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Write a short note on triceps surgery for Ms orthopedics theory examination gold medal level

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distal triceps tendon rupture repair transosseous tunnel olecranon

**Imaging Modality:** Intraoperative fluoroscopy (C-arm radiograph). **Anatomical Region:** Lateral view of the right elbow joint, including the distal humerus, proximal radius, and proximal ulna (olecranon). **Observed Pathology/Procedure:** Post-surgical repair of a triceps tendon rupture. The image demonstrates the implementation of a transosseous suture technique for tendon refixation to the olecranon process. **Characteristic Visual Features:** * **Hardware:** Multiple radiopaque, high-tensile sutures or wires are visible traversing the proximal ulna. * **Configuration:** The sutures follow a transosseous drill hole pattern, looping through the dorsal aspect of the olecranon to secure the distal triceps brachii tendon. * **Joint Alignment:** The ulnohumeral and radiocapitellar joints appear grossly aligned in a partially flexed position. * **Soft Tissue:** Subtle thickening of the posterior soft tissues is noted, consistent with the surgical site and tendon distal stump localization. **Key Diagnostic Features:** Identification of transosseous tunnels and suture material at the anatomical insertion point of the triceps tendon on the olecranon, confirming surgical stabilization of a previously ruptured extensor mechanism.

**Imaging Modality:** Intraoperative fluoroscopy (C-arm radiograph). **Anatomical Region:** Lateral view of the right elbow joint, including the distal humerus, proximal radius, and proximal ulna (olecranon). **Observed Pathology/Procedure:** Post-surgical repair of a triceps tendon rupture. The image demonstrates the implementation of a transosseous suture technique for tendon refixation to the olecranon process. **Characteristic Visual Features:** * **Hardware:** Multiple radiopaque, high-tensile sutures or wires are visible traversing the proximal ulna. * **Configuration:** The sutures follow a transosseous drill hole pattern, looping through the dorsal aspect of the olecranon to secure the distal triceps brachii tendon. * **Joint Alignment:** The ulnohumeral and radiocapitellar joints appear grossly aligned in a partially flexed position. * **Soft Tissue:** Subtle thickening of the posterior soft tissues is noted, consistent with the surgical site and tendon distal stump localization. **Key Diagnostic Features:** Identification of transosseous tunnels and suture material at the anatomical insertion point of the triceps tendon on the olecranon, confirming surgical stabilization of a previously ruptured extensor mechanism.

This intraoperative clinical photograph displays an orthopedic surgical procedure for the repair of a complete distal triceps tendon rupture in the posterior elbow region. The surgical field, accessed via a longitudinal approach, reveals the retracted and frayed distal triceps tendon (labeled 'a'), exhibiting irregular texture and discoloration indicative of high-grade injury. A synthetic tendon allograft (labeled 'b'), appearing as a structured, lighter-colored uniform band, is shown positioned through a transverse drill hole in the olecranon (labeled 'O'). Visible surgical instruments include a metal retractor holding back soft tissue to maintain exposure of the musculotendinous junction. Suture strands are present, integrated into the synthetic augmentation material to facilitate tensioning and reattachment of the triceps tendon to the bone. This image serves as an educational reference for complex tendon reconstruction techniques involving synthetic augmentation and allograft positioning.

This intraoperative clinical photograph displays an orthopedic surgical procedure for the repair of a complete distal triceps tendon rupture in the posterior elbow region. The surgical field, accessed via a longitudinal approach, reveals the retracted and frayed distal triceps tendon (labeled 'a'), exhibiting irregular texture and discoloration indicative of high-grade injury. A synthetic tendon allograft (labeled 'b'), appearing as a structured, lighter-colored uniform band, is shown positioned through a transverse drill hole in the olecranon (labeled 'O'). Visible surgical instruments include a metal retractor holding back soft tissue to maintain exposure of the musculotendinous junction. Suture strands are present, integrated into the synthetic augmentation material to facilitate tensioning and reattachment of the triceps tendon to the bone. This image serves as an educational reference for complex tendon reconstruction techniques involving synthetic augmentation and allograft positioning.

This clinical photograph displays an intraoperative view of an open orthopedic surgical field during the repair of a triceps tendon avulsion fracture of the right olecranon. The incision reveals a posterior midline approach to the elbow joint. Skin and subcutaneous adipose tissue are retracted laterally with surgical instruments, exposing the deep fascia and musculature. Central to the field is a displaced proximal ulnar bone fragment, characteristic of an olecranon avulsion. The fragment shows a clear irregular fracture line and remains attached to the triceps brachii tendon, which appears intact without longitudinal rupture. The surgical site contains significant serosanguinous fluid and highlights the anatomical relationship between the displaced bony component and the distal ulna. This visual serves to illustrate the surgical pathology of AO classification 2U1A1 fractures, emphasizing the pull of the triceps muscle on the proximal fragment and the necessity of anatomical reduction for restoring the elbow's extensor mechanism.

