Ultrasound demonstration of distal triceps tendon tears

Distal Triceps Tendon Ruptures: A Case Series Highlighting Diagnostic Challenges, Surgical Management, and Functional Outcomes

Triceps tendon ruptures are uncommon but significant injuries, often presenting diagnostic challenges due to nonspecific clinical features. Delayed or missed diagnoses can result in prolonged functional impairment. We present a retrospective case series of five patients who sustained distal triceps tendon ruptures through various mechanisms, including direct trauma and heavy lifting. Clinical presentations ranged from elbow swelling and pain to palpable tendon gaps, with radiographic "flake signs" consistently observed. Ultrasonography effectively identified tendon ruptures and retraction in four cases, reinforcing its diagnostic value. All patients underwent surgical repair using suture anchor techniques, achieving satisfactory outcomes. This case series emphasises the importance of early recognition, timely imaging, and prompt surgical intervention in managing distal triceps tendon ruptures to optimise patient recovery.

Distal Triceps Tendon Rupture-First Retrospective Study in Central Europe

Background: This retrospective study is the only one in the last 10 years from central Europe and provides a current picture of prevalence, new diagnostic modalities, new methods of surgical treatment, and also offers new insights into post-operative care. Triceps tendon rupture is the least reported among all the tendon injuries in the literature. In general, effective treatments for tendon injuries are lacking because the understanding of tendon biology lags behind that of the other components of the musculoskeletal system. Tendon tissue has a low number of cells and growth hormones and thus a lack of natural healing ability. Understanding the links between the mechanical and biological parameters involved in tendon development, homeostasis, and repair is a prerequisite for the identification of effective treatments for chronic and acute tendon injuries. Methods: The authors statistically evaluated the set of patients with this diagnosis in the largest University Hospital in Slovakia over the last 10 years. Results: Between 2014 and 2023, 23 patients with distal triceps tendon ruptures (DTTR) were treated at University Hospital. In some years not a single patient with this diagnosis underwent surgery, reinforcing the idea that DTTR may be either rare or underdiagnosed. The incidence in our region is 0.46 cases per 100,000 inhabitants. The average age of patients was 57.7 years, with a male predominance of 90%. Less than half of the patients (43.5%) underwent surgical intervention, and the median time from injury to surgery was less than 10 days. This rapid timeline indicates a high standard of medical care, given the semi-elective nature of the surgery and the need for MRI (Magnetic Resonance Imaging) confirmation of tendon rupture exceeding 50% of the fibers before proceeding with surgery. The three standard surgical techniques were employed in approximately equal proportions. Conclusions: This study suggests that none of the methods is currently preferred, and that the choice of the technique was largely determined by perioperative findings and the surgeon's discretion. Post-operative complications were minimal, with only one patient experiencing any issues after surgery.

US of Acute Tendon Tears

US is an effective tool for appraising acute tendon injury, allowing rapid evaluation of symptoms at bedside and paving the way for prompt diagnosis and treatment selection. It offers three main advantages in the acute or emergent setting. First, it is more sensitive and specific than physical examination. This is beneficial in tendons such as the distal triceps wherein incomplete and complete tears may manifest with similar clinical presentations. Tendon injury may also be clinically innocuous because bruising or a palpable defect is not always present and swelling may mask palpation of the tendon gap. Second, US provides important descriptors that may affect treatment selection, such as injury site, injury extent, and length of retraction. Pectoralis major tears at the tendon or musculotendinous junction warrant operative referral and are readily illustrated at US. A torn distal biceps tendon with significant retraction may require additional graft augmentation rather than reattachment to the insertion alone. Soleus and gastrocnemius strains may mimic each other clinically. Although both are managed conservatively, distinction between the two facilitates formulation of a specific rehabilitation regimen. Finally, US can narrow the differential diagnosis and rule out mimics of musculoskeletal abnormalities. Nonmusculoskeletal conditions, such as deep venous thrombosis and a ruptured Baker cyst, can manifest with the same clinical presentation as acute calf injuries and must be considered in a patient presenting with sudden calf, posterior leg, or ankle pain. The authors review the anatomic features, US techniques, and imaging findings of acute tendon injuries to aid in meaningful reporting and timely treatment selection. ©RSNA, 2024 Supplemental material is available for this article.

