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