Skip to main content
SpringerLink
Log in

Bifurcated distal biceps brachii tendon coexisting with separated bicipital aponeurosis: a complex variational case report

  • Case Report
  • Published:
Anatomical Science International Aims and scope Submit manuscript

Abstract

Variations appearing in biceps brachii muscle are common with accessory head, different origins, variant insertion, and different pattern of nerve innervation. However, variations appearing in both origin and insertion, and with other anomalous morphology at the same time are seldom. Here we report a complex variational case on the right arm of a 91-year-old Japanese female cadaver. The complex variations included (1) the biceps brachii muscle bifurcated at its distal ending; (2) the long head had its own tendon, which divided into two parts, i.e., a lateral part fused into the fascia between the brachioradialis and extensor carpi brevis, and a medial part attached to the radius about one centimeter ahead of the radial tuberosity; (3) the short head had an accessory origin from the shoulder capsule; (4) the bicipital aponeurosis was of two parts with an anterior superior layer formed by the long head and a posterior deep one formed by the short head; (5) the musculocutaneous nerve was especially underdeveloped that only innervated the coracobrachialis; (6) the existence of communicating branch between the musculocutaneous and median nerves, and the median nerve issued muscular branches to the biceps brachii and brachialis muscles, and (7) the brachioradial muscle had two accessory muscular bundles that originated from the fascia of the brachial muscle (proximal one) and from the bicipital aponeurosis (distal one).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

The data that support the findings of this study are avilable from the corresponding author, upon reasonable request.

Abbreviations

BA:

Bicipital aponeurosis (BA1 + BA2)

BA1:

Bicipital aponeurosis from BT1

BA2:

Bicipital aponeurosis from BT2

BT1:

Biceps tendon of the short head of biceps brachii

BT2:

Biceps tendon of the long head of biceps brachii

Com:

Communicating branch between the MCN and median nerves

ECR-B:

Extensor carpi radialis brevis

ECR-L:

Extensor carpi radialis longus

LCN:

Lateral cutaneous nerve of forearm

MCN:

Musculocutaneous nerve

Or1:

Normal origin of the short head of the biceps brachii

Or2:

Accessory origin of the short head of the biceps brachii

*1:

Proximal accessory muscular bundle of brachioradialis

*2:

Distal accessory muscular bundle of brachioradialis

References

  • Abu-Hijleh MF (2005) Three-headed biceps brachii muscle associated with duplicated musculocutaneous nerve. Clin Anat 18:376–379

    Article  PubMed  Google Scholar 

  • Adachi B (1928) Verbindungen zwischen dem N. medianus und dem N. musculo-cutaneus oder dem N. cutaneus antebrachii lateralis: Das Arteriensystem der Japaner. Bd I. Marzen, Kyoto, pp201–275.

  • Athwal GS, Steinmann SP, Rispoli DM (2007) The distal biceps tendon: footprint and relevant clinical anatomy. J Hand Surg Am 32:1225–1229

    Article  PubMed  Google Scholar 

  • Ballesteros LE, Forero PL, Buitrago ER (2015) Communication between the musculocutaneous and median nerves in the arm: an anatomical study and clinical implications. Rev Bras Ortop 50(5):567–572

    Article  PubMed  Google Scholar 

  • Benes M, Kachlik D (2021) Atypical branching of the musculocutaneous and median nerves with associated unusual innervation of muscles in the anterior compartment of the arm: case report and plea for extension of the current classification system. Surg Radiol Anat 43(5):671–678

    Article  PubMed  Google Scholar 

  • Bhat N, Bhat KMR, D’Souza AS, Kotian SR (2017) Additional muscle slip of bicipital aponeurosis and its anomalous relationship with the median cubital vein. Sultan Qaboos Univ Med J 17:e103–e105

    Article  PubMed  PubMed Central  Google Scholar 

  • Caetano EB, Vieira LA, Almeida TA, Gonzales LAM, Bona JE, Simonatto TM (2018) Bicipital aponeurosis. Anatomical study and clinical implications. Rev Bras Ortop 53:75–81

