Distal triceps tendon ruptures are rare 1,2, representing <1% of all tendon problems related to the upper extremity 3. Other than isolated case reports and reports of the injury as a complication of joint replacement 4-32, we found nothing in the literature that provides insight into the treatment, timing of treatment, and outcome of repair compared with that of reconstruction for the treatment of triceps deficiency.
Disruption occurs most commonly as an avulsion from the osseous tendon insertion. Less commonly, the injury occurs intramuscularly 33,34 or at the myotendinous junction 35-38. The mechanism of injury is usually a fall on the outstretched hand; however, direct trauma to the posterior aspect of the arm has also been reported 26,39-41. Difficulties in diagnosis as well as underestimation of the degree of injury can lead to prolonged disability and delayed surgical intervention 7,23,26,42-44.
The present study was performed to retrospectively review our experience with the diagnosis and operative management of distal triceps insufficiency. We believe that it represents the largest experience reported to date. The goal was to assess and discuss our experience with the diagnostic findings, the impact of the timing of surgical intervention, methods of repair and reconstruction, and final functional outcomes.
Materials and Methods
A retrospective review of charts and radiographs identified thirty-two patients who had had surgical treatment of distal triceps insufficiency between 1977 and 1997. Ten patients were excluded because the injury was associated with a previous total elbow arthroplasty in nine and was an intramuscular rupture in one. Twenty-three procedures were performed in the remaining twenty-two patients (one patient required a second procedure after a traumatic rupture of the primary repair one month after surgery). Of the twenty-two patients, nineteen were men and three were women; the average age was forty-seven years (range, twenty-one to sixty-nine years). Ten injuries involved the left side and thirteen, the right. Fourteen triceps ruptures, in thirteen patients, were repaired primarily, and nine were treated with reconstruction of the tendon. The average age at the time of repairs was fifty years (range, twenty-five to sixty-nine years), and the average age at the time of the reconstructions was forty-three years (range, twenty-one to sixty-two years).
The mechanism of injury was a fall in eleven instances, with a laceration occurring in two of these cases and a rerupture of a previous repair occurring in one. Forced extension of the upper extremity while the individual was skiing caused a rerupture of a triceps that had initially been repaired after a rupture sustained in a fall. A motor-vehicle accident caused the rupture in four patients. One of the four sustained a severe degloving injury; one, a laceration; and one a rerupture of a tendon that had been repaired twice, twenty-seven years before the accident. Disruption of the triceps tendon secondary to infection occurred in one patient. Chronic progressive degenerative tearing appeared to be the cause of the injury in six patients, four of whom sustained the rupture during a wheelchair transfer (see Appendix).
The group represented a heterogeneous sample of acute and chronic problems. Eight patients had had previous surgery on the involved elbow. One of these patients had had a ligament reconstruction (with use of half of the biceps and a portion of the triceps tendon) because of a chronic elbow dislocation approximately ten months prior to the presenting injury. Three patients had undergone open reduction and internal fixation of a distal humeral fracture through a triceps-sparing approach prior to the triceps injury. In one patient, an infection developed after a reconstructive procedure for osteogenesis imperfecta and required débridement of a necrotic triceps tendon. This patient presented with no triceps function one year after the procedure. Three patients had a rerupture following a primary repair. One of those patients had sustained a traumatic triceps rupture twenty-seven years prior to the index intervention. At that time, he had a primary repair as well as a repeat repair six months later. The upper extremity was functioning well until he sustained a third injury, in a snowmobile accident, three months prior to the most recent treatment. Another patient had had a triceps repair after a fall from a horse one month following débridement of an infected olecranon bursa. Four months following that repair, the patient sustained a rerupture of the triceps tendon while skiing; it was reconstructed one month later. The third patient with a rerupture following a primary repair sustained a rerupture in a fall.
Data were obtained by a retrospective review of records and radiographs before and at an average of ninety-three months (range, seven to 264 months) after surgery. Two patients had died, and information from the charts was used to determine the outcome for those two patients. After approval was given by our institutional review board, the other patients were contacted by telephone and were invited to return for clinical examination and formal strength testing. Thirteen patients returned for clinical evaluation, and the results of formal biomechanical evaluation of isokinetic strength or clinical assessment of strength and range of motion were available for all of them. Manual strength testing was graded on a scale of 0 to 5 (see Appendix), which is a standard assessment that is used uniformly in our institution.
