J Shoulder Elbow Surg (2013) 22, 70-73

www.elsevier.com/locate/ymse

ELBOW

Prognosis for recovery of posterior interosseous nerve

palsy after distal biceps repair
Phillip T. Nigro, MDa, Richard Cain, MDb, Mark A. Mighell, MDa,*

a
Florida Orthopedic Institute, Tampa, FL, USA
b
University of South Florida College of Medicine, Tampa, FL, USA

Background: There is very little information on the incidence of and usual recovery period for posterior
interosseous nerve (PIN) palsies after distal biceps repair. This study examined the incidence and the time
to resolution of PIN palsies in a large consecutive series of primary distal biceps repairs.
Materials and methods: A retrospective review was performed of a consecutive series of patients treated
by 34 fellowship-trained upper extremity surgeons with primary distal biceps repair through a single ante-
rior incision technique. Patients’ records were reviewed to determine how many experienced a postopera-
tive PIN palsy, defined as postoperative digital extension weakness on clinical examination. Demographic
information, surgical fixation used, and clinical resolution was collect for these patients. All patients had
clinical follow-up until complete resolution of PIN palsy symptoms.
Results: We found 280 patients who were treated with a single-incision technique and 1 of 2 methods of
biceps tendon fixation. Of these, 9 (3.2%) developed a postoperative PIN palsy after primary distal biceps
repair. These 9 patients had complete lack of finger and thumb extension at the first postoperative visit and
had complete resolution of symptoms at an average of 86 days (range, 41-145 days).
Conclusions: The incidence of PIN palsy after a single-incision distal biceps repair was 3.2% in our series.
These injuries typically resolve within 3 months, and at the latest, 5 months after surgery.
Level of evidence: Level IV, Case Series, Prognosis Study.
Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Posterior interosseous nerve; distal biceps repair; prognosis; recovery

Distal biceps rupture in an active patient is commonly
treated with surgical repair. Surgical treatment offers the
possibility of improved strength, function, and cosmetic
appearance. However, complications occur after 16% to 40%
of distal biceps repairs.1,2,5,8 Many of the reported compli-
cations involve superficial forearm sensory disturbance from
This study was granted Investigational Review Board exempt status by the
Western Institutional Review Board.
*Reprint requests: Mark A. Mighell, MD, Florida Orthopedic Institute,
13020 N. Telecom Pkwy, Tampa, FL 33637, USA.
E-mail address: mmighell@floridaortho.com (M.A. Mighell).
a lateral antebrachial cutaneous or superficial radial nerve
palsy. Although disconcerting for the patient, these compli-
cations do not typically affect the functional outcome of the
repair. A less common but more severe complication is
posterior interosseous nerve (PIN) palsy. This injury causes
inability to perform finger and thumb extension, while still
allowing wrist extension. PIN palsies can be treated with
a dynamic extension splint until symptoms resolve. In the
case of a permanent PIN palsy, tendon transfers can be per-
formed to allow finger and thumb extension.
There is very little information on the incidence of and
usual recovery period for PIN palsies after distal biceps

