Discussion:
Triceps tendon tears are the least common of all tendon injuries. In a review of 1014 tendon ruptures over a nine year period by Anzel et al, (2) approximately 2 % constituted the triceps tendon. Even more uncommon, is complete intramuscular rupture of the triceps brachii. Injuries of the triceps tendon may be partial or complete, with or without associated fractures. The usual mechanism of injury is a fall onto an outstretched hand with the elbow in mid-flexion, but can occur following direct blow to the posterior aspect of the elbow. Farrar and Lippart (5) stated that the most common mechanism of injury was an eccentric load superimposed on a contracted triceps muscle, a mechanism encountered in American football lineman. Triceps tendon injuries also occur in weight lifters and body builders. It has also been described in patients with hyperparathyroidism, diabetic mellitus, chronic renal failure patients on hemodialysis, patients with chronic olecranon bursitis, individuals on anabolic steroids or who had received local steroid injections in the triceps and very rarely hypocalcemic tetany.
Physical examination in cases of complete rupture often reveals a palpable gap proximal to the olecranon process, ecchymosis, soft tissue swelling and inability of the patient to hold the forearm in extension. However, the clinician can miss the initial diagnosis due to soft tissue swelling obscuring the tendinous gap. Serial examinations or confirmatory MRI or ultrasound are part of the diagnostic algorithm.
Radiographs may show a “flake” fracture of the olecranon process on the lateral view. Levy et al., (3) described radial head fractures associated with triceps tendon ruptures. Disruption of the triceps can occur in one of three locations: the osseous-tendinous junction, the myotendinous junction, or the muscular substance, in decreasing order of frequency.
Tarnsey (4) suggests that cases involving disruption of the triceps at its insertion at the olecranon are more accurately termed “avulsion of the triceps”, with the term “rupture” reserved for intramuscular or musculotendinous disruption of the triceps.
Complete avulsion or rupture of the triceps needs surgical exploration and repair. Reattachment of the triceps tendon to the olecranon process via drill holes within in the olecranon is usually successful. If the avulsed flake of bone is of reasonable size, fixation can be attempted. Early primary repair is often performed with Bunnell or Krakow-type suture. Delayed treatment (i.e., beyond the typical three week window) of rupture at the myotendinous junction usually requires more elaborate procedures including V-Y advancement and tendon grafting (palmaris longus, plantaris, semitendinosis, latissiumus dorsi or aconeus) or synthetic tissue, with a prolonged recovery. Thus, early diagnosis and subsequent surgical repair, within three weeks, is imperative for complete avulsion or rupture, to provide the best prognosis for the patient. Early treatment of partial and complete rupture generally produces good results with minimal or no functional deficits.
References:
1) Holder SF, Grana WA. Complete triceps tendon avulsion. Orthopaedics 19861581-2
2) Anzel SH, Covey KW, et al. Disruptions of muscles and tendons: an analysis of 1041 cases. Surgery 1959;45: 406-14.
3) Levy M, Fishel et al. Triceps tendon avulsion with or without fracture of the radial head-a rare injury? J Trauma 1978;18:677-9.
4) Tarnsey FT. Rupture and avulsion of the triceps. Clin Orthop 1972;83:177-83.
5) Farrar EL, Lippert FG Avulsion of the triceps tendon. Clin Orthop 1981;161:242-6
6) Mair SD, Isbell WM. Triceps tendon ruptures in professional football players. Am J Sports Med. 2004. Mar;32(2):431-4.
7) Mont MA, Torres J et al. Hypocalcemic-induced tetany triceps and bilateral quadriceps tendon ruptures. Orthrop Rev. 1994 Jan;23(1):57-60.