Formal biomechanical strength testing was performed for the purpose of this study for eight patients. Isokinetic peak strength and isokinetic work 45 were tested at an average of eighty-eight months (range, sixty-one to 182 months) after surgery. Also, data only on isokinetic peak strength were available from the charts of one of the deceased patients (assessed seven months postoperatively) and one other patient (assessed thirteen months postoperatively). Six patients were unable to return for examination and were interviewed with a telephone questionnaire; they answered a set of questions designed to determine subjective outcomes (pain and factors limiting activities of daily living) and objective outcomes (range of motion, strength, and the need for additional therapeutic measures) after the index triceps surgery. One patient was lost to follow-up, and information from the charts recorded at twenty months after surgery was used to assess that patient's outcome. All patients consented to be included in the study.
Certain physical findings could be identified in nearly all patients, irrespective of the time of presentation or the acuteness or severity of the injury. Triceps weakness (an inability to extend the elbow against gravity) was found in all patients in whom strength was tested. A palpable defect in the tendon was another common finding, both in patients who presented acutely and in those who presented in a delayed fashion. A defect was palpable after sixteen ruptures. Palpation was not performed in the three patients who sustained a laceration of the tendon, and physical examination revealed no palpable defect in four patients.
Other findings depended on the acuteness and severity of the injury. In the acute phase, pain, swelling, and ecchymosis with a decreased range of motion were the most common findings. When there was a delay of more than three weeks between the injury and presentation, a combination of triceps weakness and a decreased active range of motion (an average 30° extension lag) was frequently noted.
The triceps tendon rupture was initially misdiagnosed in ten patients for a variety of reasons. For five patients who presented with an acute injury, the differential diagnosis included a sprain, a radial head fracture, and olecranon bursitis, but not triceps tendon rupture. In three of those patients, the palpable defect and triceps weakness initially were not noted because of swelling, ecchymosis, and pain caused by a fall directly onto the elbow, as opposed to a fall on the outstretched hand. The other two patients did not have a noticeably palpable defect in the triceps tendon; one of those patients was wheelchair bound because of a C7 tetraplegia. The diagnosis was also missed in the other three wheelchair-bound patients, who had poliomyelitis. In one of them, the poliomyelitis was complicated by progressive neuromuscular weakness, and the triceps weakness was initially attributed to that problem. In another of these wheelchair-bound patients with poliomyelitis, an open reduction and internal fixation of a fracture-dislocation of the elbow had been performed. One year later, that patient presented to our institution with recurrent elbow instability. The instability was treated with a ligament reconstruction with use of a lateral slip of triceps tendon and half of the biceps tendon. Two Kirschner wires were drilled through the olecranon into the humerus to protect the ligament repair. Triceps insufficiency was noted a few months after the ligament reconstruction, but the diagnosis was not made until ten months later. The diagnosis was also delayed in the other two patients with a previous open reduction and internal fixation of an elbow fracture. Triceps insufficiency was attributed to the surgery in both.
Only one patient had associated injuries of the ipsilateral upper extremity. That patient had sustained multiple injuries, including a complex degloving injury of the elbow, in a high-speed, rollover motor-vehicle accident. Upon referral to our institution five months after the accident, he was noted to have extensive soft-tissue loss over the elbow, including absence of the medial head of the triceps, loss of the medial one-third of the olecranon, and a laceration of the ulnar nerve.
Radiographic findings were observed in five patients. An avulsion fracture of the olecranon with loss of the medial one-third of the olecranon was noted in the patient with the complex degloving injury. Calcification in the triceps tendon was noted in two patients who presented with an acute injury and in two patients who had a chronic rupture. In one of the latter patients, an ossified mass that had not been noted on the initial radiograph was seen three months after the injury. Initial radiographs were not available for the other patient, and the calcification was not noted until five months later, when the patient first presented to our institution.
Magnetic resonance imaging was performed in five patients, and the correct diagnosis was confirmed in all five.
