Bone suture anchor repair and functional outcome of a triceps tendon rupture, a rare clinical entity

Abstract

Triceps tendon rupture is rare and easily missed on presentation. A 58-year-old man was seen in our accident and emergency department with an inability to extend his right elbow against gravity after he fell. Ultrasound and MRI confirmed the suspected diagnosis of a traumatic triceps tendon rupture and excluded additional injuries. Surgical repair was carried out by a bone anchor suture reinsertion of the tendon to the olecranon. After 2 weeks of cast immobilisation, an early active range of motion (ROM) rehabilitation schedule was followed, resulting in excellent elbow function at 12 weeks postoperatively.

In conclusion, it is important to suspect this rare injury and use additional studies to confirm the diagnosis of triceps tendon rupture. Also, good clinical outcome with regards to function can be achieved using bone anchor suture repair and an early active ROM rehabilitation schedule.

Background

With an incidence of 1.1 per 100 000 person-years, triceps tendon injuries are rare.¹ Initial presentation, which includes swelling and bruising, can have a diverse differential diagnosis. Therefore, such injury can be easily missed on initial evaluation. A recent history of trauma to the elbow, forced flexion during extension in combination with clinical findings suggestive of triceps tendon injury should raise clinical suspicion. Clinical findings are swelling, haematoma formation and especially inability to extend the elbow against gravity. During testing, the elbow should be extended against gravity rather than passively extended with gravity. An index of suspicion warrants additional imaging to confirm the diagnosis and determine the extent of the injury.

The purpose of this case report is to show that early recognition and bone anchor suture repair followed by an early active range of motion (ROM) rehabilitation schedule can result in near-full recovery at 12 weeks postoperatively.

Case presentation

Presentation at accident and emergency

A 58-year-old man presented to the accident and emergency department after having tripped and fallen on his right elbow while in a 90° flexed position. Besides a penetrating glass injury to the posterior aspect of his right upper arm 35 years earlier, medical history was unremarkable. After this prior injury, no loss of function occurred. Physical examination showed a subtle swelling and pain proximal to the olecranon (figure 1). The patient was unable to extend the elbow against gravity. Based on the mechanism of injury and the findings during medical examination, a traumatic triceps tendon rupture was suspected.

Figure 1.

Left-to-right normal left upper arm, subtle swelling of the (injured) right upper arm and scar on the distal posterolateral aspect of the arm after injury 35 years prior.

Investigations

Additional studies

Plain X-ray film of the right elbow showed a small osseous avulsion fragment (<1 cm) at the distal insertion of the triceps tendon (figure 2).

Figure 2.

Plain lateral X-ray showing small osseous avulsions at the triceps tendon insertion.

Additionally, ultrasound examination showed a complete right-sided triceps tendon rupture with some degree of retraction in combination with the known osseous avulsion.

MRI was performed to assess the extent of retraction of the triceps brachialis tendon and muscle in order to potentially aid preoperative planning while excluding other ligamentous injuries. MRI showed a complete rupture of the tendinous part of the right-sided distal triceps muscle insertion with almost no retraction of the tendon and excluded additional injuries (figure 3).

Figure 3.

T1 (left) and T2 (right) weighted MRI results in sagittal plane confirming the triceps tendon rupture with slight retraction.

Treatment

Surgical technique

Surgery was performed under general anaesthesia. As antibiotic prophylaxis 2 g of cefazoline was administered intravenously. The patient was positioned in prone position with padded supports under the upper arm. An axillary tourniquet was placed. The contralateral arm was placed in an overhead position to allow access for intravenous drug administration (figure 4) (top).

Figure 4.

Top: patient in prone position with padded support and high pneumatic tourniquet. Bottom left: marking of landmarks. Bottom right: red vessel loop around the ulnar nerve and mobilised ruptured tendon end held with a forceps.

After marking of all anatomical landmarks (figure 4, bottom left), a dorsal midline incision with a slight ulnar curve at the level of the olecranon was performed. The ulnar nerve was identified and dissected, consequently being marked by a red vessel loop avoiding traction on the nerve. Dissection was continued to adequately expose the ruptured tendon (figure 4, bottom right). Further debridement of the ruptured tendon end did not prove necessary. Intraoperative findings were consistent with an acute injury, no evidence for chronic rupture was found.

Next, two GII Anchor bone suture anchors (2.4 × 8.8 mm Ti/Nitinol anchor with #2 Orthocord suture, DePuy Synthes, Raynham Massachusetts) were inserted at the triceps tendon footprint insertion site in the olecranon (figure 5). The radial and ulnar sides of the distal stump of the tendon were reattached using running locking Krackow sutures and tied to the free end of the suture at the anchor with the elbow in extension (figure 5). Subcutaneous tissue was closed using absorbable braided sutures (V.2.0 Vicryl) and skin with a running intracutaneous absorbable monofilament suture (V.3.0 Monocryl).

