Biceps and triceps injuries of the elbow

Surgical Outcomes, Trends, and Risk Factors of Distal Triceps Repairs

BACKGROUND

Distal triceps ruptures are rare, and complete ruptures are commonly treated with surgery. Studies of patients in small cohorts with distal triceps tear have reported outcomes and risk factors; however, large-scale data are scant. This study seeks to determine current trends, outcomes, and risk factors of distal triceps tears.

METHODS

Within a large insurance claims database, distal triceps repair patients were identified through Current Procedural Terminology coding with concomitant distal triceps International Classification of Diseases, 9th Revision/10th Revision diagnosis codes and 1-year active status before and after surgery. Demographics, total costs, 90-day complications, and revision rates within 1 year of index surgery were analyzed. Logistic regression was performed for revision and complication rates using sex, age, and comorbidities (anabolic steroid use, diabetes, ischemic heart disease, tobacco use, rheumatoid arthritis, and chronic kidney disease).

RESULTS

A total of 8143 patients were included in the cohort. Male patients and patients aged 40 to 59 years comprised most of the study population. The postoperative complication rate was 5.8%, and the 1-year revision rate was 2.6%. Male sex, age >60 years, ischemic heart disease, rheumatoid arthritis, and chronic kidney disease were statistically significant risk factors for higher 90-day complication rates. Anabolic steroid use significantly increased the risk of surgical revision.

CONCLUSIONS

Distal triceps repairs in this large cohort study occur most frequently in men aged 40 to 59 years. Complications are generally low, with age >60 years, male sex, ischemic heart disease, rheumatoid arthritis, and chronic kidney disease as risk factors for 90-day complications and prior anabolic steroid use as a risk factor for 1-year revision surgery. This information can help to improve education and expectations of this procedure.

Partial ruptures of the distal triceps tendons show only slightly lower ultimate load to failure: a biomechanical study

OBJECTIVE

Partial ruptures of the distal triceps tendon are usually treated surgically from a size of > 50% tendon involvement. The aim of this study was to compare the ultimate load to failure of intact triceps tendons with partially ruptured tendons and describe the rupture mechanism.

METHODS

Eighteen human fresh-frozen cadaveric elbow specimens were randomly assigned to two groups with either an intact distal triceps tendon or with a simulated partial rupture of 50% of the tendon. A continuous traction on the distal triceps tendon was applied to provoke a complete tendon rupture. The maximum required ultimate load to failure of the tendon in N was measured. In addition, video recordings of the ruptures of the intact tendons were performed and analysed by two independent investigators.

RESULTS

A median ultimate load to failure of 1,390 N (range Q_0.25-Q_0.75, 954 - 2,360) was measured in intact distal triceps tendons. The median ultimate load to failure of the partially ruptured tendons was 1,330 N (range Q_0.25-Q_0.75, 1,130 - 1.470 N). The differences were not significant. All recorded ruptures began in the superficial tendon portion, and seven out of nine tendons in the lateral tendon portion.

DISCUSSION

Partial ruptures of the distal triceps tendon demonstrate a not statistically significant lower ultimate load to failure than intact tendons and typically occur in the superficial, lateral portion of the tendon. This finding can be helpful when deciding between surgical and conservative therapy for partial ruptures of the distal triceps tendon.

Acute and Chronic Elbow Disorders

Elbow pain is very common and can be due to many pathologic conditions. After radiographs are obtained, advanced imaging is often necessary. Both ultrasonography and MR imaging can be used to evaluate the many important soft-tissue structures of the elbow, with each modality having advantages and disadvantages in certain clinical scenarios. Imaging findings between the two modalities often correlate. It is important for musculoskeletal radiologists to understand normal elbow anatomy and how best to use ultrasonography and MR imaging to evaluate elbow pain. In this way, radiologists can provide expert guidance to referring clinicians and best guide patient management.

Return to Sport Following Distal Triceps Repair

PURPOSE

The purpose of this investigation was to examine the timeline of return-to-sport following distal triceps repair; evaluate the degree of participation and function upon returning to sport; and identify risk factors for failure to return to sport.

METHODS

Patients who underwent distal triceps repair with a minimum of 1 year of follow-up were retrospectively reviewed. Patients completed a subjective sports questionnaire and were scored on a visual analog scale for pain; the Mayo Elbow Performance Index; the Quick Disabilities of the Arm, Shoulder, and Hand; and the Single Assessment Numerical Evaluation.

RESULTS

Out of 113 eligible patients who had a distal triceps repair, 81 patients (71.7%) were contacted. Sixty-eight patients (84.0%) who participated in sports prior to surgery were included at 6.0 ± 4.0 years after surgery, and the average age was 46.6 ± 11.5 years. Sixty-one patients (89.7%) resumed playing at least 1 sport by 5.9 ± 4.4 months following distal triceps repair. However, 18 patients (29.5%) returned to a lower level of activity intensity. The average postoperative Quick Disabilities of the Arm, Shoulder, and Hand; Mayo Elbow Performance; visual analog scale for pain; and Single Assessment Numerical Evaluation scores were 8.2 ± 14.0, 89.5 ± 13.4, 2.0 ± 1.7, and 82.2 ± 24.3, respectively. No patients underwent revision surgery at the time of final follow-up.

