Treatment

Nonoperative Treatment

A partial rupture of the triceps tendon can be treated non-operatively. The patient can obtain normal range of motion and strength through participation in a rehabilitation program. The patient should begin this program as soon as the acute pain has subsided.38 No consensus has been reached regarding the best way to position the elbow during the period of immobilization. Several authors have commented on the way the ruptured ends are approximated when the elbow is extended.32,42 This approximation has usually been confirmed in patients treated oper-atively. Most authors, however, prefer to place the elbow in slight flexion to facilitate recovery.36,38,42

Indications for Operative Treatment

Complete tears are debilitating and should be repaired surgically. Initially, the examiner can miss the diagnosis of a complete rupture because the patient's elbow is swollen and the patient cannot fully extend it. Nonoperative treatment of a complete tear results in incomplete extension and weakness.32,37,43 Therefore, the examiner must be careful to make the correct diagnosis.

Operative Techniques

All described surgical repairs of ruptured triceps tendons involve anatomic reapproximation of the tendon to its attachment on the proximal ulna. The triceps tendon usually retracts no more than 3 to 5 cm. The tendon does not need to be grasped with a clamp, but the distal edge should be trimmed back a few millimeters to provide fresh tissue. Securing the tendon in drill holes placed in the proximal ulna facilitates the repair.37 This repair can be augmented or protected by closing the periosteum over the tendon32,38 or oversewing a proximally based flap of forearm fascia33 or a distally based, partial-thickness flap of triceps.34 If an avulsion fracture of sufficient size is present, it can be fixed with a screw and washer,31 but the fragment should be at least three times the diameter of the screw. Sherman et al. and Levy used surgical tape to secure the tendon to the olecranon.43,44 Others have augmented the repair with either fascia lata or palmaris longus passed through drill holes in the olecranon.

Authors' Preferred Technique

The repair of the ruptured triceps tendon may be accomplished with the patient either positioned supine or prone. The senior author prefers to position the patient supine with a large bolster rolling the patient forward (Fig. 9.12). Rolling the patient forward allows the arm to be placed on the abdomen or chest, but still allows comfortable ex-

FIGURE 9.12. Patient positioning for triceps tendon repair. The patient is rolled into the lateral decubitus position.

posure of the distal aspect of the upper arm. Unlike the approach for repairing a ruptured biceps tendon, which requires a deeper dissection, the approach for repairing a ruptured triceps tendon is relatively superficial. Consequently, a tourniquet is not always necessary. If bleeding becomes a problem, a sterile tourniquet can be applied during surgery.

The surgeon makes a straight longitudinal incision over the posterior aspect of the elbow and the palpable tendon defect (Fig. 9.13). If skin integrity is a concern, the surgeon can make a curvilinear incision to avoid the bony prominence of the proximal portion of the olecra-non. The ruptured end of the tendon usually can be identified after the subcutaneous dissection is complete (Fig. 9.14). In partial tears the central portion of the tendon is disrupted. A no. 5 nonabsorbable suture is secured in the end of the tendon with either a Krakauer or Bunnell stitch (Fig. 9.15). In acute ruptures, the tendon usually can be brought down to the olecranon. The surgeon ties a knot in the nonabsorbable suture to secure it to drill holes made in the ulna (Fig. 9.16). The knot should be placed on the radial side of the ulnar ridge. Placing the knot directly posterior can cause postoperative irritation, and placing the knot ulnad can irritate the ulnar nerve. The surgeon should move the patient's elbow through a range of motion. Full extension should be obtained easily. The elbow should flex to 90°; some springiness is acceptable.

If the surgeon cannot bring the tendon down to the ole-cranon without sacrificing passive flexion, he or she must consider lengthening the tendon or using intercalated tissue. Elevating the triceps muscle off the posterior hu-

FIGURE 9.13. Posterior incision over the distal aspect of the upper arm.

FIGURE 9.14. Triceps tendon tear. The central portion of the tendon is detached, but the medial and lateral portions of the tendon are still attached to the olecranon.

merus sometimes can yield length. Care must be taken with this maneuver, because the radial nerve is vulnerable to injury in the spiral groove at the junction of the middle and distal thirds of the humerus. In chronic ruptures, mobilizing the proximal end still may be difficult.

FIGURE 9.15. The heavily braided suture is secured to the triceps tendon rupture.

FIGURE 9.16. (A) A smooth Steinmann pin is passed transversely through the proximal olecranon. (B) One limb of the suture will be passed through the hole made by the pin, and the suture will be tied on the radial side of the olecranon.

FIGURE 9.16. (A) A smooth Steinmann pin is passed transversely through the proximal olecranon. (B) One limb of the suture will be passed through the hole made by the pin, and the suture will be tied on the radial side of the olecranon.

Creating a distally based, partial-thickness flap, as Clayton and Thirupathi described, provides 2 to 4 cm of length.34 Additional length can be gained by modifying the Vulpius Achilles tendon lengthening technique. A V-shaped incision can be made proximal to the musculotendinous junction in the superficial triceps fascia. Sometimes, two incisions may be necessary. However, the use of V-shaped incisions generally weakens the triceps. In one patient I treated, the repair was augmented with a slip of the palmaris longus to bridge the gap between the olecranon and the triceps.

After surgery, the patient's arm is placed into a posterior splint with the elbow flexed from 45° to 90°. The patient begins elbow motion 3 weeks after surgery and begins strengthening exercises 6 to 8 weeks after surgery. The patient can return to full activities 12 weeks after surgery.

Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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