Distal Triceps Rupture

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Review Article Distal Triceps Rupture

Abstract Peter C. Yeh, MD Distal triceps rupture is an uncommon injury. It is most often asso- Seth D. Dodds, MD ciated with anabolic steroid use, weight lifting, and laceration. Other local and systemic risk factors include local steroid injection, L. Ryan Smart, MD olecranon bursitis, and hyperparathyroidism. Distal triceps rupture Augustus D. Mazzocca, MS, MD is usually caused by a fall on an outstretched hand or a direct Paul M. Sethi, MD blow. Eccentric loading of a contracting triceps has been impli- cated, 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 excel- lent results have been reported with surgical repair, and very good results have been achieved even for chronic tears.

istal rupture of the triceps tendon drome, osteogenesis imperfecta, Dis rare and is among the least rheumatoid arthritis, and type I common of reported tendon injuries. In diabetes.6 Persons with chronic re- a review of 1,014 tendon ruptures, nal disease generally possess ele- 0.8% constituted triceps tendon in- vated levels of parathyroid hormone, 1 juries. In a 6-year span, only 21 cases which stimulates osteoclastic activity of triceps rupture were recorded in the and bone resorption. Such circum- 2 National Football League. There is stances may ultimately predispose to a male predominance of roughly 2 to tendon rupture. Adolescent persons From the Department of 1 in all age groups. with incompletely fused or recently Orthopaedics and Rehabilitation, Most reports have associated tri- fused physes are also susceptible to Yale University School of Medicine, ceps tendon rupture with anabolic triceps tendon rupture.7 New Haven, CT (Drs. Yeh and steroid use and weight lifting.3 Pro- Dodds), New England Baptist Hospital, Boston, MA (Dr. Smart), fessional football players may be at a the University of Connecticut, higher risk for rupture than the gen- Anatomy Farmington, CT (Dr. Mazzocca), and eral population, possibly because of Orthopaedic and Neurosurgery The triceps brachii is a pennate muscle Specialists PC and the ONS the training regimen, the potential Foundation for Clinical Research for steroid use, and the violent with three heads: lateral, long, and me- and Education, Greenwich, CT (Dr. nature of the sport itself.2 Other fac- dial. The triceps extends the entire Sethi). tors that may play a role in distal length of the posterior humerus and is triceps rupture include local steroid the only muscle located in the posterior J Am Acad Orthop Surg 2010;18: 2-4 31-40 injection, metabolic bone diseases compartment of the arm. The triceps is (ie, hyperparathyroidism), renal os- innervated by the radial nerve (C6-C8). Copyright 2010 by the American 5 Academy of Orthopaedic Surgeons. teodystrophy, olecranon bursitis, The lateral head originates from the hypocalcemic tetany, Marfan syn- posterior humerus between the teres mi-

January 2010, Vol 18, No 1 31 Distal Triceps Rupture

Figure 1 Figure 2

The lateral triceps expansion is marked with a caliper. The olecranon and the triceps tendon proper are dotted with marker.

The triceps insertion is not a focal point on the olecranon. Rather, the distal triceps inserts over a wide area or footprint (Figure 1, A through C). In a cadaver study, the footprint was found to start 12 mm distal to the tip of the olecranon (Figure 1, D) and to blend with the posterior capsule; the A, AP photograph of a cadaveric elbow. The triceps footprint on the 2 8 olecranon is outlined with marker. In an anatomic study, the footprint was footprint measured 466 mm . The found to measure 466 mm2.8 B, Lateral view of the triceps footprint. Note the width of the distal triceps tendon in- distance of the proximal portion of the footprint to the articular surface. The sertion ranges from 1.9 to 4.2 cm9 footprint wraps around the tip of the olecranon distally. C, AP view of the tri- and consists of the triceps tendon ceps tendon as it is released from its footprint. The large area of attachment on the tendon itself is clearly visualized (marked in purple). D, The distance proper (ie, the confluence of tendon from the tip of the olecranon to the proximal portion of the footprint is mea- from all three heads inserting on the sured with a digital caliper. In this specimen, that measurement is 12 mm. olecranon) and the lateral triceps expansion (Figure 2). The insertion of the medial aspect nor insertion and the superior aspect of scapula blends with the shoulder cap- of the triceps expansion is located on the spiral groove, the lateral border of sule. The medial head originates on the the posterior crest of the ulna, adja- the humerus, and the lateral intermus- posterior humerus distal to the spiral cent to the medial head. Hypertro- cular septum. The long head originates groove, medial humerus, and medial in- phy of this muscle can cause ulnar at the infraglenoid tuberosity, where the termuscular septum. nerve impingement, a condition that

Dr. Dodds or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Integra and Medartis, and serves as a paid consultant to or is an employee of Replication Medical. Dr. Mazzocca or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of, serves as a paid consultant to or is an employee of, and has received research or institutional support from, Arthrex. Dr. Sethi or an immediate family member has received royalties from, is a member of a speakers’ bureau or has made paid presentations on behalf of, and has received research or institutional support from Arthrex. Neither of the following authors nor an immediate family member has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Yeh and Dr. Smart.

