Shoulder and Elbow

Evaluation and Management of Triceps Ruptures

The Problem

Triceps tendon ruptures are relatively uncommon - when present they are most commonly associated with anabolic steroid use, weight lifting and laceration.Triceps ruptures have a tendency to be misdiagnosed or underdiagnosed.

Clinical Presentation

Typically, an eccentric contraction injury mechanism is the cause; that is, an unintentional forced flexion of the elbow while the triceps is activated.This type of injury may occur, for example, during a fall on the outstretched upper extremity that forces the extended elbow to become flexed violently.There may not necessarily be a "pop" but patients often report feeling a tear on the posterior elbow. Patients typically report pain, swelling, inability to fully extend the elbow, and weakness with attempted full extension of the elbow.

Diagnostic Workup

Classic physical exam findings

In full-thickness ruptures, there may be a palpable central defect but because of the significant swelling that typically accompanies this injury, a defect may not be easily palpable. Similar to a quadriceps tendon rupture, the central portion of the tendon is often torn and the periphery may remain intact.This may allow elbow extension against gravity but not allow full extension, similar to an extension lag seen with quadriceps tendon ruptures. Resisted elbow extension demonstrates pain and weakness when compared to the contralateral side.

Imaging findings

X-rays may show an avulsion fracture of the enthesophyte at the triceps tendon insertion site. Especially when this avulsion fracture is retracted, a triceps tendon rupture is the working diagnosis until it is ruled out. This small avulsion fracture of the enthesophyte should not be ignored or minimized since it often serves as an important clue that a triceps tendon injury has occurred.

An MRI is helpful to visualize a tear of the triceps tendon (Figure 1). However, make sure to review the actual images yourself and to correlate the images with the clinical presentation. The anatomy of the triceps tendon insertion is important to understand, including the lateral expansion as well as the possibility of a rupture of the superficial tendon (lateral and long heads) with an intact deep portion (medial head), or vice versa. Radiologists may often report a partial tear in the setting of a complete tear of either the deep or superficial portions. I have personally seen several cases in which there was a palpable defect on physical examination of a full-thickness triceps tendon rupture that had an accompanying MRI dictation that reported a “partial tear”. This situation can result in a poorer prognosis due to retraction and scarring, if surgical treatment is delayed for a full-thickness triceps tendon rupture.

Figure 1.

MRI demonstrating a rupture of the triceps tendon with proximal retraction. Note that the deep layer corresponding to the medial head of the triceps is still attached. Beware that this is often reported by radiologists as a partial tear of the triceps tendon.

Non–Operative Management

There is a limited role for non-operative treatment in acute, full-thickness triceps tendon ruptures since the loss of elbow extension power is a functional disability. Remember that a displaced avulsion fracture of the triceps enthesophyte is indicative of a significant disruption.

Non-operative treatment may be attempted in cases of a nondisplaced fracture of the triceps enthesophyte. However, if the enthesophyte does not heal, then it can cause persistent pain that may require excision of the nonunion fragment and either a side-to-side margin convergence type repair of the triceps or a formal triceps repair as described below.

Non-operative treatment is also appropriate for partial tears that are not accompanied by pain or functional weakness and for low-demand patients who have medical comorbidities that preclude surgery.

Indications for Surgery

Similar to a quadriceps tendon rupture, a disruption of the extensor mechanism of the elbow is a functional disability. Therefore, unless the patient has comorbidities that preclude surgical intervention, non-operative treatment has a limited role for a full-thickness triceps tendon rupture.

Surgical Technique

Anesthesia

Pre-operative regional block with general anesthesia. Laryngeal Mask Airway is typically used for general anesthesia in acute triceps tendon ruptures but an endotracheal tube may be appropriate for chronic triceps tendon ruptures that may require muscle relaxation and paralysis in order to mobilize and reduce the retracted tendon to its insertion site.

Patient positioning

Supine with a stack of towels placed on the patient’s chest. The height and position of the stack of towels are arranged such that resting the injured upper extremity on it would result in elbow flexion no greater than 40 degrees. Secure the stack of towels with tape.

Surgical technique

Place a nonsterile tourniquet at the proximal-most aspect of the arm. After a sterile prep of the upper extremity, I prefer to use an occlusive, circumferential Ioban draping technique.

After using an esmarch bandage to exsanguinate the upper extremity, inflate the tourniquet to 250 mm Hg. Rest the arm on the stack of towels, then make an incision along the subcutaneous border of the ulna toward the torn stump of the triceps tendon. Instead of a curvilinear incision at the olecranon tip, my preference is to have a straight incision be placed lateral to the olecranon tip.

