History and Physical Examination

Most patients have experienced pain or a “pop” when performing a press-type activity or after a fall on an outstretched and slightly flexed elbow. In heavy-weight lifters, this usually occurs during a bench press activity, with resultant loss of control of the bar. In less active individuals, it can occur while pushing up from a seated position. Partial tears may begin with a subtle pain noticed in the beginning of extension from a fully flexed position. Dips and overhead triceps extension exercises, as often performed in body pump or weight-lifting classes, may represent the first time a patient begins to notice pain in the back of the elbow. This is especially true in cases of degenerative, dysvascular tear patterns.

The physical examination begins with observation for swelling or ecchymosis (Fig. 16-1). Patients with complete tears may have a complete loss of the ability to extend the elbow, whereas those with partial or degenerative tears may retain active extension but in a weakened state. In those with the more subtle tears, trying to extend the elbow from a fully flexed position reproduces pain directly over the site of the injury (i.e., triceps stress test), which can then be palpated for a defect.

FIGURE 16-1 The ecchymosis and deformity in the upper arm resulted from a triceps injury sustained during heavy bench press activity.

Diagnostic Imaging

Radiographs may show a small fragment of bone pulled off the tip of the olecranon or a fracture of a preexisting traction spur with superior migration up the arm. Magnetic resonance imaging may be more helpful in cases of incomplete or partial tears.

Conservative Management

In partial and degenerative tears, the elbow may be splinted in extension for a brief period, followed by bracing to prevent hyperflexion. Massage with anti-inflammatory cream may decrease swelling and stimulate blood flow in the tendon. As pain and inflammation subside, a rehabilitation program can be initiated to regain strength. The patient should refrain from excessive stress on the tendon for at least 3 months.

Arthroscopic Technique

The patient is placed in the prone or lateral decubitus position. The entire course of the ulnar nerve is carefully marked out. If there is too much swelling or the anatomy is distorted, a small incision is made, and the nerve is located and protected before beginning the arthroscopy.

The initial portal is a proximal anterior medial or lateral portal for a diagnostic arthroscopy of the anterior compartment. Because many of these patients use the arm for heavy lifting, there may be pathology anteriorly involving loose bodies or coronoid spurring that requires treatment before the repair procedure begins.

The initial portal into the posterior aspect of the elbow is the posterior central portal, located approximately 3 cm above the tip of the olecranon. In most triceps avulsions, this portal goes through the tear. A posterior lateral portal is then established, and the injury to the tendon is visualized (Fig. 16-2). The arthroscope is moved to the posterior lateral portal, and the shaver is introduced through the posterior central portal. The ulnar insertion is identified and lightly débrided, as are the edges of the torn tendon. A central olecranon bursa portal is then established, and a dual-sutured anchor is inserted at the proximal olecranon tip, angling toward the coronoid base to prevent inadvertent penetration through the articular surface (Fig. 16-3).

FIGURE 16-2 The triceps tear is visualized through a posterior lateral portal. Notice the exposure of the entire proximal olecranon.

FIGURE 16-3 The first anchor is placed into the proximal part of the olecranon in preparation for repair.

A retrograde retriever is then placed percutaneously through the medial and lateral aspects of the muscle-tendon junction of the triceps and is used to retrieve a suture through this area of the tendon (Fig. 16-4). Two mattress stitches are usually required to complete the proximal part of the repair (Fig. 16-5). The first set of sutures is retrieved percutaneously, and a sliding knot is tied to lock down the proximal attachment of the triceps and seal the joint. The second set of sutures is retrieved through the tendon and tied. The arthroscope is then placed into the olecranon bursa, and a second anchor is placed more distally in the ulna. These sutures are retrieved through the end of the tendon in a simple fashion to complete the repair (Fig. 16-6).

FIGURE 16-4 The sutures from the anchor are moved superiorly into the olecranon fossa and then retrieved through the proximal aspect of the triceps tendon.

FIGURE 16-5 The sutures are tied, repairing the tendon to the bone of the olecranon.

FIGURE 16-6 A-C, Repair technique for triceps avulsion injuries.

In an alternative technique, both anchors are placed before any suture shuttle or retrieval is undertaken. The proximal and distal sutures are then retrieved and tied. The sutures may be crossed to create a suture bridge that holds the tendon down to the bone.

Postoperative Management

The patient is placed in anterior and posterior splints with the elbow in almost full extension. On the first postoperative visit, a motion-limiting brace is applied, and an arc of 0 to 30 degrees is allowed. Each week, an additional 10 degrees is allowed until 6 to 8 weeks postoperatively, when the brace is discontinued.