TECHNIQUE
A Treatment Algorithm for the Management of Distal Triceps Ruptures Patrick G. Marinello, MD,* Sebastian Peers, MD,* Shafic Sraj, MD,w and Peter J. Evans, MD, PhD*
Abstract: 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. Key Words: distal triceps, partial triceps rupture, complete triceps rupture, treatment algorithm, direct triceps repair (Tech Hand Surg 2015;19: 73–80)
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upture of the distal triceps brachii muscle is a relatively rare,1 but potentially troublesome injury. The reported incidence of distal triceps rupture is 90% of the tendon is considered a full-thickness tear.4 If the tear is complete, the next step is determining the chronicity of the injury. This helps the surgeon determine whether the tendon will be easily mobilized to the insertion. A chronic, retracted tear will be less likely to mobilize. The ability to mobilize the tendon to the insertion may not be known until surgery. Any residual
Volume 19, Number 2, June 2015
shorting of the tendon after mobilization will require an alternative method of repair to compensate for tissue loss. This should be tested with arm in full extension. This uncertainty requires that the surgeon have ready a variety of methods to surgically manage this injury.
PARTIAL DISTAL TRICEPS TEAR AND ACUTE COMPLETE TEARS Conservative Management Partial tears of the triceps tendon can heal spontaneously and therefore conservative management of partial tears has been successful.3 Nonoperative treatment consists of bracing or splinting, and avoidance of heavy lifting, pushing, and resisted elbow extension until signs of healing are evident clinically, for a period of 1 to 9 weeks determined on individual basis.4,6 For high-functioning patients (ie, athletes) early primary repair can be considered on a case-by-case basis. Earlier return to strenuous activity may lead to complete rupture of the tear.4 Some patients may continue to show residual weakness that may or may not warrant surgical intervention, depending on their physical requirements.4 At 3 months after diagnosis, the patient should be pain free and able to complete all daily activities of living. If this is not the case, nonoperative treatment has failed, and delayed surgical treatment of a partial triceps rupture remains an option.
Direct Repair Acute complete and high-grade partial ruptures of the triceps tendon require surgical intervention. The direct repair is best in tears with limited tendon retraction, preservation of tendon substance, and in injuries that are
A Treatment Algorithm for the Management of Distal Triceps Ruptures Patrick G. Marinello, MD,* Sebastian Peers, MD,* Shafic Sraj, MD,w and Peter J. Evans, MD, PhD*
Abstract: 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. Key Words: distal triceps, partial triceps rupture, complete triceps rupture, treatment algorithm, direct triceps repair (Tech Hand Surg 2015;19: 73–80)
R
upture of the distal triceps brachii muscle is a relatively rare,1 but potentially troublesome injury. The reported incidence of distal triceps rupture is 90% of the tendon is considered a full-thickness tear.4 If the tear is complete, the next step is determining the chronicity of the injury. This helps the surgeon determine whether the tendon will be easily mobilized to the insertion. A chronic, retracted tear will be less likely to mobilize. The ability to mobilize the tendon to the insertion may not be known until surgery. Any residual
Volume 19, Number 2, June 2015
shorting of the tendon after mobilization will require an alternative method of repair to compensate for tissue loss. This should be tested with arm in full extension. This uncertainty requires that the surgeon have ready a variety of methods to surgically manage this injury.
PARTIAL DISTAL TRICEPS TEAR AND ACUTE COMPLETE TEARS Conservative Management Partial tears of the triceps tendon can heal spontaneously and therefore conservative management of partial tears has been successful.3 Nonoperative treatment consists of bracing or splinting, and avoidance of heavy lifting, pushing, and resisted elbow extension until signs of healing are evident clinically, for a period of 1 to 9 weeks determined on individual basis.4,6 For high-functioning patients (ie, athletes) early primary repair can be considered on a case-by-case basis. Earlier return to strenuous activity may lead to complete rupture of the tear.4 Some patients may continue to show residual weakness that may or may not warrant surgical intervention, depending on their physical requirements.4 At 3 months after diagnosis, the patient should be pain free and able to complete all daily activities of living. If this is not the case, nonoperative treatment has failed, and delayed surgical treatment of a partial triceps rupture remains an option.
Direct Repair Acute complete and high-grade partial ruptures of the triceps tendon require surgical intervention. The direct repair is best in tears with limited tendon retraction, preservation of tendon substance, and in injuries that are
