Distal Triceps Tendon Injections
Other Names
- Distal Triceps Tendon Sheath Injection
- Distal Triceps Tendon Percutaneous Tenotomy
Background
- This page covers both distal triceps tendon sheath injections and percutaneous tenotomy
Key Points
- Transducer: high-frequency, linear array
- Peritendinous Injection: 22-25 gauge, 1.5-2 inch needle
- Tenotomy: 18-20 gauge needle
- Do not inject steroids into the tendon due to risk of rupture
- Pre-scan to find radial nerve, other neurovascular structures
Anatomy: Triceps inserts distally onto the Olecranon
- This is known as the triceps footprint[2]
- Medially: insertion extends on the posterior end of the ulna
- Laterally: inserts onto the fascia of the extensor carpi ulnaris
Palpation vs Ultrasound Guidance
- To date, there are no studies comparing ultrasound-guided and palpation-guided approaches
- We highly encourage you to perform this procedure with ultrasound guidance
Indications
Contraindications
Absolute
- Triceps Tendon Rupture
- Anaphylaxis to injectates
- Overlying cellulitis, skin lesion or systemic infection
Relative
- Can be treated with less invasive means
- Hyperglycemia or poorly controlled diabetes
- Lack of symptom improvement with previous injection
Procedure
Equipment
- Sterile prep (including chloraprep, chlorhexadine, iodine, etc)
- Ultrasound with sterile probe cover
- Gloves
- Needle
- Local anesthesia: typically 21-25 gauge, 1.5 inch
- Tenotomy: 18-20 gauge, 1.5 to 3 inch needle
- Syringe: 5-10 mL
- Gauze
- Ethyl Chloride
- Bandage
- Injectate
- Local anesthetic
- Corticosteroid/ injectate
Ultrasound Findings
- Use high frequency linear transducer, typically at a depth < 3cm
- Visualize in both long and short axis
- Carefully scan the tendon along the olecranon and note its appearance
- Other structures of note:
- Olecranon
- Ulno-olecranon fossa
- Potential pathologic findings
- Hypoechoic areas
- Intra-tendon calcifications
- Tendon discontinuity
- Irregularity of bone cortex of olecranon
- Presence of fracture fragments if avulsion has occurred
- Olecranon bursitis with fluid in bursa
Technique: Peritendinous Injection
- Patient Position
- Patient is prone, shoulder abducted, elbow and arm hanging off table (see image)
- Alternate position
- Patient is supine, shoulder internally rotated and partially flexed
- Probe Position, Needle Orientation
- Probe is in short axis to the triceps tendon
- Needle orientation is in plane
- Approach is medial to lateral
- Target
- Peritendinous tissue on the superficial side of the triceps tendon
- Pearls and Pitfalls
- Identify and avoid radial nerve in your pre-scan
- Do not inject into the tendon
Technique: Needle Tenotomy
- Patient Position
- Patient is prone, shoulder abducted, elbow and arm hanging off table (see image)
- Alternate position
- Patient is supine, shoulder internally rotated and partially flexed
- Probe Position, Needle Orientation
- Probe is in long axis to the triceps tendon
- Needle orientation is in plane
- Approach is distal to proximal
- Target
- Intratendinous and pathologic region of triceps tendon
- Pearls and Pitfalls
- Identify and avoid radial nerve in your pre-scan
- Avoid other medial and lateral neurovascular structures
- Counsel patient on increased post procedural pain
Aftercare
- Council patient on increased pain immediately following the procedure
Complications
- Skin: Subcutaneus fat atrophy, skin atrophy, skin depigmentation
- Painful local reaction
- Infection
- Hyperglycmia
- Nerve or blood vessel injury
- Tendon rupture
- Frequency unknown
- Using ultrasound guidance, the tendon should never be injected
See Also
References
Created by:
John Kiel on 11 September 2023 12:37:29
Authors:
Last edited:
13 September 2023 14:40:50
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