Case report: Nonsimultaneous bilateral triceps tendon rupture and surgical repair in a healthy dog

A 7-year-old female spayed Australian shepherd dog was presented for an acute onset of inability to stand. On physical examination, the dog was unable to support weight on the thoracic limbs. On neurological examination, the thoracic limbs had absent hopping and paw placement and reduced withdrawal reflexes bilaterally. The remainder of the neurological examination was normal. The anatomic lesion localized to the C6-T2 spinal nerve roots, spinal nerves, or the named nerves of the thoracic limb, bilaterally. A lesion affecting the ventral gray column of the C6 through T2 spinal cord segments was considered less likely. In an effort to exclude an orthopedic disorder from consideration, radiographs of the shoulders, elbows, and manus were normal. Magnetic resonance imaging of the cervical and cranial thoracic vertebral column was normal. Analysis of synovial fluid from the carpi, elbows, and shoulders were normal. Ultrasonography of the triceps muscle and tendon of insertion revealed bilateral, acute-subacute tears of the tendon at insertion of the triceps muscles, bilaterally. Magnetic resonance imaging of both elbows revealed complete avulsion of the triceps tendons bilaterally. Surgical repair of both tendons was performed using the Arthrex FiberLoop system combined with autologous conditioned plasma soaked in a collagen sponge. Postoperatively, external coaptation was provided using Spica splints for 6 weeks followed by the use of soft padded orthotic braces for an additional 6 weeks. Concurrently, a front support wheelchair was used for 10 weeks postoperative. By 10 weeks postoperative, the dog was able to ambulate without support. To the authors' knowledge, this is the first report of bilateral triceps tendon avulsion in a dog. Tendon avulsion occurred without a known history of trauma or predisposing metabolic abnormalities. Magnetic resonance imaging provided excellent anatomical detail that aided in surgical repair.

Long Head of Triceps Tendon Transfer for Agenesis of Biceps and Brachialis: Two Cases

Congenital lack of elbow flexion results in significant disability and may be seen in conjunction with syndromes, plexopathies, neuromuscular disorders, or as an isolated muscular agenesis of elbow flexors. There are many tendon transfer options to address this issue, but there is a lack of data on the functional results in the pediatric population. In this series, we present 1 patient with isolated muscular agenesis of the biceps and brachialis musculotendinous units and another with this same muscular agenesis in the setting of arthrogryposis. They were treated with anterior ulnar nerve transposition and transfer of the long head of triceps tendon around 2 years of age resulting in functional elbow flexion in both patients.

Role of dynamic ultrasound in assessment of the snapping elbow and distal biceps tendon injury

Introduction

Ultrasound is useful in assessing patients with snapping syndromes around the elbow joint. The dynamic nature of the examination allows for direct visualisation of the underlying causative factor.Topic description: We discuss the role of dynamic ultrasound in assessing various snapping syndromes around the elbow, such as ulnar nerve instability, snapping triceps and less commonly, snapping brachialis. Ultrasound is also useful in evaluating the distal biceps tendon, particularly in differentiating partial from complete tendon injury.

Discussion

Ulnar nerve instability and snapping triceps can be assessed via a medial approach with the transducer placed transversely between the medial epicondyle and the olecranon. In ulnar nerve instability, the nerve can be seen crossing over the medial epicondyle on elbow flexion. In snapping triceps syndrome, both the ulnar nerve and the distal triceps can be seen dislocating over the medial epicondyle. Dynamic assessment of the distal biceps tendon using a lateral approach minimises anisotropy artefact often seen on the anterior approach. Passive pronation and supination of the forearm will reveal little or no movement in a completely torn tendon whereas moving tendon fibres will be appreciated in partial tears. In a snapping brachialis, the medial portion of brachialis will be seen abnormally translocating anterolateral to the medial border of the trochlea during elbow flexion and snapping back into its normal position on elbow extension.

Conclusion

Dynamic ultrasound of the elbow is valuable in diagnosing patients with snapping sensations around the joint and in evaluating the integrity of the distal biceps tendon.

Histologic Evaluation of the Triceps Brachii Tendon Insertion: Implications for Triceps-Sparing Surgery

PURPOSE

Triceps detachment and olecranon osteotomy are 2 techniques used to enhance exposure in elbow surgery. Both the techniques can potentially add considerable morbidity and lengthen the recovery after surgery. Triceps-sparing surgery can potentially mitigate those issues. The purpose of this study was to evaluate the triceps tendon insertion at a histologic level to help improve triceps-sparing surgical techniques used in elbow trauma and arthroplasty.

METHODS

Seventeen fresh-frozen cadaveric elbow specimens were collected. The olecranon and its soft tissue attachments were isolated. We performed gross measurements and sectioned the specimens for histologic evaluation in the saggital or coronal planes. The proximal-to-distal and medial-to-lateral dimensions of the tendon and the distance from the proximal tip of the olecranon to the proximal tendon insertion were measured microscopically on stained embedded sections.

