01Approach to the Critical Patient/attcp41

Initial priorities

›Immediate priorities

›Airway and breathing compromise uncommon

›Hemodynamic instability uncommon

›Open posterior elbow wound

›Gross elbow deformity

›Associated polytrauma triggers

›Limb threat screen

›Radial pulse

›Doppler signal if not palpable

›Ulnar pulse

›Doppler signal if not palpable

›Capillary refill

›>2 seconds concern

›Motor

›Wrist extension

›Finger abduction

›Sensory

›Median nerve distribution

›Ulnar nerve distribution

›Compartment syndrome awareness

›Forearm compartments

›Pain out of proportion

›Pain with passive finger stretch

›Upper arm compartments

›Increasing tense swelling

›Escalate for worsening pain despite analgesia

›Immediate escalation triggers

02History/hx32

Mechanism and timeline

›Injury context

›Sudden eccentric load against elbow extension

›Fall on outstretched hand

›Bench press or heavy triceps extension

›Direct blow to posterior elbow

›Laceration or contusion

›Elbow dislocation event

›Self-reduced history

›Timing

›Time since injury

›<3 weeks operative timing relevance

›Progressive swelling or bruising timeline

›Delayed bruising typical

›Symptoms

›Posterior elbow pain

›Extension weakness

›Loss of push-off function

›Audible pop sensation

Risk factors and modifiers

›Patient factors

›Chronic kidney disease and dialysis history

›Diabetes mellitus

›Rheumatoid arthritis or inflammatory arthropathy

›Hyperparathyroidism history

›Prior elbow surgery

›Medication and exposure factors

›Systemic corticosteroid exposure

03Physical Exam/exam30

Inspection and palpation

›Local findings

›Posterior elbow swelling

›Ecchymosis pattern

›Skin compromise

›Abrasion

›Open wound

›Palpable gap proximal to olecranon

›Increased suspicion for complete rupture

›Deformity evaluation

›Elbow alignment

›Suspicion for dislocation or fracture

Function and special tests

›Extensor mechanism function

›Active elbow extension against gravity

›Extension against resistance

›Extension lag

›Modified Thompson squeeze test

›Lack of elbow extension with triceps squeeze

›False negatives with partial tears

›Neurovascular exam

›Radial nerve motor and sensory

›Ulnar nerve motor and sensory

›Median nerve motor and sensory

›Distal perfusion

PITFALLS

›Missed partial rupture patterns

›Preserved active ROM with reduced power

04Differential Diagnosis/ddx15

Posterior elbow pain and extension weakness

›Bone and joint injury

›Olecranon fracture

›ICD-10 compatible term

›Elbow dislocation

›Radial head fracture

›Tendon and muscle injury

›Triceps tendinopathy

›Partial triceps tendon tear

›Complete triceps tendon rupture

›Neurologic causes

›C7 radiculopathy

›Ulnar neuropathy at elbow

›Infectious and inflammatory mimics

›Olecranon bursitis

›Septic bursitis

05Laboratory Tests/lt16

Routine testing strategy

›Labs usually unnecessary

›Isolated closed tendon rupture

›Stable vitals

›Preoperative pathway labs

›Operative planning labs

›Complete blood count for anemia or infection concern

›Electrolytes and creatinine for anesthesia planning

›Anticoagulation context

›INR for warfarin exposure

›aPTT only if heparin exposure concern

Special scenarios

›Open injury or contaminated wound

›White blood cell count for infection concern

›Serum lactate only if systemic illness concern

›Chronic disease context

›Renal function trend for CKD or dialysis

›Calcium and phosphate only if metabolic bone disease concern

06Diagnostic Tests/dt41

Scoring Systems

›Functional outcome instruments

›Mayo Elbow Performance Score

›Baseline documentation option

›Follow-up outcome tracking option

›QuickDASH

›Baseline disability estimate

›Follow-up disability estimate

›Strength grading

›MRC scale

›Extension strength baseline

›Post-treatment comparison

Radiographs

›Plain radiography plan

›Elbow radiographs

›AP view

›Lateral view

›Key signs

›Small olecranon avulsion fragment

›Posterior fat pad sign

›Associated injury screen

›Olecranon fracture

›Radial head fracture

›Elbow dislocation alignment

MRI

›MRI indications

›Uncertain clinical diagnosis

›Partial versus complete tear differentiation

07Disposition/dispo25

Consultation and follow-up timing

›Orthopedics referral

›Suspected complete rupture

›Urgent referral for repair window

›Partial rupture with significant weakness

›Early referral for imaging-confirmed extent

›ED discharge criteria

›Pain controlled with oral regimen

›Neurovascularly intact

›No open wound

›No unstable dislocation or fracture requiring admission

›Admission or transfer triggers

›Open injury needing operative washout

›Neurovascular compromise

›Irreducible elbow dislocation

›Unstable fracture-dislocation

Activity restrictions and immobilization plan

›Immobilization disposition items

›Posterior long arm splint

›Elbow near extension or slight flexion per local protocol

›Sling support

