Shoulder & ElbowElbow/Elbow

Distal Triceps Rupture

• Rarest major tendon rupture — <1% of all tendon injuries; most common in males aged 30–50 • Mechanism: eccentric load on a contracting triceps (FOOSH, fall on elbow, direct blow) • Insertion at the olecranon tip — bony avulsion is the most common pattern (~75%) • Strong association with systemic risk factors: anabolic steroids, chronic renal failure, hyperparathyroidism, fluoroquinolone use • Clinical diagnosis: palpable gap at olecranon tip + weak or absent active elbow extension • Thompson squeeze test: squeeze triceps belly — elbow should extend; no extension = complete rupture • Complete rupture → surgical repair; partial rupture (<50%) → non-operative if extension is maintained • Repair within 2–3 weeks strongly recommended — chronic tears require tendon reconstruction

Assoc. Prof. Mehmet KAPICIOGLU· Bezmialem Vakif University, Department of Orthopedics and Traumatology
Apr 28, 2026

Definition

  • Disruption of the triceps tendon insertion on the olecranon

  • Can be:

    • Partial

    • Complete

Rare but commonly misdiagnosed

Epidemiology

  • <1% of all tendon injuries

  • More common in:

    • Males

    • Athletes (weightlifting)

Mechanism of Injury

  • Sudden eccentric contraction of triceps

  • Fall on outstretched hand

  • Direct trauma

Risk Factors

  • Anabolic steroid use

  • Chronic renal failure

  • Hyperparathyroidism

  • Diabetes

  • Local steroid injections

Pathophysiology

  • Failure at:

    • Tendon insertion (most common)

    • Musculotendinous junction (rare)

Often associated with:

  • Olecranon avulsion fragment

Clinical Presentation

  • Posterior elbow pain

  • Swelling / ecchymosis

  • Weakness in extension

  • Difficulty pushing

Physical Examination

  • Palpable gap proximal to olecranon

  • Decreased extension strength

Key Test

  • Modified Thompson test (triceps squeeze test)

    • Absence of extension → rupture

Imaging

Xray

  • “Flake sign” (olecranon avulsion)

MRI

  • Gold standard

  • Distinguishes:

    • Partial vs complete rupture

Ultrasound

  • Useful bedside tool

Classification

Partial Rupture

  • Tendon continuity preserved

Complete Rupture

  • Full disruption of insertion

Treatment

Nonoperative Management

Indications

  • Partial tears

  • Low-demand patients

Management

  • Immobilisation (extension)

  • Gradual rehabilitation

Operative Treatment

Indications

  • Complete rupture

  • High-demand patients

  • Significant weakness

Surgical Techniques

  • Transosseous repair

  • Suture anchors

Goal:

  • Restore extensor mechanism

Postoperative Protocol

  • Initial immobilisation

  • Gradual ROM

  • Strengthening after healing

Complications

  • Re-rupture

  • Weak extension

  • Stiffness

  • Wound issues

Prognosis

  • Good outcomes with early repair

  • Delayed diagnosis → worse results

Pits & Pearls

  • Rare injury → easy to miss

  • Look for flake sign on X-ray

  • Always test active extension

  • Early repair = better outcome

Pitfalls

  • Misdiagnosing as elbow sprain

  • Missing partial tears

  • Delayed surgical referral

  • Inadequate rehab

Mini Decision Algorithm

Condition

Decision

Action

Posterior elbow pain + weakness

Suspect

Triceps rupture workup — palpate gap, Thompson test

X-ray flake sign present

High suspicion

Bony avulsion confirmed — proceed to MRI

MRI confirms partial tear (<50%)

Conservative

Splint at 30° flexion × 4 weeks + serial imaging

MRI confirms complete tear

Surgery

Repair within 2–3 weeks — double-row anchor

Delayed diagnosis (>3–4 weeks)

Expect worse

Reconstruction with graft — counsel patient on reduced outcomes

High Yield

• Complete rupture = absent active elbow extension against gravity — surgical repair mandatory

• Partial rupture: extension maintained AND MRI confirms <50% tear → non-operative acceptable

• Bony avulsion (most common ~75%): suture anchor repair to olecranon footprint

• Chronic tear (>3–4 weeks): primary repair often impossible — plan reconstruction

• Strong association with anabolic steroid use and chronic renal failure — always enquire

• Bilateral triceps rupture: systemic cause mandatory — check renal function, PTH, calcium

References

  • McKee MD et al. Open reduction and internal fixation compared with total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. Journal of Bone and Joint Surgery American, 2009.

  • Elmi-Terander A et al. ORIF versus total elbow arthroplasty: Two-year outcomes in distal humerus fractures. Journal of Bone and Joint Surgery, 2021.

  • Sanchez-Sotelo J et al. Biomechanical comparison of parallel versus orthogonal plating in distal humerus fractures.Journal of Bone and Joint Surgery, 2007.

  • Jupiter JB & Mehne DK Fractures of the distal humerus.Clinical Orthopaedics and Related Research, 1992.

  • O'Driscoll SW. Optimizing stability in distal humeral fracture fixation. Journal of Bone and Joint Surgery, 2000.

  • Srinivasan RC et al.Ulnar nerve management in distal humerus fractures. Journal of Bone and Joint Surgery, 2005.

  • Doornberg JN et al. Long-term outcomes of ORIF for distal humerus fractures.Journal of Bone and Joint Surgery American, 2006.

  • Morrey BF et al. Functional evaluation of the elbow. Journal of Bone and Joint Surgery American, 1981.

← All TopicsMore in Shoulder & Elbow →