CONCLUSIONS

Distal triceps repair enables 89.7% of patients to return to sport by 5.9 ± 4.4 months following surgery. However, 29.5% of patients were unable to return to their preinjury level of activity. It is imperative that patients are appropriately educated to manage postoperative expectations regarding sport participation following distal triceps repair.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[Lesions of the triceps tendon : Diagnostics, management, treatment]

The triceps brachii muscle is the main extender of the elbow joint. Triceps tendon rupture or tearing presents a rare injury pattern in general. Distal tendon ruptures occur most commonly in the area of the insertion of the olecranon. Fractures of the radial head are reported as the most common concomitant injury. In many cases, pre-existing degenerative damage predisposes for tendon injury. These include local steroid injections, anabolic steroid abuse, renal insufficiency requiring dialysis, hyperparathyroidism, lupus erythematosus and Marfan's syndrome. However, the most frequent trauma mechanism is a direct fall onto the extended forearm or a blow to the elbow. Beside clinical examination and sonography, magnetic resonance imaging is the diagnostic gold standard. The treatment of triceps tendon injuries includes conservative as well as operative approaches, whereby the indications for surgical treatment must be generously considered depending on the patient's age, functional demands of the patient, involvement of the dominant extremity as well as on the extent of the tendon rupture.

[Transosseous reconstruction of triceps tendon rupture : Surgical technique]

Operationsziel

Transossäre Rekonstruktion der Trizepssehne.

Indikation

Sämtliche Trizepssehnenrupturen, die eine spannungsfreie Rekonstruktion erlauben.

Kontraindikation

Retrahierte Trizepssehnenrupturen, die nach Mobilisation keine spannungsfreie Rekonstruktion erlauben.

Operationstechnik

Durch 2 sich kreuzende transossäre Kanäle erfolgt das Durchfädeln eines nichtresorbierbaren Fadens. Direkt im Footprint erfolgt zudem das Setzen eines Fadenankers. Durch den primären Faden erfolgt nach transossärem Shutteln am Footprint beginnend das Durchflechten der Sehne in Krackow-Nahttechnik und, erneut am Footprint angekommen, das erneute transossäre Shutteln sowie das körperferne Verknoten. Mit dem ersten Fadenpaar des Ankers erfolgen in ähnlicher Weise das Armieren der Sehne und anschließend das intratendinöse Verknoten. Durch ein Verknoten des zweiten Fadenpaares des Ankers auf den primären körperfernen Knoten kann der Anpressdruck auf das Avulsionsfragment erhöht werden. Alternativ kann mit den Fäden des Fadenankers eine Mason-Allen Naht-durchgeführt werden.

Weiterbehandlung

Die ersten 6 Wochen erfolgt die Nachbehandlung in einer „ROM brace“ mit einem stufenweisen Freigeben der Flexion. Nach 6 Wochen freie Flexion. Beginn mit Kräftigungsübungen nach 12 Wochen.

Ergebnisse

Autoren beschreiben gute Ergebnisse nach operativer Versorgung von Trizepssehnenrupturen. Im vorliegenden Fall wird 6 Monate postoperativ, ungeachtet von einem in der Literatur beschriebenen möglichen Extensionsdefizit, ein exzellentes Outcome mit freiem Bewegungsausmaß erreicht.

Return to work following distal triceps repair

PURPOSE

The purpose of this study was to evaluate the rate and duration of return to work in patients undergoing distal triceps repair (DTR).

METHODS

Consecutive patients undergoing DTR from 2009 to 2017 at our institution were retrospectively reviewed at a minimum of 1 year postoperatively. Patients completed a standardized and validated work questionnaire; a visual analog scale for pain; the Mayo Elbow Performance Score; the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; and a satisfaction survey.

RESULTS

Of 113 eligible patients who underwent DTR, 81 (71.7%) were contacted. Of these patients, 74 (91.4%) were employed within 3 years prior to surgery (mean age, 46.0 ± 10.7 years; mean follow-up, 5.9 ± 3.9 years). Sixty-nine patients (93.2%) returned to work by 2.2 ± 3.2 months postoperatively. Sixty-six patients (89.2%) were able to return to the same level of occupational intensity. Patients who held sedentary-, light-, medium-, and high-intensity occupations were able to return to work at a rate of 100.0%, 100.0%, 80.0%, and 76.9%, respectively, by 0.3 ± 0.5 months, 1.8 ± 1.5 months, 2.5 ± 3.6 months, and 4.8 ± 3.9 months, respectively, postoperatively. Of the workers' compensation patients, 15 (75%) returned to work by 6.5 ± 4.3 months postoperatively, whereas 100% of non-workers' compensation patients returned to work by 1.1 ± 1.6 months (P < .001). Seventy-one patients (95.9%) were at least somewhat satisfied, with 50 patients (67.6%) reporting excellent satisfaction. Seventy-two patients (97.3%) would undergo the operation again if presented the opportunity. A single patient (1.4%) required revision DTR.

