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C OPYRIGHT Ó 2023 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Triceps Rupture After Olecranon Fixation with

Proximal Ulna Plate and Suture Augmentation
A Case Report
Sergio Eduardo Flores, MD, Joseph Ryan Sheridan, MD, Eric Stanley Larson, MD, and Igor Immerman, MD

Investigation performed at the University of California San Francisco, San Francisco, CA

Abstract
Case: Olecranon fractures treated with proximal ulna plate fixation and repairing the triceps with suture augmentation to
the plate decrease the risk of “olecranon escape,” but may lead to failure through triceps rupture. In this case report, a
rare complication of triceps rupture occurred, and the patient underwent triceps repair.
Conclusion: When fixing olecranon fractures, surgeons should minimize triceps dissection for hardware placement. If subjected
to significant force, a surgical insult to the tendon footprint for a better plate contact on the bone and the presence of suture
augmentation may change the construct failure mechanism and result in triceps rupture as opposed to fracture redisplacement.

O
lecranon fractures are a common elbow injury, have this particular case, the central portion of the distal triceps
been reported to account for up to 10% of elbow insertion on olecranon was dissected to allow the plate to sit
fractures, and are generally treated surgically to restore directly on the bony cortex. We hypothesize this dissection
the extensor mechanism and the elbow joint1. Complications was a potential risk factor for this delayed postoperative triceps
after olecranon fixation include symptomatic hardware, fixa- tendon rupture.
tion failure, infection, elbow stiffness, nonunion, malunion, The patient was informed that data concerning the case
and heterotopic ossification2. Fracture fixation is accomplished would be submitted for publication, and he provided consent.
using a variety of techniques, and anatomically, precontoured
proximal ulna plates have become popular. Depending on plate Case Report
design, manufacturer techniques may recommend dissection
through the distal triceps insertion to allow plate-bone contact
on the proximal olecranon3.
T he patient was a 40-year-old healthy, active man, who
had a ground-level fall onto his left arm and fractured his
left olecranon. The patient denied history of steroid intake or
Postoperative failure of the extensor mechanism after injections to the distal triceps area, and there were no known
olecranon fixation is rare; however, this typically occurs risk factors that might have weakened the triceps tendon.
in osteoporotic olecranon fractures because the extensor Radiographs of the displaced olecranon fracture are shown in
mechanism pulls off a tenuously fixated proximal fragment Fig. 1. One week after the injury, the patient underwent an
of the olecranon. This mechanism is often termed “olecra- open reduction internal fixation with a 108-mm proximal ulna
non escape”4. To mitigate this risk, off-loading triceps suture plate (Skeletal Dynamics). The procedure was uncomplicated,
techniques have been described as a load-sharing mecha- and per the manufacturer’s technique guide, the triceps tendon
nism to decrease distraction forces imposed by the extensor insertion was split longitudinally for approximately 1 cm and
mechanism4,5. Distal triceps rupture after olecranon fixation, elevated from the olecranon to allow the proximal end of the
on the other hand, is not described readily in olecranon plate and “home run” screw tab to sit in an appropriate posi-
fixation literature6,7. tion with a direct bony contact3. After bony fixation, the 1-cm
We describe a case of distal triceps tendon rupture after incision in the triceps was primarily repaired with a No. 2
plate fixation of an olecranon fracture and the use of suture Orthocord partially resorbable braided suture (Orthocord No.
augmentation of the triceps tendon during the primary pro- 2, DePuy Mitek) in a running Krakow fashion and secured
cedure. Failure of the extensor mechanism was not due to through suture holes in the plate. Postoperative radiographs are
failure of bony fixation, but rupture of the triceps tendon. In shown in Fig. 2.

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C160).
Keywords Complication; Elbow; Olecranon; Rupture; Triceps

JBJS Case Connect 2023;13:e23.00179 d http://dx.doi.org/10.2106/JBJS.CC.23.00179

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Fig. 1-A Fig. 1-B

Radiographs of the left elbow (Fig. 1-A Anterior-Posterior view, Fig. 1-B lateral view) demonstrate the displaced olecranon fracture.

The immediate postoperative course was uncomplicated. head triceps fibers appeared intact. The distal end of the tendon
The patient was made non–weight-bearing and placed into a was cleaned and freed, and with the elbow in full extension, the
posterior elbow splint after surgery. At 2 weeks, he began tendon was able to easily reach the triceps footprint with
passive range, active-assisted, and active elbow range of motion appropriate tension. A double-row repair using proximal to
with therapy. At 6 weeks, he was progressed to weight-bearing distal transosseous tunnels on both sides of the plate through
as tolerated and cleared for a gradual return to low impact the olecranon (Fig. 4-B) and suture fixation with No. 2 Fi-
activities at around 12 weeks. Approximately 16 weeks post- berWire nonresorbable braided suture (Arthrex) secured into
operative, the patient fell onto his left elbow after slipping on the original plate was performed. Fig. 4-C demonstrates the
ice and returned for evaluation. restoration of the footprint of the triceps tendon insertion. The
On examination of his left arm, he was neurovascularly middle suture limbs were passed through the plate holes, and
intact. There was a palpable defect around his distal triceps the outer limbs were passed through the transosseous tunnels.
insertion with swelling around the posterior elbow. He had a This essentially created a “6-core” repair. The elbow was then
20° extensor lag while testing the triceps against gravity, and brought into 30° of extension, the medial and lateral suture
resisted triceps strength was graded as 4/5. Radiographs showed limbs were tied respectively, and the repair was stable through
no new fractures nor hardware disruption, but concern for full arc of motion. The patient was splinted in 30° of extension.
bony fleck proximal to olecranon, which could represent tri- At 2 weeks postoperatively, the patient was transitioned
ceps disruption. A magnetic resonance imaging of the elbow to a hinged elbow brace with range of motion from 0° to 45°. He
was obtained and demonstrated a complete tear of the triceps started rehabilitation to begin active flexion and passive exten-
tendon with approximately 2 cm of retraction (Fig. 3). sion with the goal to increase flexion by 10° to 15° per week, with
Because of predicted poor outcomes with nonoperative no active extension for 6 weeks postoperatively. Full active
treatment of this complete and retracted tendon rupture, sur- motion was permitted at 6 weeks, and strengthening was started
gical management was indicated. Twelve days after his new at 3 months postoperatively. At 6 months, the patient had
injury, he underwent a distal triceps repair using a similar symmetric elbow range of motion, with 0° to 140° of flexion,
transosseous repair technique as described by Carpenter et al8. and was cleared for activities. At 1-year follow-up, he had 5/5
The patient’s previous direct posterior incision was used for the triceps strength and has returned to full activities without issues.
approach. On examination of the triceps tendon, almost all
of the superficial tendon attachment was disrupted, and the Discussion
previous suture augmentation through the plate had failed by
pulling through the triceps tendon (Fig. 4-A). Part of the deep I solated distal triceps tendon rupture without fracture of the
proximal ulna is an uncommon orthopaedic injury, with a
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Fig. 2-A Fig. 2-B

