Fracture of the head of the radius with a tear or avulsion of the triceps tendon. A new syndrome?

Abstract

A tear or avulsion ofthe triceps tendon is very rare, but the combined injury offracture ofthe radial head and avulsion or tear ofthe triceps tendon is even rarer still. The purpose ofthis article is to describe a series of 16 patients with this combined injury and to call into question the rarity of this combination. In an earlier article (Levy, Fishel and Stern i978) we described six patients with avulsion of the triceps tendon, four of whom also had a fracture of the radial head. Since then we have treated 1 2 more patients with this combined injury. To the best of our knowledge this is the first and the largest series describing this combination. In our article we suggested that an awareness of the hazard of a fall on the outstretched arm with fracture of the radial head ought to increase the frequency of the diagnosis of avulsion or tear of the triceps which can result from such an accident. CLINICAL MATERIAL Since 1973 16 patients have been treated (Table I) for the combined injury. All but one had a fracture of the radial head; the one exception (Case 4) had a fracture of the capitulum of the humerus. Twelve patients had avulsion and a tear of the triceps tendon, and four patients had a tear only. Clinical findings. These showed relatively little variation. In most of the patients we could prove that the mechanism of injury was a fall on the outstretched arm; in no patient was there a direct injury to the elbow. The symptoms and signs of the fractured radial head understandably dominated the clinical picture, the pain and tenderness being localised to the region of the radial head. Every patient had painful limitation of movement and diffuse swelling, but a palpably painful gap in the tendon was not consistently present. In all patients with avulsion of the tendon, the lateral radiograph of the elbow revealed an avulsed fragment of olecranon lying posterior to the distal end ofthe humerus (Figs 1 and 2). Treatment. In three patients without avuision of the triceps tendon we made a clinical diagnosis of a partial tear, and therefore we did not operate. The remaining 13 patients were operated on. In the i2 patients with avulsion (even of a very small olecranon fragment) we found that there was a complete or almost complete tear of the triceps tendon, and this was sutured with chromic catgut or Dexon sutures passed through holes drilled in the olecranon (Tarsney 1 972 ; Pantazopoulos et al. 1 975 ; Levy et al. 1 978). Additional sutures were inserted medially and laterally between tendon and muscle along the course of the tear caused by the avulsed fragment. In the fourth patient without avulsion (Case 2) we also found an almost complete rupture ofthe tendon. In five patients we had to excise the radial head, and in two we performed an open reduction. After operation the patients remained in a cast for three weeks with the elbow immobilised at an angle approximately 45 to 50 degrees short of full extension. Thereafter, physiotherapy was continued for four to six