CONCLUSIONS

Approximately 93% of patients who underwent DTR returned to work by 2.2 ± 3.2 months postoperatively. Patients with higher-intensity occupations had an equivalent rate of return to work but took longer to return to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.

Triceps Tendon Rupture - A Novel Repair of an Uncommon Injury

Introduction

Triceps tendon rupture is a rare injury accounting for <1% of all tendon injuries with varying repair techniques described. We present this novel repair to supplement available literature and help optimize the clinical outcomes for affected patients. We report this technique because it is unique in that we augmented our surgical fixation with a subtle variation in the described technique by repairing the deep portion of the triceps tendon as a separate step, maximizing the recreation of the anatomic footprint of the triceps.

Case Report

The patient is a 70-year-old Caucasian male presenting with pain, swelling, and ecchymosis around the elbow after the episode of injury. He also complained of a painful popping sensation whenever he ranged the elbow and an inability to extend, with pain and weakness any time he attempted elbow extension. Radiographs reviewed at his initial visit revealed a small osseous fragment approximately 5 cm proximal to the olecranon tip. Subsequent MR imaging confirmed our suspicion, showing a complete tear of the triceps tendon with hematoma at its insertion site and tendon retraction approximately 3 cm proximally. With the diagnosis of triceps tendon rupture conformed, we took the patient for primary tendon repair using suture with bone bridge and suture anchor, using elements from described techniques. Our technique was unique in that we performed repair of the deep and superficial triceps attachments as separate steps, in an endeavor to improve the anatomic reconstruction of the footprint and biomechanical strength.

Conclusions

We combined findings from our review of the available literature with novel surgical techniques and suture design to maximize the patient outcome and minimize complications. The patient went on to have a very satisfactory functional recovery. We hope that this case report will complement the evidence-based care of these patients by orthopedic surgeons and lead to the best results possible.

Distal Triceps Tendon Injuries

Distal triceps ruptures are uncommon, usually caused by a fall on an outstretched hand or a direct blow. Factors linked to injury include eccentric loading of a contracting triceps, anabolic steroid use, weightlifting, and traumatic laceration. Risk factors include local steroid injection, hyperparathyroidism, and olecranon bursitis. Initial diagnosis can be complicated by pain and swelling, and a palpable defect is not always present. Plain radiographs can be helpful. MRI confirms the diagnosis and directs treatment. Incomplete tears can be treated nonsurgically; complete tears are best managed surgically. Good to excellent restoration of function has been shown with surgical repair.

Triceps Tendon Ruptures: Risk Factors, Treatment, and Rehabilitation

Triceps tendon ruptures (TTRs) are rare and often occur as a result of falling on an outstretched hand, forceful eccentric contraction, direct trauma to the elbow, or lifting against resistance. TTRs are most commonly seen in middle-aged men, football players, and weightlifters. Radiography, ultrasonography, and magnetic resonance imaging may be utilized for diagnosis and to guide treatment. Acute partial TTRs may have good outcomes with nonoperative management. Surgery should be considered if nonoperative treatment is unsuccessful or if substantial musculotendinous retraction is present. Surgical repair is strongly recommended for complete TTRs.

Surgical Repair of Distal Triceps Tendon Injuries: Short-term to Midterm Clinical Outcomes and Risk Factors for Perioperative Complications

Background

Few large-scale series have described functional outcomes after distal triceps tendon repair. Predictors for operative success and a comparative analysis of surgical techniques are limited in the reported literature.

Purpose

To evaluate short-term to midterm functional outcomes after distal triceps tendon repair in a broad patient population and to comparatively evaluate patient-reported outcomes in patients with and without pre-existing olecranon enthesopathy while also assessing for modifiable risk factors associated with adverse patient outcomes and/or revision surgery.

Study Design

Case series; Level of evidence, 4.

Methods

This study was a retrospective analysis of 69 consecutive patients who underwent surgical repair of distal triceps tendon injuries at a single institution. Demographic information, time from injury to surgery, mechanism of injury, extent of the tear, pre-existing enthesopathy, perioperative complications, and validated patient-reported outcome scores were included in the analysis. Patients with a minimum of 1-year follow-up were included.

