Triceps tears/rupture/avulsion
Condition Overview
The conditions under which the diseases or problem may occur. Include issues of
prevalence and aetiology, such as social history, age, hereditary conditioning
medical or environmental background.
Distal tricep ruptures are the rarest tendon rupture in upper extremity,
less than 1%
Predominantly males, 30-50s (2-3 times more common in males)
Commonly involved in sports, weight lifting, or older with underlying
systemic illness
Often traumatic injuries. Usually from eccentric load (i.e. fall on
outstretched arm, or lowering weight), or blow to posterior elbow, or post
surgical i.e. post total elbow arthroplasty or post tricep repair
Predisposing factors: systemic endocrine disorders, hyperparathyroidism,
insulin dependent diabetes, rheumatoid arthritis, renal failure, anabolic
steroid use, local steroid injection and possible chronic olecranon bursitis
The Fault: e.g pathological process
Mechanism often eccentric deceleration stress on the contracted tricep
muscle (with or without blow to elbow) resulting in distal avulsion of the
tendo-osseous insertion.
Rupture commonly occurs at the tendon-osseous insertion of medial or
lateral head
Tendon usually retracts, and osseous fragment of olecranon can become
embedded in (resulting in fracture)
Subjective Features:
Pts often hear a ‘pop’ followed by pain, swelling, bruising and a feeling of
weakness
May have palpable defect (or may not be able to tell due to swelling)
Sometimes don’t notice no active elbow extension as arm hangs down in
gravity
Physical Findings:
May have swelling and bruising
May have palpable gap but sometimes missed because of bruising/
swelling
May be tender on palpation
Unable to extend arm against gravity
If pt can perform active elbow extension against gravity (triceps 3/5
power) then is partial
Squeeze test or ‘modified’ triceps test (similar to achilles Thomson test).
Arm hanging off table in prone elbow flexed at 90, squeeze triceps- should
get elbow extension if intact.
Imaging
Early xray lateral view may show a ‘Flake’ sign (small avulsion fracture of
olecranon)
Xrays can exclude concomitant injuries such as radial head / distal
humerus fractures
MRI gold standard to differentiate extent and location of injury
List possible differential diagnosis
Difficult to differentiate partial or complete tears without MRI
Large avulsion of osseous fragment of olecranon
Radial head fracture/ distal humerus fracture
Ulnar collateral ligament laxity /avulsion
Joint dislocation
Intramuscular tear
Weakness due to radial nerve neuropathy
Treatment
Partial ruptures can be managed non-operatively= immobilise elbow at 30
degrees for 4 weeks, then start ROM + strengthening. Should regain full
strength and ROM at 6 months.
Most research recommends surgical reattachment for complete tricep
avulsion (as is only significant elbow extensor). if >50 % fibres torn on MRI
and unable to actively extend against gravity- then indicator for surgery
Surgery depends on time since injuries, delays in surgical repairs leads to
worse outcome
Most acute injuries can be managed with immediate surgical reattachment
Chronic tears where there has been proximal retraction of the muscle
tendon unit makes this difficult. In these cases reconstruction techniques
are indicated, either using aconeus or other tendon allograft. But any graft
that affects tricep muscle resting length leads to poor outcomes
Often in splint post op but recommendations vary- either long arm splint
with elbow in 30-45 degrees elbow flexion or hinged splint
Usually immobilised up to 6 weeks with progressive increased flexion,
allowing active extension only from week 6. Strengthenig extension only
from week 12. Unrestricted activity from 5 months.
There are good outcomes from surgery with low re-rupture rate
Complications include joint stiffness, tendon shortening, surgical
complications
References
Blackmore, S. M., Jander, R. M., & Culp, R. W. (2006). Management of Distal
Biceps and Triceps Ruptures. Journal of Hand Therapy, 19(2), 154–169.
[Link]
Bunshah, J. J., Raghuwanshi, S., Sharma, D., & Pandita, A. (2015). Triceps tendon
rupture: an uncommon orthopaedic condition. Case Reports, 2015(mar12 1),
bcr2014206446–bcr2014206446. [Link]
Giannicola, G., Bullitta, G., Rotini, R., Murena, L., Blonna, D., Iapicca, M.,
Restuccia, G., Merolla, G., Fontana, M., Greco, A., Scacchi, M., & Cinotti, G.
(2018). Results of primary repair of distal triceps tendon ruptures in a general
population: a multicentre study. The Bone & Joint Journal, 100-B(5), 610–616.
[Link]
Tom, J. A., Kumar, N. S., Cerynik, D. L., Mashru, R., & Parrella, M. S. (2014).
Diagnosis and Treatment of Triceps Tendon Injuries. Clinical Journal of Sport
Medicine, 24(3), 197–204. [Link]