Intraarticular Distal Humerus Fracture With Triceps Tendon Avulsion
by S. Robert Rozbruch, MD; David S. Levine, MD; John P. Lyden, MD; David L. Helfet, MD

Abstract
A case report of a patient with a comminuted intraarticular fracture of the distal humerus with an associated triceps tendon avulsion is presented with seven-year followup. This particular combination of injuries has not been previously reported in the English language Orthopaedic literature and presents a challenge in terms of diagnosis, surgical exposure, decision making regarding olecranon osteotomy, and post-operative rehabilitation.

Introduction
Avulsion of the triceps tendon from its insertion on the tip of the olecranon is an uncommon injury and is mentioned in the literature mainly in the form of case reports.²⁴ It has been described as the least common of all tendon injuries. Anzel et al³ recorded only eight cases of triceps disruption among 1,014 cases of tendon rupture reviewed at The Mayo Clinic. Associated injuries reported include fractures of the radial head and neck^16,17 and of the wrist.¹⁴ Patients with chronic renal failure are thought to be at increased risk for such tendon injury following minor trauma.²³ Triceps tendon avulsion in weightlifters13,18 and in patients with olecranon bursitis⁶ have also been reported. These injuries require surgical repair and generally heal with acceptable functional results.^{4,7,15,16,17,24}

Intraarticular fractures of the distal humerus are relatively uncommon and difficult injuries to treat. Anatomic reconstruction of the joint, rigid stabilization, and early motion are the goals of treatment.^{1,8,9,10,11,12,25}

A case of a comminuted intraarticular distal humerus fracture with a triceps tendon avulsion is presented in this report. This has not been previously reported in the English language Orthopaedic literature. Surgical exposure for an open reduction and internal fixation of an intraarticular distal humerus fracture usually requires an olecranon osteotomy.^5,8 With an associated triceps tendon avulsion, the standard recommended olecranon osteotomy presents a problem. Based on experience with this unusual case, an approach for treatment is suggested.

Case Report
The patient is a 72-year-old right-hand dominant woman who is employed as a graphic artist. She fell landing directly on her right elbow and presented to the emergency room with pain and swelling of the right upper extremity. Physical examination revealed a tender and swollen elbow with an inability to extend against gravity. The right upper extremity neurovascular examination was within normal limits. Radiographs (Fig. 1A, Fig. 1B) revealed a comminuted intraarticular fracture of the distal humerus including a fracture of the capitellum and a coronal fracture of the trochlea (AO/Association for the Study of Internal Fixation [AO/ASIF] comprehensive classification of fractures, 13-C3.1).¹⁹ Displacement of the distal humerus was into flexion. Also noted was an avulsion of the tip of the olecranon with one centimeter of displacement. The patient was admitted to the hospital, splinted for comfort, and was taken to the operating room the following morning for an open reduction and internal fixation of the distal humerus and triceps tendon repair. The patient was placed in the lateral decubitus position with the arm bolstered over a roll. A posterior midline approach was performed. The ulnar nerve was identified and protected. Approximately 75 percent of the triceps tendon was noted to be avulsed off the tip of the olecranon along with a fleck of bone. Rather than using an olecranon osteotomy to expose the articular surface of the distal humerus, the remaining triceps tendon was dissected from the tip of the olecranon. The rationale was to avoid the need for an olecranon osteotomy since a majority of the tendon was already avulsed from the bone. Additionally, a triceps tendon repair would already be necessary. The extent of the intraarticular comminution, particularly the coronal split in the trochlea, was not fully appreciated from the preoperative radiographs. Intraoperatively, greater exposure of the articular surface was needed, which mandated an olecranon osteotomy. This was predrilled and was of the chevron type. With this additional exposure afforded by the olecranon osteotomy, the distal humeral articular surface was well visualized, reduced and stabilized. One third tubular plates were used to rigidly stabilize the medial and lateral columns of the distal humerus.⁹ The olecranon osteotomy was then reduced and stabilized with a 6.5 mm cancellous screw and a tension-band wire (Fig. 2A, Fig. 2B). The triceps tendon was then repaired to the olecranon tip with number 5 Mersilen suture. After closure, the arm was placed in a posterior splint at 90° of flexion, and one week post surgery, the patient was placed in a removable posterior splint and gentle passive range of motion exercises were started.