32 Journal of the American Academy of Orthopaedic Surgeons Peter C. Yeh, MD, et al is occasionally seen in weight lifters. but this finding is less common. Figure 3 Laterally, the triceps expansion has a Higher-energy mechanisms, such as a wide insertion on the fascia of the motor vehicle accident or a fall from extensor carpi ulnaris muscle and the a height, may also cause concomitant deep fascia of the anconeus muscle.10 ulnar nerve injury and compartment Because of its wide lateral insertion, syndrome; these possible causative 12,13 the triceps expansion often requires factors must not be overlooked. concomitant repair in cases of triceps Regardless of mechanism of injury, rupture. The triceps expansion also triceps tendon ruptures are usually 12 inserts on the antebrachial fascia of seen at the osseous insertion. How- ever, there have been reports of rup- the forearm distally. ture within the muscle belly14 and The distal portion of the medial head tears at the myotendinous junc- Clinical photograph of a palpable has been shown to have a distinct mus- tion.6,15 Fatigue failure of the muscle defect proximal to the olecranon in cle belly and a tendon that is separate a patient with distal triceps rupture. has been suggested as a mechanism from and deep to the common triceps The abrasion just distal to the for intramuscular tears.14 tendon. However, histologic analysis olecranon indicates the area of Patients present with pain and impact during injury. has revealed that the distal expansion swelling over the posterior aspect of of the medial head becomes confluent the elbow. Physical examination re- with the common triceps tendon as they veals tenderness to palpation, swell- lowed to hang down over the edge of insert onto the olecranon.10 This dis- ing, and ecchymosis. A palpable de- the table so that the elbow is flexed tinct insertion may provide the ratio- fect proximal to the olecranon can 90° in a relaxed position. The exam- nale for a distinct medial (proximal) also be apparent and may confirm iner firmly squeezes the triceps mus- repair to achieve anatomic restora- the clinical diagnosis (Figure 3). In cle. The patient with an incomplete tion of the medial insertion, along the acute stage, a defect may not be triceps rupture will be able to extend with primary repair of the lateral palpable secondary to swelling, body the elbow against gravity.18 The pa- head insertion. habitus,16 or the degree of rupture. tient with complete disruption of the The main function of the triceps is The inability to actively extend triceps proper and lateral expansion to extend the forearm at the ulno- against resistance is a sign of com- will not be able to extend the elbow humeral joint. However, because of plete rupture. However, the converse against gravity. its origin at the infraglenoid tuberos- is not always true—that is, not all Fundamental differences between ity, it is believed that the long head complete tears result in the inability the Thompson squeeze test used on of the triceps may also aid in arm ad- to actively extend against resistance. the Achilles tendon and the modifi- duction and extension. The overall This finding is likely secondary to an cation for evaluating the triceps muscle-tendon length of the triceps intact lateral expansion or a compen- could affect the utility of this evalua- critically affects its motor function. sating anconeus muscle. Thus, the di- tion tool. The long lever arm of the Biomechanical studies show that as agnosis of a triceps tear can be con- forearm distal to a triceps tear makes little as 2 cm of shortening between founding. In fact, one study showed distal resistance much higher than origin and insertion causes a 40% that almost 50% of acute triceps that seen with the short lever arm of loss of extension strength.11 ruptures were initially misdiag- the foot distal to an Achilles tear. nosed.12 In the setting of chronic The bulk of the triceps is relatively Presentation and Physical tears, the most common complaints small compared with that of the Examination are of pain and weakness with exten- gastrocnemius-soleus complex, which sion. makes it more difficult to tightly The most common mechanism of in- A modified Thompson squeeze squeeze the triceps muscle. jury is a sudden eccentric load ap- test, similar in execution to that per- It may be challenging to accurately plied to a contracting triceps muscle, formed on the Achilles tendon, has see and/or quantify the amount of re- such as during weight lifting or from been reported as a potential clinical sidual motion. The amount of fore- a fall onto an outstretched hand. diagnostic tool.17 During this passive arm motion required to declare the Lacerations and open injuries can extension test, the patient lies prone modified Thompson squeeze test to also cause distal triceps rupture. A with the elbow at the edge of the ex- be positive or negative is not known. direct blow may result in such injury, amination table. The forearm is al- The presence of some extension on

