Snapping of Triceps Tendon After Anterior Nerve Transposition for Recurrent Subluxation of the Ulnar Nerve

Snapping Triceps Syndrome: Surgical Technique

Snapping triceps syndrome is a rare cause of medial elbow pain and ulnar neuritis caused by subluxation and triggering of the medial tricipital muscle belly over the medial distal humeral ridge and condyle. The diagnosis and surgical management of snapping triceps syndrome can be challenging due to the subtlety of the symptoms and the infrequent presentation. Despite the diagnosis relying largely on clinical examination, noninvasive dynamic ultrasonography may facilitate detection. Correct recognition of this condition is crucial in the avoidance of surgical misadventure and revision surgery. This paper illustrates our surgical technique for the management of snapping triceps and reviews the available literature on this relatively obscure condition.

[Surgical treatment of snapping triceps syndrome]

OBJECTIVE

Treatment of a persistently painful snapping triceps and possibly snapping ulnar nerve.

INDICATION

Snapping triceps.

CONTRAINDICATIONS

General surgical risks.

SURGICAL TECHNIQUE

Following the anterior transposition of the ulnar nerve (subcutaneously or submuscular), the snapping portion of the triceps tendon is transsected and reinforced, and transposition of the medial triceps margin into the central triceps portion is carried out.

POSTOPERATIVE MANAGEMENT

Cast for 5-7 days; for a total of 6 weeks functional exercise without maximum flexion and resistance exercise of the triceps. Weight loading after 3 months.

RESULTS

In the case presented, complaints were absent after 3 months. Full load exercise, e.g., push-ups, was achieved 4 months after surgery. There was no recurrent snapping within the first year. The results of this case are in agreement with the 25 patients previously reported in the PubMed literature. Recurrence, gross restrictions of movement, and complications were not observed in patients who underwent surgery.

Snapping elbow-A guide to diagnosis and treatment

AIM

To develop practical guidelines for diagnosis and treatment of the painful snapping elbow syndrome (SE).

METHODS

Clinical studies were searched in the databases PubMed and Scopus for the phrases “SE”, “snapping triceps”, “snapping ulnar nerve” and “snapping annular ligament”. A total of 36 relevant studies were identified. From these we extracted information about number of patients, diagnostic methods, patho-anatomical findings, treatments and outcomes. Practical guidelines for diagnosis and treatment of SE were developed based on analysis of the data. We present two illustrative patient cases-one with intra-articular pathology and one with extra-articular pathology.

RESULTS

Snapping is audible, palpable and often visible. It has a lateral (intra-articular) or medial (extra-articular) pathology. Snapping over the medial humeral epicondyle is caused by dislocation of the ulnar nerve or a part of the triceps tendon, and is demonstrated by dynamic ultrasonography. Treatment is by open surgery. Lateral snapping over the radial head has an intra-articular pathology: A synovial plica, a torn annular ligament or a meniscus-like remnant from the foetal elbow. Pathology can be visualized by conventional arthrography, magnetic resonance (MR) arthrography, high resolution magnetic resonance imaging (MRI) and arthroscopy, while conventional MRI and radiographs often turn out normal. Treatment is by arthroscopic or eventual open resection. Early surgical intervention is recommended as the snapping can damage the ulnar nerve (medial) or the intra-articular cartilage (lateral). If medial snapping only occurs during repeated or loaded extension/flexion of the elbow (in sports or work) it may be treated by reduction of these activities. Differential diagnoses are loose bodies (which can be visualized by radiographs) and postero-lateral instability (demonstrates by clinical examination). An algorithm for diagnosis and treatment is suggested.

CONCLUSION

The primary step is establishment of laterality. From this follows relevant diagnostic measures and treatment as defined in this guideline.

Distal triceps injuries (including snapping triceps): A systematic review of the literature

AIM

To review current literature on types of distal triceps injury and determine diagnosis and appropriate management.

METHODS

We performed a systematic review in PubMed, Cochrane and EMBASE using the terms distal triceps tears and snapping triceps on the 10^th January 2017. We excluded all animal, review, foreign language and repeat papers. We reviewed all papers for relevance and of the papers left we were able to establish the types of distal triceps injury, how these injuries are diagnosed and investigated and the types of management of these injuries including surgical. The results are then presented in a review paper format.