A complete tendon rupture was found in eight cases. Six had an avulsion from the osseous tendon insertion, one had an avulsion fracture of the olecranon, and one had a complete, open laceration of the tendon approximately 3 cm proximal to the olecranon. Fifteen patients had a partial injury of the triceps tendon. Eight had an avulsion of the central one-third of the tendon, with the medial and lateral insertions appearing to be intact. Two had a rupture involving the medial and central portions of the triceps, and two others had involvement of the medial portion alone. A lateral defect was noted in one patient, and a combined lateral and central defect was present in another. A partial-thickness rupture was seen in two patients: one had an avulsion and one had a laceration. The latter patient had a full-thickness laceration of the medial part of the triceps and a superficial laceration of the lateral part of the distal triceps, with the deeper layers remaining intact.
Timing of the Surgical Intervention
The injuries that were diagnosed in an acute fashion were treated surgically in an average of seven days. All of these patients but one were treated surgically within eight days after the injury (range, zero to forty-four days). In one patient, the diagnosis was not missed but conservative treatment was attempted first. After forty-four days, repair was impossible and reconstruction had to be performed. All other acutely diagnosed injuries were treated with a primary suture repair of the triceps tendon.
In the three patients who had a tendon rupture after open reduction and internal fixation of the elbow, surgical treatment was delayed for 145, 393, and 609 days. Surgical intervention was also delayed in all four patients who sustained the triceps tendon rupture during a wheelchair transfer. In two of those patients, we were unable to determine the exact time of injury, but diagnosis and surgery were certainly delayed for several months. In the other two patients, surgery was delayed for twenty-five and twenty-eight days.
Type of Procedure
Fourteen primary repairs were done in thirteen patients. The average time from the injury to the primary repair was sixty-three days (range, zero to 609 days). We were unable to determine the exact time of the injury in one patient who had a primary repair, but surgery was delayed for several months. Nine of the fourteen primary repairs were suture repairs with a Bunnell-type stitch ( Fig. 1 ), and four were Krakow-type suture repairs. Reattachment in all instances was through drill holes in the olecranon. The patient who fell and sustained a rupture of a primary Bunnell-type repair one month postoperatively underwent repeat repair with the same technique. One patient with a small avulsion fracture of the olecranon was treated with tension-band wiring.
Reconstruction of the ruptured triceps was done in nine elbows. The time between the injury and the reconstruction averaged 163 days (range, twenty-eight to 393 days). We were unable to determine the exact time of injury in one patient in this group, but the patient stated that surgery had been delayed for several months. The nine reconstructive procedures varied in complexity and technique, depending on the nature of the defect and the quality of the remaining triceps tendon. Six patients were treated with autogenous tissue transfer and three, with synthetic tissue. Our preference was to use the anconeus rotation as the first option if the pathological condition was amendable to this technique; however, this was possible in only one patient. Six patients were treated with a variety of tendon autografts, including the palmaris longus (one patient), the palmaris longus with a portion of the Achilles tendon (one), the plantaris (one), the semitendinosus (one), the latissimus dorsi (one), and the anconeus (one). The feature common to the techniques was weaving of the tendon graft through the remaining triceps tendon and then attaching it through drill holes to the olecranon.
Acute Compared with Chronic Triceps Tendon Ruptures
In eight instances, surgery was performed within three weeks after the initial injury (average, three days [range, zero to eight days] after the injury). A primary repair was possible in all eight. In the five patients who presented more than three weeks after the injury and the ten patients in whom the diagnosis was initially missed, the average time to surgery was 172 days (range, twenty-five to 609 days). A primary suture repair was still possible in six of these patients with a chronic rupture, whereas a variety of reconstructive procedures was performed in the remaining nine.
Postoperative management entailed two to six weeks of immobilization in thirteen of the twenty-three cases. The position of immobilization ranged from full extension to 90° of flexion. In seven cases, the elbow was placed in a dynamic extension splint immediately after surgery; this was combined with continuous passive motion in two. One patient started using a continuous passive motion machine immediately after surgery and continued to do so for three weeks. Two patients had a sling applied after a primary repair and were encouraged to perform active motion exercises immediately.
An ulnar neuropathy developed in the patient with the olecranon avulsion that was treated with tension-band wiring. It resolved without a residual deficit. Prominent hardware was later removed from the elbow of this patient. Three patients had rerupture following primary repair. A rerupture and a stitch abscess both occurred in the same patient (Case 2), who had had a primary repair of the triceps. The rerupture was repaired primarily without further sequelae (Case 2a). Another patient presented in a delayed fashion after rerupture of a primary repair, and a reconstruction was necessary. Finally, one patient had two reruptures after a primary repair. The first rerupture was sustained in a fall six months after the first repair. The tendon was again repaired, and it functioned well for twenty-seven years, until a third rupture was sustained in a snowmobile accident. The third rupture was also repaired primarily, with a good functional result.