Figure 5.

Top: insertion of two bone suture anchors at the triceps tendon footprint insertion site in the olecranon. Bottom: tied off running Krackow suture repair of the ruptured tendon ends (radial and ulnar).

A plaster cast in 40° flexion was applied for the initial 2 weeks postoperatively.

Outcome and follow-up

Postoperative course and functional outcome

The rehabilitation schedule described by Kocialkowski et al was used.² During follow-up, Disability of Arm, Shoulder and Hand (DASH) scores and Constant Murley Scales were determined (table 1).

Table 1.

Functional and patient-reported outcomes, parameter baseline (preinjury) at 6 and 12 weeks

Parameter	Baseline (preinjury)	6 weeks	12 weeks
ADL function	Unhindered	Unhindered	Unhindered
Pain	None	At end of ROM	None reported
Pain NRS (range 0–10)	0	3	1
ROM
Flexion/extension	150-0-0	100-5-0	150-0-0
Pronation/supination	90-0-90	80-0-85	90-0-90
DASH score (range 0–100)	N/A	67	91
Constant Murley Scale (range 0–100)	N/A	63.5	86.5

ADL, activities of daily living; DASH, disabilities of the arm, shoulder and hand; NRS, numeric rating scale; ROM, range of motion.

Outpatient clinic visits at 1 and 2 weeks postoperatively showed no wound healing abnormalities. There was no ulnar nerve neuropraxia present at follow-up. No pain was reported during cast immobilisation.

Two weeks after surgery, the plaster cast was removed and an elbow brace (Sprofit, Genk, Belgium), limiting movement from 0 to 90 degrees of flexion without impairing supination and pronation, was applied for a total of 4 weeks. Furthermore, the patient was referred to a physiotherapist guiding the recovery. Exercises in postoperative weeks 2–4 included active pro and supination, active elbow extension and light isometric elbow flexion. Shoulder exercises and anconeus muscle strengthening were performed. Progression to active full extension with shoulder at 90 degree abduction was allowed.

At week 4–6, an increase in ROM from 0 to 120 degrees in the elbow brace was instituted. Still, no active resisted extension was allowed as well as passive flexion beyond 120 degrees when out of the brace. Physiotherapy exercises were progressed to flexion/abduction open chain and loaded supination/pronation exercises. At 6 weeks follow-up, ROM (flexion/extension) in the elbow joint was 100-5-0 (ie, 5° extension deficit). Slight pain was reported at the ends of the different ranges of motion.

In the next phase at 6–12 weeks, postoperatively the elbow brace was removed to allow full ROM. Any exercises or activities that elicit pain were still avoided as well as heavy lifting. Physiotherapy was aimed at strengthening, kinetic chain and proprioceptive exercises.

At 12 weeks follow-up, little to no pain was reported with a good function of the shoulder, elbow wrist and hand. After 3 months postoperatively, physiotherapy had focused on gradual training in regaining strength, this included weightlifting and push-ups. At 12 months postoperatively the patient reported excellent functional results. Full recovery of strength and ROM compared with the uninjured arm. No pain or other residual symptoms were reported. He fully resumed his normal work (bus driver) and was even able to pave his terrace with his neighbour.

Discussion

Case discussion

In this case, the injury that the patient sustained 35 years ago might have contributed to the current injury. If the tendon had been injured, then it might have always remained a weakness resulting from scar tissue formation and perhaps altered local biomechanical forces resulting in a higher chance of injury.

No other known risk factors for triceps tendon ruptures were present in this case. These risk factors include anabolic steroid use, local steroid injections, renal disease, diabetes, familial, tendinopathy or hypoparathyroidism,.³

Literature review

When a clinical suspicion on a triceps rupture is raised, clinicians rely on imaging techniques to confirm the diagnosis. Based on its anatomy and function, we tested the extension of the elbow against gravity to assess for potential triceps rupture. However, literature only reports a triceps squeeze test, without any diagnostic accuracy.⁴

In our case, we have shown osseous avulsions superior to the olecranon at the triceps insertion site using conventional radiography, whereas ultrasound confirmed the diagnosis. Although, widely available, ultrasonography of tendons is considered to be able to confirm the initial diagnosis, but data on specificity and sensitivity are lacking.⁵ A systematic evaluation from proximal (musculotendinous junction) to distal has been described in the literature.⁶ Using a 5–15 MHz, linear transducer with the elbow in 90 degrees flexion, the triceps should be identified at the musculotendinous junction and moved distally on the longitudinal axis up towards olecranon insertion site. Hyperechoic or anechoic areas are associated with haematomas and, thus, the possibility of tendon disruption, whereas a complete torn tendon is traditionally retracted and thickened.