January 2010, Vol 18, No 1 33 Distal Triceps Rupture

Figure 4 Figure 5 Figure 6

Lateral radiograph of the elbow in a patient with a distal triceps rupture. A flake of bone has avulsed off the T1-weighted sagittal magnetic olecranon (arrow). resonance image of partial triceps tendon rupture. The arrow points to partial attachment of the tendon. (Reproduced with permission from this test does not rule out the possi- Mair SD, Isbell WM, Gill TJ, bility of complete rupture of the ten- Schlegel TF, Hawkins RJ: Triceps Sagittal fat-suppressed T2- don proper. It may be that the triceps tendon ruptures in professional weighted spin-echo magnetic resonance image of the elbow expansion is still intact and is re- football players. Am J Sports Med 2004:32:431-434.) demonstrating a large fluid-filled sponding to the passive extension gap (arrowhead) between the squeeze test. completely torn and retracted distal triceps tendon (arrow) and the triceps tendon, with edema also af- olecranon process. (Reproduced fecting the surrounding subcutane- with permission from Kijowski R, Diagnostic Imaging ous tissues. The defect appears as a Tuite M, Sanford M: Magnetic bright area on T2-weighted images resonance imaging of the elbow: AP and lateral radiographs of the in- Part II. Abnormalities of the (Figure 5). In one study, 8 of 10 inju- volved elbow should be obtained at pre- ligaments, tendons, and nerves. ries classified as partial triceps rup- sentation. The lateral radiograph may Skeletal Radiol 2005:34:1-18.) tures predominantly involved the show the presence of flecks of avulsed medial side of the tendon insertion.2 osseous material from the olecranon (ie, Complete rupture of the triceps ten- belly, musculotendinous junction, flake sign), which is almost always don is characterized by a large fluid- tendinous insertion, avulsion off pathognomonic of a triceps tendon filled gap (ie, paratricipital edema) bone). It is also important to note rupture19 (Figure 4). Plain radio- between the distal end of the triceps the integrity of the lateral expansion graphs of the ipsilateral wrist joint tendon and the olecranon process (intact versus torn). should be strongly considered when with23 (Figure 6). Several nonanatomic factors must rupture is clinically suspected. be considered when managing tri- CT can be helpful in excluding asso- ceps ruptures. These include the ciated osseous injuries, such as radial Classification functional and medical status of the head fracture and distal radius fracture, patient as well as the chronicity and both of which have been reported to oc- No formal classification system for atrophy of the muscle-tendon unit. cur in association with triceps tendon distal triceps rupture has been estab- Based on these factors, the surgeon rupture.15,20 MRI and ultrasonography lished. We describe these injuries can determine the most appropriate are useful in difficult cases in which it based on results of imaging studies treatment to administer. is hard to distinguish whether an injury (ie, ultrasonography, MRI), as well is partial or complete.21-23 Sagittal as on intraoperative findings. Ana- MRI accurately demonstrates the in- tomic factors important to the de- Management tegrity of the triceps tendon. Partial scription include the degree of the rupture is characterized by a small tear (ie, complete, partial, intact) and Management of triceps tears is gener- fluid-filled defect within the distal the location of the tear (ie, muscle ally guided by tear location and by

