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  • summary
    • Triceps Ruptures are rare injuries to the elbow extensor mechanism that most commonly occurs as a result of a sudden forceful elbow contraction in weightlifters or older males with underlying systemic illness. 
    • Diagnosis can be made clinically with the inability to extend the elbow against resistance. MRI studies can help discern between partial and complete tears. 
    • Treatment is either immobilization or primary repair depending on patient age, patient underlying systemic disease, chronicity of injury and patient activity demands. 
  • 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
  • Etiology
    • 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
        • inserts on average 1.1 cm 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
          • transosseous tunnels
          • suture anchor 
            • studies have shown no difference in biomechanical strength or functional outcomes between transosseous bone tunnels and suture anchors
              • higher re-rupture rate and complication rate noted with transosseous repair compared to suture anchor repair 
          • 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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