Identify the torn triceps tendon stump. If there is a displaced avulsion fragment of the enthesophyte embedded within the distal edge of the torn tendon stump, carefully remove it. Place an Allis clamp on the tendon stump and perform a blunt lysis of adhesions along the tissue plane immediately anterior and posterior to the triceps tendon. Extend the elbow and reduce the triceps tendon. If the tendon does not reach the insertion site, then additional lysis of adhesions is necessary. Place two #2 nonabsorbable braided sutures of different color along the tendon in a modified Mason-Allen fashion while traversing across the width of the entire tendon (Figure 2).

Figure 2.

Nonabsorbable sutures placed on the retracted stump of the retracted distal triceps tendon (bottom purple sutures). The white sutures are passing sutures that are placed through the cruciate bone tunnels in the proximal ulna.

Prepare the insertion site by first removing any osteophytes on the olecranon tip. Then, create a smooth, bleeding bony surface using a combination of a rongeur and rasp.

At the distal aspect of the incision, create a longitudinal split in the fascia between the extensor carpi ulnaris (ECU) and the flexor carpi ulnaris (FCU), in line with the subcutaneous border of the ulna. Perform a subperiosteal elevation of the ECU and FCU.

Using a 2.0 mm drill bit, create two cruciate tunnels for suture passage starting from the triceps tendon insertion site and aiming toward the portion of the distal ulna exposed after the subperiosteal elevation of the ECU and FCU. When aiming the drill toward the medial distal ulna, care must be taken to avoid the ulnar nerve. When aiming toward the lateral distal ulna, care must be taken to avoid the drill hole from exiting too superficial to the posterior cortex. When the sutures are tied over the bone bridge, the suture knot is placed on the lateral side of the distal ulna and buried under the ECU; therefore, if the drill hole exits too close to the apex of the subcutaneous border of the ulna, then the bulky suture knot will not be able to be buried.

Irrigate the surgical wound as well as the drill holes. Remove any bony debris that may become a nidus for heterotopic ossification. Place two long Keith needles through the cruciate drill holes. It is important to place both of the Keith needles at the same time and then pass the sutures at the same time rather than to pass the sutures sequentially through one drill hole and then the other. If a Keith needle is used to pass a suture through one of the drill holes, and then a Keith needle is passed through the other drill hole, then it is possible to accidentally cut the previously passed suture.

Pass the two different colored sutures located on the medial aspect of the triceps tendon stump together and the two different colored sutures located on the lateral aspect of the triceps tendon stump together. Fully extend the elbow and reduce the tendon stump to it insertion site. While maintaining tension with one pair of the same color sutures, tie the other pair of the same color suture securely over the bone bridge (Figure 3). Make sure to use the suture strand exiting the lateral aspect of the distal ulna as the post so that the knot will be away from the ulnar nerve and the subcutaneous border of the ulna (Figure 4). Tie the second pair of sutures in the same manner.

Figure 3.

Triceps tendon reduced to its anatomic footprint.

Figure 4.

Suture knot placed on the lateral side of the proximal ulna, so that it will be buried underneath the extensor carpi ulnaris. This ensures that the bulky suture knot will not become a source of irritation when the patient leans on the elbow.

At this time, gently flex the elbow to assess the tension-free range of motion. This will be the initial range of motion parameter and restriction for physical therapy in the early post-operative period. Maintain the elbow in extension for the remainder of the procedure.

Repair the split in the fascia between the ECU and FCU after burying the bulky suture knot underneath the fascia. If the olecranon bursa has areas of hard nodularity, then I perform an excision of the bursa. Deflate the tourniquet. Assess for any significant bleeding. Irrigate the surgical field and close the wound in layers. After sterile dressings have been placed, apply a well-padded posterior plaster splint with the elbow fully extended.

An alternative method for fixation is to use suture anchors. My own preference is to avoid the use of standard suture anchors because the suture knots become quite irritating for the patient since the location of these knots are superficial. Newer generation anchors using knotless fixation are better suited. For small, centrally located, crescenteric defects, the use of a single knotless suture anchor may suffice. Care should be taken to ensure that the anchor does not penetrate into the ulnotrochlear joint. For complete ruptures, Mazzocca's group has described a transosseous-equivalent technique using four knotless suture anchors, similar to a technique used in the shoulder for rotator cuff repair. This study reported better coverage of the distal triceps tendon footprint and less motion at the repair site at time zero in their cadaver model using this technique. As of this writing, there has not been a published outcome study that has demonstrated the clinical superiority of any specific technique of triceps repair. Therefore, my personal preference remains to use the cruciate drilling technique given the technical simplicity, high patient satisfaction, successful functional outcomes, and the avoidance of implant costs.