34 Journal of the American Academy of Orthopaedic Surgeons Peter C. Yeh, MD, et al the functional extension strength of rect suturing has been reported26 and reduced, although still functional, the extremity. The amount of exten- may be an option for the young, strength. However, medical status sion strength is important because, in highly functioning athlete who de- and activity level need to be consid- triceps injuries, complete anatomic sires to return to sports. No objective ered. When possible, repair should ruptures do not necessarily cause full results for surgical intervention of be performed within 2 weeks, al- loss of function.24 The intact lateral muscle belly tears have been reported though primary repair has been triceps expansion or anconeus may other than the few case reports dem- described as late as 8 months after 28 compensate adequately for the loss onstrating return to previous level of injury. Surgical treatment is also of triceps function. The patient with activity. appropriate for partial tears at the complete anatomic rupture but with Good results have been reported myotendinous junction or tendon insertion in patients who are highly ac- some function remaining should be with nonsurgical management, with tive or who have failed nonsurgical identified and treated according to published studies indicating a return treatment. goals set specifically for that patient. to preinjury level of function.2,18,27 Surgical repair involves identifica- Treatment decisions must be indi- One report of bilateral partial rup- tion of the level of tendinous rupture vidualized based on the patient’s ture at the tendinous insertion in a with primary reattachment of the medical and functional status. For weight lifter showed quantitatively avulsed triceps tendon to the olecra- example, a partial tear at the tendi- normal function at 41 weeks, but fa- non. Most of the recently published nous insertion may be managed non- tigue with combined lifting at 55 repair techniques describe use of the 25 surgically in a debilitated, elderly pa- weeks. A report of a patient who Bunnell or Krackow whipstitch tech- tient, whereas the same tear may be was treated nonsurgically for an in- nique, which includes placement of managed surgically in a highly func- tramuscular tear of the triceps dem- nonabsorbable sutures through the 24 tioning athlete. Healthy older per- onstrated no acute muscle weakness tendon. The sutures are then passed 14 sons require normal triceps function (performing one push-up). How- through transosseous drill holes in for activities of daily living, such as ever, fatigue was present after endur- the olecranon and are tied over a getting out of a chair. ance exercises, especially after peri- bone bridge12,29-31 (Figure 7). The In general, any tear <50% can be ods of relative inactivity. This finding transosseous drill hole technique can treated nonsurgically with satisfac- was still present 9 years after injury. also be used in skeletally immature 7 2 tory results. Tears >50% are treated Mair et al reported that of 10 pro- patients.32 Other repair techniques nonsurgically in the sedentary per- fessional football players with partial include direct tendon repair to a pe- son; however, in the active person, tears, 6 healed with nonsurgical riosteal flap raised from the olecra- surgical intervention may be appro- treatment and experienced no resid- non. Intraosseous suture anchors 2,24 priate. Complete tears are gener- ual pain or weakness. Three players may be used to firmly seat the triceps 12,16,19 ally managed surgically. were treated with bracing for the re- tendon against the olecranon.15,19 mainder of the season, after which An alternative technique involves Nonsurgical they received surgical treatment to the creation of three parallel drill Partial tears at the muscle belly, mus- correct residual pain and weakness. holes.33 The drill holes must be an- culotendinous junction, and tendon One player sustained a complete rup- gled in an oblique and dorsal fashion insertion with insignificant loss of ture on return to play despite brac- from proximal to distal through the extension strength can be managed ing. The mixed results of this study olecranon, taking care to avoid the nonsurgically.25 Nonsurgical manage- demonstrate that treatment should joint surface. Using nonabsorbable ment consists of splint immobiliza- be individually tailored to the needs sutures, two parallel Krackow-type tion for approximately 4 weeks at of each patient and should not be de- stitches are placed through the de- 30° of flexion.7,16,18,25 termined by the type of tear only. tached tendon, leaving four tails. The Muscle belly tears tend to heal with two middle tails are passed through scar tissue rather than with newly re- Surgical the central hole, and the medial and generated muscle. Outcomes are rela- Early primary repair is appropriate lateral tails are passed through the tively similar with these tears regardless for acute, complete triceps tear at the medial and lateral holes, respectively of treatment. Thus, even complete tears tendinous insertion with significant (Figure 8). The arm is held in ap- within the muscle belly can be managed loss of triceps strength.24 Surgery is proximately 35° to 40° of flexion for nonsurgically. Nonetheless, surgical in- typically performed in patients with tensioning, and the sutures are tied. tervention of muscle belly tears with di- such injury who have symmetric or A subset of patients presents with a