No residual palpable defect was noted in any of the twenty-two patients.
Loss of elbow extension averaged 10°, whereas flexion averaged 136°. These values averaged 8° and 138° after the primary repairs and 13° and 133° after the reconstructions. Manual testing showed triceps strength to be 4/5 or 5/5 in all patients who were tested. Formal isokinetic strength testing was performed in ten patients, and isokinetic peak strength averaged 82% (range, 35% to 106%) of that of the uninvolved extremity after more than one year of follow-up (average, sixty-four months; range, thirteen to 182 months). Peak strength averaged 92% (range, 75% to 106%) of that of the untreated extremity after the suture repairs compared with 66% (range, 35% to 100%) after the triceps reconstructions. On the average, the isokinetic work value for the involved extremity was 100% that of the uninvolved arm after more than one year of follow-up (average, seventy-one months; range, twenty to 182 months). The value was 102% (range, 68% to 171%) following the suture repairs (at an average of eighty months; range, twenty-four to 182 months) and 92% (range, 84% to 101%) after the reconstructions (at an average of forty-two months; range, twenty to sixty-three months).
Objective peak extension strength was also measured preoperatively in two patients who subsequently had a reconstruction of the triceps. In one (Case 22), the strength on the involved side increased from 9% (compared with that on the normal side) preoperatively to 35% at twelve months after the reconstruction. A radial nerve palsy was diagnosed preoperatively with electromyography in that patient. In the other patient (Case 16), the strength of the involved arm initially decreased from 32% preoperatively to 31% at four months postoperatively. Seven months after surgery, the strength had improved to 57% of that on the uninvolved side.
Subjectively, all thirteen patients with an acute repair and all seven patients with a reconstruction who were still alive were satisfied or very satisfied with the result of the surgery. The clinical records for both deceased patients who had had a tendon reconstruction indicated that the outcome of the surgery had been satisfactory.
Two patients had a limited range of motion due to posttraumatic arthritis after open reduction and internal fixation of the elbow. The arthritis was not painful in one, and loss of motion, not weakness, limited the activities of daily living of that patient. The other patient reported moderate pain due to the posttraumatic osteoarthritis. The arthritis had been present before the tendon repair. The function of the elbow increased after the repair in this patient, and he stated that he was very satisfied with the result of the procedure. An inability to work overhead was demonstrated by this patient and by one other. However, this problem was attributed to posttraumatic osteoarthritis in the first patient and to ulnar and radial neuropathies in the second; it was not attributed to triceps weakness in either patient. The second patient also reported painful snapping of the triceps with certain sudden movements.
Distal triceps tendon ruptures and avulsions are uncommon injuries. Hence, there is very little information in the literature to guide the clinician regarding the surgical treatment of the problem. Anzel et al. reported only eight triceps injuries among 1014 tendon disruptions 3. Reports in the literature typically have associated triceps rupture with weight-lifting 10,12,24,26-28,35,46-51 and anabolic steroid use 24,27,28,47,48,51-56.
We found that an eccentric triceps contraction, such as that sustained during a fall on the outstretched hand, was the most common mechanism of injury among our patients. Direct trauma to the posterior aspect of the elbow was a factor in two of the injuries in this series, and four patients sustained the triceps injury as a result of forceful elbow extension during wheelchair transfer.
Substantial force is usually required to rupture or avulse normal tendons; however, when the structural integrity of the tendons has been altered, spontaneous rupture can occur following minimal to moderate force 28,47,53-55. Many local and systemic factors have been reported to be associated with triceps tendon ruptures. Systemic entities such as chronic renal failure with secondary hyperparathyroidism 9,18,38,57-62, hypocalcemic tetany 21, rheumatoid arthritis 63, osteogenesis imperfecta 20, anabolic steroid use 24,27,28,47,48,51-56,64, and possibly insulin-dependent diabetes 42 have been reported.
Local factors associated with triceps disruption include local steroid injections 27,28,48, attritional changes from degenerative arthritis 2,9, and olecranon bursitis 8,28. In this study, olecranon bursitis was diagnosed in three patients prior to rupture. Corticosteroids had been injected in one, and a débridement had been done in another. In one patient, degenerative joint disease of the elbow was noted on radiographs after the rupture. In this patient, only moderate force caused the rupture of the tendon: while he was gardening, his rake caught a stone and broke. He did not fall, but he noted immediate pain posterior to the elbow.
The diagnosis of an acute triceps tendon rupture can be difficult and can easily be missed, as it was initially in ten of our cases. When the triceps tendon is ruptured, extension against gravity is difficult or impossible. A palpable defect may be detected, but marked local swelling may limit the usefulness of this finding in the acute phase.
Radiographic findings in association with distal triceps ruptures are usually minimal, and the small flakes of avulsed bone reported in the literature 7,11,23,39,43,44,65,66 were seen in only four patients in our series. If present, this finding can be quite useful, especially if the diagnosis is not otherwise apparent. On rare occasions (once in this series), a larger avulsion fracture of the olecranon may occur.
Physical examination and radiographs should be used to identify uncommon associated injuries that may occur around the elbow 25,28,65-67 or wrist 44. Imaging studies, such as magnetic resonance imaging 13,29,31,34,68-70 and ultrasound 10,19, are usually recommended to assess triceps deficiency. Magnetic resonance imaging proved to be useful in the preoperative planning for three patients who presented for delayed reconstruction. However, one should be cautious not to rely too heavily on imaging studies in lieu of a careful clinical examination. In the senior author's experience, a careful examination has generally led to the appropriate diagnosis.
We believe, as do others 11,23,35,43,66, that early surgical intervention is the appropriate treatment for an acute, complete rupture of the triceps tendon at the tendo-osseous junction. However, as data regarding the function of tendons with an untreated rupture are not available, we made no attempt to compare the results of conservative treatment with those of surgical repair in this report. Repair of the ruptured triceps tendon can be accomplished reliably by direct reattachment of the tendon through drill holes in the olecranon with use of nonabsorbable suture. Our results with this technique have been quite good, especially when the repairs were performed within three weeks after the injury. The distal triceps tendon rupture was always amenable to suture repair in patients treated within three weeks after the injury.
The greater challenge is the treatment of patients presenting in a delayed manner. Although there have been reports of good results with conservative treatment of partial triceps ruptures 33,68 and authors who have advocated conservative treatment of partial ruptures 7,11, we found that six of nine patients presenting for delayed evaluation and reconstruction had a partial triceps rupture at the time of surgery; thus, the initial injury had not healed or conservative treatment had failed. This suggests that early surgical intervention may be the best treatment for these injuries. However, in six patients it was still possible to perform a primary repair as late as twenty months after injury.
When treatment has been delayed, surgical options are more complex because of the availability and quality of the local soft tissues. Direct reattachment alone is less likely to be possible as a result of tendon retraction and scarring, as was the case in nine of the fifteen ruptures that were managed in a delayed fashion. When direct reattachment is impossible, repairs can be augmented with autologous tendon grafts 42, forearm fascial flaps 39, or a triceps turndown flap 8. The anconeus slide technique, which was performed in one of our patients, has recently been reported on separately 71.
For the reasons mentioned above, a variety of reconstructive techniques was used in this series, depending on surgeon preference and experience. Although there were no reruptures in this group, the time to recovery was prolonged (six to twelve months). This finding is in contrast to the recovery of the patients who presented with an acute injury: in those patients, the majority of elbow motion and triceps strength returned over the first three to four months, with continued improvement noted up to six months after surgery.
In summary, careful evaluation of distal triceps injuries should be performed to ensure an accurate early diagnosis. The clinical examination needs to be repeated when the findings are initially inconclusive because of pain and swelling. Complete ruptures can be repaired acutely by direct reattachment of the triceps tendon to the olecranon, with predictably good results. Delayed surgical intervention is indicated for persistent triceps weakness, which frequently is associated with a partial triceps rupture. While a primary repair may still be possible, there is a high likelihood that some type of tendon-grafting will be required. Delayed treatment can still result in an effective return of extension strength and elbow function; however, the recovery period is prolonged, with up to one year required before the full merits of the intervention are demonstrated.
A table showing clinical data on all patients in the study is available with the electronic versions of this article, on our web site at http://www.jbjs.org (go to the article citation and click on Supplementary Material) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
Investigation performed at the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
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