›Comfort and protection

›Follow-up interval

›Suspected complete rupture

›2 to 5 days

›Suspected partial rupture

›5 to 10 days with imaging plan

08Treatment/t89

Immediate life-saving interventions

›Immediate stabilization framework

›Threatened limb perfusion

›If absent distal pulses, immediate reduction if dislocation suspected

›Immediate vascular consultation if persistent pulselessness

›Open injury management

›Sterile dressing

›Antibiotics per open injury pathway

›Analgesia strategy

›Acetaminophen

›1000 mg PO every 6-8 hours

›Maximum 3000 mg/day typical outpatient target

›Ibuprofen

›400-600 mg PO every 6-8 hours

›Avoid in high GI bleed risk or advanced CKD

›Opioid for breakthrough pain

›Hydromorphone 1-2 mg PO every 4-6 hours as needed

›Avoid coadministration with sedatives

›Procedural sedation readiness if reduction required

›Continuous pulse oximetry

›Capnography if available

›Airway equipment at bedside

›Resuscitation meds available

Immobilization and Splinting

›Splint selection

›Posterior long arm splint

›Elbow position near extension or 20-30 degrees flexion

›Forearm neutral rotation

09Special Populations/sp27

Pregnancy

›Pregnancy considerations

›Imaging

›Radiographs acceptable with shielding as appropriate

›MRI without gadolinium preferred for soft tissue detail

›Analgesia

›Acetaminophen preferred

›NSAID avoidance in later pregnancy per obstetric guidance

›Disposition

›Obstetric consultation if trauma concerns beyond isolated elbow injury

Geriatric

›Older adult considerations

›Higher comorbidity burden

›CKD and dialysis association with tendon rupture risk

›Anticoagulation prevalence

›Lower opioid tolerance

›Delirium risk

›Fall risk counseling

›Surgical candidacy assessment

›Frailty and anesthesia risk

Pediatrics

›Pediatric considerations

›True tendon rupture rarity

›Apophyseal avulsion considerations near olecranon

›Imaging

›Radiographs for physeal and apophyseal injury

›MRI if diagnosis uncertain

›Management

10Background/b33

Epidemiology

›Epidemiology summary

›Rare injury

›Approximately 0.8% of tendon ruptures reported in orthopedic summaries

›Male predominance reported in series

›Central Europe retrospective cohort male predominance around 90%

›Incidence estimate example

›0.46 cases per 100,000 inhabitants in one regional retrospective study

Pathophysiology

›Mechanism and anatomy

›Distal triceps insertion at olecranon

›Rupture at tendon-bone junction common

›Injury mechanics

›Eccentric overload during attempted extension

›Direct trauma with forced flexion

›Associated injury patterns

›Olecranon avulsion fragment

›Elbow dislocation and collateral ligament injury

Therapeutic Considerations

›Operative versus nonoperative rationale

›Complete rupture

›Primary repair commonly recommended

›Early repair within about 3 weeks associated with easier repair and better outcomes in surgical series

›Partial rupture

›<50% involvement

›Nonoperative trial considered in lower-demand patients

›>50% involvement

›Operative consideration common in reviews and series

11Patient Discharge Instructions/pdi24

Copy discharge instructions

›Discharge instructions

›Splint care

›Keep splint clean and dry

›Do not remove splint unless instructed

›Activity restrictions

›No lifting or pushing with the injured arm

›Avoid active resisted elbow extension

›Swelling control

›Elevation above heart when possible

›Ice 15-20 minutes at a time with skin protection

›Pain plan

›Acetaminophen as directed

›Ibuprofen as directed unless contraindicated

›Opioid only if needed for breakthrough pain

›Follow-up

›Orthopedics appointment within recommended interval

›Imaging appointment if arranged

›Return to ED now

›Increasing pain not controlled with medication

›New numbness or weakness in hand or fingers

›Fingers becoming cold, pale, or blue

›Splint feels too tight or increasing swelling with tingling

›Fever or drainage from any wound

›Recurrent deformity after reduction

12References/r19

Evidence-based sources and guidance

›Key sources

›van Riet et al

›Early surgical repair within three weeks described as treatment of choice in surgical series

›PubMed

›EFORT Open Reviews 2016

›Review summary of distal triceps rupture diagnosis and treatment approaches

›AJR sonography study

›Ultrasound performance for differentiating full versus partial tear reported with high sensitivity

›Central Europe retrospective cohort 2024

›Incidence estimate and operative threshold discussion around >50% fibers

›OSU distal triceps repair clinical care guideline

›Repair preferably within first three weeks statement

›Orthobullets summary

›MRI role for partial versus complete differentiation

›Coding references

›ICD-10 S46.3

›Injury of muscle, fascia and tendon of triceps category

›ICD-10 S46.312A

›Strain of muscle, fascia and tendon of triceps, left arm, initial encounter

Evidence & Review

Evidence & Review