This clinical photograph displays an intraoperative view of an open orthopedic surgical field during the repair of a triceps tendon avulsion fracture of the right olecranon. The incision reveals a posterior midline approach to the elbow joint. Skin and subcutaneous adipose tissue are retracted laterally with surgical instruments, exposing the deep fascia and musculature. Central to the field is a displaced proximal ulnar bone fragment, characteristic of an olecranon avulsion. The fragment shows a clear irregular fracture line and remains attached to the triceps brachii tendon, which appears intact without longitudinal rupture. The surgical site contains significant serosanguinous fluid and highlights the anatomical relationship between the displaced bony component and the distal ulna. This visual serves to illustrate the surgical pathology of AO classification 2U1A1 fractures, emphasizing the pull of the triceps muscle on the proximal fragment and the necessity of anatomical reduction for restoring the elbow's extensor mechanism.

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TRICEPS SURGERY

Applied Anatomy

The triceps brachii is the sole extensor of the forearm at the elbow. It has three heads:
  • Long head - arises from the infraglenoid tubercle of the scapula
  • Lateral head - arises from the posterior surface of the humerus (above the spiral groove)
  • Medial head - arises from the posterior surface of the humerus (below the spiral groove, deepest component)
All three heads converge into a single common tendon that inserts onto the posterior surface of the olecranon process of the ulna. The long and lateral heads form the superficial, tendinous component; the medial head is deeper and mainly muscular at insertion. The entire muscle is innervated by the radial nerve (C6, C7, C8), which courses around the spiral groove before giving branches to each head.
The anconeus muscle, also innervated by the radial nerve, can partially substitute elbow extension, which is why some complete triceps ruptures are initially missed.

I. TRICEPS TENDON RUPTURE AND REPAIR

Epidemiology & Etiology

Rupture of the triceps tendon is the rarest of all tendon ruptures - far less common than biceps, quadriceps, or patellar tendon ruptures. It occurs most often in middle-aged males. The injury usually occurs as an avulsion of the tendon with a small piece of bone from the olecranon tip.
Risk factors:
  • Anabolic steroid use
  • Multiple local corticosteroid injections (e.g., for olecranon bursitis)
  • Chronic olecranon bursitis
  • Systemic conditions: hyperparathyroidism, chronic renal failure, lupus, rheumatoid arthritis
Mechanisms:
  • Sudden forceful flexion of an extended elbow (most common - eccentric overload)
  • Direct blow to the posterior elbow
  • Fall on an outstretched hand
Sites of rupture (in order of frequency):
  1. Olecranon insertion (most common - avulsion type)
  2. Musculotendinous junction
  3. Midsubstance (least common)

Clinical Features

  • Pain and swelling over the posterior elbow
  • Ecchymosis - may track distally
  • Palpable gap/defect just proximal to the olecranon (may be masked by swelling acutely)
  • Weakness of elbow extension; inability to actively extend against resistance in complete tears
  • ~50% of injuries are initially missed (because the anconeus can still produce some extension)
Modified Thompson test (Ruland test): Patient prone, elbow flexed, forearm hanging over table edge - squeezing the triceps does not produce elbow extension (analogous to Thompson test for Achilles).

Investigations

  • X-ray: "Flake sign" - a small fleck of avulsed bone from the olecranon tip on lateral view (pathognomonic)
  • MRI (gold standard): Sagittal T2 images most useful
    • Partial rupture: small fluid-filled defect in the tendon (bright on T2)
    • Complete rupture: large fluid-filled gap between the distal tendon and olecranon
  • Ultrasound: Dynamic assessment of partial tears

Treatment

Non-operative: Reserved for elderly, low-demand patients or partial tears involving <50% of tendon width. Splint in ~30° flexion for 4 weeks, followed by progressive mobilisation.
Operative indications:
  • All complete ruptures in active individuals
  • Partial tears involving >50% of tendon width in active individuals
  • Any complete tear where extension strength is significantly compromised