January 2010, Vol 18, No 1 35 Distal Triceps Rupture

Figure 7 Figure 8 Figure 9

Intraoperative photograph demonstrating triceps tendon repair. Krackow stitches were placed through the detached tendon and passed through three Triceps suture bridge construct for parallel drill holes in a proximal-to- distal triceps repair. Four suture distal direction, angling dorsally. anchors form a “bridge” over the (Reproduced with permission from entire tendon footprint. (Illustration Sierra RJ, Weiss NG, Shrader MW, by Maxwell C. Park, MD.) Steinmann SP: Acute triceps The Bunnell suturing technique for ruptures: Case report and retrospective chart review. J primary repair of the triceps Authors’ Preferred tendon. The sutures are passed Shoulder Elbow Surg through transosseous cruciate drill 2006:15:130-134.) Technique holes made in the olecranon. Anatomic (ie, footprint) repair of the (Reproduced with permission from 35,36 the Mayo Foundation of Medical been reported in the literature. rotator cuff, Achilles tendon, and bi- Education and Research, However, there is a risk of bursitis ceps tendon has gained in popularity Rochester, MN.) postoperatively with this construct, because it is believed that restoring and it is mentioned here for histori- preinjury anatomy may play a role cal perspective only. in postoperative rehabilitation and torn triceps in which a portion of the Triceps rupture at the myotendi- function. A biomechanical study olecranon has avulsed with the at- nous junction can be challenging to showed the triceps footprint area to tached tendon on the bony fragment. manage because of the poor quality be larger than a point insertion (tri- This is more commonly seen in skele- of tissue available for primary repair. ceps footprint area, 466 mm2).8 In tally immature patients whose ossifi- Wagner and Cooney6 described the this study, footprint repair yielded cation center of the olecranon has use of a V-Y triceps tendon advance- the most anatomic restoration of dis- yet to fuse. In these cases, the olecra- ment technique in which strength tal triceps ruptures, and significantly non fracture can be reduced and was augmented by interweaving an less motion occurred at the repair fixed either with a screw and washer autologous plantaris tendon with the site under cyclic loading (P < 0.001). or with stainless steel wires via a remaining proximal and distal tri- Based on our enhanced understand- tension-band construct.17 Smaller ceps tissue. Postoperative care in- ing of the triceps footprint anatomy fragments can be reduced and se- cluded immobilization for 6 weeks, and on the biomechanical basis for cured with suture fixation or can be followed by use of a static elbow repair shown in our study, our pref- excised with primary reattachment brace for protected motion for an erence is to perform anatomic triceps of the tendon to the olecranon.34 The additional 6 weeks. Strength training tendon footprint repair. We do this use of wire suture (as opposed to was instituted at 12 weeks postoper- using suture anchors to create a su- braided nonabsorbable suture) has atively. ture bridge (Figure 9). This technique

36 Journal of the American Academy of Orthopaedic Surgeons Peter C. Yeh, MD, et al

Figure 10 Figure 11

Photograph of a cadaver elbow demonstrating placement of a proximal row of suture anchors in distal triceps repair. The purple A, AP photograph of a cadaver elbow demonstrating the distal free triceps markings indicate the triceps tendon (held up and reﬂected by Adson forceps) after placement of the footprint on the olecranon. The proximal row of suture anchors into the proximal portion of the triceps suture anchors rest just distal to tendon. B, The distal free triceps tendon is laid down on its native anatomic the proximal portion of the footprint. footprint. Press-ﬁt anchors will be placed distal to the footprint of the laid- down tendon. The Krackow stitches have been partially removed from the triceps tendon for the purpose of this illustration. restores preinjury anatomy, thereby restoring a wider area of tendon- bone contact. the proximal end of the footprint should be taken not to drill directly The patient is placed in the lateral site, one on the lateral edge and the toward the joint surface but rather to decubitus position. The upper ex- other on the medial edge (Figure 10). drill obliquely, aiming distally on the tremity is draped free and is hung A biomechanical study showed the ulnar shaft. over an arm rest so that the elbow distance from the olecranon tip to Three suture tails (one suture tail may be manipulated comfortably. A the articular surface to be 12 mm.8 from each anchor and one suture tourniquet is not used because of the As a result, the anchors are placed limb of the free Krackow suture) are risk of inhibiting triceps tendon mo- 13 to 15 mm distal to the tip of the then threaded into the anchor eyelet bilization during repair. A postero- olecranon and are directed distal to of a 3.5-mm knotless press-fit an- lateral approach to the elbow is per- the articular surface to avoid the risk chor. Tension is held on the sutures formed so that wound healing is not of joint penetration. to reduce the triceps tendon to its de- hindered by postoperative range of A mattress suture from each an- sired position on the footprint. With motion (ROM), considering that the chor is placed in the distal tendon 2 this tension applied, the anchor is tip of the olecranon becomes more cm proximal to the tendon edge. advanced with a mallet into the pilot prominent with elbow flexion. Dis- This secures the proximal tendon hole until it sits flush. The sutures section is carried proximally to iden- down to the bone and restores the can then be cut flush to the level of tify the extent of tendon rupture. distinct medial insertion (medial-side the press-fit anchor. The remaining The exposure should be made distal anchor) and lateral insertion (lateral- three sutures are threaded into the enough to visualize the entire inser- side anchor). The sutures from these eyelet of a second knotless press-fit tion of the tendon onto the olecra- anchors should not be cut because anchor; this anchor is driven into the non. The incision should extend ap- they will be used later to form the other pilot hole, and the suture ends proximately 2 cm distal on the shaft bridge. There should be free tendon are cut flush (Figure 12). Repair of of the olecranon. The bony insertion still remaining distal to the anchors the triceps expansion is then per- site is excoriated to remove any in- (Figure 11). formed using side-to-side sutures. terposed soft tissue. A locking-type The distal footprint is estimated, Postoperatively, the patient is not whipstitch (ie, Krackow) is placed on and two pilot holes are created to ac- splinted. Rather, a sling is used for the tendon, with four throws placed commodate the next two anchors. comfort. The patient is allowed to on each side. The holes should be placed just distal discontinue use of the sling when she Two suture anchors are placed on to the anatomic footprint. Care or he feels comfortable. Active mo-