RESULTS

Three hundred and seventy-nine papers were identified of which 65 were relevant to distal triceps injuries. After exclusion we had 47 appropriate papers. The papers highlighted 2 main distal triceps injuries: Distal triceps tears and snapping triceps. Triceps tear are more common in males than females occurring in the 4^th-5^th decade of life and often due to a direct trauma but are also strongly associated with weightlifting and American football. The tears are diagnosed by history and clinically with a palpable gap. Diagnosis can be confirmed with the use of ultrasound (US) and magnetic resonance imaging. Treatment depends on type of tear. Partial tears can be treated conservatively with bracing and physio whereas acute tears need repair either open or arthroscopic using suture anchor or bone tunnel techniques with similar success. Chronic tears often need augmenting with tendon allograft or autograft. Snapping triceps are also seen more in men than women but at a mean age of 32 years. They are characterized by a snapping sensation mostly medially and can be associated with ulna nerve subluxation and ulna nerve symptoms. US is the diagnostic modality of choice due to its dynamic nature and to differentiate between snapping triceps tendon or ulna nerve. Treatment is conservative initially with activity avoidance and if that fails surgical management includes resection of triceps edge or transposition of the tendon plus or minus ulna nerve transposition.

CONCLUSION

Distal triceps injuries are uncommon. This systematic review examines the evidence base behind diagnosis, imaging and treatment options of distal triceps injuries including tears and snapping triceps.

Management of subluxating ulnar nerve at the elbow

Musculotendinous variations around the medial epicondyle can contribute to subluxation of the ulnar nerve at the elbow. This article reviews the presenting symptoms, operative findings, and results of surgery for subluxation of the ulnar nerve at the elbow. A retrospective evaluation was performed of 200 elbows managed operatively for medial elbow pathology over a 17-year period between 1990 and 2007. The patient charts were reviewed for chief complaint, radiographic studies, operative reports, and postoperative examination data. Seventeen patients (18 elbows) were treated for a subluxating ulnar nerve. Three patients were women and 14 were men, with a mean age of 27.6 years. Medial elbow pain was the chief complaint in all 17 patients. Seventeen elbows also demonstrated paresthesias in an ulnar nerve distribution. All patients were treated with anterior transposition of the ulnar nerve, and 11 patients (61%) were found to have a muscular anomaly. At a mean follow-up of 17 months, the mean visual analog scale for pain improved from 6.0 to 2.0. There was no functional impairment reported for any patient at final follow-up. Of the 200 elbows surgically treated for medial elbow pathology, 17 patients (8.5%) demonstrated a subluxating ulnar nerve. These patients tend to be young and present with a primary complaint of medial elbow pain. In addition, a subluxating ulnar nerve is often associated with muscular anomalies, which must be addressed concurrently.

Medial or lateral dislocation (snapping) of a portion of the distal triceps: a biomechanical, anatomic explanation

Medial and lateral snapping (dislocation) of the distal triceps over the epicondyle during elbow flexion has been reported but is frequently misdiagnosed and is not well understood. In this study a mathematical model was designed to simulate the effect that bony abnormalities at the distal humerus and soft tissue variations of the distal triceps have on the line of pull of the triceps. The predictions were then tested on prefabricated and fabricated plastic elbow models, as well as 8 cadaveric elbows. When the bony alignment was altered, varus angulation had the greatest effect: 30 degrees varus malalignment of the distal humerus displaced the centroid of the triceps vector medially by approximately 2.0 cm. Valgus malalignment had a lesser effect: 30 degrees valgus displaced it laterally by 1.5 cm. Negligible effects on the triceps line of pull were seen with internal or external malrotation and with flexion or extension malalignment. Of the soft tissue alterations, displacement of the triceps insertion had a greater effect than movement of the triceps origin. The triceps vector was displaced by approximately 70% of the amount of translation of the triceps insertion. The relationship between the triceps line of pull and the bony alignment is represented by the triceps (T) angle. Our use of the T angle to understand snapping triceps is analogous to the use of the quadriceps (Q) angle for patellar subluxation/dislocation. Treatment should aim to restore normal triceps biomechanics with soft tissue or bony procedures.