For chronic ruptures that are severely retracted and impossible to reduce without excessive tension, various techniques have been described in the literature, including: V-Y with ipsilateral plantaris longus tendon Pulvertaft weave augmentation, hamstring autograft/allograft, and Achilles allograft with or without anconeus rotational flap. These published salvage reconstruction options have small numbers of patients and relatively short follow-up reported. As would be expected, the functional outcome after a delayed reconstruction using a graft tends to be poorer than the results after a primary repair.

Pearls and Pitfalls of Technique

The reason for cheating the incision lateral to the olecranon tip is so that the incision is not located on an area where the weight of the upper extremity will be placed when the patient leans on the elbow. When resting the elbow on an armrest of a chair or leaning on the elbow, the weight of the upper extremity is typically located in the area between the subcutaneous border of the ulna and the medial aspect of the elbow and forearm. Hence, this is the reason for placing the incision lateral to the olecranon tip.

If the drill bit exits too posterior on the lateral aspect of the distal ulna and close to the subcutaneous border of the ulna, then the bulky suture knot will be located in a superficial location. This prominent suture knot can be irritating to patients.

When using a small drill bit such as a 2.0 mm, even a slight torque of the drill can snap the small drill bit. Therefore, my preference is to use a 2.0 mm drill bit to create a bone tunnel until there is resistance. At this point, I switch to a K-wire of the same size to complete the bone tunnel. Must be careful if attempting to change the direction or angle of the drill since this can result in breaking off the drill bit while the tip of the drill is incarcerated within the bone.

Potential Complications

If the early postoperative range of motion is too aggressive, then the repair site may see undue tension. Therefore, it is important to determine the tension-free range of motion intraoperatively immediately after the tendon repair and before wound closure.

Wound dehiscence can be a problem. Meticulous handling of soft tissues as well as maintaining full-thickness skin flaps during the dissection are important to reduce the risk of wound healing problems.

Post–operative Rehabilitation

Maintain the elbow in full extension within a plaster splint for 1 week. Then, convert to a hinged elbow brace locked in extension for another week.

At 2 weeks postop, begin gentle elbow motion within the tension-free range of motion parameters that were determined intraoperatively (typically 0-40 degrees). Increase elbow range of motion gradually thereafter under the supervision of a physical/occupational therapist.

During the first 4 weeks after surgery, elbow flexion is restricted to 90 degree and active elbow extension is discouraged.

Between 4 - 10 weeks postop, active elbow extension is allowed but without any weights.

At 10 week postop, resisted active extension and gentle triceps strengthening is started.

By 4 months postop, most patients do not report any restrictions in activities of daily living.

At 6 months postop, patients may return to recreational activities with emphasis on gradual progression.

Outcomes/Evidence in the Literature

Dodds, S. D., Smart, L. R., Mazzocca, A. D., Sethi, P. M. "Distal Triceps Rupture". JAAOS. vol. 18. 2010. pp. 31-40.

(Distal biceps rupture is difficult to diagnose because a palpable defect is not always present on physical examination and pain and swelling limits the ability to test for strength and range of motion. An MRI is used to confirm the diagnosis because plain radiographs can only rule out other elbow pathology. Surgical intervention is recommended in patients with complete tears and in patients who have incomplete tears with concomitant loss of strength. Excellent surgical outcomes have been reported.)

Keener, J. D., Chafik, D., Kim, H. M., Galatz, L. M., Yamaguchi, K. "Insertional anatomy of the triceps brachii tendon". Journal of Shoulder and Elbow Surgery / American Shoulder and Elbow Surgeons [et Al.]. vol. 19. 2010. pp. 399-405.

(Both a qualitative and quantitative analysis of the distal triceps tendon and its footprint were reported in this study. Thirty-six cadaveric specimens were used to obtain the mean width of the proper triceps tendon (23.7 mm), the mean maximum olecranon width (26.9 mm), the ratio of the triceps tendon width to the olecranon width (averaged 0.88mm), the mean thickness of the central tendon insertion (6.8 mm), the mean insertional width and length of the tendon proper (20.9 mm,13.4 mm), and the mean distance from the olecranon tip to the tendon (14.8 mm). Understanding this anatomy optimizes posterior surgical approaches and can limit surgical insult.)

Madsen, M., Marx, R. G., Millett, P. J., Rodeo, S. a, Sperling, J. W., Warren, R. F. "Surgical anatomy of the triceps brachii tendon: anatomical study and clinical correlation". The American Journal of Sports Medicine. vol. 34. 2006. pp. 1839-43.

