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Ovid: Rupture of the Long Head of the Triceps Muscle in a Child: Case Report and Review of the Literature.
12-03-03 10:55 AM
The Journal of Trauma: Injury, Infection, and Critical Care
Issue: Volume 42(2), February 1997, pp 318-320
Copyright: © Williams & Wilkins 1997. All Rights Reserved.
Publication Type: [Case Reports]
ISSN: 0022-5282
Accession: 00005373-199702000-00025
[Case Reports]
Rupture of the Long Head of the Triceps Muscle in a Child: Case Report and Review of the Literature
Sheps, David BA; Black, G. Brian MD, FRCSC, FACS; Reed, Martin MD, FRCPC; Davidson, J. Michael MD, FRCPC
Author Information
From the Section of Pediatric Radiology (M.R.), Winnipeg Children's Hospital (G.B.B.), Department of Radiology (J.M.D.), St. Boniface Hospital, University of Manitoba
(D.S.), Winnipeg, Manitoba, Canada.
Address for reprints: G.B. Black, MD, Children's Hospital, 840 Sherbrook Street, Winnipeg, Manitoba, Canada R3A 1S1.
According to the literature, rupture or avulsion of the triceps muscle at its tendo-osseous junction is uncommon,
with rupture of the muscle being extremely rare. [1,2] Waugh et al. felt that the triceps is the least frequently
ruptured muscle or tendon. [3] A thorough review of the literature found only six reported cases of ruptures of the
triceps muscle, of which, none occurred in a skeletally immature individual. [1,2,4-6] This report describes a rupture
in a 13-year-old boy, injured while waterskiing, whose growth plates had yet to fuse.
CASE REPORT
A 13-year-old previously healthy boy injured his upper extremity while waterskiing. In August of 1994, while
waterskiing behind a boat traveling at approximately 25 miles per hour, the patient caught his ski edge in the boat's
wake and was pulled forward into the water. While he was falling, the nylon tow rope became wrapped around his
left, nondominant arm, and he was dragged by the rope through the water.
The patient was seen at a nearby hospital after the incident occurred, and 1 week later by his pediatrician. He
was found to have developed a severe hematoma of the left arm accompanied by a rope burn, and there was an
associated numbness in the left elbow. Upon reexamination 1 week later, the patient revealed a healing abrasion of
the upper left arm, full range of motion at the shoulder and the elbow, and a normal neurovascular status. His
pediatrician noted constriction at the area of the rope injury and advised him to attend physiotherapy to rehabilitate
the injury. The patient did not follow through with this advice and did not actively attempt any formal rehabilitation.
Approximately 9 months later, he returned for an examination by his pediatrician because of a sensation of
ripping of the muscle in the left triceps area that had occurred when he had begun golfing. On examination, the left
triceps muscle belly was found to protrude, particularly with extension. At this point, the patient was referred to the
Winnipeg Children's Hospital Orthopedic Clinic for further assessment and management.
When the patient was first seen at the Children's Orthopedic Clinic, he stated that since the accident he had
experienced continuous discomfort on extension of the left elbow and decreased strength in the upper left arm.
Physical examination revealed a scar of the left upper arm and a step deformity in the belly of the triceps muscle.
There was no palpable tenderness, and full function and range of motion were present along with a normal
neurovascular status. On extension of the left elbow against resistance, an obvious deformity of the triceps muscle
belly was visible (Figure 1). These signs and symptoms suggested that a rupture of the triceps muscle had occurred
during the waterskiing incident.
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Ovid: Rupture of the Long Head of the Triceps Muscle in a Child: Case Report and Review of the Literature.
12-03-03 10:55 AM
Figure 1. Note bulging of triceps muscle belly on extension of left elbow against resistance.
An ultrasound was performed, with the long heads of both the right and left triceps being examined. Whereas
the right long head appeared normal, there was marked thinning on the left approximately midway down the upper
arm. This 2-3 cm region had lost its normal architecture and was quite echogenic. More distally, the muscle appeared
to be slightly hypoplastic in comparison with the opposite side, but was otherwise reasonably normal in appearance.
Discontinuity of the muscle could not be demonstrated even with vigorous contractions. The ultrasound was
interpreted as an abnormally thin and fibrotic region measuring approximately 2-3 cm in the midportion of the long
head of the left triceps. This was felt to be compatible with a healed focal rhabdomyolysis resulting from the
waterskiing injury.
