American Shoulder and Elbow Surgeons
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A 40 year-old competitive weightlifter felt a painful pop in his elbow while performing a bench press. His lateral radiograph is shown in Figure A. An MRI is likely to show which of the following?
Distal biceps tendon rupture
Brachialis muscle rupture
Lateral ulnar collateral ligament tear
Medial ulnar collateral ligament tear
Triceps tendon tear
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The lateral radiograph shows a "flake sign" which is common in patients with a triceps tendon avulsion, as suggested by this clinical scenario. Triceps tendon tears occur most commonly in males age 30-50, and those involved in competitive weightlifting and football. There is an established link with anabolic steroid use. Other risk factors include renal disease, corticosteroids, history of tendon injection, and fluroquinolone antibiotics. Surgical repair is indicated in active persons with complete tears and for incomplete tears with concomitant loss of strength.
Yeh et al note the importance of obtaining radiographs and that the flake sign is pathognomonic of a triceps tendon avulsion. They note that an MRI is often used to confirm the diagnosis, classify the injury, and guide management.
van Riet et al reported a case series of triceps tendon ruptures. Making the correct diagnosis is important because primary repair is possible within 3 weeks and affords better results than late reconstruction. A high clinical suspicion and use of imaging is critical, as 10 of their 23 ruptures were missed on initial presentation.
Illustration A: MRI showing the ruptured triceps tendon on this patient.
Illustration B: Intra-operative photo during the subsequent repair with sutures being pulled through bone tunnels.
Yeh PC, Dodds SD, Smart LR, Mazzocca AD, Sethi PM.
J Am Acad Orthop Surg. 2010 Jan;18(1):31-40. PMID: 20044490 (Link to Abstract)
van Riet RP, Morrey BF, Ho E, O'Driscoll SW
J Bone Joint Surg Am. 2003 Oct;85-A(10):1961-7. PMID: 14563805 (Link to Abstract)
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Triceps ruptures are associated with all of the following EXCEPT?
Anabolic steroid use
Local corticosteroid injection
Creatine supplement use
Creatine supplement use has not been associated with triceps rupture. Triceps ruptures have been reported in weightlifters who bench press heavy weight, use anabolic steroids, have a history of local steroid injections to the triceps tendon, patients with renal osteodystrophy, and with use of fluoroquinolone antibiotics.
Rettig reviews the risk factors associated with triceps rupture as described above.
Sollender at al and Stannard et al presented cases of triceps tendon ruptures in weightlifters who used anabolic steroids or had numerous local steroid injections.
Khaliq and Zhanell reviewed fluoroquinolone tendon injury and reported two cases of triceps rupture.
Stannard JP, Bucknell AL.
Am J Sports Med. 1993 May-Jun;21(3):482-5. PMID: 8346768 (Link to Abstract)
Sollender JL, Rayan GM, Barden GA.
J Shoulder Elbow Surg. 1998 Mar-Apr;7(2):151-3. PMID: 9593095 (Link to Abstract)
Orthop Clin North Am. 2002 Jul;33(3):509-22, v. PMID: 12483947 (Link to Abstract)
Khaliq Y, Zhanel GG.
Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. PMID: 12766835 (Link to Abstract)
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