ACR Appropriateness Criteria® Acute Elbow and Forearm Pain

Acute elbow pain can be the result of traumatic and atraumatic processes. Pathologic processes include osseous, ligamentous, and tendinous etiologies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Acute and Chronic Elbow Disorders

Elbow pain is very common and can be due to many pathologic conditions. After radiographs are obtained, advanced imaging is often necessary. Both ultrasonography and MR imaging can be used to evaluate the many important soft-tissue structures of the elbow, with each modality having advantages and disadvantages in certain clinical scenarios. Imaging findings between the two modalities often correlate. It is important for musculoskeletal radiologists to understand normal elbow anatomy and how best to use ultrasonography and MR imaging to evaluate elbow pain. In this way, radiologists can provide expert guidance to referring clinicians and best guide patient management.

Muscle Injury Around the Shoulder

Acute shoulder tendon and intra-articular injuries are common and their imaging well described. However, a subset of patients present with more unusual acute shoulder muscle injury. Of these, pectoralis major muscle injuries are encountered the most often and are increasingly prevalent due to a focus on personal fitness, particularly bench-press exercises. Other muscle injuries around the shoulder are rare. This article reviews the anatomy, mechanism of injury, and the imaging findings in relation to injuries of these muscles around the shoulder. We focus on pectoralis major injury but also review proximal triceps, latissimus dorsi, teres major, and deltoid muscle injuries, providing imaging examples.

EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Elbow

ABSTRACT

In this dynamic protocol, ultrasound examination of the elbow using different maneuvers is described for several/relevant elbow problems. Scanning videos are coupled with real-time patient examination videos for better understanding. The authors believe that this practical guide-prepared by an international consensus of several experts (EURO-MUSCULUS: European Musculoskeletal Ultrasound Study Group and USPRM: Ultrasound Study Group of ISPRM [International Society of Physical and Rehabilitation Medicine])-will help musculoskeletal physicians perform a better and uniform/standard approach.

Distal Triceps Tendon Tears: Magnetic Resonance Imaging Patterns Using a Systematic Classification

OBJECTIVE

This study aimed to evaluate distal triceps tendon tear patterns using a systematic classification based on the tendon's layered structure.

METHODS

We retrospectively identified Magnetic resonance imaging (MRI) examinations with triceps tendon tears that underwent reconstructive surgery. Magnetic resonance images were reviewed independently by 2 musculoskeletal radiologists to determine tendon layer involvement and ancillary findings, including tear size, involvement of triceps lateral expansion, and presence of olecranon bursal fluid. Surgical reports were scrutinized for level of anatomic detail and correlation with imaging findings.

RESULTS

We identified 69 triceps tendon tears in 68 subjects (61 men, 7 women; mean age, 45 ± 12 years) who underwent surgical reconstruction. On MRI, the superficial layer was always involved with either a partial or full-thickness tear. The most common tear pattern was a combination of superficial layer full-thickness tear with deep layer partial tear (25 of 69 [36%]). Mean tear length was 24 ± 12 mm. We found no cases of isolated deep layer tears. Involvement of triceps lateral expansion and presence of bursal fluid correlated positively with tear severity of superficial and deep layers (P < 0.001). Detailed surgical correlation was limited, with only 9 of 69 (13%) of surgical reports containing information specifically addressing individual tendon layers.

CONCLUSIONS

Triceps tendon tears show tear patterns following its layered structure and can be assessed by MRI. Radiologists and surgeons are encouraged to describe tear patterns considering both superficial and deep tendon layers.

[Lesions of the triceps tendon : Diagnostics, management, treatment]

The triceps brachii muscle is the main extender of the elbow joint. Triceps tendon rupture or tearing presents a rare injury pattern in general. Distal tendon ruptures occur most commonly in the area of the insertion of the olecranon. Fractures of the radial head are reported as the most common concomitant injury. In many cases, pre-existing degenerative damage predisposes for tendon injury. These include local steroid injections, anabolic steroid abuse, renal insufficiency requiring dialysis, hyperparathyroidism, lupus erythematosus and Marfan's syndrome. However, the most frequent trauma mechanism is a direct fall onto the extended forearm or a blow to the elbow. Beside clinical examination and sonography, magnetic resonance imaging is the diagnostic gold standard. The treatment of triceps tendon injuries includes conservative as well as operative approaches, whereby the indications for surgical treatment must be generously considered depending on the patient's age, functional demands of the patient, involvement of the dominant extremity as well as on the extent of the tendon rupture.

