Delayed presentation of triceps tendon rupture after low-energy trauma: A case report

Abstract

BACKGROUND

Triceps tendon rupture is an uncommon injury and is most often linked to high-energy trauma or sports-related activities. However, injuries resulting from low-energy mechanisms may be overlooked, leading to delayed diagnosis. This case report was written to highlight an atypical mechanism of injury and to emphasize the need for clinical awareness of triceps tendon rupture even after minor trauma.

CASE SUMMARY

A 37-year-old medically free male patient presented with posterior elbow pain and reduced extension strength following a low-speed motorcycle accident. The patient initially received conservative management at another medical center and was subsequently referred to our institution, resulting in a seven-month delay before definitive evaluation. Clinical examination suggested a distal triceps injury. Imaging studies confirmed a high-grade partial rupture of the distal triceps tendon. The patient underwent surgical repair using a suture anchor with a Krackow technique and a structured postoperative rehabilitation program was implemented. Follow-up demonstrated good functional recovery, improvement in elbow extension strength, and resolution of pain without postoperative complications.

CONCLUSION

Triceps tendon rupture can occur after low-energy trauma, and timely diagnosis with appropriate surgical management can result in satisfactory functional outcomes.

Key Words: Triceps tendon rupture; Krakow technique; Anchor suture; Low-energy trauma; Case report

Core Tip: Triceps tendon rupture is uncommon elbow injury that is usually associated with high-energy trauma. We report the case of a 37-year-old man who sustained a near-complete distal triceps tendon rupture following a low-speed motorcycle accident. Diagnosis was established through clinical assessment and magnetic resonance imaging. The patient underwent surgical repair using a Krackow suture technique with suture anchor fixation, followed by a structured rehabilitation program. At six months, he achieved full pain-free range of motion and complete recovery of elbow extension strength. This case emphasizes the need to consider triceps tendon rupture even after low-mechanism injuries.

INTRODUCTION

Triceps muscle, situated on the posterior part of the arm, is responsible for forearm extension, a movement performed in many activities, such as pushing, lifting, and reaching. It has three heads: The long, lateral, and medial head, which all join together to form one muscle unit. A common tendon inserts the muscle into a prominent bony projection at the elbow called the olecranon, which is important for transmitting force when extended[1].

Triceps tendon ruptures are relatively rare compared to other tendon injuries[2]. However, it can cause significant discomfort because of its essential role. This injury often results in the tendon being torn, resulting in reduced or loss of function of the joint[3]. Ruptures of the distal triceps tendon are less common, but they often are serious and can incapacitate the individual if not appropriately addressed. The most common cause is high-energy trauma, such as falls, direct blows, or sports injuries. However, it has been realized that fractures can also occur after low-level mechanical stress like lifting heavy things or repetitive movements, especially when physically active or engaged in athletic activities[4].

Magnetic resonance imaging (MRI) is also invaluable in understanding the degree of tendon discontinuity, associated tendon retraction, and other abnormalities around the tendon; thus, it is essential in diagnosing triceps tendon rupture. Magnetic resonance imaging is functional before surgery as it examines the extent of the rupture, outlining the surgical objective[5].

Surgical procedures are preferred in cases where a complete tear or high-grade partial rupture occurs, as conservative management may not provide satisfactory healing of the elbow, among other conditions. Among the various surgical interventions available, the Krackow technique is commonly employed as it is well-suited for cases where a large tendon gap or retraction is present[6]. Other methods, such as suture anchors or screws, may also be utilized, depending on the type of rupture or the preferences of the surgeon[7]. Brush et al[8] found out that surgery repairs for such cases have an estimated infection rate of approximately 4%-15%. However, there are other factors also related to postoperative care management that should be taken into account. Besides, it is more common for the subjects who sustained ruptured elbow tendons to report infections, ruptures, or other functional complications after undergoing the surgery.

A literature review finds a few studies that document this procedure and outcome with most studies reporting that after undergoing surgical repair for triceps tendon rupture, their subjects are assessed to have increased functional activity in the affected arm[6,9,10]. Regular follow-up is crucial to monitor potential complications such as tendon elongation or formation of scar tissue and deficits in strength[11].

In our present study, we will present a rare case of triceps tendon rupture that was managed surgically at the Orthopedic Department. Here, we will emphasize the importance of early diagnosis and surgical intervention for distal triceps tendon rupture, particularly in cases arising from low-mechanism injuries, which are less commonly reported but can still lead to significant functional impairment if left untreated. Also, clinical presentation, surgical repair, and outcomes related to the distal triceps tendon rupture after a low mechanism injury.

We had obtained thorough clinical history, physical examination, assessment, and management. Also, the patient had provided an informed consent for the use of images and to publish this article as a case report, although the Research Unit does not require ethical approval for reporting case reports in our hospital.

CASE PRESENTATION

Chief complaints

A 37 year-old male complained of right posterior elbow pain for 7 months that was localized, non-radiating, and associated with weakness in extension limited to the right elbow compared to the contralateral side.