Results

The most common mechanisms of injury were direct elbow trauma (44.9%), extension/lifting exercises (20.3%), overuse (17.4%), and hyperflexion or hyperextension (17.4%). Eighteen patients were identified with pre-existing symptomatic enthesopathy, and 51 tears were caused by an acute injury. A total of 36 complete and 33 partial tendon tears were identified. Bone tunnels were most commonly used (n = 30; 43.5%), while direct sutures (n = 23; 33.3%) and suture anchors (n = 13; 18.8%) were also used. Perioperative complications occurred in 21.7% of patients, but no patients experienced a rerupture at the time of final follow-up. No statistically significant relationship was found between patient age (P = .750), degree of the tear (P = .613), or surgical technique employed (P = .608) and the presence of perioperative complications.

Conclusion

Despite the heightened risk of perioperative complications after primary repair of distal triceps tendon injuries, the current series found favorable functional outcomes and no cases of reruptures at short-term to midterm follow-up. Furthermore, age, surgical technique, extent of the tear, and mechanism of injury were not associated with adverse patient outcomes in this investigation. Pre-existing triceps enthesopathy was shown to be associated with increased complication rates.

Triceps Repair and Restoration of Triceps Footprint With Anchorless Suture Fixation

Triceps tendon rupture is an uncommon yet potentially devastating injury affecting patients over a broad demographic. Surgical treatment is essential to restore upper extremity functional status, and a vast array of techniques has been implemented with different fixation devices including suture buttons, intraosseous anchors, and suture repairs. Outcomes of distal triceps tendon repair have demonstrated nearly full return of functional capacity. Complications include infection, ulnar nerve neuropathy, arthrofibrosis, flexion contracture, hardware irritation, and most commonly, repair failure. We illustrate a triceps repair technique with suture fixation that restores the tendinous footprint without need of an adjunctive device.

Acute and overuse elbow trauma: radio-orthopaedics overview

Summary. The correct management of acute, subacute and overuse-related elbow pathologies represents a challenging diagnostic and therapeutic problem. While major trauma frequently requires a rapid surgical intervention, subluxation and minor trauma allow taking more time for diagnostics and planning the correct elective treatment after careful clinical and radiological investigation. In these conditions, communication between orthopaedic surgeon and radiologist allow to create a detailed radiology report, tailored to the patient’s and surgeon’s needs and optimal to plan proper management. Imaging technique as X-Ray, CT, US, MRI, CTA and MRA all belong to the radiologist’s portfolio in elbow diagnostics. Detailed knowledge of elbow pathology and its classification and of the possibilities and limits of each imaging technique is of crucial importance to reach the correct diagnosis efficiently. The aim of this review is to present the most frequent elbow pathologies and suggest a suitable diagnostic approach for each of them. (www.actabiomedica.it)

Distal triceps ruptures

Distal triceps ruptures are rare injuries due to the special anatomical features of the muscle and tendon–bone junction.

This injury typically occurs at the tendon–bone junction due to an eccentric contraction of the muscle.

The treatment is controversial, especially in partial ruptures; surgical repair is indicated for complete ruptures of the distal triceps tendon.

Several repair techniques have been described for acute complete ruptures.

Chronic ruptures often require reconstruction rather than direct repair.

Cite this article: Demirhan M, Ersen A. Distal triceps ruptures. EFORT Open Rev 2016;1:255-259. DOI: 10.1302/2058-5241.1.000038.

Elbow Trauma in the Athlete

In caring for athletes, the physician must be able to accurately diagnose and appropriately treat all forms of elbow injuries. Traumatic injuries to the elbow are common in the athlete. The late cocking phase of throwing produces tremendous valgus stress on the elbow that can lead to medial epicondyle avulsion fractures in adolescents or rupture of the medial ulnar collateral ligament in skeletally mature overhead throwers, such as baseball pitchers and javelin throwers. Common traumatic elbow injuries suffered by athletes, surgical techniques for operative repair of these injuries, as well as postoperative rehabilitation protocols and the clinical results are presented.

Triceps tendon rupture: the knowledge acquired from the anatomy to the surgical repair

Triceps injuries are relatively uncommon in most traumatic events, and the distal triceps tendon ruptures are rare. Recently, the knowledge of this tendon lesion has increased, and it seems to be related to more precise diagnostic and clinical assessments. The most common mechanism of injury remains a forceful eccentric contraction of the muscle, while several other risk factors have been studied as chronic renal failure, endocrine disorders, metabolic bone diseases as well as steroid use. Olecranon bursitis and local corticosteroid injections may also play a role. The commonest site of rupture is at the tendon's insertion into the olecranon and rarely at the myotendinous junction or intramuscularly. The surgical intervention is recommended in acute complete ruptures, and non-operative treatment is reserved for patients with major comorbidities, as well as for partial ruptures with little functional disability and in low demanding patients. Various techniques and approaches as the direct repair to bone, the tendon augmentation, the anconeus rotation flap and the Achilles tendon allograft have been proposed for the management of these challenging injuries. The goal of surgical management should be an anatomical repair of the injured tendon by selection of a procedure with a low complication rate and one that allows early mobilization. This manuscript focuses the triceps tendon ruptures starting from the anatomy to the diagnosis and entity of the triceps tendon injuries, as well as the indications and guidelines for the management.

