Skull crushers gone wrong
Authors: Peter Mitchell Martin, DO;
Peer Reviewer: R. “Max” Lystrup, MD, CAQ-SM
Editor: Alex Tomesch, MD, CAQ-SM
57 year-old weight-lifter presents after a painful pop in his left posterior elbow while doing elbow extensions. On exam he has significant posterior elbow bruising and weakness.
Figure 1: Peter Martin’s Images, AP and Lateral XR of patient’s left elbow
What is your initial workup in the ED?
It is a clinical diagnosis based on the mechanism of injury (strong, mechanical overload during eccentric muscle contraction of the triceps or fall on outstretched hand) as well as pain and weakness with resisted elbow extension. However, X-ray of the elbow can help rule out acute fracture (such as of the olecranon) [1].
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Pearl: Bedside ultrasound is also helpful, as imaging of the distal triceps insertion at the olecranon can assess the tendinous insertion, fluid accumulation, and degree of retraction. See example image below, performed in long axis to distal triceps tendon.
Figure 2 (top): Ultrasound distal triceps with tendon rupture and retraction [2]
What imaging confirms the diagnosis?
MRI is recommended for evaluation of distal tricep tears. MRI can confirm the diagnosis, rule out associated olecranon fracture, and guide further management [1].
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Pearl: MRI should be performed soon after discharge from the ED as best surgical outcomes are obtained when surgery is performed acutely, within 2-3 weeks of injury occurrence [3].
F0igure 3: Case image, MRI left elbow with near complete distal triceps rupture, supplied by Peter Martin.
References:
[1] Yeh PC, Dodds SD, Smart LR, Mazzocca AD, Sethi PM. Distal triceps rupture. J Am Acad Orthop Surg. 2010;18(1):31-40. doi:10.5435/00124635-
[2] Patel, M. Triceps tendon tear. Case study, Radiopaedia.org. (accessed on 16 Feb 2022) https://doi.org/10.53347/rID-
[3] Kocialkowski C, Carter R, Peach C. Triceps tendon rupture: repair and rehabilitation. Shoulder Elbow. 2018;10(1):62-65. doi:10.1177/1758573217706358
[4] Jaiswal A, Kacchap ND, Tanwar YS, Kumar D, Kumar B. Rupture of the triceps tendon - A case series. Chin J Traumatol. 2016;19(4):235-238. doi:10.1016/j.cjtee.2016.06.