(Described the deep and superficial distal attachment of the triceps tendon seen consistently in an anatomic study of eight cadaver elbows. Included is a case report of a young weightlifter with an isolated rupture of the deep portion of the triceps tendon who had difficulty extending the elbow from a 90 degree flexed position but had no appreciable deficit with resisted elbow extension from an extended position. Therefore, the authors suggest performing resisted extension strength testing at 90 degrees of elbow flexion especially in strength athletes.)

Sierra, R. J., Weiss, N. G., Shrader, M. W., Steinmann, S. P.. "Acute triceps ruptures: case report and retrospective chart review". Journal of Shoulder and Elbow Surgery / American Shoulder and Elbow Surgeons ... [et Al.]. vol. 15. pp. 130-4.

(Because of the rarity of triceps rupture (less than 1% of all tendon ruptures), the aim of this article is to review the treatment and outcome of sixteen reports of acute closed triceps ruptures; the most common rupture being an avulsion of the olecranon insertion. In all but one patient, a palpable gap and weakness of the elbow extensor mechanism was noted after initial swelling subsided. The article recommends a neurologic examination because compartment syndrome and cubital tunnel syndrome can complicate triceps tendon ruptures. Early surgical management with repair of the tendon to bone can provide a satisfactory outcome in most patients.)

Van Riet, R. "Surgical Treatment of Distal Triceps Ruptures". JBJS Am. 2003. pp. 42-44.

(This article recommends the patient be re-examined within 3 weeks of injury after the initial swelling subsides to decrease the chance of misdiagnosis. Of the 23 cases presented, 14 were primary repairs of the tendon and nine were reconstructions. Most patients returned to functional range of motion, triceps strength, and endurance. Triceps reconstruction is a more challenging procedure and accompanies a longer recovery, so this article argues that an early primary repair within 3 weeks of injury results in a better outcome for patients.)

Weistroffer, C. D. R. J. K., Mills, W. J., Shin, A. Y., Diego, S.. "Recurrent rupture of the triceps tendon repaired with hamstring tendon autograft augmentation: A case report and repair technique". pp. 193-196.

(The use of tendon autografts has been described to augment primary repairs, however, this article describes the use of gracilis and semitendinosus autograft in the repair of the triceps tendon in a case report of a 49 year-old man; a bilateral amputee. The patient was an active athlete who had a primary repair of his triceps 3 years before re-tearing it. Approximately 20cm of both gracilis and semitendinosus tendons were harvested and the ends “whip-stitched” before tendon reconstruction. The patient returned to high physical activity 2 years after repair.)

Wolf, J. M., McCarty, E. C., Ritchie, P. D. "Triceps reconstruction using hamstring graft for triceps insufficiency or recurrent rupture". Techniques in Hand & Upper Extremity Surgery. vol. 12. 2008. pp. 174-9.

(When primary surgical repair of the triceps tendon is difficult because of shortening or insufficiency of the native triceps tendon, allograph and autologous augmentation with gracilis and semitendinosus tendons provides superior length and size for use in triceps reconstruction. An augmented repair is desirable during re-rupture or when triceps ruptures are associated with biological abnormalities (like renal insufficiency and metabolic disease). This article presents a case report to explain.)

Yeh, P. C., Stephens, K. T., Solovyova, O., Obopilwe, E., Smart, L. R., Mazzocca, A. D., Sethi, P. M. "The distal triceps tendon footprint and a biomechanical analysis of three repair techniques". The American Journal of Sports Medicine. vol. 38. 2010. pp. 1025-33.

(Twenty-seven cadaveric elbows were examined and the triceps tendon footprint was measured before a distal tendon rupture was created. Analysis of the cruciate repair group, suture anchor group, and anatomic repair group shows load at yield and peak load to be similar for all repair types. This article also demonstrates that anatomic repair of triceps tendon ruptures show statistically significantly less repair-site motion when cyclically loaded.)

Summary

Triceps tendon ruptures have an excellent prognosis when repaired acutely.

The anatomy of the triceps tendon insertion is important to understand, including the lateral expansion as well as the possibility of a rupture of the superficial tendon (lateral and long heads) with an intact deep portion (medial head), or vice versa. Radiologists may often report a partial tear in the setting of a complete tear of either the deep or superficial portions. Chronic tendon ruptures have a poorer prognosis, especially if a salvage reconstruction with graft is required. This underscores the importance of early and accurate diagnosis of a triceps tendon injury.

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