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.

Distal biceps and triceps injuries in athletes

Biceps and triceps ruptures are rare, but can cause significant disability. They typically result from a forceful eccentric contraction, resulting in weakness and pain. Biceps and triceps tendon injuries represent the most and least common tendinous injuries about the elbow, respectively. Nonoperative management of these injuries is generally reserved for partial ruptures or patients unfit for surgery. Surgical repair has become the preferred method of treatment for acute, complete ruptures. Anatomy, epidemiology, clinical evaluation, and treatment of these injuries are described in this review.

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.

Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies

In the second part of this review article the management of medial elbow tendinopathy, distal biceps and distal triceps tendinopathy will be discussed. There is a scarcity of publications concerning any of these tendinopathies. This review will summarise the current best available evidence in their management. Medial elbow tendinopathy, also known as Golfer's elbow, is up to 6 times less common than lateral elbow tendinopathy. The tendinopathy occurs in the insertion of pronator teres and flexor carpi radialis. Diagnosis is usually apparent through a detailed history and examination but care must be made to exclude other conditions affecting the ulnar nerve or less commonly the ulnar collateral ligament complex. If doubt exists then MRI/US and electrophysiology can be used. Treatment follows a similar pattern to that of lateral elbow tendinopathy. Acute management is with activity modification and topical NSAIDs. Injection therapy and surgical excision are utilised for recalcitrant cases. Distal biceps and triceps tendinopathies are very rare and there is limited evidence published. Sequelae of tendinopathy include tendon rupture and so it is vital to manage these tendinopathies appropriately in order to minimise this significant complication. Their management and that of partial tears will be considered.

Distal biceps and triceps ruptures

Biceps and triceps tendon ruptures are rather uncommon injuries and are most commonly diagnosed clinically. Magnetic resonance imaging can help the clinician to differentiate an incomplete tear and define any degeneration of the tendon. Surgical anatomical repair is typically performed in acute complete ruptures whereas nonoperative treatment can be used for partial ruptures, as well as for patients unfit for surgery. Single incision techniques are associated with a higher rate of nerve injuries, while double incision repairs have a higher prevalence of heterotopic ossification. Although various fixation methods have been applied including bone tunnels, interference screws, suture anchors, cortical button fixation, the current evidence does not support the superiority of one method over the other. A well-planned postoperative rehabilitation programme is essential for a good final outcome. As better fixation devices are being used, more aggressive rehabilitation programmes have been applied. Epidemiology, clinical evaluation, diagnosis, surgical and conservative management of these injuries are presented in this review along with the authors' preferred technique for the anatomical repair of acute complete ruptures.

Triceps brachii distal tendon reattachment with a double-row technique

Case reports and small series have reported variable results regarding the treatment of choice for patients with triceps brachii tendon ruptures. Early surgical repair has been recommended for acute complete ruptures of the triceps brachii distal tendon to prevent late functional disability. However, controversy exists regarding the optimum surgical technique of reattachment. In addition, various attachment techniques have been described, with none shown clinically to be superior. Therefore, the authors present a technique for triceps brachii distal tendon reattachment following acute complete ruptures and evaluate their results in a series of patients.

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.

Distal partial ruptures of triceps brachii tendon in an athlete

Distal brachii triceps tendon rupture is rare. Partial lesions are not so well defined. If functionally they are well tolerated in patients with low functional demand, management guideline is not so clear for sportsmen. To our best knowledge, there is no reported technique for the repair of partial forms. A 28-year-old patient was operated on for a partial triceps rupture. He underwent a transosseous olecranon suture of the tricipital tendon, with a side-to-side suture to the healthy residual tendon. The patient was assessed at 2 years follow-up with the DASH score. He had painless and mobile elbow with no effusion and returned to sport 4 months after his surgical repair. The extension strength was comparable to the healthy side (5/5). The DASH score was 1,7 for global score, and 6,3 for work and sport modules. Partial rupture of brachii triceps tendon is not well tolerated in high functional demand patients. We think that patients should be operated in these situations and may achieve excellent results. Postoperative management is crucial to achieve good results as well as in complete rupture.

Prevalence of triceps tendon tears on MRI of the elbow and clinical correlation

OBJECTIVE

Triceps tendon injuries are reported to be very rare. To our knowledge, there have been no studies describing its prevalence or injury patterns on MR imaging. The purpose of this retrospective study was to determine the prevalence and patterns of triceps injuries based on a large series of consecutive MR examinations. Clinical correlation was obtained.