January 2010, Vol 18, No 1 37 Distal Triceps Rupture

Figure 12 has been used to augment repairs in these difficult cases.41 The allograft semitendinosus tendon is woven in a Bunnell fashion through the remaining proximal triceps tendon. A 5.5-mm transosseous tunnel is then drilled through the proximal olecranon, 1 cm distal from its tip and centered between the articular surface and the posterior cortex. The two free ends of the hamstring tendon are then passed through the transosseous tunnel in a retrograde fashion, and the elbow is placed in full extension as the tendon stump is reduced to the olecranon (Figure 13). The use of an interference screw, rather than suturing the tendon to itself, improves the fixation strength and resistance to A, Intraoperative photograph of repaired triceps tendon rupture with a suture displacement. Improved fixation bridge construct. Note the crossing sutures that help to restore the footprint strength at the repair site may allow area of the triceps attachment (arrow). B, Photograph of a cadaver specimen demonstrating the crossing sutures used to restore the wide footprint for earlier initiation of active motion attachment of the triceps insertion. and may decrease potential elbow stiffness or joint contracture. tion exercises, including supination lifting should be avoided for at least and pronation, are begun immedi- 4 to 6 months postoperatively.12 Results and ately, and the patient is allowed to Complications hang the arm against gravity as toler- Results following primary repair of ated. Weight bearing restrictions are Chronic, Revision, and acute triceps ruptures are very good. set at ≤5 lbs during this phase of re- Difficult Acute Tears Most published reports do not provide covery. Strengthening is begun 4 Chronic ruptures (injuries >6 weeks detailed quantitative data or subjective weeks postoperatively. Although no old) are usually the result of either a de- outcomes based on standardized mea- data in the literature support one lay in diagnosis or a delay between the sures such as the Disabilities of the Arm, protocol over another, we allow pa- time of injury and when the patient Shoulder and Hand score and the Med- tients to begin earlier ROM given the sought treatment. Multiple procedures ical Outcomes Study 36-Item Short biomechanical data for the anatomic have been described to augment the Form score. Instead, most studies offer repair.8 management of these more challenging a retrospective review of cases per- triceps injuries (ie, chronic, revision, formed and state that the patients clin- Postoperative Care acute tear with poor tissue quality). The ically demonstrated a certain ROM and use of anconeus or Achilles rotation strength with return to preinjury levels Most postoperative protocols in- flaps, plantaris or hamstring tendon of function.2,3,13,15-17,20,24,29 van Riet volve immobilization of the elbow in augmentation, and ligament augmen- et al12 used the transosseous cruciate 30° to 45° of flexion for 2 weeks un- tation devices have all been reported technique for primary repair of 13 til the wound heals. Therapy, con- with varying degrees of success.6,37-40 acute tears at the tendinous inser- sisting of passive extension and Factors that affect surgical technique tion. Surgery was performed an aver- guided active flexion, is begun fol- include degree of chronicity and re- age of 63 days after injury. At 1-year lowing immobilization. At 4 weeks traction, quality of the tendon tissue, follow-up, the authors demonstrated postoperatively, active ROM is initi- and the presence of medical comor- peak strength of 92% (range, 75% ated and efforts are refocused on re- bidities. to 106%) and 8° of loss of extension gaining full elbow motion. Weight Hamstring allograft reconstruction compared with the uninjured side.

38 Journal of the American Academy of Orthopaedic Surgeons Peter C. Yeh, MD, et al

Figure 13 demonstrated improved elbow extension and strength as well as patient satisfaction. We favor anatomic footprint repair of the triceps to provide optimal tendon-to-bone healing and, ultimately, optimal functional outcome.

