Distal Triceps Repair Info Evidence Consent
Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed
Why this operation has been suggested
Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The triceps is the tendon at the back of your elbow that straightens your arm. When it tears completely away from the bone, surgery is usually needed to restore that movement. This operation, called a distal triceps repair, reattaches the torn tendon.
Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess your history, examine your elbow, and arrange imaging where needed to confirm the diagnosis.
For a partial tear, non-operative care such as physiotherapy may be tried first. Surgery follows when that has not given enough improvement, or when the tear is complete. It is often recommended for active people, workers who use their arms heavily, and athletes wanting to return to competition. Repair aims to restore strength and function, with most people back at work by about 2.2 months and 89.3% returning to sport.
Before the operation
Your surgeon will confirm the tear with scans before planning your repair. This usually starts with X-rays, which show whether a small piece of bone has pulled away with the tendon. An MRI scan may be used to look closely at the tendon itself.
Before surgery, you will need to stop eating and drinking for seven hours beforehand. We ask for seven hours rather than six so your operation can be brought forward if the theatre list runs early. Your surgeon will tell you which medicines to stop and when. Bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing on the day. If you have other medical conditions, you may need blood tests or a review with the anaesthetist.
On the day
You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who puts you to sleep and manages your pain during the operation. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the repair is performed.
Afterwards, you will wake up in the recovery area, where nurses keep a close eye on you while the anaesthetic wears off. Once you are stable, you will either go to a ward or go home, depending on the procedure and how your recovery is going. If you go home the same day, you will need the person you arranged earlier to drive you.
What the operation involves
The triceps tendon attaches to a small patch of bone at the point of your elbow. In a complete tear, the tendon has pulled away from that bone, a bit like a rope coming loose from its anchor point. The aim of the operation is to stitch the tendon back down onto the bone where it belongs.
Your surgeon makes a cut at the back of your elbow to reach the torn tendon. The tendon is then reattached to its natural attachment spot on the bone using small anchors placed into the bone, with strong stitching that holds the tendon down under even tension. This restores the normal shape and position of the tendon's attachment, which gives the repair its strength.
Some repairs use a technique that covers the whole attachment area with two rows of anchors, like stitching a hem down with two parallel lines. Others use anchors made entirely of stitching material, which hold the tendon just as firmly as standard anchors. Your surgeon will choose the method that suits your injury.
Once the tendon is secure, the surgeon checks that the repair moves smoothly, then closes the cut with stitches and applies a dressing. You will keep that dressing on for about 10 days, as described in the recovery section.
The operation itself is straightforward in concept: bring the torn tendon back to the bone and hold it there firmly enough that it can heal. What happens next, how quickly you can move and use the arm, is covered in the recovery section that follows.
After the operation
You will wake up in the recovery area, where nurses watch you closely as the anaesthetic wears off. Your arm will rest in a simple sling for comfort. The elbow is not locked in place; gentle movement starts early. Pain relief is tailored to you, and the nurses will keep you comfortable. Someone should stay with you for the first 24 hours after you get home. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Most people walk and move around on the day of surgery, taking it gently.
Recovery
For the first few days your elbow will be sore and swollen. This settles gradually. Rest, keeping your hand raised when sitting, and the pain relief prescribed for you all help. Your arm rests in a simple sling for comfort, but the elbow is not locked still, and gentle movement starts early.
Hand therapy is a big part of your recovery. Your sessions are with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she guides your exercises and makes any splint you need. Early on, the focus is on protecting the repair while your elbow regains its movement. As the tendon heals, the exercises build up to restore strength for straightening your arm against resistance.
Day to day, you will manage light tasks at home with your other hand while the repair settles. You will not drive while your arm is in the sling, and you need to be able to hold the wheel with both hands and react in an emergency stop, with no strong pain medication on board, before you drive again. Our guide to driving after upper-limb surgery explains this in more detail.
Milestones come as events rather than dates. Once the swelling settles, bending and straightening feel easier. When your therapist clears your strength work, you start loading the arm. Most people return to work and sport at the same intensity they had before the injury. Your timeline may differ; your surgeon and Ruby will guide you.