Postoperative radiographs of the left elbow (Fig. 2-A lateral view and Fig. 2-B Anterior-Posterior view) demonstrate proximal ulna plate fixation.

reported incidence of 6 per 1 million individuals9,10. Triceps Few studies have investigated failure of extensor mech-
tendon rupture after olecranon fixation without failure of bony anism after olecranon fixation4,5,11. A biomechanical cadaveric
fixation is exceptionally rare and, to the best of our knowledge, study by Wild et al. examined the effect of suture augmentation
has not been previously reported in the literature. This case on single load-to-failure strength of locking plate fixation
demonstrates an unusual complication after surgical inter- for proximal olecranon fractures and found that suture aug-
vention for a common elbow injury and a successful technique mentation improved the single load-to-failure strength in all
for managing this complication. cadaver pairs11. The authors found that the most common
mode of failure was the loss of fixation of the proximal olec-
ranon fragment. Orbay et al. conducted a similar biomechan-
ical study of 10 paired cadaveric specimens, in which 1 arm
from each pair underwent an additional augmented suture
repair after plate fixation of a transverse olecranon osteotomy
where the triceps tendon was sutured directly to the plate5. With
suture augmentation, 4 elbows failed through triceps rupture.
Those without augmentation all failed through bony avulsion
fractures or failure of fixation. This demonstrated that suture
augmentation is not only an effective way to significantly in-
crease fixation strength, but also changes the potential failure
mechanism from a loss of bony fixation to a tendinous rupture.
However, it must be noted that the suturing technique used in
that study differed from what was used in our case because
Orbay et al. placed a suture in a mattress fashion engaging
Sharpey’s fibers directly at the triceps insertion5.
In our case, suture augmentation with a Krakow tech-
nique was used during primary fixation of the patient’s olec-
Fig. 3 ranon fracture after modestly splitting the triceps insertion for
MRI T2 sagittal of the left elbow demonstrates complete triceps rupture placement of the plate, with the hope of protecting the triceps
with approximately 2 cm of retraction. MRI = magnetic resonance imaging. insertion. The patient went on to achieve bony union of the
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Fig. 4-A Fig. 4-B

Fig. 4-C
Fig. 4-A Intraoperative photograph of triceps rupture during triceps repair surgery. Fig. 4-B Intraoperative fluoroscopy image of drill tunnel through olecranon
adjacent to the plate for transosseous repair. Fig. 4-C Intraoperative photograph demonstrating restoration of triceps tendon footprint before tying final
fixation.
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olecranon; however, the triceps split may have ultimately led to fashion to a standard triceps tendon repair. When fixing
the failure of the triceps tendon. Risk of failure may have been olecranon fractures, surgeons should exercise care and min-
increased by iatrogenic damage to the tendon when split for imize triceps dissection for hardware placement. Sutures be-
plate placement or through increased load placed on the ten- tween the hardware and the triceps tendon are likely to be
don with suture augmentation. Although theoretically suture protective of the fracture fixation, and logic suggests would
augmentation should be protective of the triceps insertion, the protect the triceps insertion as well. However, if subjected to a
data from Orbay et al. suggest that suturing the triceps to the significant force, a surgical insult to the tendon footprint for a
plate, while protective of the fracture, may actually increase better contact between the plate and olecranon surface and
the risk of tendon rupture5. A limitation of our case report is the presence of suture augmentation may change the con-
the possibility that the triceps ruptured independently because struct failure mechanism and result in triceps rupture as
of the mechanism of the injury, and therefore, the longitudinal opposed to fracture redisplacement. n
split and suture augmentation may not have contributed.
Given the presence of a healed olecranon fracture, man-
agement of this complication was similar to management of an
isolated triceps tendon rupture. Commonly used techniques Sergio Eduardo Flores, MD1
include transosseous tunnel fixation through the olecranon or Joseph Ryan Sheridan, MD1
suture anchors and direct repair10. In our case, we used a well- Eric Stanley Larson, MD1
described transosseous tunnel repair technique; however, given Igor Immerman, MD1
the presence of the olecranon plate, the repair was reinforced 1Department of Orthopaedic Surgery, University of California, San
with suture augmentation through the plate. Francisco, San Francisco, California
In conclusion, triceps tendon rupture after olecranon
fixation is a rare complication and can be managed in a similar E-mail address for S.E. Flores: Sergio.fl[email protected]

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