1058-2746/$ - see front matter Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2012.08.001
PIN recovery after distal biceps repair
Table I Demographics and time to resolution of posterior interosseous nerve palsy
Patient Age (years) Sex Time injury to
surgery (days)
1 54 F 4
2 55 F 126
3 35 M 50
4 67 M 55
5 37 M 155
6 43 M 13
7 61 M 16
8 42 M 3
9 54 M 13
Average 49.8 48
F, female; L, left; M, male; R, right.
repair. These injuries have been reported to occur in 1% to
8% of patients treated with distal biceps repair.3,5,6,8 The
time resolution of symptoms varies widely, from 4 weeks to
1 year.3,5,6,8 To date, a standard protocol does not exist for
the treatment of these iatrogenic injuries.
The purpose of this study is to examine the incidence
and the time to resolution of PIN palsies in a large
consecutive series of distal biceps repairs. Our hypothesis
is, first, that the overall incidence is low, and second, that
most PIN palsies after distal biceps repair are the result of
stretch or compression during surgery and thus will resolve
with nonoperative management. This information can help
surgeons to provide patients with more accurate informa-
tion on the risk of PIN palsy before surgery and prognostic
information for recovery after surgery.
Materials and methods
A retrospective review was performed of a consecutive series of
patients treated by 4 fellowship-trained upper extremity surgeons
with primary distal biceps repair through a single-technique.
Inclusion criteria included primary distal biceps repair in a patient
aged 18 years or older. Exclusion criteria included concomitant
elbow fracture, presence of elbow arthroplasty, and revision distal
biceps repair.
Electronic medical records were reviewed at the authors’
institution by searching the Current Procedural Terminology
(American Medical Association, Chicago, IL, USA) code 24342
to identify all cases involving a repair of a distal biceps or triceps
tendon performed from January 1999 to April 2012. This yielded
383 surgical cases, of which 292 were distal biceps repairs. One
patient was excluded due to concomitant radial head fracture, and
11 were excluded for being revision distal biceps repairs. This left
280 patients with primary distal biceps repair, and their records
were reviewed to determine how many experienced a post-
operative PIN palsy. This was defined as a postoperative digital
extension weakness noted on clinical examination or electro-
myelography testing. Nine patients were identified with PIN palsy,
and their records were reviewed to determine demographic
information, surgical fixation used, and time to clinical resolution.
All patients had clinical follow-up until complete resolution of
71
Surgical technique Side Time to
resolution (days)
Endobutton L 97
Suture anchor R 41
Endobutton L 46
Endobutton L 76
Suture anchor R 145
Suture anchor R 68
Endobutton R 118
Endobutton R 55
Endobutton L 130
86
PIN palsy symptoms. Clinical resolution was defined as recovery
of the ability to extend the digits with equal strength to the non-
operated-on extremity.
Results
In our series, 9 of 280 patients (3.2%) developed a post-
operative PIN palsy after primary distal biceps repair. All
patients were treated with a single-incision technique, and 1
of 2 methods of biceps tendon fixation was used (Table I).
All patients had complete lack of finger and thumb exten-
sion at the first postoperative visit. All patients had
complete resolution of PIN palsy, with an average time to
complete resolution of 86 days (range, 41-145 days).
Discussion
Distal biceps repair offers recovery of strength, function,
and muscle contour to the upper extremity after distal
biceps rupture; however, this procedure is associated with
possible neurologic complications. A PIN palsy is
a disconcerting and functionally limiting neurologic
complication. Patients that develop this complication have
inability to extend their digits while maintaining active
wrist extension. PIN palsies are most commonly temporary,
but permanent deficits have been reported.10,11 Even
temporary loss of digital extension leads to significant
disability with functional use of the hand. Patients may
develop secondary digital stiffness and reduced passive
range of motion. For this reason, patients are commonly
treated with dynamic extension splinting and occupational
therapy until resolution of the PIN palsy.
Very little information exists on the incidence of and
time to recovery for PIN palsies. Kelly et al8 reported
a series of 74 patients undergoing distal biceps repair by
a 2-incision technique. Only 1 PIN palsy occurred, and it
resolved at 6 months after surgery. Chillemi et al3
compared a small series of operatively vs nonoperatively
72
treated distal biceps ruptures. Five patients were treated
operatively with a double-incision surgical repair. Two
developed a PIN palsy, and both eventually resolved, at 2
and 6 months. Gallinet et al5 reported 28 patients under-
going single-incision suture anchor repair of distal biceps
ruptures. One of the 28 patients developed a PIN palsy,
which took 1 year to resolve. Hetsroni et al6 compared 12
patients surgically treated with a single-incision technique
and 10 patients treated conservatively.6 One surgical patient
developed a PIN palsy that resolved at 4 weeks. Case
reports have documented permanent PIN palsy after a 2-
incision technique8 and a delayed-onset PIN palsy after
a nonanatomic routing of the biceps tendon.7 To our
knowledge, no study reports more than 2 PIN palsies after
distal biceps repair, and thus, little information exists on the
prognosis for recovery in these injuries.
Different mechanisms of injury have been proposed as
causing the PIN injury during distal biceps repair. Lo et al9
looked at the trajectory of the guide pin with respect to the
location of the PIN in cadavers. They found that although
a perpendicular orientation of the guidewire allowed for an
average distance of 11.2 mm from the PIN, distal orienta-
tion of the guidewire caused an average distance of 2 mm
from the PIN and made direct contact in 30% of speci-
mens.9 Further, the PIN has varying degrees of proximity to
the radial tuberosity, with as much as 25% of patients
having a branch of the PIN within 5 mm of the radial
tuberosity.4 We would anticipate that direct contact of the
guidewire to the PIN could lead to permanent nerve defi-
cits. Because we did not observe permanent PIN dysfunc-
tion in our series, this mechanism may be less likely to
occur with proper operative technique.
PIN injury may also occur as a traction or compression
injury during retraction. Nerve injury models in animals
have demonstrated minimal neurologic recovery after
subjecting a nerve to 12% strain.12 It is possible that the use
of a levered retractor, such as a Hohman, to retract soft
tissue radially off the radius could create significant PIN
strain. This type of retractor creates a fulcrum near the tip
of the retractor around the radius that can generate
a mechanical advantage in retracting the soft tissues. This
allows the surgical assistant to more easily retract with
greater force in the vicinity of the PIN’s course. Because all
9 patients in this series recovered function, we believe that
the PIN injury most likely resulted from a traction injury
caused by retraction on the radial soft tissues. As a result,
the senior author (M.A.M.) has modified his technique to
include a direct-pull retractor radially, such as an Army-
Navy.
Despite being the largest reported series of PIN palsies, we
acknowledge that this study has weaknesses. It is a retro-
spective review over a significant period, and all information
was collected from the electronic medical record. Although
all repairs were performed through an anterior single-
incision technique, 2 different methods of fixation were
used by the 4 surgeons contributing to the study.
P.T. Nigro et al.
Nevertheless, we believe this study has important prog-
nostic information useful to upper extremity surgeons. With
this information surgeons can counsel patients considering
primary distal biceps repair that PIN palsy may occur in
approximately 3% of cases and that the risk of permanent
nerve injury is rare. Furthermore, the typical time to
recovery is less than 3 months, with all palsies recovering in
this study in less than 5 months. This may aid the surgeon in
directing postoperative therapy after PIN palsy and assuring
the patient of the expected time to recovery.
Conclusion
PIN palsy after distal biceps repair typically resolves
within 5 months of surgery. This information can help
surgeons to counsel patients postoperatively and to
direct appropriate therapy.
Disclaimer
Dr Nigro has received lecture fees from DJO Surgical
that not related to the subject of this work. Dr Mighell
has received lecture and consultancy fees from DJO
Surgical and Upex. He has existing patents with Upex
surgical. These are not related to the subject of this
work. Dr Cain, his immediate family, and any research
foundations with which they are affiliated have not
received any financial payments or other benefits from
any commercial entity related to the subject of this
article.
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