Long head of biceps in proximal fractures of the humerus: an underestimated problem? Critical analysis and review of the literature

Long head of biceps in proximal fractures of the humerus: an underestimated problem?

Critical analysis and review of the literature


  • Luigi Branca Vergano U.O. Ortopedia e Traumatologia, Ospedale M. Bufalini, Cesena (FC)
  • Giovanni Corsini Università Sapienza, Roma
  • Mauro Monesi Ortopedia e traumatologia Ospedale M. Bufalini, Cesena (FC)


long head of biceps, proximal humerus fracture, tenotomy, tenodesis


Background and aim of the work: The long head of biceps (LHB) is one of the tendons of the rotator cuff that runs strictly close to the humeral head. In case of pathology, it can be responsible for pain and shoulder impairment: in such cases, surgical options include tenotomy or tenodesis. The management of LHB along with surgery of the rotator cuff or during shoulder prosthetic replacement has been widely discussed in the literature. Conversely, the possibility of acute impingement and incarceration of LHB in proximal humerus fractures, as well as its role in shoulder pain in outcomes of these fractures, has been poorly considered. Methods: The following aspects in the literature on LHB and proximal humerus fractures have been analysed: its management during fixation of fractures, the possibility of interference of the tendon with reduction of fractures or dislocations of the shoulder and its possible role in chronic pain after fixation of proximal humerus fractures. Results: LHB can be an obstacle in the reduction of fractures, dislocations and fracture-dislocations. Only a few papers take into account acute surgery to LHB (tenotomy or tenodesis); most of the studies on fixation of proximal humerus fractures simply ignore the problem of LHB. The tendon can be a source of pain and a cause of disability in sequelae of these fractures. Conclusions: LHB should be taken into consideration both in the acute phase of fractures of the proximal humerus and in the outcomes. Other studies are needed to better understand its optimal management during fracture surgery.


Harrison JW, Howcroft DW, Warner JG, Hodgson SP. Internal fixation of proximal humeral fractures. Acta Orthop Belg. 2007 Feb;73(1):1-11.

Neer CS., 2nd Displaced proximal humeral fractures: I. Classification and evaluation. J Bone Joint Surg Am. 1970;52:1077–1089.

Tosounidis T, Hadjileontis C, Georgiadis M, Kafanas A, Kontakis G. The tendon of the long head of the biceps in complex proximal humerus fractures: a histological perspective. Injury. 2010 Mar;41(3):273-8.

Buecking B, Mohr J, Bockmann B, Zettl R, Ruchholtz S. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res. 2014 May;472(5):1576-85. doi: 10.1007/s11999-013-3415-7.

Greve F, Beirer M, Zyskowski M, Crönlein M, Müller M, Pesch S et al. Prospective outcome analysis following tenodesis of the long head of the biceps tendon along with locking plate osteosynthesis for proximal humerus fractures. Injury. 2019 Mar;50(3):681-685. doi: 10.1016/j.injury.2019.02.003.

Khmelnitskaya E1, Lamont LE, Taylor SA, Lorich DG, Dines DM, Dines JS. Evaluation and management of proximal humerus fractures. Adv Orthop. 2012;2012:861598. doi: 10.1155/2012/861598.

Konrad G, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical technique. J Bone Joint Surg Am. 2010 Mar;92 Suppl 1 Pt 1:85-95. doi: 10.2106/JBJS.I.01462.

Laux CJ, Grubhofer F, Werner CML, Simmen HP, Osterhoff G. Current concepts in locking plate fixation of proximal humerus fractures. J Orthop Surg Res. 2017 Sep 25;12(1):137. doi: 10.1186/s13018-017-0639-3.

Wu CH, Ma CH, Yeh JJ, Yen CY, Yu SW, Tu YK. Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches. J Trauma. 2011 Nov;71(5):1364-70. doi: 10.1097/TA.0b013e31820d165d.

Ramos Poroes F, Desmarchelier R, Bauer S. Atypical biceps-related complication of proximal humerus fracture leading to internal shoulder impingement due to tendon stump dislocation. BMJ Case Rep. 2020 Feb 9;13(2). pii: e232124. doi: 10.1136/bcr-2019-232124.

Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:121-30.

Warner JJ, McMahon PJ. The role of the long head of the biceps brachii in superior

stability of the glenohumeral joint. J Bone Joint Surg [Am] 1995;77-A:366-72.

Kim SH, Ka KI, Kim HS, Kim SW. Electromyographic activity of the biceps brachii

muscle in shoulders with anterior instability. Arthroscopy 2001;17:864-8.

Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg [Br] VOL. 89-B, No. 8, AUGUST 2007

Favorito PJ, Harding WG III, Heidt RS Jr. Complete arthroscopic examination of the long head of the biceps tendon. Arthroscopy 2001;17:430-432

Crenshaw AH Kilgore WE. Surgical treatment of bicipital tenosynovitis. J Bone Joint Surg Am. 1966 Dec;48(8):1496-502.