At seven-year followup the patient is without pain. Range of motion of the elbow is as follows: -30° extension to 130° flexion, 90° pronation and 90° supination. There is no extensor lag of the elbow. The strength of elbow flexion and extension are normal.

Discussion
Avulsion of the triceps tendon is an uncommon injury.²⁴ This has been described as the least common of the tendon injuries by Anzel et al³ who reviewed 1,014 tendon injuries seen at the Mayo Clinic and found only eight to involve the triceps tendon — of which four were from open lacerations. The first reported case was documented by Partridge²¹ in 1868. Prior to 1972, there were eight documented case reports of triceps rupture or avulsion in the English language literature.^2,4,14,21,22 Tarsney then reported seven cases, representing a total greater than the number reported in the literature over the previous 100 years.²⁴ Since then, several other cases have been reported.^{6,7,13,16,17,18,20}

Reports of associated fractures include those of the radial head and neck,^16,17 the wrist,¹⁴ and one case of the capitellum.¹⁷ Levy et al¹⁷ reported a series of 16 triceps avulsions or tears of which all but one had a fracture of the radial head or neck. The remaining case had a fracture of the capitellum.

Triceps tendon avulsions have been reported in weightlifters18 using anabolic steroids, those not using steroids, and in one with an associated selective radial neuropathy.¹³ Triceps tendon avulsions have been reported in patients with chronic renal failure after minor trauma²² and has been reported in a patient with olecranon bursitis.⁶

Surgical repair of the triceps tendon is the recommended treatment for complete ruptures or olecranon avulsions. Good results have been uniformly reported, and most authors have recommended 3 weeks of postoperative immobilization.^{4,7,15,16,17,24}

Although intraarticular fractures of the distal humerus are relatively uncommon, the modern treatment principles are well established. When displaced, anatomic open reduction of the joint, rigid stabilization, and early motion have been recommended with good and excellent results reported by most authors.^{1,8,9,10,11,12,25}

This case presented in the current report represents a combination of two injuries not previously reported in the English Orthopaedic literature. The more striking distal humerus fracture divests attention from the equally important triceps tendon injury. When evaluating a patient with a distal humerus fracture, one should think about the possibility of a triceps tendon injury. The pain confounds assessing active elbow extension for triceps continuity. The presence, on standard radiographs, of a bony avulsion from the olecranon might alert one to the diagnosis as in this particular patient. Although a bony avulsion off the olecranon tip has been reported to be present in 75% of cases of triceps tendon disruption,²⁴ its absence would make the diagnosis more difficult. One may consider a preoperative MRI in a case without a bony avulsion in whom there was a preoperative clinical suspicion of a triceps tendon disruption.¹³

The mechanism of injury in our patient was likely a blow to the posterior aspect of the elbow flexed beyond 90°. Strug²³ reported a case of an anterior dislocation of the elbow with a fracture of the olecranon in an eleven year-old boy after he sustained a blow to the back of his elbow. The present case may represent a partial anterior elbow dislocation that resulted in a triceps tendon avulsion and a shear fracture of the distal humerus. This may explain the coronal fracture of the trochlea, the very distal location of the fracture on the humerus, and its anterior displacement.

The necessity to treat this injury, surgically, was clear, however the surgical exposure was not. Osteotomy of the olecranon was avoided initially since adequate exposure of the articular surface of the distal humerus was thought to be achievable by the detachment of the remainder of the triceps tendon alone. Since a major part of the tendon was already avulsed, as a result of the injury, and a formal triceps tendon repair would be necessary, detachment of the remaining triceps tendon was thought not to add much to the morbidity of the surgical exposure. For a more simple intraarticular fracture of the distal humerus, (AO/ASIF Comprehensive Classification, C1 and C2),¹⁹ sufficient visualization of the humeral condyles would have been possible, even with an intact olecranon. After bony reduction and stabilization, a formal triceps tendon repair would have been performed.

