Distal triceps rupture

Triceps Tendon Repair

Complete triceps tendon rupture is relatively rare, but more commonly seen in the athletic population. Loss of extension strength is the functional deficit for the elbow after rupture of the triceps tendon. Although partial tears may be treated conservatively, complete tears of the triceps tendon must be repaired to provide active extension at the elbow. Our preferred surgical technique for repair of the acute triceps tendon rupture is presented, as well as strategies for reconstruction of the triceps tendon with an Achilles tendon allograft.

Functional outcomes and complications after surgical repair of triceps tendon rupture

OBJECTIVE

The purpose of this study was to present the functional outcomes and complications after primary repair of triceps tendon ruptures (TTR).

PATIENTS AND METHODS

A retrospective review was performed on eight patients (six males, two females) who underwent transosseous suture repair for TTR. Mayo elbow score, range of motion, muscle strength and patient satisfaction were evaluated after at least 1-year follow-up.

RESULTS

The mean age of the patients was 25.1 years (range 16-42). The mechanism of injury was a sports injury in three patients, simple fall (fall on outstretched hand) in four and motorcycle accident in one patient. Two patients had associated radial head fracture, and one had a radial head fracture and trochlear fracture, and one patient had a medial epicondyle fracture. In two patients the diagnosis was missed at the initial admission to ED (delay, 20 and 75 days). Only one patient, who was a bodybuilder, had a history of anabolic steroid use, and the rest had no underlying disease or a predisposing factor for TTR. One of the patients with radial head fracture (displaced three parts) underwent simultaneous fixation using two headless screws. Patients were followed up for a mean of 18.8 months (range 12-26). At the final follow-up, all patients were satisfied with the treatment and the Mayo elbow score was excellent in six patients and good in two patients. There was 5° extension loss in two patients. Triceps muscle strength was 5/5 in all patients. Ulnar nerve entrapment occurred in one patient, so ulnar nerve release and anterior transposition were performed 3 months after surgery. Posterior interosseous nerve palsy occurred in one patient who underwent simultaneous radial head fracture fixation, but eventually returned back to normal 3 months postoperatively. All patients returned to their previous level of activity and occupation.

CONCLUSION

Transosseous suture technique is a safe and effective treatment method for acute TTR with a low rate of complications and excellent functional outcomes.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Triceps tendon rupture: an uncommon orthopaedic condition

Triceps tendon disruption is a rare orthopaedic injury that can lead to poor outcomes if misdiagnosed or managed inappropriately. This case report illustrates the importance of early, precise diagnosis of triceps rupture by clinical and radiological examination with appropriate management. A weightlifter who had fallen while riding his bike presented with pain, swelling around the posterior aspect of the left arm just above the elbow. Physical examination revealed ecchymosis and weakness in elbow extension. A radiograph of the elbow showed a small fleck of bone proximal to the tip of the olecranon. The patient was initially stabilised. Early intervention in the form of primary tendon repair was performed within 3 days and rehabilitation was started. The patient improved significantly to his best possible functional status with Mayo elbow score of 85. Early intervention was the key to better prognosis.

Distal triceps tendon repair using Krakow whipstitches, K wires, tension band and double drilling technique: a case report

INTRODUCTION

The management of distal triceps tears must address each patient's medical and functional status: in general, the literature has described satisfactory nonsurgical treatment in tears less than 50%. Tears greater than 50% are treated nonsurgically in a sedentary person and surgically in active patients. Complete tears are generally managed surgically: most reported repair techniques describe the use of Bunnell or Krakow whipstitch techniques, passing the sutures through transosseous drill holes in the ulna. Other described techniques include the use of suture anchors and direct tendon repair to a periosteal flap raised from the olecranon.

CASE PRESENTATION

In the presented report we describe the surgical technique used to treat a complete traumatic distal triceps tendon rupture associated with olecranon fracture in a 40-year-old Caucasian man with underlying poor tendon quality and postoperative assessment. To the best of our knowledge no studies describing the performed surgical technique, utilizing Krakow whipstitches, olecranon fixation with K wires and Zuggurtung tension band through transosseous drill holes have been previously described in the literature. At 30 days postoperatively the patient had regained full elbow flexion/extension and pronation/supination.

CONCLUSIONS

The described methodology, using a double ulnar tunnel to obtain fixation of the fragment, associated with a whipstitch locking-type suture for the triceps tendon, allowed proper fixation of the fracture and optimal reinsertion of the detached tendon on its footprint with sufficient strength.

Diagnosis and treatment of triceps tendon injuries: a review of the literature

OBJECTIVE

To elucidate mechanism of injury, nonoperative protocols, surgical techniques, rehabilitation schedules, and return to sports guidelines for partial and complete triceps tendon injuries.

DATA SOURCES

The PubMed and OVID databases were searched in 2010 and peer-reviewed English language articles in 2011.