Surgical Techniques

1. Transosseous Suture Repair (Classic/Standard Technique)

The time-honoured technique, described by McLaughlin and popularised through Mersilene strip repair.
Position: Prone or lateral decubitus, arm supported, tourniquet applied.
Approach: Straight posterior midline incision ~6-8 cm centred over the olecranon tip.
Steps:
  1. Mobilise subcutaneous tissues to expose the torn tendon
  2. Debride frayed edges of the ruptured tendon and curette the olecranon footprint to bleeding bone
  3. Drill two or three longitudinal tunnels through the olecranon (2.0 mm drill)
  4. Place heavy nonabsorbable sutures (No. 2 or No. 5, e.g., Ethibond) through the tendon using a Krackow (locking) stitch or Bunnell stitch
  5. Pass suture ends through the transosseous tunnels and tie over the olecranon with the elbow in full extension
  6. A tension-relief (cerclage) suture of No. 5 nonabsorbable material can be added around the repair construct to offload stress
Mersilene strip technique (Campbell's classic): A Mersilene strip is passed through a hole in the olecranon, threaded through the tendon in a locking loop, and tied - distributing load over a wider area.
Triceps tendon anatomy and Mersilene strip repair construct
Campbell's Operative Orthopaedics Fig. 53.49 - Repair of triceps tendon avulsion. Left: Mersilene strip passed through olecranon tunnel and looped through tendon. Right: Completed repair construct.

2. Double-Row Suture Anchor Repair (Azar Technique - Campbell's Operative Orthopaedics 2026)

Current evidence favours suture anchor repair, with Mirzayan et al. (184 cases) showing significantly lower rerupture and reoperation rates compared to transosseous tunnel repair.
Steps (Technique 53.34 - Azar):
  1. Patient supine, posterior midline incision 6-8 cm over olecranon
  2. Debride tendon edges; curette olecranon footprint to bleeding bone
  3. Place #2 FiberWire (Arthrex) through tendon using Krackow stitch
  4. Drill parallel transosseous tunnels (~2 cm and ~4 cm) using 2.0 mm drill
  5. Place 2-3 suture anchors just proximal to the insertion site for the proximal row (augmentation)
  6. Pass anchor sutures through tendon in horizontal mattress pattern - leave untied
  7. Pass FiberWire sutures into tunnels using a Hewson suture passer
  8. With elbow in full extension, reattach tendon to olecranon footprint
  9. Tie transosseous sutures first, then tie the bone anchor sutures
The double-row construct restores the anatomic footprint - the "suture bridge" technique provides wider tendon-bone contact area.
Intraoperative fluoroscopy showing transosseous suture repair of triceps tendon
Lateral elbow radiograph showing transosseous tunnel repair - suture material traversing drill holes in olecranon dorsal cortex

3. V-Y Plasty for Musculotendinous Junction Ruptures

When rupture occurs at the myotendinous junction, a V-Y triceps tendon advancement technique is used. Autologous plantaris tendon is interwoven with the remaining proximal and distal triceps tissue to bridge and augment the repair.

4. Management of Chronic Ruptures (>6 weeks)

Primary repair becomes difficult due to retraction and scarring. Augmentation/reconstruction options include:
  • Anconeus rotation flap
  • Achilles tendon allograft or autograft
  • Plantaris or hamstring tendon augmentation
  • Fascia lata graft
  • Ligament augmentation device (LAD)

Postoperative Protocol

  • Splint in 0-30° flexion for 4 weeks
  • Active ROM begins at 4-6 weeks, advancing elbow flexion by 10-15° per week
  • Strengthening exercises begin at 8-10 weeks
  • Full return to sport/heavy labour at 4-6 months

II. SURGICAL APPROACHES INVOLVING THE TRICEPS (Elbow Surgery)

The following approaches are important exam topics as they relate to distal humerus ORIF and total elbow arthroplasty (TEA):
ApproachDescriptionAdvantagesDisadvantagesBest Indication
Paratricipital (Triceps-On / Alonso-Llames)Two windows alongside triceps, insertion preservedNo olecranon osteotomy; early ROM possible; preserves anconeus blood supplyLimited articular exposure; inadequate for type C3AO/OTA A2, A3, B1, B2, C1, C2
Triceps-Splitting (Campbell)Midline split of triceps tendon and insertionTechnically simple; easy conversion to TEALimited articular visibility; requires triceps repair; post-op protection neededORIF, TEA
TRAP (Triceps-Reflecting Anconeus Pedicle)Entire triceps-anconeus flap reflected proximally (Kocher interval used distally)Good posterior exposure; avoids olecranon osteotomy; preserves anconeus neurovascular pedicleRisk of triceps dehiscence and extensor weaknessTEA, complex distal humerus
Van Gorder / Triceps TongueV-shaped transection at musculotendinous junction; allows V-Y lengtheningCan lengthen extensor mechanism if neededSame weakness risk as TRAP; ~1/3 articular exposure onlyTEA, associated triceps laceration
Olecranon OsteotomyChevron or transverse osteotomy of olecranon; triceps-olecranon unit reflectedBest articular visualization (~75%); gold standard for C3 fracturesNonunion risk; symptomatic hardware; olecranon arthrosisAO/OTA C2, C3 articular fractures

III. TRICEPS TENDON TRANSFERS

These are relevant in paralytic conditions (spinal cord injury, brachial plexus injury, polio) and flexorplasty procedures.

