Triceps tendon avulsion

Definition / Description

Avulsion of the M. triceps brachii is an uncommon injury. [1][2][3][4][5] When there is a disruption from the triceps at the osseus tendon insertion at the elbow, it’s called an avulsion of the triceps. This avulsion, is the most common disruption and might be characterized by a small “flake” of bone which is avulsed from the olecranon at the point where the triceps inserts. This is also called the ‘flake sign’. Intramuscular or musculotendinous disruption is labeled as a rupture of the triceps and occurs less often.[2] [3][4][5]

Epidemiology / Etiology

Avulsion of the triceps tendon may be caused by a trauma, but can also occur spontaneously or after surgical repair from a previous injury. [1] People who suffer from chronic renal failure or hyperparathyroidism may be more at risk for tendon avulsion. [1][5] A fall on the outstretched hand with the elbow in mid-flexion, with or without a concomitant direct blow to the posterior aspect of the elbow can also result in an avulsion. Sometimes avulsion of the triceps is associated with weightlifting, humeral fractures, corticosteroid injections to the triceps region, olecranon bursitis and anabolic steroid use. [1][5]

Clinical presentation

Examination of the patients can reveal swelling , pain and a palpable gap proximal to the olecranon. [3]

Physical therapy management

Level of evidence C :


After the repair of the tendon, follows an immobilization of the elbow. After ten days, the patient is no longer immobilized and begins with the dynamic splinting protocol. [1] In the article, the patient gets a single-hinged dynamic elbow splint. During the initial oedema the patient got several instructions like: ice, elevation and active motion of his shoulder, wrist and fingers. Seven to ten times in every walking hour, the patient was instructed to perform an active elbow flexion and passive extension within a 60 degree arc. Under supervision of the orthopedic surgeon, the active elbow flexion was increased each week with 15 degrees. Two weeks after the operation, the patient performed active forearm supination and pronation out of the splint. During this exercise the patient was seated, while his forearm rested on a table and his elbow maintained a angle of 90 degrees. [1]

An isometric program started after four weeks postoperative, with shoulder and wrist strengthening. The isometric exercises were performed by applying resistance to his shoulder and wrist, while producing a muscle contraction. Over the next ten days there was a progression to resistance exercises, including active shoulder and wrist motion against the resistance of elastic bands.[1]


Six weeks after the intervention, the therapy continued with contract/relax submaximal isometric exercises, for forearm pronation/supination and elbow extension. Submaximal means that you don't contract/relax the muscle to your full ability. The patient performed the exercises two or three times per day, in sets of ten repetitions. The patient was asked to “set” his muscle during the contraction phase, enough to feel his muscle slightly tense, hold for 5 seconds , and then relax. These exercises were both performed seated and standing, with the elbow in a continue angle of 90 degrees. After eight weeks, the splint was removed for active elbow flexion, extension and forearm motion . The patient used approximately 2.3 kg of resistance for the elbow flexion exercises . The patient was seated during these exercises and moved his arm in the sagittal plane. The use of the dynamic splint was terminated at nine weeks. At ten weeks, the patient started with resistance exercises, in gravity-lessened positions , for elbow extension. He used about 1.3 kg of resistance. Over the next two weeks, the patient started with triceps–strengthening exercises which were gradually increased. hereby the exercises were against gravity and 2.0 kg of resistance. The patient continued autonomous his exercise program after 13 weeks.
Sixteen weeks after the operation, the patient started again with sport activities, namely weightlifting at the gym.[1]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Michelle A. et al., Early mobilization using dynamic splinting with acute triceps tendon avulsion. Journal of hand therapy, 2005; 18 : 365-371 Level C
  2. 2.0 2.1 Clifford P.D. et al., Isolated long-head triceps brachii tendon avulsion in a surfer detected at MR imaging. Skeletal radiology, 2009 ; 38 : 77-80 Level C
  3. 3.0 3.1 3.2 Rajasekhar C. et al., Avulsion of the triceps tendon. Emergency Medicine Journal , 2002 ; 19 : 271-272.Level C
  4. 4.0 4.1 Sharma S.C. et al., Missed diagnosis of triceps tendon rupture : a case report and review of literature. Journal of orthopaedic Surgery , 2005 ;13(3) : 307-309. Level C
  5. 5.0 5.1 5.2 5.3 5.Singh R.K. et al., Complete rupture of the triceps brachii muscle. British Journal of Sports Medicine, 2002 ; 36 : 467- 469. Level C