Abstract
Distal triceps tendon injuries are rare iin clinical settings, and the prevalence rate is twice as low in men as it is in women. The injury can present itself in a physical exam as localized pain over the posterior elbow region with tenderness and swelling. Treatment of a distal triceps injury is highly patient specific and molded toward their age and daily activities. Partial tears and low demand patients can experience high success with non-operative care, while active patients may require surgical treatment, even with a partial tear. The goal of operative intervention is to reduce the torn triceps tendon and repair it securely to the tendon footprint on the olecranon. There are many different fixation techniques that lead to good outcomes, and there has been data suggesting that knotless anatomic footprint repair technique may be a novel technique with reliable outcomes. The literature needs improvement in order to have a definitive surgical repair technique for the distal triceps tendon.
Keywords
Distal triceps tendon, epidemiology, olecranon, transosseous repair
Introduction
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Distal triceps tendon injuries are very rare.
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These injuries have a 2:1 male:female ratio and are most commonly seen in individuals 30 to 50 years of age.
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These injuries occur after an eccentric loading of the triceps tendon.
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Tears involving less than 50% of the tendon may be treated conservatively.
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Complete tears require operative fixation.
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Several techniques exist for fixation, each providing good to excellent outcomes.
Triceps tendon injuries are rare tendon injuries that can lead to significant dysfunction if not diagnosed and treated in a timely and appropriate fashion. These injuries can be encountered in the context of a high-energy trauma or with a low-energy mechanism in the setting of a predisposing systemic condition. This chapter reviews the common presentation, evaluation, and treatment strategies for triceps tendon injuries, focusing on both nonoperative and operative treatment options.
Introduction
- ▪
Distal triceps tendon injuries are very rare.
- ▪
These injuries have a 2:1 male:female ratio and are most commonly seen in individuals 30 to 50 years of age.
- ▪
These injuries occur after an eccentric loading of the triceps tendon.
- ▪
Tears involving less than 50% of the tendon may be treated conservatively.
- ▪
Complete tears require operative fixation.
- ▪
Several techniques exist for fixation, each providing good to excellent outcomes.
Triceps tendon injuries are rare tendon injuries that can lead to significant dysfunction if not diagnosed and treated in a timely and appropriate fashion. These injuries can be encountered in the context of a high-energy trauma or with a low-energy mechanism in the setting of a predisposing systemic condition. This chapter reviews the common presentation, evaluation, and treatment strategies for triceps tendon injuries, focusing on both nonoperative and operative treatment options.
Epidemiology
Distal triceps tendon ruptures are uncommon injuries. noted that fewer than 1% of all tendon injuries involved the triceps. These occur approximately twice as often in males as in females, most commonly affecting patients between 30 and 50 years of age ( ). In the general population, several systemic conditions may predispose a patient to triceps tendon rupture, including diabetes mellitus, hyperparathyroidism, and chronic renal disease ( ). Local irritation from chronic olecranon bursitis may also increase the risk of rupture ( ). Athletes who sustain triceps tendon rupture tend to engage in activities that require elbow extension against high loads, such as those seen in power lifting and American football ( ). In 1996, reported on 21 triceps tendon ruptures occurring over the previous six seasons in professional football players. Using the National Football League (NFL) Injury Surveillance System, our institution identified 37 additional cases of triceps tendon rupture occurring between 2000 and 2009 ( ). Last, both the use of systemic anabolic steroids and repeated local corticosteroid injections have also been linked to an increased occurrence of triceps tendon rupture, particularly in weight lifters ( ).
Anatomy
The triceps brachii muscle is the sole muscle occupying the posterior compartment of the upper arm and is innervated by the radial nerve (C6–C8). It is composed of three tendinous origins: the long, lateral, and medial heads. The long head originates at the infraglenoid tuberosity of the scapula. The lateral head originates on the lateral intramuscular septum and posterolateral humerus proximal to the radial groove on the posterior aspect of the humerus. The medial head arises distal to the spiral groove on the posterior humerus. The confluence of the triceps heads inserts as a broad footprint along the olecranon ( Fig. 31.1 ). The proximal aspect of the footprint begins approximately 12 mm distal to the tip of the olecranon and covers an area of 466 mm 2 ( ). The medial aspect of the triceps insertion extends along the posterior crest of the ulna. Laterally, the insertion expands to blend with the fascia of the extensor carpi ulnaris and anconeus muscle. The overall width of the insertion has been found to be between 1.9 and 4.2 cm ( ).
History and Physical Examination
The diagnosis of a distal triceps tendon injury can generally be made clinically. Most commonly, the patient will report a history involving an eccentric loading mechanism to the arm. This is commonly experienced during a fall onto an outstretched hand, weight lifting, or attempting to restrain oneself during a motor vehicle accident. Deep lacerations to the posterior distal aspect of the arm are also capable of completely transecting the triceps tendon. Rarely, a direct blow to the posterior arm can be responsible for a tear ( ).
Patients complain of pain localized over the posterior aspect of the elbow. On physical examination, they may exhibit swelling, tenderness, and ecchymosis. Patients with a complete rupture may have a palpable gap proximal to the tip of the olecranon; however, this is commonly masked by swelling during the acute injury period. Active extension of the elbow should be assessed in all patients with a suspected triceps tendon rupture. It is important to recognize that retention of the ability to actively extend the elbow against resistance does not rule out a triceps tendon rupture ( ). A complete tear may result in a total loss of active elbow extension. A patient with an intact lateral insertional expansion or with compensatory strength from the anconeus muscle may retain the ability to extend the triceps against gravity with the arm positioned below the shoulder. These patients should also be tested with the arm overhead and against resistance to help confirm the diagnosis ( ).