What can go wrong
Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.
The most serious problem is the repair tearing again. You might feel a sudden pop or give in the back of your elbow, followed by weakness when you try to straighten your arm against something. Some people notice swelling and bruising over the point of the elbow, similar to how it felt when the tendon first tore. If this happens, contact the clinic straight away. Your surgeon will examine the elbow and arrange scans to check whether the repair has held.
Some problems show up around the wound itself. Watch for pain that keeps getting worse rather than easing, redness that spreads out from the wound, or fluid leaking through the dressing. Fevers or feeling generally unwell alongside these signs also matter. If you notice any of these, call the clinic the same day rather than waiting for your next visit.
Occasionally a repair needs a further operation. This might be because the tendon has torn again, or because something else about the repair is not settling the way it should. You would usually know about it through ongoing pain, weakness or a feeling that the elbow is not recovering as expected. Raise this at your review appointment, or contact us sooner if things feel clearly wrong.
Recovery from these problems can take longer than the original plan, and some people need more time away from work or normal activity than they first expected. Your surgeon will talk you through what has happened and what the next steps are if this affects you.
The complications table on this page lists typical rates if you want the specifics.
When to call us
Most recoveries go smoothly, but some signs need quick attention. Call us if you have a fever, or if redness or discharge around the wound keeps increasing. Go to emergency if you have sudden severe pain in the elbow, or a sudden pop with weakness when straightening your arm. Go to emergency if your calf becomes swollen or painful, or if you become short of breath. Call us straight away if you lose feeling in your arm or hand, or if you cannot move the limb.
Evidence & references
This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.
Anatomy & Pathophysiology
Bony Anatomy
- The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [3].
- The trochlea articulates with the ulna within the greater sigmoid notch to form the ulnohumeral, hinged, or trochoid portion of the elbow joint [3].
- The ulnohumeral articulation provides highly congruent anatomy through almost 180° of articular contact [3].
- The greater sigmoid notch of the ulna contains a bare area devoid of cartilage [3].
- The coronoid process has medial and lateral facets that buttress the trochlea anteriorly [3].
- The sublime tubercle is located just distal and medial to the coronoid and serves as the attachment site for the anterior bundle of the medial ulnar collateral ligament [3].
- The medial epicondyle is larger and more posteriorly oriented than the lateral epicondyle [3].
- The capitellum and radial head form the radiocapitellar joint [3].
- The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [3].
- The lesser sigmoid notch is the area of the ulna that articulates with the margin of the radial head at the proximal radioulnar joint [3].
- The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [3].
- The lateral epicondyle is the origin of the lateral extensor musculature [3].
- The origin of the lateral ulnar collateral ligament complex is located just distal to the lateral epicondyle at the geometric center of the radiocapitellar articulation [3].
- The distal humeral articulation is angled 30° from the longitudinal axis [3].
- The anterior humeral line should pass through the center of the axis of rotation [3].
- The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [3].
- The olecranon provides a broad attachment site for the triceps [3].
- The ulna bends approximately 8° medially at 8 cm from the tip of the olecranon [3].
- The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [3].
Ligaments and Soft Tissue
- The medial ulnar collateral ligament is comprised of the anterior bundle, posterior bundle, and transverse ligament [2].
- The anterior bundle of the medial ulnar collateral ligament is the strongest component and the primary restraint to valgus stress [2].
- The anterior bundle of the medial ulnar collateral ligament is subdivided into anterior and posterior bands that provide reciprocal function, with the anterior band tight in extension and the posterior band tight in flexion [2].
- The lateral ulnar collateral ligament origin center is 10.7 mm from the lateral epicondyle [2].
- The lateral ulnar collateral ligament insertion is 3.3 mm from the apex of the supinator crest [2].
- The triceps muscle insertions have three distinct insertional areas to the olecranon: posterior capsular insertion, deep muscular portion, and superficial tendinous portion [2].
- The deep muscular head of the triceps corresponds to the medial head of the triceps [2].
- The superficial tendinous portion of the triceps corresponds to the long and lateral heads [2].
- The width of the triceps insertion is 2.6 cm [2].