History of present illness

It started when he was driving a small street motorcycle at low-speed of 5-10 km/hour, during which he met a slippery part of the road, and the motorcycle was momentarily out of his control and almost fell to the left side. At that moment, the patient grabbed the handlebar of the motorcycle with his right hand, right elbow in a flexed position and tried to lift the motorcycle to the other side. Then, the patient felt a pop and developed weakness of his elbow, and later pain.

The patient initially received conservative management elsewhere, and therefore definitive orthopedic evaluation was delayed for approximately seven months after the injury. He referred to orthopedic upper extremity clinic by a primary healthcare then referred to a secondary hospital then to ours, where his first visit was on November 13, 2024.

History of past illness

According to the patient, he was hypertensive; however, he did not take treatment for it. Also, he had a past surgical history of multiple fractures after a motorcycle accident 10 years ago where he was admitted to the intensive care unit and fractures were treated surgically.

Personal and family history

Patient denied using any anabolic steroid, or any illicit drugs, he also denied smoking. Patient right-handed and the nature of his work includes heavy lifting and labor work which was affected by his condition. Review of systems for the patient did not reveal any remarkable information.

Physical examination

For clinical examination, the patient’s privacy was maintained, and then he was exposed. On general inspection he is 187 cm tall, muscular build male of African descent, multiple hypertrophic scars were seen over the arms and forearms bilaterally from his previous motorcycle accident and surgeries, right arm there was tricipital atrophy compared to the other side no scars seen over the right elbow posteriorly. On palpation of the right triceps, atrophy is also noted as well as a palpable defect of the triceps tendon medially. There was a full range of motion of shoulders, elbows, wrists, and hands; however, upon testing the active extension against resistance of the right elbow there was severe weakness compared to the other side, and pain was accentuated.

Neurological examination of bilateral upper limbs was unremarkable, except for weakness of right elbow extension related to nature of injury rather than neurological injury, and the distal vascular supply is intact.

Laboratory examinations

Patient had unremarkable laboratory examinations.

Imaging examinations

Patient complaint did not improve over time which made him seek medical help first at his primary hospital where he was seen, examined, right upper limb X-rays and right elbow MRI were done on August 26, 2024, and then he was referred to our clinic.

Radiographs were unremarkable. However, right elbow MRI showed increased T2 signal within the tendon and a 4 mm gap as well as edema and increased T2 signaling within the triceps muscle.

On a follow up MRI of the right arm and elbow we ordered in our clinic showed, redemonstration of the previously noted almost complete/high grade anterior partial tear of the distal triceps tendon with 14 mm tendon gap next to the insertion site on the olecranon process as well as mild partial medial fiber retraction. There was thickening and intermediate increased signal intensity of the tendon proximal to the tear site, as shown in Figure 1.

Figure 1 Magnetic resonance imaging right arm and elbow showed almost complete/high grade partial tear of the distal triceps tendon extending to the 14 mm tendon gap next to the insertion site on the olecranon process (arrows). A: Axial view; B: Sagittal view.

Right triceps tendon rupture almost complete rupture was clearly the definitive diagnosis which was demonstrated through the history, physical examination, and imaging.

FINAL DIAGNOSIS

A near-complete rupture of the right distal triceps tendon was established as the definitive diagnosis based on the patient’s history, physical examination, and imaging findings.

TREATMENT

Given the presence of a high-grade triceps tendon tear with a measurable tendon gap of approximately 14 mm, persistent weakness of elbow extension, and the patient’s physically demanding occupation, surgical repair was recommended to restore the continuity of the extensor mechanism and optimize functional recovery. Also, using suture anchors were selected to allow anatomic reattachment of the distal triceps tendon to the olecranon while providing strong fixation.

Therefore, we prepared the patient for right triceps tendon repair by Krakow technique suturing secured with a small joint suture anchor. The patient underwent the operation on December 8, 2024, after he was admitted.

Intraoperatively, we made a 20 cm incision extending from middle arm posteriorly to 5 cm below elbow, blunt dissection was done, and the ulnar nerve was identified. Triceps tendon was mobilized and Krackow double row suturing was done with 4 limbs inserted through bone tunnel secured with small joint suture anchor SwiveLock screw. Closure was done in layers and skin was stapled; the patient was put on an above elbow backslab at 30-degree and a cuff and collar, as shown in Figure 2. Our post-operative protocol was explained to the patient preoperatively which was the following: Immobilization for 4 weeks to prevent any tension on the repair. Afterwards, we begin active-assisted flexion range of motion and passive extension. Then, we progress to light strengthening with extension, and we progress furthermore with the strengthening exercises. Our goal is unrestricted activity at 8 months postoperatively.

Figure 2 Intra-operative. A: Intra-operative exposure of ruptured part of right triceps tendon; B: Intra-operative right-sided triceps tendon after repair with Krakow technique suturing secured with a small joint suture anchor.

Post-operatively in the ward, the patient was seen, he was doing well, pain was controlled, distal neurological and vascular supply were intact. Afterwards, the patient was discharged the next day on clear instructions, proper pain management, antibiotics, and a proton pump inhibitor to prevent stress gastritis.