Biceps, Brachialis, and Triceps

Tendon injuries at the elbow affect mostly the distal biceps and can progressively degenerate over time or rupture in an acute event. The degree of retraction may depend on the integrity of the lacertus fibrosus, a fibrous expansion that merges with the forearm flexor fascia. Biceps disorders are frequently associated with fluid or synovitis of the adjacent bicipital bursa; primary bursal disorders (primary inflammatory synovitis) can also be observed. Distal triceps is less frequently injured than the distal biceps, and tears usually manifest as distal ruptures with avulsion of a small flake of bone from the tip of the olecranon. Brachialis injuries are uncommon and the consequence of sudden muscle stretching during forced elbow hyperextension, as in posterior elbow luxation.

Diagnostic Musculoskeletal Ultrasound for the Acute Evaluation and Management of Soccer Players

ABSTRACT

Musculoskeletal ultrasound (US) has many applications in the care of athletes. This article reviews the current literature and identifies research gaps regarding musculoskeletal US in the athletic training room setting to evaluate and manage soccer players. The best evidence for US in the training room setting is for diagnosis and prognosis of muscle injuries, where studies show that it is equivalent to other imaging modalities. US also has been used for injury risk prediction, although the data are mixed. Many applications of US are described in other sport settings and may have crossover applications to soccer.

A clinicoradiological classification and a treatment algorithm for traumatic triceps tendon avulsion in adults

PURPOSE

Triceps tendon avulsion (TTA) is an uncommon injury, and there are no classifications or treatment guidelines available. This study aims to describe a clinicoradiological classification and treatment algorithm for traumatic TTA in adults. The functional outcome of surgical repair has been evaluated too.

METHODS

A retrospective analysis of adult patients with traumatic TTA treated in our institution between January 2012 and December 2017 was done. We only included complete TTA injuries. Children below 15 years, with open injuries, associated fractures, or partial TTA were excluded. The data were obtained from hospital records. The intraoperative findings were correlated with the clinicoradiological presentation for classifying TTA. The functional outcome was analyzed using the Mayo Elbow Performance index and Hospital for Special Surgery elbow score. ANOVA test was used to assess the statistical significance.

RESULTS

There were 15 patients included, 11 males and 4 females. The mean age was (31.5 ± 9.15) years, and the mean follow-up was (22.4 ± 8.4) months. Fall on outstretched hand was the mode of injury. In 6 patients, diagnosis was missed on the initial visit. TTA were classified as Type I: palpable soft-tissue defect without bony mass; Type II: palpable soft-tissue defect with a wafer-thin/comminuted bony fragment on X-ray; Type III: palpable soft-tissue defect with a bony mass and a large bony fragment on X-ray without extension to the articular surface; and Type IV: an olecranon fracture with less than 25% of the articular surface. An algorithm for treatment was recommended, i.e. transosseous suture repair/suture anchor for Type I, transosseous suture repair for Type II, and tension band wiring or steel wire sutures for Types III and IV. All the patients achieved good to excellent outcome: the mean Mayo Elbow Performance index was 100 and Hospital for Special Surgery score was 98.26 ± 2.60 on final follow-up.

CONCLUSION

Our clinicoradiological classification and treatment algorithm for TTAs is simple. Surgical treatment results in excellent functions of the elbow. Since it is a single-center study involving a very small number of cases, a multicenter study with a larger number of patients is required for external validation of our classification and treatment recommendations.

Triceps Tendon Injuries

Triceps tendon injuries are an uncommon clinical entity poorly described in the literature. This review discusses the spectrum of pathology, effective diagnosis, nonsurgical treatment, surgical treatment, rehabilitation, and surgical complications of triceps tendon injuries. Management of triceps tendinopathies depends on the mechanism of injury and the patient's motor examination. Triceps tendinopathies and partial tendon tears with intact strength can be managed conservatively with rest, ice, immobilization, nonsteroidal anti-inflammatory drugs, and physical therapy. If conservative management fails for 6 months or there are strength deficits on examination, surgery should be considered. Based on the current evidence, there are no clear guidelines for "best" surgical approach. Although rare, the most significant surgical complication to be concerned about is rerupture. Rerupture rate is 4.62% among the articles we reviewed.

Is there something new regarding triceps brachii muscle insertion?

PURPOSE

Previous studies have questioned whether the triceps brachii muscle tendon (TBMT) has a double or single insertion on the ulna. Aiming to provide an answer, we describe the anatomy of the TBMT and review a magnetic resonance imaging (MRI) series of the elbow.

METHODS

Forty-one elbows were dissected to assess the details of the triceps brachii insertion. Elbow plastination slices were analyzed to determine whether there was a space on the TBMT. Magnetic resonance imaging from the records of the authors were also obtained to demonstrate the appearance of the pre-tricipital space on MRI.