McFarland EG Kim TK Savino RM. Clinical assessment of three common tests for superior labral anterior-posterior lesions. Am J Sports Med. 2002 Nov-Dec;30(6):810-5

Zhang Q, Zhou J, Ge H, Cheng B. Tenotomy or tenodesis for long head biceps lesions in shoulders with reparable rotator cuff tears: a prospective randomised trial. Knee Surg Sports Traumatol Arthrosc 2013 2015 Feb;23(2):464-9. doi: 10.1007/s00167-013-2587-8.

Ahmad CS, DiSipio C, Lester J, Gardner TR, Levine WN, Bigliani LU. Factors affecting dropped biceps deformity after tenotomy of the long head of the biceps tendon. Arthroscopy 23(5):537–541

Checchia SL, Doneux PS, Miyazaki AN, Silva LA, Fregoneze M, Ossada A et al. Biceps tenodesis associated with arthroscopic repair of rotator cuff tears. J Shoulder Elbow Surg 14(2):138–144

Franceschi F, Longo UG, Ruzzini L, Papalia R, Rizzello G, Denaro V. To detach the long head of the biceps tendon after tenodesis or not: outcome analysis at the 4-year follow-up of two different techniques. Int Orthop 31(4):537–545

Frost A, Zafar MS, Maffulli N. Tenotomy versus tenodesis in the management of pathologic lesions of the tendon of the long head of the biceps brachii. Am J Sports Med 37(4):828–833.

Lucas JC, Mehlman CT, Laor T. The location of the biceps tendon in completely displaced proximal humerus fractures in children: a report of four cases with magnetic resonance imaging and cadaveric correlation. J Pediatr Orthop. 2004 May-Jun;24(3):249-53

Henderson SR. Fracture-dislocation of the shoulder with interposition of long head of biceps .J Bone Joint Surg Br. 1952 May;34-B(2):240-1

Pantazis K, Panagopoulos A, Tatani I, Daskalopoulos B, Iliopoulos I, and Minos Tyllianakis. Irreducible Anterior Shoulder Dislocation with Interposition of the Long Head of the Biceps and Greater Tuberosity Fracture: A Case Report and Review of the Literature. Open Orthop J. 2017; 11: 327–334.

Abdel Nour HG, Joukhadar N, Maalouly J, Ayoubi RA, Aouad DK and El Rassi GS. Entrapment of the Long Head of the Biceps in a Multi-Fragmentary Proximal Humeral Fracture: A Case Report. J Physiother Res. 2:10.

Bahrs C, Zipplies S, Ochs BG, Rether J, Oehm J, Eingartner C et al. Proximal humeral fractures in children and adolescents. J Pediatr Orthop. 2009 Apr-May;29(3):238-42. doi: 10.1097/BPO.0b013e31819bd9a7.

Visser JD, Rietberg M. Interposition of the tendon of the long head of biceps in fracture separation of the proximal humeral epiphysis. Neth J Surg. 1980;32(1):12-5.

Pandya NK, Behrends D, Hosalkar HS. Open reduction of proximal humerus fractures in the adolescent population.J Child Orthop. 2012 Jun;6(2):111-8. doi: 10.1007/s11832-012-0398-y. Epub 2012 Mar 29.

White AE, Patel NK, Hadley CJ, Dodson CC. An algorithmic approach to the management of shoulder instability. J Am Acad Orthop Surg Glob Res Rev. 2019 Dec 23;3(12).

Cibulas A, Leyva A, Cibulas G 2nd, Foss M, Boron A, Dennison J et al. Acute Shoulder Injury. Radiol Clin North Am. 2019 Sep;57(5):883-896.

Wortley P, Omar L, Robertson W, Moore D, Sims GC, Omar H. Nonreducible Shoulder Due to Acute Posterior Dislocation of the Long Head of the Biceps Tendon: A Case Report and Review of the Literature. JBJS Case Connect. 2014 Mar 12;4(1 Suppl 8):e261-4.

Seo JB, Yoon SH, Yang JH, Yoo JS. Irreducible posterior fracture and dislocation of shoulder with massive rotator cuff tear due to incarceration of biceps tendon: A case report. J Orthop. 2020 Feb 4;21:6-9.

McArthur C, Welsh F, Campbell C. Posterior dislocation of long head of biceps tendon following traumatic anterior shoulder dislocation: imaging and intra-operative findings. J Radiol Case Rep. 2013 Sep 1;7(9):19-26.

Vestermark GL, Van Doren BA, Connor PM, Fleischli JE, Piasecki DP, Hamid N. The prevalence of rotator cuff pathology in the setting of acute proximal biceps tendon rupture. Shoulder Elbow Surg. 2018 Jul;27(7):1258-1262. doi: 10.1016/j.jse.2018.01.006. Epub 2018 Feb 22.

