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Basics ⬇

Author(s): ChristopherMiles, MD, CAQSM and MatthewHorn, MD

Description

Triceps rupture occurs when the triceps tendon becomes detached from its insertion on the olecranon after an elbow injury (1).

Epidemiology

Incidence

  • Least common of all tendon injuries (0.78%) (1,2)
  • Average age: 45.6 yr old (2)
  • Predominant sex: male (2)
  • Most common sports: soccer, weight lifters/bodybuilders (especially with concomitant anabolic steroid use) (1,2)
ALERT
  • Insertion of triceps tendon ossifies at age of 9 yr, so it is not visible on radiographs before this age (3).
  • In children with open growth plates, triceps tendon rupture injury typically causes avulsion of epiphysis with subsequent Salter-Harris type I or II injury (3).

Etiology and Pathophysiology

  • Triceps muscle composed of long, lateral, and medial heads (4):
    • Long head originates from the infraglenoid tuberosity on the scapula.
    • Lateral head originates from the posterior-lateral portion of the humerus and the lateral intermuscular septum.
    • Medial head extends from distal to spiral groove to trochlea.
    • All three heads insert on the olecranon.
  • Overloading an extended elbow (1)
  • Abrupt eccentric contraction of triceps muscles (1)
  • Direct posterior elbow trauma (4)

Risk-Factors

General Prevention

  • Properly warm up and stretch prior to physical activity.
  • Ensure accurate weight-lifting techniques.
  • Avoid local steroid injections and anabolic steroid use.
  • Ensure proper rehabilitation from elbow arthroplasty (1,5).

Commonly Associated Conditions

Diagnosis ⬆ ⬇

History

  • Fall on outstretched hand (4)[C]
  • Direct elbow trauma (4)[C]
  • Patients may feel a pop with resisted elbow extension such as with weight lifting or daily activities (1)[C].

Physical Exam

  • Swelling and ecchymosis at posterior elbow near triceps insertion site (5)[C]
  • Elbow tender to palpation (4)[C]
  • Palpable gap at, or proximal, to olecranon tip (1)[C]
  • Decreased range of motion (ROM) with elbow extension (4)[C]
  • Pain with active elbow extension (4)[C]
  • Positive Viegas test (modified Thompson test). With this technique, lack of elbow extension after proximal compression of muscle mass can suggest a diagnosis of complete rupture (1)[C].

Differential Diagnosis

  • Elbow strain
  • Olecranon bursitis
  • Radial head fracture
  • Distal humerus fracture (1)[C]

Diagnostic Tests & Interpretation

  • Anteroposterior (AP) and lateral elbow radiographs: “flake sign” (Dunn-Kusnezov sign) seen on lateral radiograph (1)[C],(2)[A],(4)[C]
  • Ultrasound: triceps tendon rupture (1)[C]
  • Magnetic resonance imaging (MRI) elbow: gold standard if above inconclusive despite clinical suspicion (1)[C]; also necessary for guiding management and preoperative planning (6)[C]
  • Partial versus complete triceps tendon tears (4)[A],(5)[C]:
    • Partial rupture affecting <50% of tendon:
      • Diagnosed on exam or MRI:
        • Exam findings: Patient can perform active elbow extension against gravity with strength >3/5 (6)[C].
    • Partial rupture affecting >50% of tendon or complete ruptures:
      • Diagnosed on exam or MRI:
        • Exam findings: patient with significant loss of triceps extension with strength <3/5 (6)[C]
ALERT
It is important to note that active elbow extension may be preserved with a 10% tear or even a 95% tear because of lateral triceps expansion to the forearm fascia (6)[C]. MRI is most useful for determining the percentage of tears and hence is of paramount help in preoperative management (6)[C].

Treatment ⬆ ⬇

General Measures

  • Ice and acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) initially are appropriate.
  • Arm should be placed in sling with 90 degrees or less of flexion initially after the injury. A posterior splint may be applied if necessary but should be in 90 degrees or less of flexion.

Issues for Referral

Refer all patients with complete or partial triceps rupture >50% to orthopedics for surgical consultation.

Additional Therapies

  • Conservative (1)[C]:
    • Weeks 1 to 6: immobilization:
      • Immediate immobilization with 30 degrees elbow flexion by splint or brace
    • Weeks 6 to 12: ROM:
      • Gradually increase ROM with adjustable angle elbow brace after 6 wk.
      • Full ROM targeted by 12 wk postinjury
    • Weeks 12 and on: strengthening:
      • Goal of full extension strength by 6 to 9 mo posttreatment
    • Shoulder, wrist, and hand ROM exercises may be started immediately.
    • After immobilization, physical therapy is important.
  • Physical therapy
  • Current studies are investigating the use of platelet-rich plasma (PRP) for partial ruptures.