    Article  PubMed  Google Scholar 

  • Chew ML, Giuffre BM (2005) Disorders of the distal biceps brachii tendon. Radiographics 25:1227–1237

    Article  PubMed  Google Scholar 

  • Dirim B, Brouha SS, Pretterklieber ML, Wolff KS, Frank A, Pathria MN, Chung CB (2008) Terminal bifurcation of the biceps brachii muscle and tendon: anatomic considerations and clinical implications. AJR Am J Roentgenol 191(6):W248-255

    Article  PubMed  Google Scholar 

  • Eames MH, Bain GI, Fogg QA, van Riet RP (2007) Distal biceps tendon anatomy: a cadaveric study. J Bone Joint Surg Am 89:1044–1049

    CAS  PubMed  Google Scholar 

  • Guerri-Guttenberg RA, Ingolotti M (2009) Classifying musculocutaneous nerve variations. Clin Anat 22:671–683

    Article  PubMed  Google Scholar 

  • Hayashi M, Shionoya K, Hayashi S, Hatayama N, Kawata S, Qu N, Hirai S, Miyaso H, Itoh M (2017) A novel classification of musculocutaneous nerve variations: the relationship between the communicating branch and transposed innervation of the brachial flexors to the median nerve. Annal Anatomy-Anatomischer Anzeiger 209:45–50

    Article  Google Scholar 

  • Huang AH (2017) Coordinated development of the limb musculoskeletal system: tendon and muscle patterning and integration with the skeleton. Dev Biol 429:420–428

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Hunter DD, Skrzat J, Zdilla MJ (2020) Bilateral absence of the musculocutaneous nerve: implications for humerus fracture and atypical median nerve palsy. Folia Med Cracov 60:27–32

    PubMed  Google Scholar 

  • Iwanaga J, Singh V, Ohtsuka A et al (2021) Acknowledging the use of human cadaveric tissues in research papers: recommendations from anatomical journal editors. Clin Anat 34:2–4

    Article  PubMed  Google Scholar 

  • Joshi SD, Yogesh AS, Mittal PS, Joshi SS (2014) Morphology of the bicipital aponeurosis: a cadaveric study. Folia Morphol (warsz) 73:79–83

    Article  CAS  PubMed  Google Scholar 

  • Katsuki S, Terayama H, Tanaka R, Qu N, Tanaka O, Umemoto K, Suyama K, Sakabe K (2018) Variation in origin of the long head of the biceps brachii tendon in a cadaver: a case report. Med (baltimore) 97:e10708

    Article  Google Scholar 

  • Kravarski M, Goerres GW, Antoniadis A, Guenkel S (2020) Supernumerary brachioradialis—anatomical variation with magnetic resonance imaging findings: a case report. World J Orthop 11:411–417

    Article  PubMed  PubMed Central  Google Scholar 

  • Kumar CD, Rakesh J, Tungish B, Singh DM (2017) Congenital absence of the long head of biceps tendon and its clinical implications: a systematic review of the literature. Muscles Ligam Tendons J 7:562–569

    Article  Google Scholar 

  • Latev MD, Dalley AF 2nd (2005) Nerve supply of the brachioradialis muscle: surgically relevant variations of the extramuscular branches of the radial nerve. Clin Anat 18:488–492

    Article  PubMed  Google Scholar 

  • Maeda S, Kawai K, Koizumi M, Ide J, Tokiyoshi A, Mizuta H, Kodama K (2009) Morphological study of the communication between the musculocutaneous and median nerves. Anat Sci Int 84(1–2):34–40

    Article  PubMed  Google Scholar 

  • Moore K, Prasad AM, Nayaka SB (2020) Absence of the musculocutaneous nerve and associated compensation by the median nerve. Kathmandu Univ Med J (KUMJ) 18:313–315