Barber FA, Field LD, Ryu RK (2008) Biceps tendon and superior labrum injuries: decision making. Instr Course Lect 57:527–538

Al-Hakim W, Noorani A, Lambert S. Assessment and treatment strategies for rotator cuff tears. Shoulder Elbow. 2015 Apr;7(2):76-84. doi: 10.1177/1758573214557143. Epub 2014 Oct 31.

Godenèche A, Nove‑Josserand L, Audebert S, Toussaint B, Denard PJ, Lädermann A. Relationship between subscapularis tears and injuries to the biceps pulley. Knee Surg Sports Traumatol Arthrosc (2017) 25:2114–2120

Boileau P, Baqué F, Valerio L, Ahrens P, Chuinard C, Trojani C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007 Apr;89(4):747-57.

Pietu G, Deluzarches P, Goin F, Letenneur J. Complex injuries of the proximal humerus treated with humeral head prosthesis: apropos of 21 cases review after a median follow-up of 4 years. Acta Orthopaedica Belgica 1992;58:159–69.

Moeckel BH, Dines DM, Warren RF, Altchek DW. Modular hemiarthroplasty for fractures of the proximal part of the humerus. Journal of Bone and Joint Surgery - American Volume 1992;74-A:884–9.

Green A, Barnard WL, Limbird RS, Providence RI. Humeral head replacement for acute, four-part proximal humerus fractures. Journal of Shoulder and Elbow Surgery 1993;2:249–54.

Hawkins RJ, Switlyk P. Acute prosthetic replacement for severe fractures of the proximal humerus. Clinical Orthopaedics 1993;289:156–60.

. Goldman RT, Koval KJ, Cuomo MA, Zuckerman JD. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. Journal of Shoulder and Elbow Surgery 1995;4:81–6.

Omar A. Soliman A, Wael MT. Proximal humeral fractures treated with hemiarthroplasty: Does tenodesis of the long head of the biceps improve results? Injury, Int. J. Care Injured 44 (2013) 461–464

Borer J, Schwarz J, Potthast S, Jakob M, Lenzlinger P, Zingg U. Mid-term results of minimally invasive deltoid-split versus standard open deltopectoral approach for PHILOS™ (proximal humeral internal locking system) osteosynthesis in proximal humeral fractures. Eur J Trauma Emerg Surg. 2019 Jan 14. doi: 10.1007/s00068-019-01076-7.

Mouraria GG, Zoppi A, Kikuta FK, Moratelli L, Cruz MA, Etchebehere M. Anterolateral approaches for proximal humeral osteosynthesis: a systematic review. Acta Ortop Bras. 2019 May-Jun;27(3):178-182. doi: 10.1590/1413-785220192703215572

Xie L, Zhang Y, Chen C, Zheng W, Chen H, Cai L. Deltoid-split approach versus deltopectoral approach for proximal humerus fractures: A systematic review and meta-analysis. Orthop Traumatol Surg Res. 2019 Apr;105(2):307-316. doi: 10.1016/j.otsr.2018.12.004. Epub 2019 Mar 14.

Schai PA1, Hintermann B, Koris MJ. Preoperative arthroscopic assessment of fractures about the shoulder. Arthroscopy. 1999 Nov-Dec;15(8):827-35.

Kerschbaum M, Werth M, Gerhardt C, Scheibel M. Simultaneous surgical treatment of the long head of the biceps tendon during operative treatment of proximal humeral fractures. Unfallchirurg. 2017 Oct;120(10):865-872. doi: 10.1007/s00113-016-0279-9.

Ahovuo J, Paavolainen P, Björkenheim JM. Fractures of the proximal humerus involving the intertubercular groove. Acta Radiol. 1989 Jul-Aug;30(4):373-4.

Duparc F. Malunion of the proximal humerus. Orthop Traumatol Surg Res. 2013 Feb;99(1 Suppl):S1-11. doi: 10.1016/j.otsr.2012.11.006. Epub 2013 Jan 16

Katthagen JC, Hennecke D, Jensen G, Ellwein A, Voigt C, Lill H. Arthroscopy after locked plating of proximal humeral fractures: implant removal, capsular release, and intra-articular findings. Arthroscopy. 2014 Sep;30(9):1061-7. doi: 10.1016/j.arthro.2014.04.092. Epub 2014 Jun 14




How to Cite

Long head of biceps in proximal fractures of the humerus: an underestimated problem? Critical analysis and review of the literature. Acta Biomed [Internet]. 2020 May 30 [cited 2024 Jun. 18];91(4-S):69-78. Available from: https://mattioli1885journals.com/index.php/actabiomedica/article/view/9634

Most read articles by the same author(s)