Surgery/Other Procedures

Complete triceps rupture or partial triceps tendon rupture >50% (1)[C]:

  • Primary repair of tendon within 3 wk of initial rupture
  • Transosseous cruciate technique most common (4)[C]
  • ~90% return rate to reinjury activity level after surgery (2)[A]
  • Postoperative physical therapy:
    • Weeks 0 to 6: postoperative adjustable elbow splint at 20 degrees flexion, increasing flexion by 10 degrees every week with passive elbow extension
    • Weeks 6 to 12: active elbow extension
    • Weeks 12 and on: active elbow extension against resistance
  • Complete triceps rupture untreated within the first 6 wk following rupture (4)[C]:
    • Triceps reconstruction
    • Achilles tendon allograft with a calcaneal bony attachment considered in some cases (4)[C]

Ongoing Care ⬆ ⬇

Follow-up Recommendations

Routine follow-up at 4 to 6 wk (transition from immobilization to ROM), 12 wk (transition from ROM to strengthening), and 6 mo (medical clearance) (1,6)

Patient Education

Triceps extension ROM and strengthening exercises to begin after immobilization

Prognosis

  • Nonoperative treatment of partial tears generally resulted in full ROM and subjective strength within 3 to 9 mo (4).
  • Primary repair of partial tears typically resulted in full ROM and subjective strength by 3 to 6 mo (4).
  • Primary repair of complete tears generally resulted in full ROM by 3 mo and baseline subjective strength by 6 mo (4).
  • Total triceps reconstruction typically resulted in some loss of ROM and full subjective strength by 2 to 3 yr (4).

Complications

  • Complete rupture untreated within the first 6 wk; will likely require triceps reconstruction
  • Partial rupture that progresses into complete rupture during conservative therapy
  • Postoperative rerupture
  • Postoperative wounds given thin subcutaneous tissue at posterior elbow
  • Complex regional pain syndrome
  • Compartment syndrome
  • Heterotopic ossification
  • Residual flexion contractures between 5 and 20 degrees (1)

Additional Reading ⬆ ⬇

  • Aunon-Martin I, Prada-Canizares A, Jimenez-Diaz V, et al. Treatment of a complex distal triceps tendon rupture with a new technique: a case report. Arch Trauma Res. 2016;5(1):e32221.
  • Foulk DM, Galloway MT. Partial triceps disruption: a case report. Sports Health. 2011;3(2):175–178.
  • Mair SD, Isbell WM, Gill TJ, et al. Triceps tendon ruptures in professional football players. Am J Sports Med. 2004;32(2):431–434.
  • Mancini F, Bernardi G, De Luna V, et al. Surgical repair of isolated triceps tendon rupture using a suture anchor technique: a case report. Joints. 2017;4(4):250–252.

References ⬆ ⬇

  1. Demirhan M, Ersen A. Distal triceps ruptures. EFORT Open Rev. 2016;1(6):255–259.
  2. Dunn JC, Kusnezov N, Fares A, et al. Triceps tendon ruptures: a systematic review. Hand (N Y). 2017;12(5):431–438.
  3. Paramanathan V, Brookfield S, Menon D. Paediatric triceps avulsion fracture identified with ultrasound. Int J Surg Case Rep. 2013;4(10):923–925.
  4. Tom JA, Kumar NS, Cerynik DL, et al. Diagnosis and treatment of triceps tendon injuries: a review of the literature. Clin J Sport Med. 2014;24(3):197–204.
  5. Bunshah JJ, Raghuwanshi S, Sharma D, et al. Triceps tendon rupture: an uncommon orthopaedic condition. BMJ Case Rep. 2015;2015:bcr2014206446. doi:10.1136/bcr-2014-206446.
  6. Sharma SC, Singh R, Goel T, et al. Missed diagnosis of triceps tendon rupture: a case report and review of literature. J Orthop Surg (Hong Kong). 2005;13(3):307–309.

Clinical Pearls ⬆

  • Triceps rupture should be included in differential diagnosis of every patient with an acute elbow injury (6).
  • Significant swelling increases risk of missing diagnosis initially because it hinders ability to localized pain and gap at insertion site of triceps tendon on the olecranon (5).
  • It is important to categorize triceps ruptures as partial or complete because this guides treatment (1,6).
  • It is important to note that active elbow extension may be preserved with a 10% tear or even a 95% tear because of lateral triceps expansion to the forearm fascia (6).
  • Consider point of care (POC) ultrasound if rupture not visualized on radiographs, especially in children (3).
  • MRI is most useful for determining the percentage of tears and hence is of paramount help in preoperative management (6).
  • Delay in surgical repair past 3 wk from injury increases risk of requiring triceps reconstruction and worse functional outcomes postoperatively (1).