RESULTS

A virtual space on the medial aspect near the TBTM insertion site in the olecranon was consistently found on anatomic dissections. It was a distal pre-tricipital space. Magnetic resonance imaging demonstrated the appearance of the pre-tricipital space on MRI, and its extension was measured longitudinally either in elbow flexion or extension. There was no statistically significant difference between the measurements of this space in the right and left elbows or between flexion and extension (p > 0.05). The coefficient of variation was <10% for all measurements.

CONCLUSION

Knowledge of this structure may be essential to avoid incorrect diagnosis and unnecessary therapeutic interventions.

Ultrasonographic Technique, Appearance, and Diagnostic Accuracy for Common Elbow Sports Injuries

Ultrasonography is a valuable diagnostic imaging tool because of its availability, tolerability, low cost, and utility in real-time dynamic evaluation. Its use in diagnosing elbow injuries has expanded recently and continues to do so. In particular, stress ultrasonography represents a unique imaging technique that directly visualizes the ulnar collateral ligament (UCL) and allows the assessment of ligament laxity, offering an advantage over magnetic resonance imaging and magnetic resonance arthrography in this patient population. Furthermore, ultrasonography has shown particular usefulness in instances where invasive techniques might be less desirable. This is particularly important in athletes since more invasive procedures potentially result in lost time from their sport. Ultrasonography is an important imaging tool that complements a thorough history and physical examination in the evaluation of elbow injuries in athletes. The use of ultrasonography in orthopaedic sports medicine has been investigated previously; however, to our knowledge, there has been no comprehensive review regarding the utility of ultrasonography for common elbow injuries in athletes. The current study provides a comprehensive, detailed review of the utility and indications for the use of ultrasonography for common elbow injuries in athletes.

Distal insertional anatomy of the triceps brachii muscle: MRI assessment in cadaveric specimens employing histologic correlation and Play-doh® models of the anatomic findings

OBJECTIVES

Assess the insertional anatomy of the distal aspect of the triceps brachii muscle using magnetic resonance imaging (MRI) in cadavers with histologic correlation and Play-doh^® models of the anatomic findings.

MATERIALS

Elbows were obtained from twelve cadaveric arm specimens by transverse sectioning through the proximal portion of the humerus and the midportion of the radius and ulna. MRI was performed in all elbows. Two of the elbow specimens were then dissected while ten were studied histologically. Subsequently, Play-doh^® models of the anatomic findings of the distal attachment sites of the triceps brachii muscle were prepared.

RESULTS

MRI showed a dual partitioned appearance of the distal attachment sites into the olecranon in all specimens. In the deeper tissue planes, the medial head muscle insertion was clearly identified while superficially, the terminal portion of the long and lateral heads appeared as a conjoined tendon. Histologic analysis, however, showed continuous tissue rather than separate structures attaching to the olecranon.

CONCLUSION

Although MRI appeared to reveal separate and distinct attachments of the triceps brachii muscle into the olecranon, histologic analysis delineated complex but continuous tissue related to the attachments of the three heads of this muscle. The Play-doh^® models were helpful for the comprehension of this complex anatomy and might serve as a valuable educational tool when applied to the analysis of other musculoskeletal regions.

Triceps Tendon Ruptures: Risk Factors, Treatment, and Rehabilitation

Triceps tendon ruptures (TTRs) are rare and often occur as a result of falling on an outstretched hand, forceful eccentric contraction, direct trauma to the elbow, or lifting against resistance. TTRs are most commonly seen in middle-aged men, football players, and weightlifters. Radiography, ultrasonography, and magnetic resonance imaging may be utilized for diagnosis and to guide treatment. Acute partial TTRs may have good outcomes with nonoperative management. Surgery should be considered if nonoperative treatment is unsuccessful or if substantial musculotendinous retraction is present. Surgical repair is strongly recommended for complete TTRs.

The Acutely Injured Elbow

The acutely injured elbow can present as a diagnostic challenge, encompassing a spectrum of conditions that involve the various osseous and soft tissue structures of this complex joint. Imaging plays a vital role in the management of these patients by providing an accurate interpretation of the underlying trauma sustained, which can have important implications on the preservation of joint function and stability. This article examines the mechanisms, patterns, classifications, and imaging findings of acute elbow injuries, providing key concepts for the radiologist in the interpretation of these injuries.