- The triceps insertion is located 1.1 cm from the tip of the olecranon [2].
- The primary elbow extensor, the triceps, inserts on the olecranon process [4].
- The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [4].
- The biceps brachii inserts at the ulnar margin of the radial tuberosity, with the long head inserting proximally and the short head distally [4].
- The biceps brachii is a powerful supinator of the forearm [4].
- The mobile wad consists of the brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis [4].
- The flexor-pronator mass consists of the pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis [4].
- Tensile forces are present at the medial elbow while compressive forces are present at the lateral elbow [4].
- The elbow capsule allows maximum distension at approximately 70 to 80 degrees of flexion [4].
- The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [4].
- The coronoid tip is an intraarticular structure visualized during elbow arthroscopy [4].
- The medial or ulnar collateral ligament is the primary valgus stabilizer [4].
- The anterior bundle of the medial ulnar collateral ligament is the most important component for stability [4].
- The posterior bundle of the medial ulnar collateral ligament has the greatest change in length and becomes taut at flexion beyond 120 degrees [4].
- The lateral ulnar collateral ligament is the posterolateral stabilizer [4].
- Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [4].
- The ligament of Struthers is a variant anatomy arising from the supracondylar process to attach to the medial epicondyle and is a potential site of median nerve compression [4].
Biomechanics and Motion
- The normal elbow has a range of motion from 0° to 140° from extension to flexion [1].
- The normal elbow has a range of motion of 75° in pronation and 85° in supination [1].
- A functional arc for flexion and extension is 100° [1].
- A functional arc for forearm rotation is 100° [1].
- Elbow stability is determined by primary and secondary stabilizers [1].
- The three primary stabilizers of the elbow are the ulnohumeral articulation, the medial ulnar collateral ligament, and the lateral ulnar collateral ligament complex [1].
- Secondary stabilizers of the elbow include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [1].
Investigations
Physical Examination
- The physical examination of the elbow is directed by the history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect [1].
- Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [9].
- The contralateral elbow should be examined for comparison during range of motion assessment [9].
- If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament is contracted and must be released to restore flexion [9].
- Pain during the mid-arc of motion is more common with intrinsic disease and may not improve with contracture release alone [9].
- The ulnar nerve is of utmost importance in the physical examination due to its anatomic proximity to the elbow [9].
- The posterior bundle of the medial collateral ligament forms the floor of the cubital tunnel along the course of the ulnar nerve [9].
- Electromyography and nerve conduction velocity studies should be performed if there is any question about neurologic dysfunction [9].
- An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [9].
- The soft tissue surrounding the elbow should be examined for previous skin incisions, grafts, eschar, or infection [9].
Imaging
- Plain radiographs remain the hallmark and the best screening test for elbow evaluation [1].
- Standard radiographic views include AP, lateral, and oblique views [9].
- Serial radiography is used as follow-up when heterotopic ossification is present [9].
- Primary bony landmarks assessed on radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [9].
- CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [9].
- Three-dimensional CT is used to check for heterotopic ossification [9].
- CT is not necessary when the stiffness is entirely soft-tissue related [9].
- CT is beneficial if any joint incongruity or abnormal bony anatomy is present [9].
- MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [9].
- AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [11].
- CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [11].
- MRI may be most helpful in evaluating associated injuries including partial or complete tears of the medial collateral ligament in valgus extension overload syndrome [11].
- Radiographic evaluations are essential when diagnosing an osteochondritis dissecans lesion of the elbow [12].
- Important aspects of osteochondritis dissecans lesions may be better seen with MRI [12].
References
[1] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Summary and Conclusions.
[2] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Annotated References.
[3] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Anatomy > Bony Anatomy.
[4] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > TABLE 2.3 Shoulder Spaces.
[9] Aaos Comprehensive Orthopaedic Review 3. Elbow Stiffness* > IV. Evaluation.
[11] Aaos Comprehensive Orthopaedic Review 3. Elbow Injuries in the Athlete* > III. Valgus Extension Overload Syndrome and Posterior Impingement.
[12] Orthopaedic Knowledge Update. Osteochondritis Dissecans of the Knee and Elbow* > Summary.