However, in treating a complex intraarticular fracture of the distal humerus, with displaced condylar fractures in the coronal plane, an osteotomy of the olecranon will likely be necessary for adequate exposure of the articular surface. This should be done from the start in order to preserve the remaining soft-tissue and triceps tendon attachments to the olecranon tip. Following humeral fracture reduction and stabilization, reduction and fixation of the olecranon osteotomy should be performed followed by repair of the disrupted portion of the triceps tendon with heavy nonabsorbable suture through olecranon drill holes. This would have been optimal and allowed preservation of any remaining blood supply to the olecranon process. To help determine the complexity of the articular fracture, high quality anterior/ posterior, and lateral roentgenograms and traction X-rays should be reviewed, and a detailed preoperative plan should then be developed.¹⁰ If in doubt following evaluation, tomograms, CT scan, or even MRI would be indicated. The decision regarding approach in these combined injuries is thus dependent on the extent and characterization of the intraarticular distal humeral fracture.

The postoperative rehabilitation of a triceps tendon avulsion repair and an open reduction and internal fixation of an intraarticular distal humeral fracture are somewhat in conflict. Most authors recommend 3 weeks of immobilization following triceps tendon repair^{4,7,15,16,17,24} while immediate elbow motion is preferable following open reduction and internal fixation of an intraarticular fracture of the distal humerus.^{1,8,9,10,11,12,25} A compromise between these rehabilitation programs was utilized in the present patient with limited gentle passive range of motion of the elbow one week after surgery. A technique for triceps tendon repair recommended by Levy¹⁵ in which the triceps tendon repair is reinforced and protected by a 4 mm Mersilen band (Ethicon LTD., Scotland) that spans from the olecranon tip to the musculotendinous junction of the triceps would have allowed early active motion. Levy¹⁵ started active motion on the first day after surgery in 9 patients, all of whom achieved full function. Early active motion would have been beneficial in a patient such as the one presented in this case report, and should be considered for this combination injury.

In summary, an unusual case of a comminuted intraarticular fracture of the distal humerus with a triceps tendon avulsion has been reported. The diagnosis of triceps tendon avulsion may be difficult in the presence of the fracture of the distal humerus. A high index of suspicion is necessary. Although the presence of a small avulsion fracture off the tip of the olecranon should alert one to the presence of a triceps tendon avulsion, it is only present in approximately 75% of these injuries.²⁴ Most authors have recommended surgery for both of these injuries, when they occur individually and hence is mandated when combined. For the exposure of the articular surface of the distal humerus, in a simple intraarticular fracture, (AO/ASIF Comprehensive Classification, C1 and C2)¹⁹ the current authors recommend removal of the remaining triceps from the olecranon tip. If, however, there is intracondylar comminution, (AO/ASIF Comprehensive Classification, C3)¹⁹ the current authors recommend an olecranon osteotomy with preservation of the limited remaining soft-tissue attachments to the olecranon tip in order to adequately expose and reduce the condyles of the distal humerus. A triceps tendon repair must follow in either circumstance. To optimize the postoperative rehabilitation, a method of triceps tendon repair that would allow early active and passive range of motion of the elbow is desirable.