Triceps Repair and Restoration of Triceps Footprint With Anchorless Suture Fixation

Triceps tendon rupture is an uncommon yet potentially devastating injury affecting patients over a broad demographic. Surgical treatment is essential to restore upper extremity functional status, and a vast array of techniques has been implemented with different fixation devices including suture buttons, intraosseous anchors, and suture repairs. Outcomes of distal triceps tendon repair have demonstrated nearly full return of functional capacity. Complications include infection, ulnar nerve neuropathy, arthrofibrosis, flexion contracture, hardware irritation, and most commonly, repair failure. We illustrate a triceps repair technique with suture fixation that restores the tendinous footprint without need of an adjunctive device.

Operative Management of Acute Triceps Tendon Ruptures: Review of 184 Cases

BACKGROUND

Distal triceps tendon ruptures are rare. The authors present a series of 184 surgically treated, acute, traumatic triceps tendon avulsions and compare the complications between those treated with anchors (A) versus transosseous (TO) suture repair.

HYPOTHESIS

No difference exists in the retear rate between TO and A repairs. Study Designed: Cohort study; Level of evidence, 3.

METHODS

All patients who underwent an open primary repair of a traumatic triceps tendon avulsion within 90 days of injury, between 2007 and 2015, were retrospectively reviewed. Surgeries were performed within a multisurgeon (75 surgeons), multicenter (14 centers), community-based integrated health care system. Patient demographic information, type of repair, complications, and time from surgery to release from medical care were recorded.

RESULTS

184 triceps tears in 181 patients met the inclusion criteria. The mean age was 49 years (range, 15-83 years). There were 169 males. The most common mechanisms of injury were fall (56.5%) and weight lifting (19%). Mean time from injury to surgery was 19 days (range, 1-90 days); in 74.5% of cases, surgery was performed in 3 weeks or less. There were 105 TO and 73 A repairs. No significant difference was found between the two groups in the mean age ( P = .18), sex ( P = .51), completeness of tears ( P = .74), tourniquet time ( P = .455), and prevalence of smokers ( P = .64). Significant differences were noted between TO and A repairs in terms of reruptures (6.7% vs 0%, respectively; P = .0244), overall reoperation rate (9.5% vs 1.4%; P = .026), and release from medical care (4.3 vs 3.4 months; P = .0014), but no difference was seen in infection rate (3.8% vs 0%; P = .092). No difference was noted in release from medical care in patients who underwent surgery 3 weeks or less after injury compared with those undergoing surgery more than 3 weeks after injury (3.90 vs 4.09 months, respectively; P = .911).

CONCLUSION

Primary repair of triceps ruptures with TO fixation has a significantly higher rerupture rate, higher reoperation rate, and longer release from medical care than does repair with A fixation. Implementation of suture anchors in triceps repairs offers a lower complication rate and earlier release from medical care.

Surgical management and follow-up of triceps tendon avulsion after repeated local infiltration of steroids: two cases

Disruption of the triceps tendon insertion is an uncommon injury, with only a few reports of traumatic triceps tendon avulsion in dogs or cats present in the veterinary literature. Although this injury has been previously described in two dogs that had received a local injection of corticosteroids for the treatment of soft tissue injuries, reports with long term clinical follow-up and outcome in working dogs are lacking.

This report describes two surgically treated cases of complete triceps tendon avulsion rupture in Malinois police dogs. These two dogs had a history of repeated local infiltration of a corticosteroid preparation used to treat adventitial bursitis. The clinical features, surgical treatment, long-term management and outcome are reported. A modified triple locking loop pattern was used to suture the tendons. The long-term outcome was considered excellent with both dogs resuming work. Although it is an uncommon condition in small animals, avulsion of the triceps tendon should remain on the differential diagnosis list for acute onset forelimb lameness, particularly if there is a history of local infiltration with corticosteroids. The diagnosis should be based on clinical, radiographic and ultrasonographic examination.

The distal triceps tendon insertional anatomy-implications for surgery

Background

Improved knowledge of the distal triceps insertion is needed as a result of an increase in procedures involving this area, including distal triceps repair, posterior capsulectomy, and olecranon tip osteotomy for coronoid reconstruction.

Materials and methods

Five pair-matched upper limbs were dissected to study the morphology and dimension of the distal triceps tendon, triceps tendon insertion, capsular insertion on the olecranon, and triceps lateral retinaculum. Muscle origins of the triceps insertions were identified proximally.