A magnetic resonance imaging scan demonstrated abnormal morphology isolated to the long head of the left
triceps muscle (Figure 2). The muscle belly bulged posteriorly with a definite defect within the central portion of the
muscle belly at a level slightly distal to the proximal humeral metaphysis. T2 weighted sequences showed decreased
signal intensity most consistent with scarring and with no evidence of an intramuscular hematoma. The underlying
bone and overlying deltoid muscle both appeared normal with no evidence of injury. The appearance was consistent
with tearing and subsequent scarring of the proximal belly of the long head of the triceps muscle with the resultant
deformity.
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Ovid: Rupture of the Long Head of the Triceps Muscle in a Child: Case Report and Review of the Literature.
12-03-03 10:55 AM
Figure 2. Sagittal T1 weighted image through lateral aspect of arm demonstrating defect within long head of triceps
muscle (arrow). Note division of triceps and posterior deltoid above defect.
Cybex strength testing demonstrated a large left extension and pronation deficit at both 60 and 180 degrees per
second. The patient was also slow to reach peak torque on extension of the left elbow. Finally, testing revealed
decreased endurance on both flexion and extension of the left elbow. Despite the measured deficiencies on Cybex
testing, the patient did not demonstrate any clinically significant functional weakness. Since the injury, he has
remained physically active without any significant disability.
Treatment in this case was nonsurgical because the patient did not demonstrate any clinically functional
weakness secondary to the tear. Despite Cybex testing indicating a large extension and pronation deficit, he was able
to carry out his activities of daily living without any significant disability. At the time, a repair could not be justified
based on cosmetic reasons alone. To this date, surgical exploration of the tear has not been performed.
DISCUSSION
According to Gray, the triceps arises anatomically from the dorsal arm and consists of three heads forming a
tripennate structure. The long head arises from the infraglenoid tuberosity of the scapula, the lateral head from the
upper half of the posterior surface of the shaft of the humerus above the spiral groove, and the medial head from the
posterior surface of the lower half of the shaft of the humerus below the spiral groove. The common tendon, a
bilaminated aponeurotic structure beginning at the middle of the muscle, inserts into the upper surface of the
olecranon with a small band of fibers continuing distally and laterally over the anconeus to join with the deep fascia.
[7]
Ruptures and avulsions of the triceps have been noted to occur in a number of anatomic locations, including the
tendo-osseous insertion, the tendon itself, the musculotendinous junction, and the muscle belly. [2] Most disruptions
of the triceps occur as avulsion fractures of the olecranon process. [4,8] This finding is due to a strong contraction of
the triceps muscle overcoming the tensile strength of its osseous insertion into the proximal part of the ulna. [4]
Least common of these injuries is the rupture of the muscle belly. [1,2] In these cases, the rupture is either due to
direct trauma to the muscle or an indirect stress, such as elbow flexion, occurring against an already contracted
triceps muscle. [9]
The diagnosis of triceps muscle rupture can usually be made in patients who present with a characteristic
history. [9] Features commonly associated include a ripping or tearing sensation experienced by the patient, pain
and/or tenderness and swelling of the posterior compartment of the arm, weakness of extension of elbow, and the
presence of a palpable gap in the muscle or the appearance of a mass with contraction of the muscle. [1,2,5,6,9-16]
In general, Farrar and Lippert state the importance of determining whether the tear was complete or partial.
The literature suggests that significant loss of elbow motion and triceps power reflects a complete tear that is
unlikely to improve with nonoperative therapy. [9,17,18] However, the literature has also shown that in those
individuals with partial tears, conservative, nonoperative treatment is effective, with good long-term results.
[1,2,9,11]
Of the six previously documented cases of triceps muscle belly rupture, only Brumback reported such a rupture
in the younger age group. [1,2,4-6] However, skeletal maturity with fusion of the ossification centers is generally
reached by age 15. [19,20] In Brumback's case, the patient, a 16-year-old boy, was skeletally mature (Brumback, RJ:
personal communication, 1996). The injury, which occurred as a result of a throwing motion, did not affect the
epiphyseal growth plates because they had matured to the point of fusion [4] (Brumback, RJ: personal
communication, 1996).
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Ovid: Rupture of the Long Head of the Triceps Muscle in a Child: Case Report and Review of the Literature.
12-03-03 10:55 AM
In our case, the patient, being only 13 years of age, was not skeletally mature and did have open growth plates.
