomical variations of the biceps brachii insertion: a proposal for a new classification

Journal

Folia Morphologica

Issue

Vol 82, No 2 (2023)

Article type

Original article

Pages

359-367

Published online

2022-02-28

Page views

2636

Article views/downloads

1734

DOI

10.5603/FM.a2022.0022

Pubmed

35239179

Bibliographic record

Folia Morphol 2023;82(2):359-367.

Keywords

biceps brachii
biceps brachii tendon
lacertus fibrosus
bicipital aponeurosis
new classification

Authors

B. Szewczyk
F. Paulsen
R. F. LaPrade
A. Borowski
N. Zielinska
Ł. Olewnik

References (46)
  1. Al-Kushi G. Anatomical study of the third head of biceps brachii muscle and its innervation by median nerve in human dissection. J Clin Med Res. 2013; 5(4): 47–52.
  2. Athwal GS, Steinmann SP, Rispoli DM. The distal biceps tendon: footprint and relevant clinical anatomy. J Hand Surg Am. 2007; 32(8): 1225–1229.
  3. Audenaert EA, Barbaix EJ, Van Hoonacker P, et al. Extraarticular variants of the long head of the biceps brachii: a reminder of embryology. J Shoulder Elbow Surg. 2008; 17(1 Suppl): 114S–117S.
  4. Balabaud L, Ruiz C, Nonnenmacher J, et al. Repair of distal biceps tendon ruptures using a suture anchor and an anterior approach. J Hand Surg Br. 2004; 29(2): 178–182.
  5. Ballesteros LE, Forero PL, Buitrago ER. Evaluation of additional head of biceps brachii: a study with autopsy material. Folia Morphol. 2014; 73(2): 193–198.
  6. Bardeen C. Studies of the development of the human skeleton. Am J Anat. 1905: 265–302.
  7. Bardeen C. Development and variation of the nerves and the musculature of the inferior extremity and of the neighboring regions of the trunk in man. Am J Anat. 2005; 6(1): 259–390.
  8. Blasi M, de la Fuente J, Martinoli C, et al. Multidisciplinary approach to the persistent double distal tendon of the biceps brachii. Surg Radiol Anat. 2014; 36(1): 17–24.
  9. Camp CL, Voleti PB, Corpus KT, et al. Single-Incision technique for repair of distal biceps tendon avulsions with intramedullary cortical button. Arthrosc Tech. 2016; 5(2): e303–e307.
  10. Citak M, Backhaus M, Seybold D, et al. Surgical repair of the distal biceps brachii tendon: a comparative study of three surgical fixation techniques. Knee Surg Sports Traumatol Arthrosc. 2011; 19(11): 1936–1941.
  11. Cucca YY, McLay SVB, Okamoto T, et al. The biceps brachii muscle and its distal insertion: observations of surgical and evolutionary relevance. Surg Radiol Anat. 2010; 32(4): 371–375.
  12. Dirim B, Brouha SS, Pretterklieber ML, et al. Terminal bifurcation of the biceps brachii muscle and tendon: anatomic considerations and clinical implications. AJR Am J Roentgenol. 2008; 191(6): W248–W255.
  13. Eames MHA, Bain GI, Fogg QA, et al. Distal biceps tendon anatomy: a cadaveric study. J Bone Joint Surg Am. 2007; 89(5): 1044–1049.
  14. Eardley WGP, Odak S, Adesina TS, et al. Bioabsorbable interference screw fixation of distal biceps ruptures through a single anterior incision: a single-surgeon case series and review of the literature. Arch Orthop Trauma Surg. 2010; 130(7): 875–881.
  15. Enad JG. Bifurcate origin of the long head of the biceps tendon. Arthroscopy. 2004; 20(10): 1081–1083.
  16. Forthman C, Zimmerman R, Sullivan M, et al. Cross-sectional anatomy of the bicipital tuberosity and biceps brachii tendon insertion: Relevance to anatomic tendon repair. J Shoulder Elbow Surg. 2008; 17(3): 522–526.
  17. Greig HW, Anson BJ, Budinger JM. Variations in the form and attachments of the biceps brachii muscle. Q Bull Northwest Univ Med Sch. 1952; 26(3): 241–244.
  18. Gupta RK, Bither N, Singh H, et al. Repair of the torn distal biceps tendon by endobutton fixation. Indian J Orthop. 2012; 46(1): 71–76.
  19. Ilayperuma I, Nanayakkara G, Palahepitiya N. Incidence of Humeral Head of Biceps Brachii Muscle: Anatomical Insight. Int J Morphol. 2011; 29(1): 221–225.
  20. Jeong JY, Park SM, Park YE, et al. Morphological classification of anatomical variants of the intra-articular portion of the long head of the biceps brachii tendon and analysis of the incidence and the relationship with shoulder disease for each subtype. J Orthop Surg (Hong Kong). 2017; 25(3): 2309499017742207.
  21. Joshi SD, Yogesh AS, Mittal PS, et al. Morphology of the bicipital aponeurosis: a cadaveric study. Folia Morphol. 2014; 73(1): 79–83.
  22. Kopuz C, Sancak B, Ozbenli S. On the incidence of third head of biceps brachii in Turkish neonates and adults. Kaibogaku Zasshi. 1999; 74(3): 301–305.