Results

Three distinct insertional areas were found in the olecranon corresponding to the posterior capsular insertion, the deep muscular portion, and the superficial tendinous portion of the triceps with areas of 1.5, 1.2, and 2.8 cm², respectively. The deep muscular head corresponded to the medial head of the triceps and the tendinous portion corresponded to the long and lateral heads and correlated with the height of the specimen. The triceps width at insertion was 2.6 ± 0.5 cm (standard deviation), and the triceps lateral retinaculum extended the tendon laterally for 2.5 ± 0.7 cm. The tendinous portion of the triceps tendon extended proximally 15.3 ± 1.4 cm. The triceps inserted at a mean of 1.1 cm from the tip of the olecranon.

Conclusions

The distinct insertional heads of the triceps provides additional knowledge that can aid in diagnosing and treating partial triceps tears. In addition, a safe zone for capsulectomy and olecranon tip osteotomy is described that can be used to increase the safety of these procedures.

Distal triceps injuries (including snapping triceps): A systematic review of the literature

AIM

To review current literature on types of distal triceps injury and determine diagnosis and appropriate management.

METHODS

We performed a systematic review in PubMed, Cochrane and EMBASE using the terms distal triceps tears and snapping triceps on the 10^th January 2017. We excluded all animal, review, foreign language and repeat papers. We reviewed all papers for relevance and of the papers left we were able to establish the types of distal triceps injury, how these injuries are diagnosed and investigated and the types of management of these injuries including surgical. The results are then presented in a review paper format.

RESULTS

Three hundred and seventy-nine papers were identified of which 65 were relevant to distal triceps injuries. After exclusion we had 47 appropriate papers. The papers highlighted 2 main distal triceps injuries: Distal triceps tears and snapping triceps. Triceps tear are more common in males than females occurring in the 4^th-5^th decade of life and often due to a direct trauma but are also strongly associated with weightlifting and American football. The tears are diagnosed by history and clinically with a palpable gap. Diagnosis can be confirmed with the use of ultrasound (US) and magnetic resonance imaging. Treatment depends on type of tear. Partial tears can be treated conservatively with bracing and physio whereas acute tears need repair either open or arthroscopic using suture anchor or bone tunnel techniques with similar success. Chronic tears often need augmenting with tendon allograft or autograft. Snapping triceps are also seen more in men than women but at a mean age of 32 years. They are characterized by a snapping sensation mostly medially and can be associated with ulna nerve subluxation and ulna nerve symptoms. US is the diagnostic modality of choice due to its dynamic nature and to differentiate between snapping triceps tendon or ulna nerve. Treatment is conservative initially with activity avoidance and if that fails surgical management includes resection of triceps edge or transposition of the tendon plus or minus ulna nerve transposition.

CONCLUSION

Distal triceps injuries are uncommon. This systematic review examines the evidence base behind diagnosis, imaging and treatment options of distal triceps injuries including tears and snapping triceps.

Distal triceps ruptures

Distal triceps ruptures are rare injuries due to the special anatomical features of the muscle and tendon–bone junction.

This injury typically occurs at the tendon–bone junction due to an eccentric contraction of the muscle.

The treatment is controversial, especially in partial ruptures; surgical repair is indicated for complete ruptures of the distal triceps tendon.

Several repair techniques have been described for acute complete ruptures.

Chronic ruptures often require reconstruction rather than direct repair.

Cite this article: Demirhan M, Ersen A. Distal triceps ruptures. EFORT Open Rev 2016;1:255-259. DOI: 10.1302/2058-5241.1.000038.

Outcomes and complications of triceps tendon repair following acute rupture in American military personnel

INTRODUCTION

Triceps tendon ruptures are uncommon injuries primarily occurring in young, active males or elderly individuals with various systemic diseases. Relatively little is known about the epidemiology of this injury, or the results of surgical management in high-demand populations. The purpose of this study was to define the incidence and outcomes of surgical treatment in active duty American military personnel.

PATIENTS AND METHODS

The Military Data Repository (MDR) was queried for all active duty military personnel undergoing surgical repair or reconstruction of a triceps tendon rupture between January 2012 and December 2014. The electronic health records of all patients with at least 12 months clinical follow-up were searched for demographic information, injury details, preoperative imaging findings, post-operative complications, and ability to return to duty following surgical repair. Incidence was calculated based on total active duty population in the MDR over the study period. Risk factors for postoperative complication and inability to return to duty following surgical repair were assessed using univariate analyses.

RESULTS

A total of 54 acute triceps tendon ruptures were identified in the search, of which 48 had at least 12 months follow-up and complete post-operative records. The incidence of acute triceps tendon rupture was 1.1 per 100,000 person-years. Twelve patients experienced post-operative complications, six of which were traumatic re-ruptures within four months of the index surgery. No patient had a post-operative infection or atraumatic repair failure. 94% of patients were able to return to active military service following surgical repair. Enlisted rank was a significant risk factor for a post-operative complication, but no factor predicted inability to return to active duty service.