RESULTS

The proximal-to-distal dimension of the triceps tendon insertion was less than previously reported, whereas the medial-to-lateral dimension was similar. The true distance from the tip of the olecranon to the proximal tendon insertion was greater than the previously reported distance obtained via gross measurement.

CONCLUSIONS

Gross measurement of the triceps tendon insertion overestimates and inaccurately represents the true insertional footprint. Gross measurement has been shown to demonstrate consistent disparity compared with histologic measurement. Histologic investigation provides a more accurate description.

CLINICAL RELEVANCE

The finding that the distance from the articular tip of the olecranon to the proximal tendon insertion is greater than previously reported may have clinical implications. A triceps split approach may allow more visualization and exposure of the posterior joint and, therefore, lessen the need for triceps detachment or olecranon osteotomy.

The Van Gorder approach for total elbow arthroplasty

BACKGROUND

Surgical management of the triceps during exposure for total elbow arthroplasty (TEA) is critical to a successful outcome. Previously described techniques include elevating the triceps insertion from one side or leaving the triceps insertion attached and dislocating the joint. Another approach to the elbow, first described in 1933 by Willis Campbell, MD, and subsequently modified by George Van Gorder, MD, involves turning down the triceps tendon without disrupting the triceps insertion. This approach offers complete visualization of the joint and provides excellent exposure for TEA. Only the original report of the technique and a small series of patients using this technique for TEA exist in the literature. The goal of this study was to evaluate outcomes of the Van Gorder approach in a large series of patients undergoing TEA.

METHODS

All patients who underwent TEA from 2008 to 2016 were retrospectively reviewed. Only patients who underwent primary TEA performed through the Van Gorder approach with at least 6 months' follow-up were included for analysis. Patients with prior elbow surgery were excluded. Demographic data, indication for surgery, postoperative range of motion, triceps function, and need for additional surgery were recorded. Prospectively collected visual analog scale (VAS) and Global Health Quality of Life scores were also analyzed.

RESULTS

A total of 53 patients met inclusion criteria. The mean age was 62 years, 81% were female, and the average follow-up was 30.2 months. The most common surgical indications included inflammatory arthritis (47%), osteoarthritis (24%), and fracture (19%). Postoperatively, average elbow arc of motion was an 8°-137°. There was 1 patient (1.89%) who developed failure of their triceps extension mechanism. A total of 10 patients (19%) underwent additional elbow surgery most commonly for superficial wound complications. Preoperative VAS scores decreased significantly, starting at 3 months postoperatively (6.76 to 3.37, P < .001), and remained constant at the 12- and 24-month postoperative visits.

CONCLUSIONS

This is the largest study evaluating the Van Gorder surgical approach to the elbow for primary TEA with an average follow-up of 32 months. Overall rates of triceps failure and reoperation are consistent with other approaches for TEA.

The surgical management of distal triceps tendon ruptures: a systematic review

BACKGROUND

Distal triceps tendon ruptures (DTTRs) are highly uncommon injuries and can be treated with surgical repair. The purpose of this review was to compare the outcomes and complications of various surgical techniques used for primary repair of DTTRs.

METHODS

The electronic databases MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed were searched from data inception to October 15, 2020. The Methodological Index for Non-randomized Studies tool was used to assess study quality. Data are presented descriptively.

RESULTS

A total of 19 studies were identified, comprising 560 patients (565 triceps tendons), of whom 78.6% were male patients. The mean age was 46.1 ± 8.4 years, and the mean follow-up period was 31.8 ± 21.0 months. The overall complication rate across all DTTR repair procedures was 14.9%. The distribution of complications for each technique was 29.2% for the direct repair technique, 15.2% for the transosseous technique (transosseous suture), and 7.7% for the suture anchor technique. Common complications include ulnar neuropathies, infections, and pain. The overall rerupture rate for transosseous suture, suture anchor, and direct repair was 4.3% (n = 12), 2.1% (n = 3), and 0% (n = 0), respectively. Patients undergoing DTTR repair experience significant improvements postoperatively regarding pain, strength, and range of motion.

CONCLUSIONS

Patients undergoing DTTR experience improvements in postoperative outcomes; however, there is a moderate reported risk of rerupture or complication. Owing to the heterogeneity in rupture patterns, surgical procedures, and outcome measures, it is difficult to ascertain the superiority of one surgical technique over another. Future studies should use large prospective cohorts and long-term follow-up to determine more accurate complication rates and outcome scores.

Defining the Reliability of Deltoid Reanimation by Nerve Transfer When Using Abnormal but Variably Recovered Triceps Donor Nerves

Upper brachial plexus injuries to the C5/6 roots or axillary nerve can result in severe deficits in upper limb function. Current techniques to reinnervate the deltoid muscle utilise the well-described transfer of radial nerve branches to triceps to the axillary nerve. However, in around 25% of patients, there is a failure of sufficient deltoid reinnervation. It is unclear in the literature if deltoid reanimation should be attempted with a nerve transfer from a weak but functioning triceps nerve. The authors present the largest series of triceps to axillary nerve transfers for deltoid reanimation in order to answer this clinical question. Seventy-seven consecutive patients of a single surgeon were stratified and analysed in four groups: (1) normal triceps at presentation, (2) abnormal triceps at presentation recovering to clinically normal function preoperatively, (3) abnormal triceps at presentation remaining abnormal preoperatively, and lastly (4) where pre-operative triceps function was deemed insufficient for use, requiring alternative reconstruction for deltoid reanimation. The authors considered deltoid re-animation of ≥ M4 as successful for the purpose of this study. Median Medical Research Council (MRC) values demonstrate group 1 achieves this successfully (M5), while median values for groups 2–4 result in M4 power (albeit with decreasing interquartile ranges). Median post-operative shoulder abduction active range of motion (AROM) values were represented by 170° (85–180) in group 1, 117.5° (97.5–140) in group 2, 90° (35–150) in group 3, and 60° (40–155) in group 4. For both post-operative assessments, subgroup analyses demonstrated statistically significant differences when comparing group 1 with groups 3 and 4 (p < 0.05), while all the other group to group pairwise comparisons did not reach significance. The authors postulated that triceps deficiency can act as a surrogate marker of a more extensive plexus injury and may predict poorer outcomes if the weakness persists representing the trending differences between groups 2 and 3. However, given no statistical differences were demonstrated between groups 3 and 4, the authors conclude that utilising an abnormal triceps nerve that demonstrates sufficient strength and redundancy intraoperatively is preferable to alternative transfers for deltoid reanimation. Lastly, in group 4 patients where triceps nerves are damaged and unusable for nerve transfer, alternative operations can also achieve sufficient outcomes and should be considered for restoration of shoulder abduction.

Schwannoma in an accessory branch of the posterior cord of the brachial plexus: a rare case report

BACKGROUND

Variation in the posterior cord of the brachial plexus is complicated and creates a risky relationship with the neighbouring structures. This is of importance to the surgeons, anaesthetists who must deal with the region in surgeries and procedures. Moreover, any benign tumour like Schwannoma is rare in the plexus comprising 5 % of total head and neck schwannomas.

METHODS

We present a case of Schwannoma of the brachial plexus in a cadaver during routine anatomy dissection for the medical students. The origin and order of branching of the posterior cord were recorded and photographs were taken. The tumour was present in an accessory branch of the posterior cord and removal was made in-toto. An immunohistochemistry study was done for confirmation of diagnosis.

RESULTS

The classical branching of the posterior cord was present. Additionally, a branch existed that was supplying the triceps muscle and emerged directly from the posterior cord. Tumour having the dimension of 2 x 1.8x 0.5 cm was present.

CONCLUSIONS

Schwannomas are indolent but may cause compression of the nerve and resulting neurological symptoms. They might mimic nodules of supraclavicular fossa in breast carcinoma. Variations of the brachial plexus can also make the surgeons confused during surgery due to which anatomical knowledge of the possible variations is important. Pre- and Post-operative complications can be easily predicted from it. Follow-up of the tumour is essential to track its progress and differentiation.

Distinct Corticospinal and Reticulospinal Contributions to Voluntary Control of Elbow Flexor and Extensor Muscles in Humans with Tetraplegia

Humans with cervical spinal cord injury (SCI) often recover voluntary control of elbow flexors and, to a much lesser extent, elbow extensor muscles. The neural mechanisms underlying this asymmetrical recovery remain unknown. Anatomical and physiological evidence in animals and humans indicates that corticospinal and reticulospinal pathways differentially control elbow flexor and extensor motoneurons; therefore, it is possible that reorganization in these pathways contributes to the asymmetrical recovery of elbow muscles after SCI. To test this hypothesis, we examined motor-evoked potentials (MEPs) elicited by transcranial magnetic stimulation over the arm representation of the primary motor cortex, maximal voluntary contractions, the StartReact response (a shortening in reaction time evoked by a startling stimulus), and the effect of an acoustic startle cue on MEPs elicited by cervicomedullary stimulation (CMEPs) on biceps and triceps brachii in males and females with and without chronic cervical incomplete SCI. We found that SCI participants showed similar MEPs and maximal voluntary contractions in biceps but smaller responses in triceps compared with controls, suggesting reduced corticospinal inputs to elbow extensors. The StartReact and CMEP facilitation was larger in biceps but similar to controls in triceps, suggesting enhanced reticulospinal inputs to elbow flexors. These findings support the hypothesis that the recovery of biceps after cervical SCI results, at least in part, from increased reticulospinal inputs and that the lack of these extra inputs combined with the loss of corticospinal drive contribute to the pronounced weakness found in triceps.SIGNIFICANCE STATEMENT Although a number of individuals with cervical incomplete spinal cord injury show limited functional recovery of elbow extensors compared with elbow flexor muscles, to date, the neural mechanisms underlying this asymmetrical recovery remain unknown. Here, we provide for the first time evidence for increased reticulospinal inputs to biceps but not triceps brachii and loss of corticospinal drive to triceps brachii in humans with tetraplegia. We propose that this reorganization in descending control contributes to the asymmetrical recovery between elbow flexor and extensor muscles after cervical spinal cord injury.

Intramuscular cavernous haemangioma of the triceps

A 16-year-old teenager presented himself with a swollen left elbow, with no associated vascular-nerve complications. The standard radiography was without abnormalities. The echography showed the presence of an oblong vascularized formation occupying the posterior part of the elbow. The magnetic resonance imaging (MRI) showed a hyper vascularized lesion developing at the expense of the brachial triceps muscle with an intermediate signal intensity on the sequences weighted in T1 and a hyper signal in T2. The anatomopathological study of the initial biopsy and of the tumor part concluded with a cavernous hemangioma. Although their origin is vascular, hemangiomas never metastasize and do not undergo malignant transformation. The treatment of symptomatic hemangioma consists of surgical excision.

Does the triceps-on approach affect alignment in total elbow arthroplasty? A cadaveric study

BACKGROUND

The triceps-on approach for total elbow arthroplasty has gained popularity due to the theoretical benefit of preserving the extensor mechanism. However, there is concern that the exposure may be reduced in comparison to a triceps-off approach and may affect the implant alignment achieved.

METHOD

Total elbow arthroplasties were implanted in 18 randomised, paired cadaveric elbows using the triceps-on or triceps-off approach. The bones were dissected out and the position of the implants measured relative to anatomical landmarks. The flexion/extension and varus/valgus angles, and the distance of centre of rotation from the anatomic centre of rotation in the sagittal plane for both components were obtained as well as the humeral component rotation relative to the transepicondylar axis.

RESULTS

All humeral components were positioned in external rotation and all ulna components were placed in flexion. Seven components were positioned greater than 5° away from the ideal in one measurement, with no significant difference between the two approach groups.

DISCUSSION

This unique study showed no significant difference in the alignment of the implants between the two approaches. These results support the theory that the triceps-on approach does not result in larger alignment errors in component positioning when performing total elbow arthroplasty.

Specific prime movers' excitation during free-weight bench press variations and chest press machine in competitive bodybuilders

The current study compared the muscle excitation in free-weight bench press variations and chest press machine. Ten competitive bodybuilders were recruited. The EMG-RMS amplitude of clavicular and sternocostal head of pectoralis major, long head of triceps brachii and anterior and lateral deltoid was recorded while performing horizontal (BP), inclined (45°) (IBP) or declined (-15°) bench press (DBP) and chest press machine (CP). Four non-exhaustive repetitions were performed using 80% of 1-repetition maximum of each exercise. Both concentric and eccentric phases were recorded. During the concentric phase, [d effect size: 2.78/7.80] clavicular head was more excited in IBP and less excited in CP (d: -9.69/-4.39) compared to all other exercises. The sternocostal head was similarly excited in DBP vs. BP and BP vs. CP and more excited (d: 2.42/9.92) compared to IBP. Triceps brachii excitation was overall greater (d: 2.01/6.75) in BP and DBP compared to all other exercises. Anterior deltoid was less excited (d: 3.84/19.77) in DBP compared to all other exercises. Lateral deltoid excitation was greater (d: 0.96/3.10) in BP, IBP and DBP compared to CP. Muscle excitation during the eccentric phase followed a similar pattern, with the exception of the greater (d: 3.89/11.32) excitation in the clavicular head in BP compared to all other exercises. The present outcomes showed that the excitation of the clavicular and sternocostal head of pectoralis major depends on the bench inclination angle. The use of BP variations vs. CP allows overall greater triceps brachii and lateral deltoid excitation, due to the greater instability.

Outcomes of Triceps Rupture in the US Military: Minimum 2-Year Follow-up

BACKGROUND

The objective of this study was to examine the subjective and objective midterm functional clinical outcomes of surgically repaired triceps injuries in a moderate- to high-demand population.

METHODS

The US Military Health System was queried to identify all surgically treated triceps tendon ruptures between 2008 and 2013. Primary endpoints included rates of rerupture, perioperative complications, or significant persistent elbow dysfunction; Disability of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow score, and ability to do push-ups were also extracted.

RESULTS

Thirty-seven patients underwent triceps tendon repair with a mean follow-up of 49.8 ± 17.3 months (range: 26.8-80.2). The most common mechanisms of injury were military duties (27%), sporting activity (24%), or fall-related (21.6%), with most injuries occurring during an eccentric movement (54%). While 45% experienced occasional elbow pain postoperatively, only 1 patient (2.7%) had a rerupture. Despite this, at 2 years, 31 patients (84%) were able to return to full military duty. While 6 patients were discharged from military service, only 1 underwent medical separation while 5 retired for reasons unrelated to their triceps tendon rupture. Patient-reported outcomes were available for 14 patients at final follow-up. The average DASH and Mayo Elbow scores were 4.7 (SD ± 4.7, range: 0-15.9) and 85.4 (SD ± 11.7, range: 60-100), respectively. The cohort could perform mean 54.2 (range: 9-90) push-ups. In additional, 12 of 14 (85.7%) were satisfied with their elbow function.

CONCLUSIONS

The active duty cohort experienced excellent postoperative results with a high rate of return to military duty, despite nearly half of the patients recognizing some degree of activity-related, elbow pain.

Surgical Implications of Innervation Pattern of the Triceps Muscle: A Cadaveric Study

The innervation pattern of triceps is complex and not fully comprehended. Anomalous innervations of triceps have been described by various authors. We have attempted to delineate the nerve supply of the triceps and documented the anomalous innervations of its different heads. The brachial plexus and its major branches (in the region of the axilla and arm) and triceps were dissected in 36 embalmed cadaver upper limbs. Long head received one branch from radial nerve in 31 (86%) specimens. Four (11%) specimens received two branches including one that had dual innervation from the radial and axillary nerves, and one (3%) specimen had exclusive innervation from a branch of the axillary nerve. Medial head received two branches arising from the radial nerve in 34 (94%) specimens. One (3%) specimen received three branches from the radial nerve whereas one (3%) had dual supply from the radial and ulnar nerves. Lateral head received multiple branches exclusively from the radial nerve, ranging from 2 to 5, in all (100%) specimens. Knowledge of the variations in innervation of the triceps would not only help the surgeon to avoid inadvertent injury to any of the nerve branches but also offers new options for nerve and free functional muscle transfers.

Neglected Anterior Dislocation of the Elbow Joint: Case Report of a Rare Injury

We present an unusual case of five months old neglected anterior dislocation of the right elbow joint in a 19-year old man. The patient had been initially treated by a traditional bone setter, but the elbow remained unreduced. He presented to us with pain, deformity and limited range of motion of his right elbow joint. Radiographs revealed an unreduced anterior dislocation of the right elbow joint. We describe the problems encountered during open reduction and rehabilitation and result one year after the operation with the patient having a stable elbow and a functional range of motion.

Triceps brachii tendon injury in four Pomeranians

The cases of 4 Pomeranians with injury of the triceps brachii tendon that underwent surgical treatment were retrospectively reviewed to evaluate some clinical findings including signalment, cause of injury, clinical signs, pattern of injury, surgical technique, external coaptation after operation, complications, and outcomes. While all of the dogs showed non-weight bearing posture of the affected limbs and severe pain shortly after injury onset, the pain level decreased over time. A characteristic finding of the 4 cases was an absence of tension in the triceps brachii tendon when the elbow joint was flexed. The pattern of triceps brachii tendon injury was either laceration of the central part of the tendon (n=1) or tendon rupture at its insertion to the olecranon (n=3). Although there were no major complications after surgery in 3 cases, the remaining case required a revision surgery. Long lateral splint was effective method for external coaptation after operation. Diagnosis of triceps brachii tendon injury was not difficult if we even recognize this trauma. This form of injury can have a good prognosis with adequate surgery and postoperative coaptation.

Triceps Tendon Anatomic Repair Utilizing the "Suture Bridge" Technique

Triceps tendon ruptures are uncommon injuries, but they typically require surgical repair. Multiple primary repair techniques are available, including transosseous, suture anchor, and anatomic repairs. The technique described here, the "suture bridge" repair, provides an anatomic repair of the distal triceps tendon to its footprint. It has the potential advantages of increased load to failure, better footprint coverage, higher load resistance, and allows for early motion.

Triceps Ruptures After Fluoroquinolone Antibiotics: A Report of 2 Cases

Rupture of the triceps brachii tendon is exceedingly rare, and surgical repair is generally indicated. Fluoroquinolone antibiotics have been implicated in tendon pathology, including tendon ruptures. Triceps rupture has not been previously reported in the setting of fluoroquinolone antibiotic therapy. We present 2 cases of triceps tendon rupture after treatment with fluoroquinolones. In both cases, triceps repair was performed with good outcomes. These cases highlight a risk of fluoroquinolone-induced tendinopathy to athletes. The sports medicine team should be aware of this risk and consider it when choosing antibiotics to treat athletes.

A Comparative Biomechanical Analysis of 2 Double-Row, Distal Triceps Tendon Repairs

BACKGROUND

Triceps tendon ruptures are rare orthopaedic injuries that almost always require surgical repair. This study tests the biomechanical properties of an original anchorless double-row triceps repair against a previously reported knotless double-row repair.

HYPOTHESIS

The anchorless double-row triceps repair technique will yield similar biomechanical properties when compared with the knotless double-row repair technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen cadaver arms were randomized into 2 groups. One group received the anchorless repair and the other received the knotless anchor repair. A materials testing system (MTS) machine was used to cycle the repaired arms from 0° to 90° with a 2.5-pound weight for 1500 cycles at 0.25 Hz. Real-time displacement of the tendon was measured during cycling using a probe. Load to failure was performed after completion of cyclic loading.

RESULTS

The mean displacement with the anchorless technique was 0.77 mm (SD, 0.25 mm) at 0° (full elbow extension) and 0.76 mm (SD, 0.38 mm) at 90° (elbow flexion). The mean displacement with the anchored technique was 0.83 mm (SD, 0.57 mm) at 0° and 1.01 mm (SD, 0.62 mm) at 90°. There was no statistically significant difference for tendon displacement at 0º (P = .75) or 90º (P = .31). The mean load to failure with the anchorless technique was 618.9 N (SD, 185.6 N), while it was 560.5 N (SD, 154.1 N) with the anchored technique, again with no statistically significant difference (P = .28).

CONCLUSION

Our anchorless double-row triceps repair technique yields comparable biomechanical properties to previously described double-row triceps tendon repair techniques, with the added benefit of avoiding the cost of suture anchors.

CLINICAL RELEVANCE

This anchorless double-row triceps tendon repair can be considered as an acceptable alternative to a knotless anchor repair for triceps tendon ruptures.

Triceps and Subscapular Skinfold in Men Aged 40-65 and Dementia Prevalence 36 Years Later

BACKGROUND

The relationship of obesity with risk for dementia is complex and may change with age.

OBJECTIVE

To analyze the relationship between measures of obesity at age 40-65 and dementia prevalence in survivors 36 years later.

METHODS

Obesity-related measures of triceps and subscapular skinfold thickness were assessed in 1963 in n = 9,760 men aged 40-65 participating in the Israel Ischemic Heart Disease study. Cognitive evaluation and assessment of dementia prevalence were performed in n = 1,643 participants of the original cohort who survived until 1999/2000 (age ≥76 years) and had anthropometric measures in 1963.

RESULTS

Age-adjusted prevalence of dementia in survivors in 1999/2000 by baseline triceps skinfold quintile was 20.5%, 21.2%, 17.6%, 15.6%, and 14.5%, respectively, from lowest to highest (p = 0.006 in trend test). Using logistic regression, a 6-mm increment of triceps skinfold was associated with an age and BMI-adjusted odds ratio of 0.81 (95% CI, 0.70-0.94) for dementia prevalence among survivors. Age-adjusted risk for dementia by subscapular skinfold quintile demonstrated 20.5%, 17.1%, 15.7%, 19.4%, and 18.1%, respectively, in groups of subjects by subscapular skinfold quintile from lowest to highest (p = 0.6 in trend test).

CONCLUSIONS

Lower triceps skinfold at age 40-65, reflecting diminished peripheral fat, was associated with higher dementia prevalence in late life, potentially suggesting a protective role of peripheral fat to brain health.

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.

Surgical repair of isolated triceps tendon rupture using a suture anchor technique: a case report

Rupture or avulsion of the distal triceps tendon is one of the least common tendon injuries. The most common clinical presentation of the injury is avulsion from the olecranon. The diagnosis of acute triceps tendon rupture may be missed and this can result in prolonged disability. We report the case of a 42-year-old man with isolated triceps rupture treated by an open surgical repair technique involving the use of bone suture anchors.

[Transfer of the long head of triceps for elbow flexion in braquial plexus sequelae]

The independent neurovascular anatomy of the long head of the triceps brachii and its suitability as a free muscle transfer have been extensively studied. Instead muscle transposition of the long head of the triceps brachii to enhance elbow flexion has been rarely described. We describe in this paper two cases of injury of brachial plexus sequel in which transposition was performed only on the long head of the triceps. The elbow flexion was improved, the extension was preserved.

Exercise and gait training in persons with paraplegia and its effect on muscle properties

BACKGROUND

Upper extremity strengthening and gait training with orthoses form a major part of inpatient rehabilitation of paraplegic patients in developing countries. This helps to overcome architectural barriers and limited wheelchair accessible environment in the community.

OBJECTIVES

To evaluate the changes in physiological properties of the Triceps Brachii muscle following exercise training in individuals with paraplegia. The authors also explored the correlation between muscle property changes and gait parameters using orthoses in paraplegic persons.

METHODS

Twelve subjects with complete paraplegia and neurological level of injury (NLI) from T9 to L1, underwent exercise training for a mean 64.1 ± 4.1 days. Triceps brachii was chosen as the sample muscle. Variables like arm circumference, time to fatigue and mean power frequency (MF) (surface EMG parameter), were recorded at the beginning and the end of training, during a sub-maximal isometric elbow extension. Non-parametric tests were used to assess statistical significance between the two recordings. Additionally, gait parameters like walking speed and distance (with the help of orthoses) were obtained and compared with the above variables, to determine impact of upper extremity strengthening on gait improvements in such patients.

RESULTS

Statistically significant changes were noted in bilateral arm circumferences (p= 0.003 bilaterally) and MF drop, expressed as percentage (right p= 0.04, left p= 0.01), indicative of better muscle resilience and adaptation. Significant positive correlation was observed between `time to fatigue' and the orthoses-aided total walking distance (right ρ = 0.65, left ρ = 0.69).

CONCLUSIONS

Exercise training induces noticeable changes in the muscles of upper extremities favoring better muscle adaptation. Furthermore, positive correlation between `time to fatigue' and (orthotic) aided walking distance highlights the positive impact of strengthening program on gait parameters in paraplegic patients. These findings are important and relevant in developing countries with environmental barriers. Upper extremity strengthening should be included in the rehabilitation of paraplegic patients who are being trained for ambulation with orthoses.

Rupture of the triceps tendon - A case series

Triceps rupture is the least common among all tendon injuries. The usual mechanism of injury is a fall on an outstretched hand, although direct contact injuries have also been reported to cause this injury. The diagnosis of acute triceps tendon rupture may be missed, which can result in prolonged disability and delayed operative management. We presented three cases of acute triceps tendon rupture each at different site showing the spectrum of injury to the muscle and mechanism of injury and management were also discussed.

Chronic Tendonopathy as a Unique Cause of Non Traumatic Triceps Tendon Rupture in a (Risk Factors Free) Bodybuilder: A Case Report

Introduction:

Distal triceps tendon rupture is an uncommon lesion rarely due to a non-traumatic mechanism. In these cases, the majority of patients show predisposing factors for tendon degeneration: underlying medical co-morbidities, previous systemic and locally injected corticosteroids and systemic anabolic steroids. A clear evidence for an etiopathogeneticroleforchronictendonopathy in triceps tendon rupture is sti 11 lacking.

Case Report:

We report the case of a rare non-traumatic complete rupture of the triceps tendon, at the olecranon insertion, occurring in a healthy male middle-aged non-professional bodybuilder. He presented to our attention with a five days history of weakness, swelling and pain at the left elbow, started after a snapping sound during a single arm triceps extension exercise. He was a healthy sportsman, no smoker and no drinker. He had suffered, in the two months before, of mild bilateral exercise-related elbow discomfort, never limiting his sport and daily activities. The man was treated by an early surgical repair. Histological analysis was conducted on intraoperative samples. The treatment allowed complete remission and return to sport practice without functional deficit.

Conclusion:

An overload-related chronic tendonopathy was identified as the unique factor with causal role in the determinism of the above described lesion. This case highlights, for the first time in literature, that just a chronic tendonopathy, in absence of any other predisposing condition, can lead to a non-traumatic complete triceps tendon rupture.

Open arthrolysis with pie-crusting release of the triceps tendon for treating post-traumatic contracture of the elbow

BACKGROUND

Extensive loss of elbow flexion compromises the performance of daily activities. We examined the clinical outcomes of patients with post-traumatic extension contracture of the elbow treated with open arthrolysis and pie-crusting release of the triceps tendon.

METHODS

We retrospectively reviewed the records of 7 patients (5 men and 2 women; mean age, 35 years) who underwent open arthrolysis via a combined lateral and medial approach with pie-crusting release of the triceps tendon for the treatment of post-traumatic elbow stiffness. All the patients had heterotopic ossification that restricted elbow motion and underwent removal of the ossified tissue and capsular release. The triceps tendon was gradually stretched by making multiple stab incisions on the tendon by using a No. 11 surgical blade. The range of motion of the elbow was recorded both preoperatively and at the final postoperative follow-up. Elbow function was assessed with the Mayo Elbow Performance Score.

RESULTS

The patients were followed up for a mean of 24 months. After treatment, significant improvement was noted in the total arc of motion (from 44° to 116°, P <.001), mean flexion (from 80° to 124°, P < .001), and mean extension (from 31° to 8°, P = .004). The mean Mayo Elbow Performance Score improved significantly from 59 points preoperatively to 92 points at the final evaluation. No major postoperative complications developed in any of the patients.

CONCLUSION

Our findings indicate that open arthrolysis with pie-crusting release of the triceps tendon is an effective and safe treatment approach for post-traumatic extension contracture of the elbow.

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.

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.

Assessment of overweight and obesity among Nigerian children and adolescents using triceps skin-fold thickness and body mass index

The prevalence of obesity is increasing in children and adolescents even in resource-poor countries. The study aimed to determine the prevalence of obesity in a group of Nigerian school children using triceps skin-fold thickness (SFT) and body mass index (BMI). The subjects were 1235 randomly selected primary and secondary Lagos school children aged 5-18 years, triceps SFT was measured with Harpenden® calipers and BMI calculated from weight and height. Using BMI, overweight and obesity were defined as values of 85th to 94th percentile for age and sex and ≥95th percentile, respectively. Using triceps SFT, obesity was defined as SFT > 85th percentile of the NHANES III study. Fifty-seven subjects (15 boys and 42 girls) had SFT > 85th percentile with a higher prevalence in girls than boys (6.4% vs. 2.6%, P = 0.001). The prevalence of BMI-defined overweight and obesity were also higher among girls (11.9% vs. 5.7%, P < 0.001 and 4.7% vs. 2.2%, P = 0.02, respectively). Females of upper socioeconomic class were more likely to be overweight (16.2% vs. 6.6%, P < 0.0001), obese (6.3% vs. 2.8%, P = 0.03) or have elevated SFT (8.2% vs. 4.2%, P = 0.03) than those of low socioeconomic status. Forty-seven of 57 subjects (82.5%) with elevated SFT also had high BMI. The prevalence of obesity is low in the study population but the much higher prevalence of overweight suggests that steps should be taken to control fatness before the figures worsen. In more than 80% of subjects, elevated SFT co-existed with elevated BMI.

Partial triceps disruption: a case report

Partial triceps tendon disruptions are a rare injury that can lead to debilitating outcomes if misdiagnosed or managed inappropriately. The clinician should have a high index of suspicion when the mechanism involves a fall onto an outstretched arm and there is resultant elbow extension weakness along with pain and swelling. The most common location of rupture is at the tendon-osseous junction. This case report illustrates a partial triceps tendon disruption with involvement of, primarily, the medial head and the superficial expansion. Physical examination displayed weakness with resisted elbow extension in a flexed position over 90°. Radiographs revealed a tiny fleck of bone proximal to the olecranon, but this drastically underestimated the extent of injury upon surgical exploration. Magnetic resonance imaging is essential to ascertain the percentage involvement of the tendon; it can be used for patient education and subsequently to determine treatment recommendations. Although excellent at finding associated pathology, it may misjudge the size of the tear. As such, physicians must consider associated comorbidities and patient characteristics when formulating treatment plans.

Population-based centile curves for triceps, subscapular, and abdominal skinfold thicknesses in Polish children and adolescents--the OLAF study

Skinfold thicknesses are used as valid anthropometric indicators of regional body fatness. Actual population-based values for skinfold thicknesses for Polish children are not available. The purpose of this study was to provide population-based values for triceps, subscapular, and abdominal skinfold thicknesses in healthy children and adolescents. A total number of 17,416 boys and girls aged 6.5-18.5 years, randomly selected from whole Polish population of children and adolescents, were enrolled in the study. Skinfold thicknesses (triceps, subscapular, and abdominal) were measured using Harpenden skinfold caliper. All measurements were taken after the training of participating investigators. The LMS method was used to fit percentile curves across age for each skinfold. Q tests for fit were used to assess the global goodness of fit of our final models. The study shows for the first time smoothed population-based values of body fat distribution indices for Polish children and adolescents 7-18 years of age. Reported skinfold centiles are higher compared to previously established for Warsaw children and very close to the actual US data.

CONCLUSION

Our study provided for the first time population-based values for skinfold thicknesses evaluation in a way allowing to calculate reliable Z scores. The early detection of abnormal fat stores, using our population-based values and respective Z scores, may be now implemented for practice.

Myositis ossificans circumscripta of the triceps due to overuse in a female swimmer

Myositis ossificans is a rare condition characterized by non-neoplastic heterotopic bone formation in soft tissue and skeletal muscle. It is a benign and often self-limiting disease with no need for surgery. Here, we describe a young female swimmer with myositis ossificans circumscripta of the triceps due to overuse. Because of the benign character of the lesion, conservative treatment was initiated with rest and anti-inflammatory drugs. She obtained complete resolution after 6 months and was able to return to normal sporting activities. Myositis ossificans circumscripta is a rare benign lesion with an excellent prognosis. Most lesions in athletes occur due to contusions or strains; however, overuse is now described as well. Spontaneous resolution is seen in almost all cases. Cases in which, despite conservative treatment, a painful mass persists, surgical excision can be considered.

Mono- versus biarticular muscle function in relation to speed and gait changes: in vivo analysis of the goat triceps brachii

The roles of muscles that span a single joint (monoarticular) versus those that span two (biarticular) or more joints have been suggested to differ. Monoarticular muscles are argued to perform work at a joint, whereas biarticular muscles are argued to transfer energy while resisting moments across adjacent joints. To test these predictions, in vivo patterns of muscle activation, strain, and strain rate were compared using electromyography and sonomicrometry in two major elbow extensors, the long and lateral heads of the triceps brachii of goats (Capra hircus), across a range of speed (1-5 m s(-1)) and gait. Muscle recordings were synchronized to limb kinematics using high-speed digital video imaging (250 Hz). Measurements obtained from four goats (25-45 kg) showed that the monoarticular lateral head exhibited a stretch-shortening pattern (6.8+/-0.6% stretch and -10.6+/-2.7% shortening; mean+/-s.e.m. for all speeds and gaits) after being activated, which parallels the flexion-extension pattern of the elbow. By contrast, the biarticular long head shortened through most of stance (-16.4+/-3.4%), despite elbow flexion in the first half and shoulder extension in the last half of stance. The magnitude of elbow flexion and shoulder extension increased with increasing speed (ANCOVA, P<0.05 and P<0.001), as did the magnitude and rate of active stretch of fascicles in the lateral head (P<0.001 for both). In all individuals, shortening fascicle strain rates increased with speed in the long head (P<0.001), and, in three of the four individuals, strain magnitude increased. Few independent effects of gait were found. In contrast to its expected function, the biarticular long head appears to produce positive work throughout stance, whereas the monoarticular lateral head appears to absorb work at the elbow. The biarticular anatomy of the long head may mitigate increases in muscle strain with speed in this muscle, because strain magnitude in the second phase of stance (when the shoulder extends) decreased with speed (P<0.05).