MATERIALS AND METHODS

From 801 consecutive elbow MR examinations over a 15-year period, 28 patients with 30 triceps tendon injuries were identified and graded as partial tendon tear and complete tendon tear. The patients' medical records were reviewed to determine age, gender, cause of tears, and management.

RESULTS

The prevalence of triceps tendon injuries was 3.8%. There were 5 women and 23 men with partial or complete tears (mean age: 46.6 years; range: 2.7 to 75.1 years). The most common injury was partial tear, found in 18 patients. There were 10 patients with 12 complete tears (2 had re-torn following surgical repair). A tear was suspected in 12 out 28 (43%) patients prior to the MRI. The most common presenting symptom was pain. The most common cause was athletic injury (8 patients [29%], including weightlifting [2 patients]). Tendon tear was found to be a complication of infection in 6 patients, and in 3 patients the tears were a complication of steroid use. Thirteen tendon tears were surgically repaired (8 of these were complete tears).

CONCLUSIONS

Triceps tendon injury is not as rare as commonly reported and may often be clinically underdiagnosed.

Prevalence of triceps tendon tears on MRI of the elbow and clinical correlation

OBJECTIVE

Triceps tendon injuries are reported to be very rare. To our knowledge, there have been no studies describing its prevalence or injury patterns on MR imaging. The purpose of this retrospective study was to determine the prevalence and patterns of triceps injuries based on a large series of consecutive MR examinations. Clinical correlation was obtained.

MATERIALS AND METHODS

From 801 consecutive elbow MR examinations over a 15-year period, 28 patients with 30 triceps tendon injuries were identified and graded as partial tendon tear and complete tendon tear. The patients' medical records were reviewed to determine age, gender, cause of tears, and management.

RESULTS

The prevalence of triceps tendon injuries was 3.8%. There were 5 women and 23 men with partial or complete tears (mean age: 46.6 years; range: 2.7 to 75.1 years). The most common injury was partial tear, found in 18 patients. There were 10 patients with 12 complete tears (2 had re-torn following surgical repair). A tear was suspected in 12 out 28 (43%) patients prior to the MRI. The most common presenting symptom was pain. The most common cause was athletic injury (8 patients [29%], including weightlifting [2 patients]). Tendon tear was found to be a complication of infection in 6 patients, and in 3 patients the tears were a complication of steroid use. Thirteen tendon tears were surgically repaired (8 of these were complete tears).

CONCLUSIONS

Triceps tendon injury is not as rare as commonly reported and may often be clinically underdiagnosed.

The distal triceps tendon footprint and a biomechanical analysis of 3 repair techniques

BACKGROUND

Anatomic repair of tendon ruptures is an important goal of surgical treatment. There are limited data on the triceps brachii insertion, footprint, and anatomic reconstruction of the distal triceps tendon.

HYPOTHESIS

An anatomic repair of distal triceps tendon ruptures more closely imitates the preinjury anatomy and may result in a more durable repair.

STUDY DESIGN

Descriptive and controlled laboratory studies.

METHODS

The triceps tendon footprint was measured in 27 cadaveric elbows, and a distal tendon rupture was created. Elbows were randomly assigned to 1 of 3 repair groups: cruciate repair group, suture anchor group, and anatomic repair group. Biomechanical measurement of load at yield and peak load were measured. Cyclic loading was performed for a total of 1500 cycles and displacement measured.

RESULTS

The average bony footprint of the triceps tendon was 466 mm2. Cyclic loading of tendons from the 3 repair types demonstrated that the anatomic repair produced the least amount of displacement when compared with the other repair types (P < .05). Load at yield and peak load were similar for all repair types (P > .05).

CONCLUSION

The triceps bony footprint is a large area on the olecranon that should be considered when repairing distal triceps tendon ruptures. Anatomic repair of triceps tendon ruptures demonstrated the most anatomic restoration of distal triceps ruptures and showed statistically significantly less repair-site motion when cyclically loaded.

CLINICAL RELEVANCE

Anatomic repair better restores preinjury anatomy compared with other types of repairs and demonstrates less repair-site motion, which may play a role in early postoperative management.

Distal triceps rupture

Distal triceps rupture is an uncommon injury. It is most often associated with anabolic steroid use, weight lifting, and laceration. Other local and systemic risk factors include local steroid injection, olecranon bursitis, and hyperparathyroidism. Distal triceps rupture is usually caused by a fall on an outstretched hand or a direct blow. Eccentric loading of a contracting triceps has been implicated, particularly in professional athletes. Initial diagnosis may be difficult because a palpable defect is not always present. Pain and swelling may limit the ability to evaluate strength and elbow range of motion. Although plain radiographs are helpful in ruling out other elbow pathology, MRI is used to confirm the diagnosis, classify the injury, and guide management. Incomplete tears with active elbow extension against resistance are managed nonsurgically. Surgical repair is indicated in active persons with complete tears and for incomplete tears with concomitant loss of strength. Good to excellent results have been reported with surgical repair, and very good results have been achieved even for chronic tears.

Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group

BACKGROUND

Few data are available regarding the results of nonoperative treatment of distal biceps ruptures. The present study was designed to assess the outcomes associated with unrepaired distal biceps tendon ruptures.

METHODS

Eighteen patients with twenty unrepaired distal biceps tendon ruptures were assessed retrospectively. The median duration of follow-up was thirty-eight months. Sixteen of the eighteen patients were male, and the median age at the time of the injury was fifty years (range, thirty-five to seventy-four years). Supination strength and elbow flexion strength were measured bilaterally, and patient outcomes were assessed with use of the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire. Data were compared with historical controls compiled from six published series of operatively treated patients.

RESULTS

The median supination and elbow flexion strengths for the injured arm were 63% (mean, 74%; range, 33% to 162%) and 93% (mean, 88%; range, 58% to 110%) of those for the contralateral arm, compared with values of 92% (mean, 101%; range, 42% to 297%) and 95% (mean, 97%; range, 53% to 191%) for the historical controls that had been treated surgically. The difference between the mean values was significant for supination strength (p = 0.002) but not for flexion strength (p = 0.164). Patients had satisfactory outcomes overall, with median scores on the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire of 85, 95, and 9, respectively.

CONCLUSIONS

Nonoperative treatment of distal biceps tendon ruptures can yield acceptable outcomes with modestly reduced strength, especially supination.

Bilateral and simultaneous triceps avulsions in a patient with chronic renal failure receiving long-term peritoneal dialysis

Simultaneous bilateral triceps tendon avulsions are extremely rare; only 4 cases have been reported in the international literature. This article describes a case of a 32-year-old woman with bilateral and simultaneous avulsions of the triceps tendons. She suffers from chronic renal failure and undergoes peritoneal dialysis every day. The patient presented with ecchymosis and swelling at the posterior aspect of both elbows. While climbing stairs a few hours earlier, she had fallen back on both outstretched arms, experienced moderate pain, and heard a sudden popping sound in her right elbow, followed by similar pain in the left elbow. On examination, she revealed intact extensor mechanism. Radiographs revealed a small osseous flake just proximal to the olecranon in both arms and the absence of associated fractures. During surgery, both triceps tendons appeared normal, other than being avulsed at their tendo-osseous junction. The patient obtained a successful result and full range of motion bilaterally within 3 months postoperatively. A high index of suspicion is needed and careful attention should be paid to elbow pain after minor trauma so that triceps injuries, especially in chronic kidney disease cases, are not missed.

Bilateral ruptures of the distal biceps brachii tendon

BACKGROUND

The purpose of this study was to identify characteristics associated with bilateral ruptures of the distal biceps tendons.

METHODS

We present a retrospective case series of 25 patients who sustained non-simultaneous bilateral distal biceps brachii tendon ruptures that were repaired surgically, with follow-up available on 10 patients. The average age of the patients was 50 years (range 28-76). All patients were male. The mean time from the first tendon rupture to the contralateral tendon rupture was 2.7 years (range 0.5 - 6.3). Follow-up averaged 45 months (range 24-85).

RESULTS

Patients with bilateral ruptures tended to be middle-aged men, who commonly participated in weight lifting, manual labor, or sports, and who had higher rates of nicotine (50%) and anabolic steroid use (20%) than the general population. After surgical repair of 9 of 10 patients, patients with bilateral distal biceps tendon ruptures had good to excellent outcomes. With the numbers available, outcomes were not statistically associated with manual labor, past medical history, prescription medications, prior tendon injury, body mass index, current activity in sports, use of nutritional supplements, or anabolic steroid use, although worker's compensation claims approached statistical significance (p = 0.059).

CONCLUSIONS

Patients who sustained bilateral distal biceps tendon ruptures tended to be middle-aged men with higher rates of nicotine and anabolic steroid use than the general population.

Avulsion of the distal biceps brachii tendon in middle-aged population: is surgical repair advisable? A comparative study of 22 patients treated with either nonoperative management or early anatomical repair

INTRODUCTION

Operative anatomical repair following complete avulsion of the distal biceps brachii tendon in athletic population is usually recommended. However, there is no clear consensus as to the advisability of the operation in middle-aged population. We therefore undertook a study to examine whether early anatomical repair in this specific population is preferable to nonoperative management.

PATIENTS AND METHODS

We evaluated the outcome at a mean of 2 years following this injury in a group of 22 middle-aged active men. Of this group, 12 were managed with early anatomical repair and 10 were managed nonoperatively. Our evaluation included subjective functional outcome scales, isokinetic measurements, and postoperative complication survey.