MAIN RESULTS

After a fall on an outstretched hand, direct trauma on the elbow, or lifting against resistance, patients often present with pain and weakness of extension. Examination may reveal a palpable tendon gap, and radiographs may reveal a Flake sign. Acute partial injuries have positive outcomes with immobilization in 30-degree flexion for 4 to 6 weeks. Primary repair for complete rupture can restore normal extensor function after 3 to 4 months. Reconstruction returns normal extensor function up to 4 years. Most authors support postoperative immobilization for 2 to 3 weeks at 30- to 40-degree flexion, flexion block bracing for an additional 3 weeks, and unrestricted activity at 6 months. Athletes may be able to return to sports after 4 to 5 weeks of recovery from a partial injury, but return may be delayed if operative tendon repair is performed.

CONCLUSIONS

Acute partial triceps tendon injuries may be managed conservatively at first and should be repaired primarily if this fails or if presentation is delayed. Reconstruction should first use the anconeus rotation technique. If the anconeus is devitalized, the Achilles tendon may be the allograft of choice.

Synthetic augmented suture anchor reconstruction for a complete traumatic distal triceps tendon rupture in a male professional bodybuilder with postoperative biomechanical assessment

Bodybuilding is a high-risk sport for distal triceps tendon ruptures. Management, especially in high-demanding athletes, is operative with suture anchor refixation technique being frequently used. However, the rate of rerupture is high due to underlying poor tendon quality. Thus, additional augmentation could be useful. This case report presents a reconstruction technique for a complete traumatic distal triceps tendon rupture in a bodybuilder with postoperative biomechanical assessment. A 28-year-old male professional bodybuilder was treated with a synthetic augmented suture anchor reconstruction for a complete triceps tendon rupture of his right dominant elbow. Postoperative biomechanical assessment included isokinetic elbow strength and endurance testing by using multiple angular velocities to simulate the "off-season" and "precompetition" phases of training. Eighteen months postoperatively and after full return to training, the biomechanical assessment indicated that the strength and endurance of the operated elbow joint was fully restored with even higher ratings compared to the contralateral healthy arm. The described reconstruction technique can be considered as an advisable option in high-performance athletes with underlying poor tendon quality due to high tensile strength and lack of donor site morbidity, thus enabling them to restore preinjury status and achieve safe return to sports.

MR imaging of the elbow in the injured athlete

This article summarizes key MR imaging findings in common athletic elbow injuries including little leaguer's elbow, Panner disease, osteochondritis dissecans, olecranon stress fracture, occult fracture, degenerative osteophyte formation, flexor-pronator strain, ulnar collateral ligament tear, lateral ulnar collateral ligament and radial collateral ligament tear, lateral epicondylitis, medial epicondylitis, biceps tear, bicipitoradial bursitis, triceps tear, olecranon bursitis, ulnar neuropathy, posterior interosseous nerve syndrome, and radial tunnel syndrome. The article also summarizes important technical considerations in elbow MR imaging that enhance image quality and contribute to the radiologist's success.

Partial triceps disruption: a case report

Partial triceps tendon disruptions are a rare injury that can lead to debilitating outcomes if misdiagnosed or managed inappropriately. The clinician should have a high index of suspicion when the mechanism involves a fall onto an outstretched arm and there is resultant elbow extension weakness along with pain and swelling. The most common location of rupture is at the tendon-osseous junction. This case report illustrates a partial triceps tendon disruption with involvement of, primarily, the medial head and the superficial expansion. Physical examination displayed weakness with resisted elbow extension in a flexed position over 90°. Radiographs revealed a tiny fleck of bone proximal to the olecranon, but this drastically underestimated the extent of injury upon surgical exploration. Magnetic resonance imaging is essential to ascertain the percentage involvement of the tendon; it can be used for patient education and subsequently to determine treatment recommendations. Although excellent at finding associated pathology, it may misjudge the size of the tear. As such, physicians must consider associated comorbidities and patient characteristics when formulating treatment plans.

Evaluation and management of elbow tendinopathy

Context:

Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic surgeons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment outcomes will enable the appropriate management of patients and their expectations.

Evidence Acquisitions:

The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy.

Results:

Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments.

Conclusions:

Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate benefit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diagnosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury.

Clinical outcome after suture anchor repair for complete traumatic rupture of the distal triceps tendon

PURPOSE

To evaluate the clinical results of surgical repair of complete distal triceps tendon rupture using suture anchors and high-strength sutures by use of validated outcome measures.

METHODS

A consecutive series of traumatic distal triceps tendon ruptures at a single institution were studied. All cases were surgically repaired by use of suture anchors double loaded with ultrahigh-molecular-weight polyethylene-containing sutures. All patients were evaluated with a physical examination, radiographs, and questionnaires. The following postoperative validated outcome measures were used: the Disabilities of the Arm, Shoulder and Hand (DASH) score; the Oxford Elbow Score; the American Shoulder and Elbow Surgeons elbow assessment form; and the Mayo Elbow Performance Index.

