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Distal Triceps Tendon Injections

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Other Names

  • Distal Triceps Tendon Sheath Injection
  • Distal Triceps Tendon Percutaneous Tenotomy

Background

Illustration of the triceps brachii[1]
  • 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

Relative

  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

Procedure

Probe and patient positioning for sonographic evaluation of the triceps[1]
Alternative supine position for triceps evaluation[1]
Probe and needle position for the peritendinus injection[1]
Needle placement for peritendinus approach from medial to lateral[1]
Probe and needle position for tenotomy[1]
Ultrasound image and needle trajectory for tenotomy[1]

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

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  2. Yeh PC, Dodds SD, Smart LR, et al. Distal triceps rupture. J Am Acad Orthop Surg. 2010;18:31–40.
Created by:
John Kiel on 11 September 2023 12:37:29
Authors:
Last edited:
13 September 2023 14:40:50
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