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. [2, 10] 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.
Partial tendon avulsions or midsubstance muscle tears are treated nonoperatively with the arm in extension for 3-4 weeks. Gradual range-of-motion (ROM) exercises may be allowed at 3-4 weeks, as the patient's symptoms allow. [17, 18]
Surgical Care
All complete triceps tendon avulsions must be surgically repaired to restore extension strength. [2, 4, 5] Partial ruptures involving more than 50% of the tendon are commonly managed surgically as well. [2]
The role of surgery in the treatment of incomplete tears remains 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. [4]
Methods of repair
For complete tears or avulsion, the accepted method of repair is reattachment of the avulsed triceps tendon to the olecranon. [19] This repair is accomplished by using drill holes with heavy nonabsorbable sutures. [4, 5, 20, 21, 22]
A retrospective study comparing anchor fixation with transosseous fixation in 181 patients with 184 surgically treated acute traumatic triceps tendon avulsions found that transosseous fixation was associated with a significantly higher rerupture rate, a higher reoperation rate, and a longer time to release from medical care. [23]
If a large fragment (>50%) of the olecranon is fractured and displaced, open reduction with 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. [24] Care must be taken to avoid injuring the radial nerve with proximal mobilization. [17]
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. [25, 26] 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. [17]
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. [27]
Arthroscopic repair of distal triceps tendon rupture has been described, albeit rarely. [28]
Zacharia and Roy proposed the following treatment algorithm, [14] based on their classification of traumatic triceps tendon avulsions into four types (see Workup):
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Type I - Transosseous suture repair/suture anchor
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Type II - Transosseous suture repair
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Types III and IV - Tension band wiring or steel wire sutures
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. [10]
According to Bennett and Mehlhoff, the elbow is generally immobilized at 30-40° of flexion for 4 weeks. A graduated ROM and strengthening program is then begun. For example, the elbow is immobilized at 30° of flexion for 4 weeks, and then 0-45° of ROM is allowed during the next 2 weeks. After this time, graduated ROM and strengthening exercises begin. [17, 18]
An extension night splint is used for the first 3 months after repair.
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. [29] Overall, acceptable extension strength is restored after surgical repair. [10, 4] Many investigators have noted mild flexion contracture of 5-20° in approximately 10% of their reported cases. [13, 5]
A systematic review of 19 studies (N = 560) determined that in 565 instances of surgically repaired distal triceps tendon rupture, the overall incidence of postoperative complications was 14.9%. [30] Common complications included ulnar neuropathy, infection, and pain. When different repair techniques were compared, the incidence of complications was found to be 29.2% for the direct repair technique, 15.2% for the transosseous technique (transosseous suture), and 7.7% for the suture anchor technique.
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. [17]