RESULTS

Five male patients with a mean follow-up of 32 months underwent suture anchor repair for traumatic rupture of the distal triceps tendon. Of the repairs, 3 were in the dominant arm and 2 in the nondominant arm. The mean patient age was 47 years (range, 35 to 54 years). Postoperatively, the mean DASH score was 1.4, the mean American Shoulder and Elbow Surgeons elbow score was 99.2, the mean Mayo Elbow Performance Index was 95.8, the mean Oxford Elbow Score for pain was 98.8, the mean Oxford Elbow Score for function was 100, and the mean Oxford Elbow Score for the social domain was 96.2. A lower score for the DASH indicates less disability and better function.

CONCLUSIONS

This retrospective case series of suture anchor repair of distal triceps tendon ruptures showed excellent elbow function based on validated clinical outcome measures.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Chronic triceps insufficiency managed with extensor carpi radialis longus and palmaris longus tendon grafts

Chronic triceps insufficiency, causing prolonged disability, occurs due to a missed diagnosis of an acute rupture. We report a 25 year old male with history of a significant fall sustaining multiple injuries. Since then, he had inability in extending his right elbow for which he sought intervention after a year. Diagnosis of triceps rupture was made clinicoradiologically and surgery was planned. Intraoperative findings revealed a deficient triceps with a fleck of avulsed bone from olecranon. Ipsilateral double tendon graft including extensor carpi radialis longus and palmaris longus were anchored to triceps and secured with the olecranon. Six-months follow revealed a complete active extension of elbow and a full function at the donor site.

Triceps tears in athletes: different injury patterns and surgical treatment

INTRODUCTION

Triceps muscle tears requiring surgical treatment are uncommon injuries.

METHOD

We present 10 cases, all of them were athletes. All these patients were treated surgically between 1993 and 2009. Three operations were performed in the acute phase and the rest seven cases an average of 6 months (range 3-12 months) after the primary injury. The mean follow-up period after surgery was 6 years (range 2-9 years).

RESULTS

The result was evaluated to be excellent in five cases, good in four, and fair in one patient. All except one patient were able to resume full training.

CONCLUSION

Our results show that surgical treatment seems to be beneficial in severe triceps tears even after failed conservative treatment.

Sonography of partial-thickness tears of the distal triceps brachii tendon

OBJECTIVES

The purpose of this study was to retrospectively characterize the sonographic appearance of partial-thickness distal triceps brachii tendon tears.

METHODS

After Institutional Review Board approval, sonographic records were searched for patients who had an unequivocal partial-thickness triceps tendon tear at surgery or magnetic resonance imaging. Sonograms were retrospectively characterized for tendon discontinuity of the superficial or deep layers, tendon retraction, osseous fracture fragments, and joint effusion. Imaging findings were then compared with clinical, imaging, and surgical results.

RESULTS

Five patients had a partial-thickness distal triceps brachii tendon tear at surgery (n = 4) or magnetic resonance imaging (n = 1). All cases only involved the superficial tendon layer (combined long and lateral heads) with retraction of a fractured olecranon enthesophyte fragment. The deep tendon layer (medial head) was intact in all cases with no joint effusion.

CONCLUSIONS

Partial-thickness distal triceps brachii tendon tears have a characteristic appearance with selective superficial tendon retraction and olecranon enthesophyte avulsion fracture.

Ultrasound demonstration of distal triceps tendon tears

PURPOSE

Rupture of the distal triceps tendon is an uncommon injury that may be unrecognized on clinical examination. The purpose of the study is to describe the role of US in distal triceps tendon tears evaluation.

MATERIALS AND METHODS

IRB approval was obtained and patients gave written informed consent. Of 77 consecutive US examinations of the elbow obtained over a five-year period, eight patients with correlative MR and surgery available were identified having partial or complete distal triceps tendon tear.

RESULTS

N = 4 complete tears of the triceps tendon and n = 4 partial tears of the distal triceps involving the lateral/superficial head were identified. Patients with partial tear had a history of a single traumatic event that determined a sudden eccentric contraction of the triceps muscle against resistance. US demonstrated on axial and longitudinal planes a partial tear of the triceps brachii tendon that resulted in a fusiform swelling and retraction of the lateral/superficial head in four patients. It was possible to identify the normal insertion of the medial head of the triceps moving the transducer medially. MR and surgical findings were concordant with US findings in every patient.

CONCLUSION

Ultrasound is able to differentiate complete from partial triceps tendon tears. US has the potential to identify isolated lesions of the lateral/superficial head of the triceps with an intact medial head.