References
1. Aitken GK, Rorabeck CH(1986) Distal humeral fractures in the adult. Clin Orthop Rel Res 207:191-197
2. Anderson KJ, Le Cocq JF(1957) Rupture of the triceps tendon. J Bone Jt Surg 39A:444-446
3. Anzel SH, Covey KW, Weiner AD, Lipscomb PR(1959) Descriptions of muscles and tendons, an analysis of 1014 cases. Surgery 45:406-414
4. Bennett BS(1962) Triceps tendon rupture, case report and a method of repair. J Bone Jt Surg 44A:741-744
5. Cassebaum WH(1969) Open reduction of T and Y fractures of the lower end of the humerus. J Trauma 9:915-925
6. Clayton M, Therupathi RG(1984) Rupture of the triceps tendon with olecranon bursitis- a case report and a new method of repair. Clin Orthop Rel Res 184:183-185
7. Farrar EL, Lippert FG(1981) Avulsion of the triceps tendon. Clin Orthop Rel Res 161:242-246
8. Gabel GT, Hanson G, Bennett JB, Noble PC, Tullos HC(1987) Intraarticular fractures of the distal humerus in the adult. Clin Orthop Rel Res 216:100-108
9. Helfet DL, Hotchkiss RN(1990) Internal fixation of the distal humerus a biomechanical comparison of methods. J Ortho Trauma 4(3):260-264
10. Helfet DL(1994): Bicondylar intraarticular fractures of the distal humerus in adults. Advances in Orthopaedic Surgery 18(1):50-53
11. Helfet DL, Schmeling GJ(1993) Bicondylar intraarticular fractures of the distal humerus in adults. Clin Orthop Rel Res 292:26-36
12. Jupiter JB, Neff U, Holzach P, Allgoewer M(1995) Intercondylar fractures of the humerus. J Bone Jt Surg 67A:226-239
13. Klemme WR, Peterson SA(1995) Avulsion of the triceps brachii with selective radial neuropathy. Orthopedics 18:285-287
14. Lee MLH(1960) Rupture of the triceps tendon. Br Med J 2:197
15. Levy M(1987) Repair of triceps tendon avulsions or ruptures. J Bone Jt Surg 69B:115
16. Levy M, Fishel RE, Stern GM(1978) Triceps tendon avulsion with or without fracture of the radial head- a rare injury? J Trauma 18:677-679
17. Levy M, Goldberg I, Meir I(1982) Fracture of the head of the radius with a tear or avulsion of the triceps tendon: a new syndrome? J Bone Jt Surg 64B:70-72
18. Louis DS, Peck D(1992) Triceps avulsion fracture in a weightlifter. Orthopedics 15:207-208
19. Muller ME, Allgower M, Schneider R, Willenegger H(1991) Manual of Internal Fixation: Techniques Recommended by the AO-ASIF Group Springer Verlag, New York (ed 3) pp128-129, 411-426, 446-452
20. Pantazopoulos TH, Exarchou E, Stavrou Z, Hartfilakidis-Garofalidis G(1975) Avulsion of the triceps tendon. J Trauma 15:827-829 21. Partridge(1868) A case of rupture of the triceps cubiti. Med Times Gaz 1:175
22. Preston FS, Adicoff A(1962) Hyperparathyroidism with rupture of three major tendons, report of a case. New Eng J Med 266:968-971
23. Strug LH(1948) Anterior dislocation of the elbow with fracture of the olecranon. Am J Surg 75(5):700-703
24. Tarnsey FF(1972) Rupture and avulsion of the triceps. Clin Orthop Rel Res 83:177-183
25. Zagorski JB, Jennings JJ, Burkehalter WE, Uribe JW(1986) Comminuted intraarticular fractures of the distal humeral condyles, surgical versus nonsurgical treatment. Clin Orthop Rel Res 202:197-204

Legend of Figures

Fig 1A-B.
(A) Injury anteroposterior radiograph showing intraarticular distal humerus fracture.
(B) Injury lateral radiograph showing showing intraarticular distal humerus fracture and avulsion of the tip of the olecranon.

Fig 2A-B.
(A) Three-year followup anteroposterior radiograph following open reduction and internal fixation of the distal humerus fracture and olecranon osteotomy repair.
(B) Three-year followup lateral radiograph following open reduction and internal fixation of the distal humerus fracture and olecranon osteotomy repair.