OUTCOME AND FOLLOW-UP

Patient was asked to come for post-operative follow-ups in our clinic, his 1^st post operative visit, patient was pain free 3 days postoperatively, backslap applied and was well maintained and distal neurological and vascular supply were intact.

Seventeen days postoperatively, we removed the slap to inspect the wound which looked clean and dry, and was already healed. Also, staples were removed and backslap was reapplied to continue the immobilization period.

Six months postoperatively, the patient had flawless clinical recovery, having returned to usual activities of daily living without restraint or residual symptoms. The patient also reported satisfaction with the surgical outcome, with complete resolution of the pain and weakness experienced prior to surgery and was able to resume his normal daily activities.

The physical examination consisted of a complete, painless full range of motion of the elbow joint (0-140 degree), with normal muscle power of 5/5. The operative wound had healed with no evidence of infection, inflammation, or neurovascular compromise.

Elbow MRI, performed in multiple planes as shown in Figure 3, was consistent with the status post triceps tendon repair with suture anchors. Radiologic evaluation confirmed that the anchors were well and stable without loosening, hardware migration, or unfavorable bony reaction. Overall, radiological findings were consistent with successful healing and stable fixation at the tendon repair site.

Figure 3 Status post triceps tendon repair magnetic resonance imaging demonstrating repair site suture anchors at it is site, no tendon avulsion (arrows). A: Axial view; B: Sagittal view.

DISCUSSION

Worldwide, triceps tendon rupture is considered as one of uncommon upper extremity injuries, with an incidence rate of 0.8%[2,12]. However, missed diagnosis of this type of injury can lead to crucial outcomes[13].

In comparison to previously reported cases to our case, all of which had the same mechanism of injury which include sudden extension of elbow joint in different scenarios such as fall, direct trauma or weightlifting[14]. In our case, a patient has a sudden onset of forceful elbow contraction while trying to lift the motorcycle. Both previously reported case reports and series[4-6,11,13,14] and our case had excessive tension on maximum eccentric contractions on triceps muscle that led to rupture of tendon associated with reporting of painful pop sound. However, in our case low mechanism is what led to rupture compared to other previously published ones, and from this perspective, further studies should be obtained to illustrate low mechanism of injuries for triceps tendon rupture.

Although anabolic steroid use, oral steroids, local steroid injections for bursitis, renal illness, diabetes, and familial tendinopathy are potentially predisposing risk factors for rupture of triceps tendon[3], in our case report, the patient denied using any anabolic steroid or any illicit drugs. Also, he is only known to have hypertension. However, the patient’s occupation involved heavy lifting and manual labor, which may subject the distal triceps tendon to repetitive mechanical loading. Such repetitive occupational stress can lead to cumulative microtrauma and subclinical tendinopathy over time, potentially increasing the susceptibility of the tendon to rupture even after relatively low-energy trauma[3].

In order to approach appropriate diagnosis, radiological imagings are necessary to be obtained. For example, in triceps tendon rupture X-rays lateral film can have one of pathognomonic features including Dunn-Kusnezov Sign (DKS)[3]. However, in our study it is not there and even though there were many other reports included in a systematic review publication as DKS was presented by 61%[3], more studies should be done to assess its sensitivity.

Another modality can be used is MRI, in which it assesses location and severity of tendon rupture as a golden standard confirmatory. Furthermore, a false-positive MRI assessment of distal triceps injury is not rare as sometimes it may have low accuracy in differentiating partial-thickness from full-thickness tears[5]. Similarly, in our case, MRI of the right elbow shows almost complete/high grade partial tear of the distal triceps tendon.

Triceps tendon rupture has both nonoperative and operative management; however, operative management is considered as indicative one in case of complete tear or high-grade partial rupture to provide satisfactory results in terms of healing and return to function[6]. Available surgical options that were widely used include, Anchor suture technique[6], transosseous tunnel technique[6], suture bridge technique[7], anatomical repair[7]. Also, other techniques can be used to augment such as Achilles and Hamstrings grafts[7]. In our case, through a posterior approach, we used Krackow and suture anchor technique was used. While comparing Anchor suture to transosseous technique, both of them were favorable for the patients in reported systematic review, whereas, in terms of retear rates, complication rates, and isokinetic strength testing, suture anchor repair performed noticeably better[6].

This study has several limitations. First, it describes a single case, which limits the generalizability of the findings. Second, the follow-up duration was short (six months), which limits long-term complications such as tendon re-rupture or elongation. In addition, validated functional outcome scores were not documented at the time of treatment, limiting the objective evaluation of postoperative functional recovery. Therefore, further studies with larger patient cohorts and longer follow-up periods are needed to better assess the outcomes of distal triceps tendon repair following low-energy trauma.

CONCLUSION

This case demonstrates that distal triceps tendon rupture can occur even after minor trauma in otherwise healthy individuals, and may present late. Ongoing pain with weakness in elbow extension should prompt clinical suspicion. Therefore, early imaging and timely surgical management are important to achieve good functional recovery and avoid long-term complications.