CONCLUSIONS

Surgical repair of acute triceps tendon ruptures reliably restores strength and function even in high-demand individuals. In our population, traumatic rerupture was the most common complication.

A treatment algorithm for the management of distal triceps ruptures

Rupture of the distal triceps brachii muscle is a relatively rare, but potentially troublesome injury. Recent literature has increased awareness of the injury and highlighted the importance of accurate diagnosis and prompt appropriate treatment of these injuries. The history, physical examination findings, and imaging studies are key to determine complete versus partial rupture of the distal triceps. We propose a treatment algorithm based on the chronicity of the injury and associated tendon quality. Such a guide can help surgeons navigate the most appropriate treatment and be equipped with the surgical tools to provide the best surgical result.

Traumatic Rupture of the Distal Triceps Tendon (A Series of 7 Cases)

Even non-traumatic ruptures of the triceps tendon are rare, surgical therapy should be recommended in all cases, because of poor results after non-operative treatment. A golden standard for the surgical procedure is not established. A small series of traumatic distal tendon ruptures was treated surgical in our hospital and was followed up after 12 months concerning their function. Very good and good results could be found with a strong reintegration of the tendon by using transosseus sutures with non resorbable suture material. The refixation with suture anchors showed disappointing results with early pull-outs of the anchor. Revision with screw augmentation with a washer had to be performed. Concerning the biomechanical forces, which show up on the olecranon (up to 40 NM), the refixation of the triceps tendon has proved to be extremely resistant against pull out forces. The good results by using non absorbable transosseus sutures led to a standardized procedure in our trauma center, even the rupture is not traumatic.

Bilateral triceps tendon tear

Triceps tendon tear is one of the least commonly recognized major tendon tears. Bilateral triceps tendon tears are especially rare. We present a case of simultaneous complete tears of bilateral triceps tendons secondary to a fall. The anatomy, etiology, image findings, and current literature are discussed.

Triceps Tendon Ruptures Requiring Surgical Repair in National Football League Players

Background:

Complete triceps tendon ruptures are relatively rare in the general population but slightly more prevalent in professional football. One prior study found 11 complete ruptures over a 6-season period.

Hypothesis:

Triceps ruptures occur more commonly in football linemen due to forced elbow flexion during an eccentric contraction and may occur more commonly with the increasing size and speed of professional players. Surgical repair allows full return to sports, but with a lengthy recovery time.

Study Design:

Case series; Level of evidence, 4.

Methods:

A search of the National Football League Injury Surveillance System (NFLISS) found a total of 37 triceps tendon ruptures requiring surgical repair from the years 2000 to 2009. Data were obtained for setting of injury, player position, activity causing injury, play type, time of game when injury occurred, height, weight, body mass index (BMI), and number of days lost from football.

Results:

There were 37 players requiring surgical repair for triceps tendon ruptures over the 10-season period. The average height, weight, and BMI of the players were 75 inches, 292 pounds, and 36.5 kg/m², respectively. The majority of players were linemen (86%): 16 defensive, 15 offensive, and 1 tight end. The injury took place while blocking or being blocked in 29 players (78%) and while tackling or being tackled in 5 players (14%). Players missed an average of 165 days (range, 49-318 days) from football as a result of their injury and surgery.

Conclusion:

Triceps tendon tears requiring surgical repair are more common in professional football players than in the general population and are occurring more commonly than previously reported. Surgical repair allows return to play.

Clinical Relevance:

Our study identifies the rate of triceps tendon tears requiring repair in the NFL according to position, identifying which players may be most at risk for this injury.

Right Lower Quadrant Pain in a Young Female: Ultrasound Diagnosis of Rectus Abdominis Tear

BACKGROUND

Right lower quadrant pain in young females presents a frequent diagnostic challenge for emergency physicians, with a broad differential and several important diagnoses. Using an "ultrasound first" imaging strategy can help decrease the use of computed tomography scans, with associated savings in radiation exposure, cost, and other resource use.