References

Evidence-based Medicine: Levels of evidence are listed in the table of contents. The references in this article are level IV case series or case report studies. AP (A) and lateral (B) views of the hamstring allograft technique used to Citation numbers printed in bold type augment distal triceps repair. The allograft semitendinosus tendon is woven indicate references published within through the remaining proximal triceps tendon edge. The transverse tunnel is drilled through the olecranon 1 cm from the tip. The tunnel is centered the past 5 years. between the articular surface and the posterior cortex. 1. Anzel SH, Covey KW, Weiner AD, Lipscomb PR: Disruption of muscles and tendons: An analysis of 1,014 cases. Quantitative data and subjective fixation, and rerupture.31 Rerupture Surgery 1959;45:406-414. outcome measures are lacking in re- is rare and usually results from a 2. Mair SD, Isbell WM, Gill TJ, Schlegel ports of chronic or difficult ruptures. traumatic fall after complete recov- TF, Hawkins RJ: Triceps tendon ruptures in professional football players. 12 12 However, van Riet et al quantified ery from the first rupture. Results Am J Sports Med 2004;32:431-434. the outcome of nine chronic ruptures of repairs and reconstructions fol- 3. Sollender JL, Rayan GM, Barden GA: managed with triceps reconstruction. lowing three cases of rerupture in the Triceps tendon rupture in weight lifters. The time from injury to treatment study by van Riet et al12 were found J Shoulder Elbow Surg 1998;7:151-153. averaged 163 days (range, 28 to to be functionally equivalent to re- 4. Lambert MI, St Clair Gibson A, Noakes 393). These patients demonstrated TD: Rupture of the triceps tendon sults with primary repair of first-time associated with steroid injections. Am J an average peak strength of 66% ruptures. Sports Med 1995;23:778. (range, 35% to 100%) and average 5. Clayton ML, Thirupathi RG: Rupture of loss of extension of 13° compared the triceps tendon with olecranon with the uninjured arm. Despite the bursitis: A case report with a new Summary method of repair. Clin Orthop Relat Res wide range in peak strength, this re- 1984;184:183-185. Acute triceps ruptures are uncom- port demonstrates that reconstruc- 6. Wagner JR, Cooney WP: Rupture of the tions of chronic tears are inferior to mon, occurring mainly in athletes, triceps muscle at the musculotendinous primary repairs of acute tears. In weight lifters (especially those who junction: A case report. J Hand Surg [Am] 1997;22:341-343. contrast, augmentation of primary use anabolic steroids), and persons who sustain elbow trauma. Acute tri- 7. Vidal AF, Drakos MC, Allen AA: Biceps repairs with hamstring autograft tendon and triceps tendon injuries. Clin have demonstrated good outcomes. ceps rupture is a clinical diagnosis, Sports Med 2004;23:707-722.

Case reports indicate that patients although MRI may aid in confirma- 8. Yeh PC, Stephens KT, Solovyova O, have returned to manual labor as tion and surgical planning. Anatomic et al: The distal triceps tendon footprint well as competitive weight lifting classification of these ruptures, in and a biomechanical analysis of three repair techniques. Am J Sports Med,in with 5/5 manual strength testing in conjunction with functional and press. 6,40 the clinic. medical status, is helpful in deter- 9. Windisch G, Tesch NP, Grechenig W, Potential postoperative complica- mining the proper treatment proto- Peicha G: The triceps brachii muscle and tions include olecranon bursitis sec- col. Surgical repair offers predictable its insertion on the olecranon. Med Sci Monit 2006;12:BR290-BR294. ondary to wire suturing, flexion con- return of function with a small risk 10. Madsen M, Marx RG, Millett PJ, Rodeo tractures ranging from 5° to 20°, of loss of elbow motion. Even surgi- SA, Sperling JW, Warren RF: Surgical irritation from underlying internal cal treatment of chronic tears has anatomy of the triceps brachii tendon:

January 2010, Vol 18, No 1 39 Distal Triceps Rupture

Anatomical study and clinical 22. Zionts LE, Vachon LA: Demonstration 32. Kibuule LK, Fehringer EV: Distal triceps correlation. Am J Sports Med 2006;34: of avulsion of the triceps tendon in an tendon rupture and repair in an 1839-1843. adolescent by magnetic resonance otherwise healthy pediatric patient: A imaging. Am J Orthop 1997;26:489- case report and review of the literature. 11. Hughes RE, Schneeberger AG, An KN, 490. J Shoulder Elbow Surg 2007;16:e1-e3. Morrey BF, O’Driscoll SW: Reduction of triceps muscle force after shortening of 23. Kijowski R, Tuite M, Sanford M: 33. Sierra RJ, Weiss NG, Shrader MW, the distal humerus: A computational Magnetic resonance imaging of the Steinmann SP: Acute triceps ruptures: model. J Shoulder Elbow Surg 1997;6: elbow: Part II. Abnormalities of the Case report and retrospective chart 444-448. ligaments, tendons, and nerves. Skeletal review. J Shoulder Elbow Surg 2006;15: 12. van Riet RP, Morrey BF, Ho E, Radiol 2005;34:1-18. 130-134. O’Driscoll SW: Surgical treatment of 24. Strauch RJ: Biceps and triceps injuries of 34. Farrar EL III, Lippert FG III: Avulsion of distal triceps ruptures. J Bone Joint Surg Am 2003;85:1961-1967. the elbow. Orthop Clin North Am 1999; the triceps tendon. Clin Orthop Relat 30:95-107. Res 1981;161:242-246. 13. Brumback RJ: Compartment syndrome complicating avulsion of the origin of the 25. Harris PC, Atkinson D, Moorehead JD: 35. Pantazopoulos T, Exarchou E, Stavrou triceps muscle: A case report. J Bone Bilateral partial rupture of triceps Z, Hartofilakidis-Garofalidis G: Joint Surg Am 1987;69:1445-1447. tendon: Case report and quantitative Avulsion of the triceps tendon. J Trauma assessment of recovery. Am J Sports Med 1975;15:827-829. 14. O’Driscoll SW: Intramuscular triceps 2004;32:787-792. rupture. Can J Surg 1992;35:203-207. 36. Anderson KJ, Lecocq JF: Rupture of the 26. Singh RK, Pooley J: Complete rupture of triceps tendon. J Bone Joint Surg Am 15. Bach BR Jr , Warren RF, Wickiewicz TL: the triceps brachii muscle. Br J Sports 1957;39:444-446. Triceps rupture: A case report and Med 2002;36:467-469. literature review. Am J Sports Med 1987; 37. Sanchez-Sotelo J, Morrey BF: Surgical 15:285-289. 27. Aso K, Torisu T: Muscle belly tear of the techniques for reconstruction of chronic triceps. Am J Sports Med 1984;12:485- insufficiency of the triceps: Rotation flap 16. Sharma SC, Singh R, Goel T, Singh H: Missed diagnosis of triceps tendon 487. using anconeus and tendo achillis rupture: A case report and review of allograft. J Bone Joint Surg Br 2002;84: 28. Inhofe PD, Moneim MS: Late 1116-1120. literature. J Orthop Surg (Hong Kong) presentation of triceps rupture: A case 2005;13:307-309. report and review of the literature. Am J 38. Sai S, Fujii K, Chino H, Inoue J, Ishizaka 17. Viegas SF: Avulsion of the triceps Orthop 1996;25:790-792. J: Old rupture of the triceps tendon with tendon. Orthop Rev 1990;19:533-536. unique pathology: A case report. 29. Tsourvakas S, Gouvalas K, Gimtsas C, J Orthop Sci 2004;9:654-656. 18. Bos CF, Nelissen RG, Bloem JL: Tsianas N, Founta P, Ameridis N: Incomplete rupture of the tendon of Bilateral and simultaneous rupture of the 39. Dos Remedios C, Brosset T, Chantelot triceps brachii: A case report. Int Orthop triceps tendons in chronic renal failure C, Fontaine C: Repair of a triceps tendon rupture using autogenous semi-tendinous 1994;18:273-275. and secondary hyperparathyroidism. and gracilis tendons: A case report and Arch Orthop Trauma Surg 2004;124: 19. Pina A, Garcia I, Sabater M: Traumatic retrospective chart review [French]. Chir 278-280. avulsion of the triceps brachii. J Orthop Main 2007;26:154-158. Trauma 2002;16:273-276. 30. Langenhan R, Weihe R, Kohler G: 40. Weistroffer JK, Mills WJ, Shin AY: 20. Levy M, Goldberg I, Meir I: Fracture of Traumatic rupture of the triceps brachii Recurrent rupture of the triceps tendon the head of the radius with a tear or tendon and ipsilateral Achilles tendon repaired with hamstring tendon avulsion of the triceps tendon: A new [German]. Unfallchirurg 2007;110:977- autograft augmentation: A case report syndrome? J Bone Joint Surg Br 1982; 980. and repair technique. J Shoulder Elbow 64:70-72. Surg 2003;12:193-196. 31. Esenyel CZ, Oztürk K, Ortak O, Kara 21. Kaempffe FA, Lerner RM: Ultrasound AN: Rupture of the triceps brachii ten- 41. Mazzocca AD: Allograft reconstruction diagnosis of triceps tendon rupture: A don: A case report [Turkish]. Acta of triceps tendon ruptures. Am J Sports report of 2 cases. Clin Orthop Relat Res Orthop Traumatol Turc 2003;37:178- Med, in press. 1996;332:138-142. 181.

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