Triceps Tendon Avulsion Treatment & Management

Updated: Oct 09, 2017
  • Author: Bhavuk Garg, MBBS, MS, MRCS; Chief Editor: Harris Gellman, MD  more...
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Treatment

Medical Care

Nonsurgical treatment has generally been reserved for patients with partial ruptures or with ruptures of the muscle belly who demonstrated some ability to extend their arm against gravity. [8]

Avulsion of the lateral head of the triceps alone is recognized to cause no clinically significant functional impairment. This injury may be more frequent than has been recognized. [22]

Partial tendon avulsions or midsubstance muscle tears are treated nonoperatively with the arm in extension for 3-4 weeks. Gradual range-of-motion exercises may be allowed at 3-4 weeks, as the patient's symptoms allow. [28, 29]

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Surgical Care

All complete triceps tendon avulsions must be surgically repaired to restore extension strength. [5, 30, 6]

The role of surgery in the treatment of incomplete tears is somewhat controversial. However, Farrar and Lippert stated that if full active extension can be demonstrated on physical examination a few days after injury, incomplete injuries may be considered partial and therefore may be closely observed without surgical repair. [5]

Methods of repair

For complete tears or avulsion, the accepted method of repair is reattachment of the avulsed triceps tendon to the olecranon. [31] This repair is accomplished by using drill holes with heavy nonabsorbable sutures. [5, 4, 6, 32, 33, 34]

If a large fragment (>50%) of the olecranon is fractured and displaced, open reduction and internal fixation (ORIF) of the olecranon by using the Arbeitsgemeinschaft für Osteosythesefragen/Association for the Study of Internal Fixation (AO/ASIF) technique of tension band wiring is indicated. Mobilization of the triceps tendon may be required. [35] Care must be taken to avoid injuring the radial nerve with proximal mobilization. [28]

Otherwise, excision of bone fragments and repair of the triceps tendon to the articular surface are indicated. Repair of the tendon to the articular surface is necessary to minimize anterior-posterior instability of the elbow after the proximal olecranon fragment is excised.

Additional methods of triceps repair are described in the literature. These methods include use of a posterior forearm fascial flap, use of a periosteal flap from the olecranon, and use of an inverted tongue of triceps as a turned-down flap. [18, 30] These additional methods may be useful if diagnosis is delayed, if the triceps tendon is retracted, or if primary reconstruction fails.

In the instances of delayed or late reconstruction, Bennett and Mehlhoff described triceps immobilization and use of a turned-down triceps fascia flap or a fascial strip of the palmaris longus tendon or tensor fasciae latae placed through a drill hole in the olecranon. [28]

In a method of triceps tendon reconstruction with VY-plasty in the musculotendinous junction of the triceps, the required length of tendon is easily obtained by V-shaped splitting of the tendon, which does not weaken the tendon. Excellent muscle power is achieved, the blood supply is preserved because of patent continuity in the distal section, soft-tissue damage is minimal, and functional outcome is good. In addition, the method is simple and reproducible. [36]

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Postoperative Care

After surgery, the elbow is immobilized in a posterior splint in extension for anywhere from 10 days to 6 weeks, as described in the literature. [8]

According to Bennett and Mehlhoff, the elbow is generally immobilized at 30-40° of flexion for 4 weeks. A graduated range-of-motion and strengthening program is then begun. For example, the elbow is immobilized at 30° of flexion for 4 weeks, and then 0-45° of range of motion is allowed during the next 2 weeks. After this time, graduated range-of-motion and strengthening exercises begin. [28, 29]

An extension night splint is used for the first 3 months after repair.

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Complications

Complications after surgical repair have been described in the literature and include skin sloughing, infection, and repeat rupture. Pantazopoulos et al reported the development of olecranon bursitis after wire-suture fixation. The bursitis resolved after the wire was removed. [4] Overall, acceptable extension strength is restored after surgical repair. [8, 5] Many investigators have noted mild flexion contracture of 5-20° in approximately 10% of their reported cases. [25, 6]

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Long-Term Monitoring

The patient's return to contact sports should be restricted until maximal motion and extension strength are achieved. These outcomes are usually attained after 6 months. Patients should perform active resistive strengthening to achieve equal strength in the triceps for 3-6 months after surgery. [28]

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