McMaster, in his study on tendon and muscle ruptures, noted that injuries involving muscle contractions most
frequently result in fractures, particularly if they occur before the epiphyses are closed. [21] Viegas reported two
cases of skeletally immature boys who, after sustaining a traumatic or stress injury of a contracted triceps muscle,
presented with avulsions of the olecranon. Viegas felt that the unique characteristics of the maturing olecranon
predispose adolescents to a particular pattern of avulsion fracture. [20] Thus, in those rare cases where a rupture of
the triceps occurs in a skeletally immature individual, it is most likely that the injury will result in an avulsion at the
tendo-osseous insertion.
CONCLUSION
This case, the first report of which we are aware of a triceps muscle rupture in a skeletally immature individual,
identifies the possibility, although rare, of such an injury occurring in pediatric patients. It also reinforces the
constellation of signs and symptoms that may accompany an injury of this type. Other authors have suggested that
nonsurgical management is appropriate in incomplete tears of the triceps muscle. Although, Cybex testing would
suggest otherwise, the patients clinical outcome indicates that such management is indeed appropriate. Whether or
not surgical repair, performed for cosmetic reasons, would improve strength testing results or clinical function, is
unknown.
REFERENCES
1. Aso K, Torisu T: Muscle belly tear of the triceps. Am J Sports Med 12:485, 1984 Bibliographic Links [Context Link]
2. O'Driscoll SW: Intramuscular triceps rupture. Can J Surg 35:203, 1992 [Context Link]
3. Waugh RL, Hathcock TA, Elliot JL: Ruptures of muscles and tendons. Surgery 25:370, 1949 Bibliographic Links
[Context Link]
4. Brumback RJ: Compartment syndrome complicating avulsion of the origin of the triceps muscle. J Bone Joint Surg
Am 69:1445, 1987 Bibliographic Links [Context Link]
5. Montgomery AH: Two cases of muscle injury. Surgical Clinics (of Chicago) 4:871, 1920 [Context Link]
6. Penhallow DP: Report of a case of ruptured triceps due to direct violence. NY Med J 91:76, 1910 [Context Link]
7. Warwick R, Williams PL (eds): Gray's Anatomy. 35th ed. Edinburgh, Longman Group, 1973, pp 541-542, Figs. 5.615.64 [Context Link]
8. Bach BR, Warren RF, Wickiewicz TL: Triceps rupture: A case report and literature review. Am J Sports Med 15:285,
1987 Bibliographic Links [Context Link]
9. Farrar El, Lippert FG: Avulsion of the triceps tendon. Clin Orthop 161:242, 1981 [Context Link]
10. Holder SF, Grana WA: Complete triceps tendon avulsion. Orthopedics 9:1581, 1986 [Context Link]
11. Holleb PD, Bach BR: Triceps brachii injuries. Sports Med 10:273, 1990 Bibliographic Links [Context Link]
12. Klemme WR, Peterson SA: Avulsion of the triceps brachii with selective radial neuropathy. Orthopedics 18:285,
1995 Bibliographic Links [Context Link]
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Ovid: Rupture of the Long Head of the Triceps Muscle in a Child: Case Report and Review of the Literature.
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1995 Bibliographic Links [Context Link]
13. Levy M, Fishel RE, Stern GM: Triceps tendon avulsion with or without fracture of the radial head: A rare injury? J
Trauma 18:677, 1978 Ovid Full Text Bibliographic Links [Context Link]
14. Levy M, Goldberg I, Meir I: Fracture of the head of the radius with a tear or avulsion of the triceps tendon. J Bone
Joint Surg Br 64:70, 1982 Bibliographic Links [Context Link]
15. Louis DS, Peck D: Triceps avulsion fracture in a weightlifter. Orthopedics 15:207, 1992 [Context Link]
16. Tiger E, Mayer DP, Glazer R: Complete avulsion of the triceps tendon: MRI diagnosis. Comput Med Imaging
Graphics 17:51, 1993 [Context Link]
17. Anderson KJ, LeCocq JF: Rupture of the triceps tendon. J Bone Joint Surg Am 39:444, 1957 Bibliographic Links
[Context Link]
18. Tarnsey FF: Rupture and avulsion of the triceps. Clin Orthop 83:177, 1972 [Context Link]
19. Morrey BF: The Elbow and Its Disorders. Philadelphia, W.B. Saunders Company, 1985, pp 154-160 [Context Link]
20. Viegas SF: Avulsion of the triceps tendon. Orthop Rev 19:533, 1990 Bibliographic Links [Context Link]
21. McMaster PE: Tendon and muscle ruptures. J Bone Joint Surg 15:705, 1933 [Context Link]
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