Triceps Repair for Acute Triceps Tendon Rupture
Table of Contents
The function of the triceps tendon is elbow extension. Triceps tendon ruptures are uncommon tendon injuries of the upper extremity and generally result from either direct injury and/or forced eccentric contracture during a fall on an outstretched hand. The treatment goal is re-approximating the distal triceps tendon to the olecranon in order to restore elbow extension strength and upper extremity function. The surgical technique demonstrated in this video is the suture bridge technique.
Triceps tendon ruptures are rare injuries, with Anzel et al. finding a total prevalence of 8 in 1014 patients with tendon ruptures of any type.1 In a more recent study of the military population, triceps tendon ruptures were found to occur at only 1.1 per 100,000 person years.2 These injuries most often occur in young, physically active men such as weightlifters, in older adults with systemic diseases such as chronic renal failure or hyperparathyroidism, and in relation to pharmacologic treatments such as chronic corticosteroids, statins, or fluoroquinolones.2, 3 The general mechanism of the injury is during eccentric contraction of the triceps, with overloading force on the tendon’s insertion at the olecranon, such as during a fall onto an outstretched hand or during an extension movement while weightlifting.2 Alternatively, penetrating trauma can also result in a triceps rupture. Anatomically, the injury can occur in three specific places: from intramuscular separation of the tendon, rupture of the myotendinous junction or avulsion of the tendinous insertion off of the olecranon, which occurs most commonly.3 There is no formal grading system for triceps tendon tears but they can be broadly considered as full or partial tears, with partial representing a less than 50% tear.
The male patient in this video suffered a fall on an outstretched hand, leading to a forceful eccentric contracture of the triceps. He complained of pain in the posterior elbow region, and his physical exam demonstrated weakness with resistance to elbow extension. A plain film of the arm ruled out an olecranon fracture but did reveal an avulsion of the triceps tendon off of the ulna. An MRI for preoperative planning further demonstrated the avulsion of the tendon on T2 imaging.
Patients with an acute triceps tendon rupture will often present with tenderness, ecchymosis, and edema in the posterior elbow. A bulge in the upper arm may be present with a palpable gap proximal to the elbow joint, representing the unattached distal end of the triceps muscle. On strength testing, patients will likely show weakness to extension of the elbow against resistance.4
We recommend to begin with a plain film radiograph of the joint to determine if there is an olecranon fracture as this represents the major differential diagnosis, although other elbow joint fractures, olecranon bursitis, and elbow sprain are additional diagnoses to consider.5 A positive “flake sign”, or an extra-articular avulsion fracture of the olecranon, on lateral view is consistent with a triceps tendon rupture.6 Magnetic resonance imaging is most useful in making the diagnosis, determining if there is a complete or partial tear, and for preoperative planning.
Unrepaired triceps tendon ruptures will result in persistent weakness of elbow extension strength, and therefore surgery is typically recommended. A patient with a complete rupture of the triceps tendon may opt for conservative management if they have minimal physical demands, minimal restriction of motion from the injury, or if they are not a surgical candidate secondary to medical comorbidities.6 Partial ruptures can be treated surgically or non-surgically based on patient symptoms and the extent of weakness or dysfunction.
Surgical repair falls into three categories: transosseous tunnels, suture anchor, and anatomic.2, 4, 8, 9 In this patient, the anatomic suture bridge technique was utilized, using a running locked (Krackow) suture that allows for maximal exposure, repair, and coverage of the triceps tendon insertion site.8, 9
The patient was taken to the operating room and underwent general anesthesia, although regional anesthesia can be used. They were placed in the lateral decubitus position with the operative limb sterilely draped over a bolster. An incision was made over the posterior aspect of the arm at the level of the proximal ulna and extended proximally, with care taken to avoid the medial olecranon as that is where many patients rest their arms. At that point, local anesthesia with 0.5% bupivicaine was injected into the incision. The operative limb was then exsanguinated with a tourniquet to 250 mmHg. Dissection was carried through the subcutaneous tissue down to triceps fascia. Next, a dissection to mobilize the triceps tendon from surrounding tissue was performed with care taken to avoid radial or ulnar nerves, although these structures do not need to be dissected out and isolated.
At this point, with a mobilized triceps tendon, a running Krackow stitch starting distally, going proximally, and then returning distally is performed followed by an additional parallel running Krackow stitch, creating two ends which are brought distally.
Next, attention is turned to the triceps insertion site at the proximal ulna, which is debrided of soft tissue down to bleeding bone. After this, suture anchors are then placed, with care taken to avoid placement into the articular surface at the ulnar-humeral joint space. Two preloaded 2-0 FiberWire suture anchors are drilled into this space. With a free needle, all four suture limbs are brought through the proximal tendon for ultimate repair in a mattress fashion, consisting of two pairs of two sutures.
The arm is then brought into extension, resting on a padded Mayo stand with traction pulled on the triceps tendon to increase the anatomic footprint. The suture tack mattress sutures are then placed bilaterally using the suture bridge technique. First, the posterior ulna is sharply exposed at least 2–3 cm distal to the proximal ulna. Two PushLocks are placed into the drill holes through the posterior cortex in the proximal ulna, directed away from the articular surface. Three suture limbs are placed per islet. The position of the push locks is then finalized using a mallet to make them flush with the cortex of the ulna. The suture tails are cut sharply. The suture bridge repair of the triceps tendon has now been completed.
The operative limb is then brought through gentle range of motion to test the integrity and stability of the repair; once satisfactory, the operative site is irrigated and closed in layered fashion, beginning with subcutaneous interrupted 3-0 Vicryl sutures. Skin is closed with a running 4-0 Monocryl suture. Dermabond and Steri-Strips are applied over the incision followed by a splint applied on the volar aspect to avoid inadvertent flexion of the elbow in the early postoperative period.
The patient in this case suffered an acute triceps tendon rupture and opted for surgical repair to restore function. His physical exam findings of tenderness at the olecranon and weakness against resistance during elbow extension, combined with plain film imaging revealing a positive fleck sign representing an avulsion the triceps tendon off of the olecranon, gave us the diagnosis of acute triceps tendon rupture. The patient underwent surgical repair under general anesthesia, was placed in lateral decubitus position, and a sterile tourniquet was used for hemostasis.
Following surgery, the patient will be placed in a splint with the elbow at 0 degrees of flexion and then be transitioned to a removable brace in clinic within 1 week after the operation. The brace will remain on for 6 weeks as the patient gradually trials active elbow flexion up to 90 degrees. At 6 weeks, patients generally begin physical therapy and can return to full use or participation in sports 6 weeks later. Avinesh et al. found that these patients averaged a return to work within 10 weeks from their surgeries.10
Triceps tendon ruptures represent an uncommon injury and can be easily missed by an unsuspecting clinician. The time from injury to operation may be an important factor in determining whether the patient returns to preinjury levels of strength and function. In a study by van Riet et al., they found that outcomes in patients undergoing surgery within 3 weeks of injury had more robust return to function timelines as well as fewer intraoperative difficulties compared to surgical repair of chronic ruptures.11 Patients did undergo operations up to 20 months out from the initial injury but surgical findings included retraction of the triceps tendon and significant scar tissue formation.11
Key aspects of the surgical repair for triceps tendon ruptures include triceps tendon mobilization, identification of the ulnar nerve, removal of adhesions from the tendon and the olecranon insertion site, creation of the suture, and fixation into the olecranon.8 In this video, the suture bridge technique was utilized for operative repair as it has been shown to increase the anatomic exposure, repair, and coverage of the triceps tendon.9 Other considerations would be the speed bridge anatomic repair, which also avoids drilling tunnels into the olecranon and is a knotless technique, but is associated with a type 2 failure pattern.8 Overall, the anatomic repair has been shown to most closely approximate preinjury function.8, 12 Specific risks of this surgery include rerupture, postoperative stiffness, and neurapraxia of the ulnar nerve given its proximity. At this time, the best surgical technique remains unclear; however, knotless suture technique has shown increased load and cycle to failure when compared to transosseous tunnel repair.9, 13 Positive results have also been shown when utilizing suture anchors. The infrequent nature of the injury makes prospective surgical technique comparison studies challenging as well as management guidelines for partial tears.5, 14
Arthrex suture anchors.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Anzel SH, Covey KW, Weiner AD, Lipscomb PR. Disruption of muscles and tendons; an analysis of 1,014 cases. Surgery. 1959;45(3):406-414.
- Balazs GC, Brelin AM, Dworak TC, et al. Outcomes and complications of triceps tendon repair following acute rupture in American military personnel. Injury. 2016 Oct;47(10):2247-2251. doi:10.1016/j.injury.2016.07.061.
- Shybut TB, Puckett ER. Triceps ruptures after fluoroquinolone antibiotics: a report of 2 cases. Sports Health. 2017;9(5):474-476. doi:10.1177/1941738117713686.
- Mancini F, Bernardi G, De Luna V, Tudisco C. Surgical repair of isolated triceps tendon rupture using a suture anchor technique: a case report. Joints (Roma). 2016;4(4):250-252. doi:10.11138/jts/2016.4.4.250.
- Harris PC, Atkinson D, Moorehead JD. Bilateral partial rupture of triceps tendon: case report and quantitative assessment of recovery. Am J Sports Med. 2004;32(3):787-792. doi:10.1177/0363546503258903.
- Celli, A. Triceps tendon rupture: the knowledge acquired from the anatomy to the surgical repair. Musculoskelet Surg. 2015 Sep;99 Suppl 1:S57-66. doi:10.1007/s12306-015-0359-y.
- Sharma P, Vijayargiya M, Tandon S, Gaur S. Triceps tendon avulsion: a rare injury. Ethiop J Health Sci. 2014 Jan;24(1):97-9. doi:10.4314/ejhs.v24i1.14.
- Luthringer TA, Lowe DT, Egol KA. Acute distal triceps tendon rupture repair: case presentation and surgical technique. J Orthop Trauma. 2021 Aug 1;35(Suppl 2):S18-S19. doi:10.1097/BOT.0000000000002164.
- Edelman D, Ilyas AM. Triceps tendon anatomic repair utilizing the "suture bridge" technique. J Hand Microsurg. 2018 Dec;10(3):166-171. doi:10.1055/s-0038-1636729.
- Agarwalla A, Gowd AK, Jan K, et al. Return to work following distal triceps repair. J Shoulder Elbow Surg. 2021 Apr;30(4):906-912. doi:10.1016/j.jse.2020.07.036.
- van Riet RP, Morrey BF, Ho E, O'Driscoll SW. Surgical treatment of distal triceps ruptures. J Bone Joint Surg Am. 2003 Oct;85(10):1961-7. doi:10.2106/00004623-200310000-00015.
- Yeh PC, Stephens KT, Solovyova O, et al. The distal triceps tendon footprint and a biomechanical analysis of 3 repair techniques. Am J Sports Med. 2010 May;38(5):1025-33. doi:10.1177/0363546509358319.
- Clark J, Obopilwe E, Rizzi A, et al. Distal triceps knotless anatomic footprint repair is superior to transosseous cruciate repair: a biomechanical comparison. Arthroscopy. 2014 Oct;30(10):1254-60. doi:10.1016/j.arthro.2014.07.005.
- Bava ED, Barber FA, Lund ER. Clinical outcome after suture anchor repair for complete traumatic rupture of the distal triceps tendon. Arthroscopy. 2012 Aug;28(8):1058-63. doi:10.1016/j.arthro.2011.12.016.
Cite this article
Schneider G, Ilyas AM. Triceps repair for acute triceps tendon rupture. J Med Insight. 2023;2023(330). doi:10.24296/jomi/330.
Table of Contents
- Patient Positioning
- Mark Incision
- Injection of Local Anesthesia
- Limb Exsanguination with Tourniquet
- Mattress Suture Placement
- Divide Sutures and Load into PushLocks
- Posterior Proximal Ulna Exposure
- Suture Bridge Repair
This is a case of an acute triceps rupture occurring from a fall onto the outstretched hand, resulting in eccentric contracture of the triceps. The patient presents with pain in his posterior elbow region and weakness with resistance to elbow extension. Imaging is useful in these cases. Firstly, getting a radiograph to rule out an olecranon fracture is helpful, as that is the primary differential. In this case, no olecranon fracture is identified, but an avulsion fragment off the proximal ulna from the avulsed triceps is identified, helping to make the diagnosis. Furthermore, if the diagnosis is in question or for preoperative planning purposes, an MRI may also be helpful. On the lateral or sagittal T2 images, avulsion of the triceps should be readily identified. The technique being presented here is referred to as the suture bridge technique, published in the Journal of Hand and Microsurgery in 2018. This technique involves the use of multiple Arthrex anchors. I have no conflicts or financial relationships with Arthrex. This technique allows for maximal exposure and repair and coverage of the footprint of the triceps tendon insertion site. This technique is in contradistinction to what's known as the speed bridge technique. Both techniques are relatively similar and result in a knotless repair of the triceps mechanism. As we go through the video, I'll show the differences between the two techniques to avoid any confusion.
The surgery begins with general anesthesia. Regional could also be used. The patient positioned in the lateral decubitus position, as demonstrated here.
The operative limb is then draped over a bolster so that the posterior aspect of the elbow is readily identified. Here I'm marking out the distal insertion site of the ruptured triceps. I'm now marking out where the ulna is, and then I'm gonna extend the incision proximally. I avoid the medial aspect of the olecranon, as that is where folks rest their arm, so I avoid incision to that area. So I will cheat the incision slightly lateral or radial so that it's not centered over where one would rest their arm. And the incision's placed straight down the posterior elbow, off the tip of the olecranon and down to the level of the proximal ulna, as demonstrated here.
Next, the incision is injected with a local anesthetic. Here I'm using 0.5% bupivacaine or Marcaine to provide analgesia in the surgical site.
The limb is then exsanguinated, and the sterile tourniquet is inflated to 250 mmHg. Alternatively, the procedure can be performed without tourniquet hemostasis.
The incision is then placed. Dissection through the subcutaneous tissue is then taken down to the triceps fascia. My preference is to do this with electrocautery to minimize bleeding.
Once down to the level of the triceps fascia, the dissection has taken a bit slower to help mobilize the triceps tendon from the surrounding soft tissue. Care is taken not to take the dissection too aggressively medial, as to inadvertently injure the ulnar nerve, or too proximal along the radial border to inadvertently injure the radial nerve. Of note with this technique, neither nerve needs formal exposure and dissection. As can be seen here, the ruptured triceps tendon is coming into view. The soft tissue and fascia overlying the tendon continues to be mobilized. This will help in mobilization of the tendon and access to the tendon for placement of its suture. Once the distal aspect of the triceps tendon is exposed, it can then be tagged as shown here with an Allis clamp. This will help in mobilization of the tendon, and blunt dissection deep to it, and sharp dissection superficial to it to continue to mobilize the tendon for subsequent repair.
Once the tendon is fully exposed, a running Krackow stitch is placed, starting distally, running proximally, and then exiting distally once more, resulting in two tails. In this case, we are using a number 2 FiberWire to do this running Krackow stitch. Once the proximal limb has been run up, the same suture is then run distally along the other side, as shown here in a similar Krackow fashion. Once run proximal and then distal once more, the two ends of the suture are brought distal. These will be integral to the ultimate repair of the footprint. Good repair is confirmed with tensioning the triceps tendon, as demonstrated here. This will also help eliminate any slack in the suture within the tendon.
Next, attention is turned to the insertion site of the triceps tendon in the proximal ulna. Here you can see that the proximal ulna insertion site is being debrided of any remaining soft tissue. A clean bony bed is the goal. In order to achieve that, all soft tissue has to be removed. In addition, a burr is used to help debride the proximal ulna down to bleeding bone.
Next, attention is turned to placement of the suture anchors. It's important to understand the anatomy of the proximal ulna to avoid inadvertent placement of the suture anchors within the articular surface or the joint of the ulna humeral articulation. Here, the proximal anchors are placed at an angle underneath trochlea as shown here. Similarly, the PushLocks are placed in a different angle away from the articular surface once more. Here is a schematic of the same point. The SutureTaks in the proximal ulna will follow the path of the yellow arrow. Later, the PushLocks will follow the path of the red arrow, as shown here. In this way, the articular surface will be avoided. As such, now two suture anchors are being placed in the proximal ulna at the level of the triceps insertion, or footprint. Again, the angle with which they're being placed is as demonstrated previously. The anchors being used here are SutureTaks. These are preloaded 2-0 FiberWire suture anchors. Free needles will then subsequently be used to provide the needle for these. The second SutureTak in the proximal ulna is placed in the same manner, as shown here.
Next, with the aid of a free needle, all four limbs of the suture is then brought through the proximal tendon, as shown here, for ultimate repair in a mattress fashion. Once the first pair of limbs of sutures are brought through the proximal tendon for later repair in a mattress fashion, the same technique is then used to place the second pair of sutures just next to it, as shown here. With both suture limbs in place, the first repair of the tendon back to its footprint can be performed. The arm is brought into extension by resting it on a padded Mayo Stand. With an assistant pulling tension on the triceps tendon to maximize coverage of the footprint, as shown here, the SutureTak mattress sutures are then put down with the arm in extension and with at least six or seven knots placed on each side.
Here is a closeup of the repaired tendon onto its footprint. You'll see excellent coverage of the footprint by the tendon. Now this Raytec gauze is being placed to help you see the relationship of the sutures that will be placed with the PushLock in the proximal ulna. One limb will be crossed to each side so as to maximize coverage of the footprint and tension on the footprint. Next, each set of three suture limbs are placed through the eyelet of each PushLock, as shown here. The suture bridge technique requires the placement of two PushLock anchors in the proximal ulna. In contrast, the [speed] bridge technique consists of a single swivel lock placed in the proximal ulna, with all sutures running through it.
Next, the proximal ulna is prepared to receive the PushLocks. The posterior aspect of the ulna is exposed sharply, at least 2-3 cm distal to the proximal ulna.
Each PushLock is then placed over its drill hole in a staggered fashion, and directed away from the articular surface through the posterior cortex of the ulna. The PushLock is then placed following the trajectory of the drill hole, while tensioning all three suture limbs running through its eyelet. Once down, tension is relieved of the suture. Once in position, the PushLock is malleted into place, until flush with the cortex of the ulna. The same steps are then repeated for the other set of three suture tails, as shown here. Once down and in place, the suture tails are then cut sharply. With that, the suture bridge repair of the triceps tendon has been completed.
The elbow is taken through gentle range of motion to cycle the sutures and to confirm secure repair. Once satisfied, the wound is washed and closed in a layered fashion. I generally do not close the fascia over the triceps. I close only the subcutaneous tissue with a 3-0 Vicryl and a skin with a 4-0 Monocryl in a running fashion, and then apply a skin glue on the surface of the skin, followed by a splint. The splint that is applied involves placing the plaster slab on the volar or anterior aspect of the elbow to avoid inadvertent flexion of the elbow during the early postoperative period.
Subsequently, my postoperative protocol consists of seeing the patient in the office a few days after surgery and converting the patient to a hinged elbow brace. The patient will then work on passive range of motion of the elbow, slowly allowing progressive more flexion over the first 6 weeks to 90 degrees. Once they achieve full flexion to 90 degrees actively and passively, at that point, the brace is discontinued and formal therapy initiated, focusing on TheraBand strengthening the second 6 weeks. After 12 weeks, therapy can be discontinued and full use of the arm, including free weights, can be initiated on a progressive manner. Thank you.