CASE REPORT

We report a case of right lower quadrant pain in a young woman. After her initial history and physical examination, appendicitis was the leading differential. A bedside ultrasound was performed, leading to the uncommon diagnosis of rectus abdominis muscle tear. The sonographic findings of a muscle tear include increase in size, loss of linear, homogeneous architecture, and decreased echogenicity. Making this diagnosis at the bedside using ultrasound obviated the need for further imaging, avoiding unnecessary radiation exposure, and decreasing emergency department length of stay and overall cost, while leading to a tailored treatment plan. Why Should an Emergency Physician Be Aware of This? Rectus abdominis tear is a cause of right lower quadrant pain that may mimic appendicitis and should be considered in patients with this complaint. The ability to make this diagnosis with bedside ultrasound may assist in several important patient-oriented outcomes.

Elbow US: Anatomy, Variants, and Scanning Technique

As with other musculoskeletal joints, elbow ultrasonography (US) depends on the examination technique. Deep knowledge of the relevant anatomy, such as the bone surface anatomy, tendon orientation, nerves, and vessels, is crucial for diagnosis. It is important to be aware of the primary imaging pitfalls related to US technique (anisotropy) in the evaluation of deep tendons such as the distal biceps and peripheral nerves. In this article, US scanning technique for the elbow as well as the related anatomy, primary variants, and scanning pitfalls are described. In addition, an online video tutorial of elbow US describes a possible approach to elbow evaluation. Online supplemental material is available for this article.

Diagnosis and treatment of triceps tendon injuries: a review of the literature

OBJECTIVE

To elucidate mechanism of injury, nonoperative protocols, surgical techniques, rehabilitation schedules, and return to sports guidelines for partial and complete triceps tendon injuries.

DATA SOURCES

The PubMed and OVID databases were searched in 2010 and peer-reviewed English language articles in 2011.

MAIN RESULTS

After a fall on an outstretched hand, direct trauma on the elbow, or lifting against resistance, patients often present with pain and weakness of extension. Examination may reveal a palpable tendon gap, and radiographs may reveal a Flake sign. Acute partial injuries have positive outcomes with immobilization in 30-degree flexion for 4 to 6 weeks. Primary repair for complete rupture can restore normal extensor function after 3 to 4 months. Reconstruction returns normal extensor function up to 4 years. Most authors support postoperative immobilization for 2 to 3 weeks at 30- to 40-degree flexion, flexion block bracing for an additional 3 weeks, and unrestricted activity at 6 months. Athletes may be able to return to sports after 4 to 5 weeks of recovery from a partial injury, but return may be delayed if operative tendon repair is performed.

CONCLUSIONS

Acute partial triceps tendon injuries may be managed conservatively at first and should be repaired primarily if this fails or if presentation is delayed. Reconstruction should first use the anconeus rotation technique. If the anconeus is devitalized, the Achilles tendon may be the allograft of choice.

Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies

In the second part of this review article the management of medial elbow tendinopathy, distal biceps and distal triceps tendinopathy will be discussed. There is a scarcity of publications concerning any of these tendinopathies. This review will summarise the current best available evidence in their management. Medial elbow tendinopathy, also known as Golfer's elbow, is up to 6 times less common than lateral elbow tendinopathy. The tendinopathy occurs in the insertion of pronator teres and flexor carpi radialis. Diagnosis is usually apparent through a detailed history and examination but care must be made to exclude other conditions affecting the ulnar nerve or less commonly the ulnar collateral ligament complex. If doubt exists then MRI/US and electrophysiology can be used. Treatment follows a similar pattern to that of lateral elbow tendinopathy. Acute management is with activity modification and topical NSAIDs. Injection therapy and surgical excision are utilised for recalcitrant cases. Distal biceps and triceps tendinopathies are very rare and there is limited evidence published. Sequelae of tendinopathy include tendon rupture and so it is vital to manage these tendinopathies appropriately in order to minimise this significant complication. Their management and that of partial tears will be considered.

Video: Musculoskeletal ultrasound imaging of the elbow: part 2, Pathology

OBJECTIVE

The purpose of this video article is to aid examiners in clinical practice in identifying intraarticular and extraarticular pathologic changes in the elbow, including intraarticular structures, fluid in the joint, arthritis, synovitis, and loose bodies.

CONCLUSION

Common pathologic findings can be identified with a standardized ultrasound technique based on landmarks, and intraarticular injection and aspiration, dynamic imaging, and ulnar stress maneuvers can be performed. Extraarticular pathologic findings are evaluated in an approach based on quadrants.

Evaluation and management of elbow tendinopathy

Context:

Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic surgeons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment outcomes will enable the appropriate management of patients and their expectations.

Evidence Acquisitions:

The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy.

Results:

Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments.

Conclusions:

Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate benefit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diagnosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury.