TRICEPS TENDON AVULSIONS

Triceps Tendon Avulsions

Steven B. Singleton and John E. Conway

Rupture of the triceps tendon is among the most rare of all tendinopathies, comprising less than 1% of upper extremity tendon injuries. Since the first documented case of triceps tendon avulsion by Partridge in 1868, approximately 50 cases have been recorded in the American and European literature. These injuries occur with a female-to-male ratio of 2:3. The mean age of occurrence is approximately 30 years, though the spectrum ranges from ages 7 to 72. There is no association between the site of rupture and hand dominance.

Prior to 1984, only two case reports existed of triceps tendon avulsions occurring in athletics. Since then, however, triceps tendon injuries have been reported in a variety of athletes including mainly bodybuilders and power lifters.

Mechanisms of Injury

1. Most commonly, avulsion of the triceps tendon occurs as a result of an eccentric load imparted across the triceps. The primary mechanism is a deceleration force placed upon an actively extending elbow.

2. The most common event described in the literature is a fall. Less frequently, a direct blow to the posterior aspect of the triceps tendon at its insertion has been reported.

Mechanism of Injury Reported in Athletes

1. Throwing

2. Weight lifting

3. Skiing, martial arts practice, football, serves in volleyball

Associated Injuries

1. Radial head fractures

2. Wrist injuries

Physical Examination

1. Posterior elbow and arm pain.

2. Palpable defect adjacent to the olecranon, depending on the extent of triceps retraction.

3. Loss of extension power—some active elbow extension may be present and is thought to be provided by the anconeus/triceps expansion. This effect may be negated by the inability to extend overhead against gravity.

4. Viegas described a modification of the Thompson test for the assessment of triceps injury. In this test, the patient lies in the prone position and lets the forearm hang over the edge of the table. Squeezing of the triceps muscle belly should produce slight elbow extension; however, no motion will occur if a complete rupture is present.

Diagnostic Tests

1. Radiographs: anteroposterior and lateral films may demonstrate the “Flake sign” in approximately 70% of cases (Fig. 53–1).

2. Ultrasound or magnetic resonance imaging may be useful in assessing partial lesions.

Associations

1. Olecranon bursitis

2. Renal osteodystrophy

3. Secondary hyperparathyroidism/chronic hypercalcemia

4. Anabolic steroids

5. Oral corticosteroids for treatment of lupus erythematosus

6. Chronic acidosis

7. Marfan’s syndrome

8. Triceps insufficiency following total elbow replacement

Pathoanatomy

1. Muscle belly disruption

2. Musculotendinous junction disruption (occasional)

3. Osseous tendon insertion avulsion (most common)

a. Partial tendon rupture

b. Complete rupture

i. Continuity laterally with the fascia overlying the anconeus is a common finding.

ii. Horizontal delamination of the tendon has been reported in patients with chronic tendinosis.

Preoperative Planning and Timing of Surgery

1. Indication for surgery: loss of active elbow extension.

2. In the face of these injuries, it is important to determine whether a partial tendon or complete tendon rupture is present. According to some investigators, partial tendon ruptures can be treated nonoperatively.

3. Immediate surgery is the treatment of choice for complete rupture. The results of delayed repair or reconstruction are also good (as recorded in the literature), though few reports exist.

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