RESULTS

Although subjective functional assessment demonstrated higher satisfaction in the operated group (p<.05), 9 of the 10 nonoperated patients reported good to excellent outcome as well. Isokinetic evaluation revealed higher performance of elbow flexors and forearm supinators in the group managed operatively (p<.05), while two patients in this group suffered nerve injuries, though both resolved eventually.

DISCUSSION AND CONCLUSIONS

Surgical repair of complete avulsion of the distal biceps brachii tendon in middle-aged active population may be advised to patients, as it achieves superior outcome both subjectively and objectively. However, nonoperative management should be seriously discussed with each patient, as it is expected to result in good to excellent outcome as well, while avoiding potential complications related to the surgery.

Management of distal biceps and triceps ruptures

The management of distal biceps and triceps ruptures is reviewed. Epidemiology, clinical presentation, evaluation, surgical management, nonoperative management, and rehabilitation rationale and techniques are presented. Although various surgical repair techniques are used, none has been shown to produce superior clinical outcomes. The literature is lacking information to provide evidence-based decisions regarding rehabilitation strategies. Prospective studies comparing types and timing of repairs and timing and techniques for a postoperative program are needed. As that information is not yet available, the rehabilitation plan outlined in this article is based on timetables for healing tissue, strength of repair, prevention of complications, consideration of patient's medical history and injury history, and review of the literature. Familiarity with the different treatment options assists the surgeon and therapist tailor a therapy program that is optimal for each individual patient.

Missed diagnosis of triceps tendon rupture: a case report and review of literature

Rupture of the triceps tendon is an uncommon injury, probably the rarest of all tendinous ruptures. We present a case of missed diagnosis of triceps tendon rupture. Such diagnosis should be considered when a patient presents with pain and swelling at the back of the elbow after a fall on an outstretched hand.

Tear of the distal biceps branchii tendon: A new method of ultrasound evaluation

Tear of the distal biceps brachii tendon is an uncommon injury. Ultrasound evaluation of the distal tendon using an anterior approach is often difficult because of technical factors. We describe a new method of ultrasound evaluation of the distal biceps tendon insertion. This involves a posterior approach with the forearm pronated. With pronation of the forearm, the radial tuberosity faces posteriorly, bringing the distal biceps tendon insertion into view. A surgically proven case of distal biceps tendon tear is presented to illustrate our technique.

Magnetic resonance imaging of the elbow. Part II: Abnormalities of the ligaments, tendons, and nerves

Part II of this comprehensive review on magnetic resonance imaging of the elbow discusses the role of magnetic resonance imaging in evaluating patients with abnormalities of the ligaments, tendons, and nerves of the elbow. Magnetic resonance imaging can yield high-quality multiplanar images which are useful in evaluating the soft tissue structures of the elbow. Magnetic resonance imaging can detect tears of the ulnar collateral ligament and lateral collateral ligament of the elbow with high sensitivity and specificity. Magnetic resonance imaging can determine the extent of tendon pathology in patients with medial epicondylitis and lateral epicondylitis. Magnetic resonance imaging can detect tears of the biceps tendon and triceps tendon and can distinguishing between partial and complete tendon rupture. Magnetic resonance imaging is also helpful in evaluating patients with nerve disorders at the elbow.

Biceps tendon and triceps tendon injuries

Injuries to the biceps and triceps tendons about the elbow are relatively infrequent. Typically, they are traumatic events that occur as a result of a forceful eccentric contraction. Early recognition of these injuries and prompt intervention are the cornerstones to a successful outcome. Acute anatomic repair of complete injuries offers predictably good results. Conservative management, on the other hand, is typically reserved for partial injuries with little functional compromise, and for patients unfit for surgery. The challenges posed by chronic injuries can be addressed with a variety of surgical options. This article focuses on the timely identification and diagnosis of these injuries and specific indications and guidelines for their treatment.

A history of hand surgery in New York City

The origins of Hand Surgery in New York City are temporally centered around World War II. Arthur J. Barsky, MD, Condict W. Cutler, Jr, MD and Emanuel B. Kaplan, MD laid the groundwork for our regional specialty prior to the War. J. William Littler, MD, Robert E. Carroll, MD, served in the Armed Forces and were instrumental in the development of the specialty in the second half of the 20th century. Hand services evolved in each of the major academic centers in New York including those led by Lee Ramsey Straub, MD, at the Hospital for Special Surgery, Richard J. Smith, MD at the Hospital for Joint Disease, Robert W. Beasley, MD at New York University and Berish Strauch, MD, and Morton Spinner, MD, at Albert Einstein and Montefiore. Several surgeons who worked with or were trained by these masters formed the nucleus of the next generation of leaders including Richard G. Eaton, MD, Martin A. Posner, MD, Harold M. Dick, MD, and Charles Melone, MD. Their proteges and a relatively small number of surgeons trained elsewhere, like Andrew J. Weiland, MD, and Robert Hotchkiss, MD, make up the current leadership of Hand Surgery in New York City.