Triceps Rupture

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Introduction
  • Epidemiology
    • demographics
      • usually males
      • age 30-50 most common
      • commonly seen in
        • competitive weightlifting
        • body building
        • football players
    • risk factors 
      • systemic illness (renal osteodystrophy)
      • anabolic steroid use
      • local steroid injection 
      • flouroquinolone use
      • chronic olecranon bursitis
      • previous triceps surgery
  • Pathophysiology
    • mechanism
      • usually forceful eccentric contraction
    • pathoanatomy
      • rupture most common at the insertion of medial or lateral head
      • less frequently through muscle belly or musculotendinous junction
Presentation
  • History
    • patients often note a painful pop
  • Symptoms
    • loss of ability to extend elbow against gravity
  • Physical exam
    • may have palpable gap
    • swelling, ecchymosis, and pain
Imaging
  • Radiographs
    • recommended views
      • AP/lateral of elbow
    • findings
      • may show "flake sign" on lateral view  
  • MRI
    • useful for determining location and severity 
Treatment
  • Non-operative
    • supportive treatment
      • indications
        • partial tears and able to extend against gravity
        • low demand patients in poor health
  • Operative
    • primary surgical repair
      • indications
        • acute complete tears
        • partial tears (>50%) with significant weakness
      • technique
        • delayed reconstruction may need tendon graft 
Complications
  • Elbow stiffness
  • Ulnar nerve injury
  • Failure of repair
 

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Questions (2)

(OBQ11.135) 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? Review Topic

QID:3558
FIGURES:
1

Distal biceps tendon rupture

1%

(23/1681)

2

Brachialis muscle rupture

0%

(3/1681)

3

Lateral ulnar collateral ligament tear

0%

(8/1681)

4

Medial ulnar collateral ligament tear

0%

(8/1681)

5

Triceps tendon tear

97%

(1634/1681)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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.

ILLUSTRATIONS:

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Question COMMENTS (0)

(OBQ05.266) Triceps ruptures are associated with all of the following EXCEPT? Review Topic

QID:1152
1

Anabolic steroid use

1%

(8/735)

2

Local corticosteroid injection

1%

(9/735)

3

Renal osteodystrophy

9%

(67/735)

4

Fluoroquinolone use

2%

(12/735)

5

Creatine supplement use

87%

(639/735)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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.


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