Triceps Tendon Repair

Indication. A symptomatic distal triceps rupture — classically an inability to actively extend the elbow against gravity after an eccentric load (a fall onto the outstretched hand while the triceps is firing), with a palpable defect at the olecranon insertion and a positive modified Thompson test (inability to hold extension from 90° flexion). Repair is offered for a complete rupture in an active or young patient, a partial tear greater than 50% that has failed conservative care (splint, therapy, NSAIDs, and at least one injection), an iatrogenic detachment during a posterior elbow approach or revision arthroplasty, and a chronic rupture with a persistent functional deficit. A partial tear that still extends against resistance is managed without surgery. The pivotal decision is partial versus complete, made on MRI. MRI confirms the diagnosis, classifies the injury, measures retraction, and judges muscle quality — this single assessment decides non-operative care versus repair. Plain films (AP and lateral) are obtained first to look for an avulsed bone fragment (present in about 40% of avulsions); ultrasound offers a fast dynamic check of the gap. Acute versus chronic. An acute tear (less than 6 weeks) with good tissue is the setting for a straightforward primary repair. A chronic tear (greater than 6 weeks), a tear with retraction greater than 3 cm, or poor tissue on MRI shifts the plan toward reconstruction and augmentation — a high-risk patient (dialysis, steroid or fluoroquinolone exposure, revision) lowers that threshold further. The one decision that matters. Every repair begins with the same work — exposure, pattern recognition, footprint preparation, and locking sutures in the stump. The real choice is how you reattach and whether you augment:

Contraindicated in the presence of active infection at the surgical site, comorbidity precluding anaesthesia, severe limb ischaemia, or a non-compliant patient. Relative caveats are the elderly low-demand patient with a chronic rupture, severe osteoporosis (threatening fixation purchase — favour tunnels), multiple failed prior repairs, extensive soft-tissue compromise, and a chronic tear over a year old with severe retraction and atrophy. Consent specifically for a posterior scar, wound problems over the olecranon prominence, ulnar nerve symptoms, residual extension weakness, a small re-rupture risk, and stiffness — the commonest complication — plus the donor or allograft considerations if augmentation is planned. Setup. Lateral decubitus (preferred) or prone, arm over a bolster or hand table, upper-arm tourniquet inflated to 250–300 mmHg after exsanguination. General or regional anaesthesia (interscalene block). Loupe magnification helps nerve and tendon-edge identification.

The goal is to reattach the triceps to its olecranon footprint under correct tension while protecting the ulnar nerve, staying extra-articular, and preserving the skin envelope over the olecranon. The exposure — a posterior midline incision curved around the olecranon tip — is laid out in full below (and in depth on the posterior approach to the elbow page), with fixation, tensioning, and augmentation built on top of it.

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Rehabilitation follows an extension-priority programme — stiffness with a flexion contracture is the commonest complication, so regaining extension takes precedence over flexion throughout. | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 | 0–2 weeks | Posterior splint or hinged brace locked at 30–40° flexion | Finger, wrist and hand ROM only; wound care | | 2 | 3–6 weeks | Hinged brace, protected ROM 0–90° | Passive and active-assisted ROM; no active extension against resistance | | 3 | 6–8 weeks | Brace as needed | Full passive ROM; begin active extension (gravity only); extension stretching | | 4 | 8–12 weeks | Wean the brace | Light resistance extension (1–2 lb); no heavy lifting or push-ups | | 5 | 3–6 months | None | Progressive strengthening, sport-specific training; unrestricted by 4–6 months if strength is greater than 80% of the other side | Most patients return to desk work around 6 weeks and to heavy manual work by 4–6 months, with extension strength recovering to roughly 85–90% of the contralateral side by a year. Follow up at 2 weeks (wound check and suture removal), 6 weeks (ROM and strength, with radiographs if a bone fragment was fixed), 12 weeks (progress to unrestricted activity if appropriate), and 6 months (final outcome). Red flags between visits include wound drainage or erythema (infection), increasing pain with fever (deep infection), a palpable gap or new inability to extend actively (re-rupture or fixation failure), a progressive flexion contracture (over-tensioned repair or over-aggressive therapy), and ulnar nerve symptoms (compression or scarring).

Epidemiology. Distal triceps rupture is uncommon overall but over-represented in specific groups — weight-lifters using anabolic steroids (Sollender, 1998), patients on dialysis or chronic fluoroquinolones, and those with local steroid injection, olecranon bursitis, or hyperparathyroidism. It is most frequent in the third to fifth decade with a male predominance, and bilateral cases are described in systemic tendinopathy. Pathoanatomy. The triceps (long head from the infraglenoid tubercle, lateral head from the posterior humerus above the radial groove, medial head below it) converges on a broad, thin, dome-shaped footprint on the olecranon. Keener's cadaveric study defined a mean insertional width of about 21 mm and length of about 13 mm, beginning about 15 mm distal to the olecranon tip — so the proximal tip is not covered by tendon. A consistent lateral triceps expansion (about 70% of the central tendon width, continuous with the anconeus fascia) can preserve some active extension and thereby mask a central tear. The distal 2–3 cm of the tendon is a relative vascular watershed, contributing to degeneration. The radial nerve supplies all three heads (C7–C8), travelling in the spiral groove between the lateral and medial heads. Classification. Ruptures are described by location, by completeness, and by chronicity — and the three together guide management:

Key evidence. The management logic rests on four messages. First, diagnosis is often missed early — van Riet and Morrey (JBJS Am, 2003) found 10 of 23 ruptures initially misdiagnosed because acute swelling and pain mask the defect, and established the 3-week primary-repair window (3 of 14 primary repairs re-ruptured; final arc about 10–136° with strength near 82% of the uninjured side). Second, MRI is the pivotal investigation, distinguishing partial from complete tears — the Yeh JAAOS review (2010) frames partial tears with preserved extension as non-operative and complete tears in active patients as surgical. Third, anchors and tunnels are equivalent when suture number is matched (Carpenter, JSES 2018), removing any dogma about one being stronger. Fourth, chronic or poor tissue needs reconstruction, not over-tensioning — Sanchez-Sotelo and Morrey (JBJS Br, 2002) reconstructed seven chronic cases by anconeus rotation flap or Achilles allograft, with a final MEPS of 100 in five patients. The Alkhalfan meta-analysis (Cureus, 2023) synthesises this: no single technique is clearly superior across the literature.