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Introduction
  • Overview
    • triceps rupture is a traumatic condition that is rare and seen in middle aged men
      • treatment is either supportive treatment or primary repair
  • Epidemiology
    • incidence
      • accounts for 0.8% of tendon ruptures
    • demographics
      • more common in males 2:1
      • age 30-50 most common
      • commonly seen in
        • competitive weightlifting
        • body building
        • football players
    • risk factors 
      • systemic illness (hyperparathyroidism, renal osteodystrophy, OI, RA, type I DM)
      • anabolic steroid use
      • local steroid injection 
      • fluoroquinolone use
      • chronic olecranon bursitis
      • previous triceps surgery
      • Marfan syndrome
  • Pathophysiology
    • mechanism of injury
      • results from forceful eccentric contraction or FOOSH
    • pathoantomy
      • rupture most commonly occurs at the osseous insertion of the medial or lateral head
        • less frequently occurs through the muscle belly or at the musculotendinous junction
Anatomy
  • Triceps brachii
    • pennate muscle comprised of 3 heads
      • lateral
        • originates from the posterior humerus between the insertion of the teres minor and the superior aspect of spiral groove, the lateral border of humerus, and the lateral intermuscular septum
      • long
        • originates from the infraglenoid tuberosity
      • medial
        • originates from the posterior humerus distal to spiral groove, the medial humerus, and the medial intermuscular septum
    • insertion occurs over a wide area/footprint
      • located 12mm distal to the tip of the olecranon
      • width ranges from 1.9-4.2cm
      • consists of
        • triceps tendon proper
          • confluence of tendon from all three heads
          • inserts on the olecranon
        • lateral triceps expansion
          • medial aspect inserts on the posterior crest of the ulna, adjacent to the medial head
          • lateral aspect inserts on the fascia of the extensor carpi ulnaris muscle and the deep fascia of the anconeus muscle
          • distal aspect inserts on the antebrachial fascia
    • only muscle in the posterior compartment of the arm
    • innervated by radial nerve (C6-C8)
Classification
 
  • No formal classification system exists
  • Can describe the characteristics of the rupture
    • degree of tear
      • complete
      • partial
      • intact
    • location of tear
      • muscle belly
      • musculotendinous junction
      • tendinous insertion
      • avulsion
    • integrity of lateral expansion
      • intact
      • torn
Presentation
  • History
    • patients often note a painful pop
  • Physical exam
    • inspection
      • pain, swelling, and ecchymosis over the posterior aspect of the elbow
      • may have palpable defect
    • motion
      • inability to extend elbow against resistance
        • not always present -- some patients are able to extend elbow against resistance if intact lateral expansion or compensating anconeus muscle
    • provocative tests
      • modified Thompson squeeze test
        • patient lies prone with the elbow at the end of the table and forearm hanging down
        • triceps muscle is firmly squeezed
        • inability to extend the elbow against gravity suggests complete disruption of triceps proper and lateral expansion
Imaging
  • Radiographs
    • recommended views
      • AP
      • lateral
    • findings
      • may show "flake sign" on lateral view  
  • MRI
    • indications
      • useful for determining location and severity 
    • findings
      • partial rupture
        • small fluid-filled defect within distal triceps tendon
      • complete rupture
        • large fluid-filled gap (paratricipital edema)
Treatment
  • Non-operative
    • splint immobilization
      • indications
        • partial tears and able to extend against gravity
        • low demand patients in poor health
      • techniques
        • immobilize elbow in 30 degrees of flexion for 4 weeks
  • Operative
    • primary surgical repair
      • indications
        • acute complete tears
        • partial tears (>50%) with significant weakness
      • technique
        • delayed reconstruction may need tendon graft 
Techniques
  • Primary surgical repair
    • approach
      • posterolateral approach
    • techniques
      • based of location of tear
        • myotendinous junction
          • V-Y triceps tendon advancement
          • can augment using plantaris tendon
        • tendinous insertion
          • Bunnell or Krackow whipstitch technique using non-absorbable sutures secured via
            • transosseous tunnels
            • direct repair to periosteal flap from the olecranon
            • intraosseous suture anchors
        • avulsion
          • tension-band construct
          • screw and washer
    • post-op
      • immobilization in 30-45 degrees of flexion for 2 weeks
      • active ROM initiated at 4 weeks
      • avoid weightlifting for 4-6 months
    • complications specific to this treatment
      • olecranon bursitis
      • flexion contractures
      • re-rupture
Complications
  • Elbow stiffness/weakness
  • 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? Tested Concept

QID: 3558
FIGURES:
1

Distal biceps tendon rupture

1%

(50/3964)

2

Brachialis muscle rupture

0%

(5/3964)

3

Lateral ulnar collateral ligament tear

1%

(24/3964)

4

Medial ulnar collateral ligament tear

0%

(19/3964)

5

Triceps tendon tear

97%

(3847/3964)

L 1 C

Select Answer to see Preferred Response

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

QID: 1152
1

Anabolic steroid use

1%

(26/2271)

2

Local corticosteroid injection

1%

(25/2271)

3

Renal osteodystrophy

9%

(209/2271)

4

Fluoroquinolone use

2%

(53/2271)

5

Creatine supplement use

86%

(1945/2271)

L 2 D

Select Answer to see Preferred Response

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