  23. Kosugi K, Shibata S, Yamashita H. Supernumerary head of biceps brachii and branching pattern of the musculocutaneus nerve in Japanese. Surg Radiol Anat. 1992; 14(2): 175–185.
  24. Landa J, Bhandari S, Strauss EJ, et al. The effect of repair of the lacertus fibrosus on distal biceps tendon repairs: a biomechanical, functional, and anatomic study. Am J Sports Med. 2009; 37(1): 120–123.
  25. Lee SE, Jung C, Ahn KY, et al. Bilateral asymmetric supernumerary heads of biceps brachii. Anat Cell Biol. 2011; 44(3): 238–240.
  26. Mazzocca AD, Cohen M, Berkson E, et al. The anatomy of the bicipital tuberosity and distal biceps tendon. J Shoulder Elbow Surg. 2007; 16(1): 122–127.
  27. McDonald LS, Dewing CB, Shupe PG, et al. Disorders of the proximal and distal aspects of the biceps muscle. J Bone Joint Surg Am. 2013; 95(13): 1235–1245.
  28. Miyazaki AN, Fregoneze M, Santos PD, et al. Functional evaluation of patients with injury of the distal insertion of the biceps brachii muscle treated surgically. Rev Bras Ortop. 2014; 49(2): 129–133.
  29. Moore K, Arthur F, Dalley I, Agur AM. Clinically Oriented Anatomy. 7th ed. Lippincott Williams & Wilkins 2013.
  30. Olewnik Ł. Is there a relationship between the occurrence of frenular ligaments and the type of fibularis longus tendon insertion? Ann Anat. 2019; 224: 47–53.
  31. Olewnik Ł, Gonera B, Kurtys K, et al. A proposal for a new classification of the fibular (lateral) collateral ligament based on morphological variations. Ann Anat. 2019; 222: 1–11.
  32. Olewnik Ł, Karauda P, Gonera B, et al. Impact of plantaris ligamentous tendon. Sci Rep. 2021; 11(1): 4550.
  33. Olewnik Ł, Kurtys K, Gonera B, et al. Proposal for a new classification of plantaris muscle origin and its potential effect on the knee joint. Ann Anat. 2020; 231: 151506.
  34. Olewnik Ł, Paulsen F, Tubbs RS, et al. Potential compression of the musculocutaneous, median and ulnar nerves by a very rare variant of the coracobrachialis longus muscle. Folia Morphol. 2021; 80(3): 707–713.
  35. Olewnik Ł, Zielinska N, Karuda P, et al. he co-occurrence of a four headed coracobrachialis muscke, split coracoid process and tunnel for the median and musculocutaneous nerve: the potential clinical relevance of a very rare variation. Surg Radiol Anat. 2021; 43(5): 661–669.
  36. Olewnik Ł, Zielinska N, Paulsen F, et al. A proposal for a new classification of soleus muscle morphology. Ann Anat. 2020; 232: 151584.
  37. Olsen JR, Shields E, Williams RB, et al. A comparison of cortical button with interference screw versus suture anchor techniques for distal biceps brachii tendon repairs. J Shoulder Elbow Surg. 2014; 23(11): 1607–1611.
  38. Podgórski M, Olewnik Ł, Rusinek M, et al. 'Superior biceps aponeurosis' - Morphological characteristics of the origin of the short head of the biceps brachii muscle. Ann Anat. 2019; 223: 85–89.
  39. Seiler JG, Parker LM, Chamberland PD, et al. The distal biceps tendon. Two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. J Shoulder Elbow Surg. 1995; 4(3): 149–156.
  40. Snoeck O, Lefèvre P, Sprio E, et al. The lacertus fibrosus of the biceps brachii muscle: an anatomical study. Surg Radiol Anat. 2014; 36(7): 713–719.
  41. Szewczyk B, Paulsen F, Duparc F, et al. A proposal for a new classification of coracobrachialis muscle morphology. Surg Radiol Anat. 2021; 43(5): 679–688.
  42. Tarallo L, Mugnai R, Zambianchi F, et al. Distal biceps tendon rupture reconstruction using muscle-splitting double-incision approach. World J Clin Cases. 2014; 2(8): 357–361.
  43. Tarallo L, Lombardi M, Zambianchi F, et al. Distal biceps tendon rupture: advantages and drawbacks of the anatomical reinsertion with a modified double incision approach. BMC Musculoskelet Disord. 2018; 19(1): 364.
  44. Vangsness CT, Jorgenson SS, Watson T, et al. The origin of the long head of the biceps from the scapula and glenoid labrum. An anatomical study of 100 shoulders. J Bone Joint Surg. British Vol. 1994; 76-B(6): 951–954.
  45. Zielinska N, Olewnik Ł, Karauda P, et al. A very rare case of an accessory subscapularis muscle and its potential clinical significance. Surg Radiol Anat. 2021; 43(1): 19–25.
  46. Zielinska N, Tubbs RS, Podgórski M, et al. The subscapularis tendon: A proposed classification system. Ann Anat. 2021; 233: 151615.

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