In order to select candidates for surgery, clinicians should differentiate between partial and complete tendon injuries. Conservative treatment using an extension splint has a role in partial triceps brachii tendon ruptures and can be chosen in selected patients (ie, elderly patients and/or involvement of the nondominant arm), whereas complete tendon injuries are routinely operated. Although ultrasonography is widely available, its traditional high intraobserver variability might be of concern. Therefore, an additional MRI could be considered whenever there is uncertainty about the diagnosis or if there is a clinical suspicion of other concomitant injuries (eg, ulnar nerve injury, other tendinous disruptions).

The choice of the surgical technique for surgical management largely depends on the tissue quality, the extensity of muscle retraction and surgeon’s personal preference. Thus, all techniques rely on reinsertion of the triceps to the olecranon using heavy nonabsorbable sutures in a locking fashion as a Bunnell or Krackow suture repair. Fixation on the olecranon is performed using two transverse drilling holes, exiting at the dorsal sites, tying the suture on the radial side of the ulnar crest.⁷ In case of severe tendon injury or muscle retraction, an autograft augmentation is indicated using the palmaris longus or plantaris tendon autograft or a flexor carpi radialis allograft.⁷ In case of severe retraction or tendon tissue deficiency, an Achilles tendon autograft provides a solid alternative, connecting the distal stump of the triceps to the allograft using locking nonabsorbable N.5 sutures.⁷ The fixation to the olecranon is similar to the direct repair technique. In case of olecranon osseous deficiency, k-wire fixation of a piece of calcaneus bone on the olecranon provides additional surgical options.

Given our extensive experience with bone anchor sutures, we opted for using these to perform the triceps tendon fixation. We believe that in comparison with the previously described techniques, bone anchoring provides a ‘one-stop-solution’ minimising osseous injury in case the olecranon is intact. Biomechanical studies have shown that suture anchors do not provide a stronger repair in comparison with transosseous tendon repair,⁸ nor do they provide improved functional outcomes.⁹ Transosseous tendon repair provides an alternative cheaper option, requiring more extensive drilling, potentially inducing more soft-tissue injury, leading to longer operative times.

After surgery, the elbow of our patient was immobilised using a plaster cast in 40 degrees flexion. Others suggest that extension of the elbow is initially required in order to minimise traction on the repaired tendon, stating that contractures of the elbow are seldomly seen,¹⁰ while an average loss of extension of 10 degrees is reported in another study.¹¹ However, due to the incidence of the injury, no scientific evidence to date is available supporting either extension-directed or flexion-directed casting postoperatively.

Following the generalised belief that early restoration of the ROM of the elbow joint is necessary to reduce stiffness, we opted for a quick controlled limited flexion (90°), protecting the elbow joint as described earlier.²

Little is known about the optimal rehabilitation strategy in patients after surgical repair for a triceps tendon injury.^12–15 Two papers concerning professional football players with triceps tendon injury reported a return to professional football in 56 out of a total of 57 patients.^{14 15} In a cohort evaluating 50 military subjects, 94% eventually returned to active military service. Therefore, in these high-demand populations, good results have been observed.

Studies evaluating nonathletic subjects are sparser. One study performed by Bava et al found significant improvements in DASH score, American Shoulder and Elbow Surgeons Score and Mayo Elbow scores in five patients followed for a mean period 32 months after surgical repair.¹² Another small-volume series evaluating eight patients showed excellent Mayo Elbow scores in six patients and good results in two patients.¹³

Following the rehabilitation strategy proposed by Kocialkowski et al,² our patient showed significant impairment of mainly flexion after 6 weeks, leading to significant reductions in the DASH score (67) and Constant Murley Scale (63.5), whereas its ROM improved up until normal levels with is associated DASH-score of 91 and Constant Murley Scale of 86.5. Therefore, our results support the current literature on the outcome after surgical repair of these injuries.

Although rare, clinicians participating in trauma care should be aware of the possibility of triceps tendon ruptures in patients presenting themselves with elbow trauma with inability to extension and/or a subtle swelling proximal to the olecranon. Ultrasound may be helpful in the initial diagnosis, but MRI allows complete visualisation of the extent of the injury and aids in planning the surgical repair. Surgical repair allowing for early active ROM rehabilitation using bone suture anchors led to excellent functional results after 3 months, comparable to that seen in the available literature.⁹

Learning points.

• Triceps tendon rupture is a rare injury.

• An index of suspicion warrants further diagnostic studies to identify the injury, that is, ultrasound and/or MRI.

• Surgical repair using bone anchors, allowing for postoperative early active range of motion rehabilitation, offers excellent functional results.

Ethics statements

Patient consent for publication

Obtained.