Special tests include a modified Thompson test that is akin to the Thompson test used for Achilles tendon rupture ( ). During this examination, the patient is placed in a prone position with the affected arm over the edge of the table and the elbow flexed to 90 degrees. The examiner then squeezes the triceps and watches the elbow for passive extension. If there is a compete rupture of the triceps tendon, then there will likely be no motion at the elbow.
Diagnostic Imaging
The initial evaluation should include anteroposterior and lateral radiographs of the elbow. Ruptures most commonly occur at the level of the tendon osseous insertion ( ). An avulsion fracture of the olecranon can be visualized on the lateral radiograph and is termed the “flake sign” ( ) ( Fig. 31.2 ). MRI is a useful imaging modality to help differentiate between a partial and complete tendon rupture if the history and physical examination are equivocal. MRI is also helpful to assess the level of tendon retraction and to evaluate for injury to adjacent structures ( ). Partial-thickness tears appear as fluid within the distal triceps tendon and surrounding swelling. Full-thickness tears show complete avulsion of the tendon with a fluid-filled gap between the distal triceps and its insertion site on the olecranon ( Fig. 31.3 ). Sagittal cuts of T1- and T2-weighted images help to fully elucidate and characterize the injury. Ultrasound examination is also a low-cost and convenient method to further evaluate for damage to the triceps tendon and is capable of differentiating between partial and complete tears ( ) ( Fig. 31.4 ).
Nonoperative Management
Treatment of triceps tears is dictated based on patient specific factors and functional deficits and the characteristics of the tear. Older, low-demand patients who retain the ability to actively extend the elbow may be treated conservatively. Partial tears, specifically tears involving less than 50% of the tendon, can be successfully treated nonoperatively ( ). Tears involving more than 50% of the tendon width most often require operative fixation, depending on the functional demand of the patient and the extension strength remaining in the arm. In older adult patients, these partial tears may be treated conservatively. In athletes or laborers, however, with high functional demands, operative intervention is most appropriate for these partial tears ( ).
Tear characteristics also play a role in the decision for operative intervention. Proximal tears localized to the muscle belly are typically treated conservatively. Tears to the muscle belly have been reported in both a singular head of the triceps as well as a complete rupture of the confluence of the heads ( ). Both partial and complete ruptures of the triceps muscle belly heal with fibrotic scar tissue, allowing for some element of tissue apposition and return of extension strength ( ). There have been selected case reports of tears of the triceps muscle belly treated operatively with suture apposition; however, this is rarely performed, and most patients can be adequately managed conservatively with good outcomes ( ).
High-demand athletes with partial tearing of the triceps have also been successfully managed conservatively ( ). In a study of triceps tendon tears in NFL players, reported on 10 partial tendon tears, six of which healed without surgical intervention. Three players were treated with bracing for the remainder of the season but subsequently underwent operative fixation during the offseason secondary to continuing pain and weakness. The average time missed for these players was 4.8 weeks (range, 0–9 weeks). Finally, one player progressed to a complete rupture requiring operative intervention after returning to practice in a brace 5 days after the index injury.
Nonoperative management for appropriate distal triceps tendon injuries consists of initial immobilization followed by a progressive rehabilitation program. Immobilization in a brace or splint at 30 degrees of elbow flexion is maintained for the initial 4 weeks followed by a progressive increase in elbow mobilization ( ). The rate of progression is generally dictated by the patient’s level of comfort. Resisted elbow extension and heavy lifting activity should be limited for 8 to 12 weeks after injury. At 3 months, most patients should be pain-free and able to perform activities of daily living without significant discomfort. Continued pain and weakness at the 3-month time mark may indicate a failure of conservative management and consideration should be given toward proceeding with operative intervention ( ).
Operative Management
Complete ruptures of the triceps tendon at the tendinous insertion with loss of strength should be treated with primary repair. Before operative intervention, all medical comorbidities need to be optimized, particularly in patients with significant systemic disease. If possible, it is ideal to repair the tendon within 2 weeks of the initial injury. , however, have described a successful primary repair in a patient that presented in a delayed fashion 8 months after the initial injury.
The goal of operative intervention is to reduce the torn tendon and repair it securely to the tendon footprint on the olecranon. There are several methods by which this process can be achieved. Most methods use a Krackow whipstitch or Bunnell cruciate stitch to secure the tendon. Four frequently used techniques to repair the distal triceps tendon to bone are (1) transosseous cruciate drill tunnels ( ), (2) standard suture anchor repair ( ), (3) anatomic transosseous equivalent repair ( ), and (4) knotless anatomic footprint repair ( ). The transosseous cruciate repair technique involves securing the tendon to the footprint by passing the stitches through crossing bone tunnels in the olecranon. Typically, a 2-mm drill bit is used to place drill tunnels within the olecranon. The tunnels begin at the medial and lateral tendon footprint and extend distally to the contralateral cortical side on the dorsal ulna. A suture passer is then used to pass the stitches in the tendon distally through the bone tunnels. These stitches are then tied over a bone bridge ( Fig. 31.5 ).