A. Anterior Transfer of Triceps (Bunnell Technique)

Indication: To restore active elbow flexion when elbow flexors are paralysed (e.g., C5-C6 tetraplegia, but elbow extension is preserved at C7).
Steps:
  1. Posterolateral incision - divide triceps tendon at its insertion and dissect free from posterior distal humerus
  2. Transfer the tendon around the lateral aspect of the humerus
  3. Anterolateral incision - expose the radial tuberosity
  4. Prolong triceps tendon with a 4 cm fascia lata tube graft (as the tendon won't reach the tuberosity)
  5. Attach to roughened radial tuberosity with a pull-out steel suture through a drill hole; tie over a padded button
  6. Cast with elbow in acute flexion, forearm mid-rotation for 6 weeks; wire removed at 4 weeks

B. Posterior Deltoid-to-Triceps Transfer (Moberg Technique, Modified)

Indication: Restore elbow extension in C5/C6 tetraplegia (posterior deltoid preserved but triceps paralysed).
Steps:
  1. Lateral decubitus - 10-13 cm incision along posterior deltoid border
  2. Elevate posterior 1/3 to 1/2 of deltoid with strip of periosteal insertion
  3. Split muscle fibers distally, preserving axillary nerve and posterior circumflex humeral vessels
  4. Separate posterior incision over distal triceps-olecranon; if adequate tendinous overlap, direct weave fixation; if not, interpose fascia lata graft (or great toe extensors, anterior tibial tendon)
  5. Tension adjusted so full passive elbow flexion is possible; stainless steel sutures through bone tunnel in olecranon
Postoperative care: Arm splinted 0-30° flexion, adducted; gradual flexion increase 10-15°/week from 4-6 weeks; extension splint at night for 3 months; no wheelchair push-ups/transfers for 3 months.

C. Distal Biceps-to-Triceps Transfer

Indication: Restore elbow extension when deltoid is insufficient; transfers biceps to the posterior compartment.
Key steps: Three incisions (antecubital, medial, posterior); biceps tendon detached from radial tuberosity, tunnelled posteriorly through an intermuscular route, and woven into the triceps aponeurosis.

IV. COMPLICATIONS OF TRICEPS SURGERY

ComplicationNotes
ReruptureHigher with transosseous tunnels vs. suture anchors (Mirzayan et al.)
Loss of full extensionMost common functional deficit; ~10-15° extension lag is acceptable
Ulnar nerve injuryFrom direct injury or traction during medial exposure
Wound problemsPosterior elbow skin is thin and poorly vascularized
Olecranon bursitisFrom prominent suture knots or hardware
Extensor weaknessAfter triceps-reflecting approaches (TRAP, Van Gorder) if repair fails
Triceps dehiscenceMost feared complication after triceps-splitting/reflecting approaches

Key Examination Points (Gold Medal Level)

  1. "Rarest tendon rupture" - triceps is the least commonly ruptured of all major tendons
  2. "Flake sign" on lateral X-ray is pathognomonic of triceps avulsion
  3. ~50% missed acutely because anconeus preserves some elbow extension
  4. Suture anchors > transosseous tunnels - lower rerupture and reoperation rates (Mirzayan et al., 184 cases, Am J Sports Med 2018)
  5. Double-row technique restores the anatomic footprint and distributes load over wider area
  6. Paratricipital approach - preserves triceps insertion, allows early ROM, no osteotomy complications
  7. TRAP approach - preserves anconeus neurovascular supply (via Kocher interval), but risks triceps dehiscence
  8. Anterior triceps transfer (Bunnell) needs fascia lata graft to bridge to radial tuberosity
  9. Posterior deltoid-to-triceps (Moberg) - preferred for C7 tetraplegia restoration of elbow extension
  10. Repair tension: always set with elbow in full extension for distal repairs; full passive flexion for transfers
Sources: Campbell's Operative Orthopaedics 15th Ed 2026; Rockwood and Green's Fractures in Adults 10th Ed 2025; Miller's Review of Orthopaedics 9th Edition; Gray's Anatomy for Students; Imaging Anatomy Vol. 3 (THIEME)
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