    Article  PubMed  Google Scholar 

  • Nayak SB, Swamy RS, Shetty P, Maloor PA, Dsouza MR (2016) Bifurcated bicipital aponeurosis giving origin to flexor and extensor muscles of the forearm—a case report. J Clin Diagn Res 10:01–02

    Google Scholar 

  • Ozan H, Atasever A, Sinav A, Simsek C, Basar R (1997) An unusual insertion of accessory biceps brachii muscle. Kaibogaku Zasshi 72:515–519

    CAS  PubMed  Google Scholar 

  • Raza K, Singh S, Rani N, Mishra R, Mehta K, Kaler S (2017) anomalous innervation of the median nerve in the arm in the absence of the musculocutaneous nerve. Sultan Qaboos Univ Med J 17:e106–e108

    Article  PubMed  PubMed Central  Google Scholar 

  • Rodriguez-Niedenfuhr M, Vazquez T, Choi D, Parkin I, Sanudo JR (2003) Supernumerary humeral heads of the biceps brachii muscle revisited. Clin Anat 16:197–203

    Article  PubMed  Google Scholar 

  • Rodriguez-Niedenfuhr M, Vazquez T, Parkin I, Nearn L, Sanudo JR (2001) Incidence and morphology of the brachioradialis accessorius muscle. J Anat 199:353–355

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Salmons S (1995) Form and function in skeletal muscles. Gray’s anatomy, 38 ed. Tokyo: Churchill Livingstone. pp 783–788

  • Sato T, Akita K (2000) Anatomic variations in Japanese. University of Tokyo Press (in Japanes), Tokyo

    Google Scholar 

  • Srinivasan RC, Pederson WC, Morrey BF (2020) Distal biceps tendon repair and reconstruction. J Hand Surg Am 45:48–56

    Article  PubMed  Google Scholar 

  • Venieratos D, Anagnostopoulou S (1998) Classification of communications between the musculocutaneous and median nerves. Clin Anat 11(5):327–331

    Article  CAS  PubMed  Google Scholar 

  • Wilk KE, Hooks TR (2016) The painful long head of the biceps brachii: nonoperative treatment approaches. Clin Sports Med 35:75–92

    Article  PubMed  Google Scholar 

  • Zhou M, Ishizawa A, Akashi H, Suzuki R, Bando Y (2021) Bilateral accessory heads of biceps brachii muscle coexisting with brachioradial artery passing between two layers of atypical bicipital aponeurosis. Transl Res Anat. https://doi.org/10.1016/j.tria.2021.10034

    Article  Google Scholar 

  • Zhou M, Ishizawa A, Akashi H, Suzuki R, Kanatsu Y, Abe H, Bando Y (2020) An anomalous case of the flexor carpi radialis with an excessive muscular bundle. Anat Sci Int 95:293–296

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors sincerely thank the members and their families of “Shiragiku-Kai” of Akita University Graduate School of Medicine for their dedicated supports for medical education and research. The authors totally agree with the anatomical journal editor’s recommendation expressing deep gratitude for the donor cadaver (Iwanaga et al. 2021): “The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially increase mankind’s overall knowledge that can then improve patient care. Therefore, these donors and their families deserve our highest gratitude.” The authors also appreciate the staff of the Medical Technology Center for their technical assistance.

Author information

Authors and Affiliations

  1. Department of Anatomy, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan

    Ming Zhou, Hideo Akashi, Ryoji Suzuki & Yoshio Bando

  2. Guidance Division, Kashiwa City Board of Education, 48-1 Oshimada, Kashiwa, 277-8503, Japan

    Akimitsu Ishizawa

Authors
  1. Ming Zhou
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Akimitsu Ishizawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hideo Akashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ryoji Suzuki
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yoshio Bando
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ming Zhou.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhou, M., Ishizawa, A., Akashi, H. et al. Bifurcated distal biceps brachii tendon coexisting with separated bicipital aponeurosis: a complex variational case report. Anat Sci Int 98, 611–617 (2023). https://doi.org/10.1007/s12565-023-00719-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12565-023-00719-5

Keywords

Search

Navigation