12. O’DRISCOLL’S RING OF INSTABILITY
O'Driscoll et al. described a valgus, axial, and posterolateral force that
results in the typical posterolateral dislocation of the elbow joint
16. • Not associated with fracture
• Posterior and Posterolateral (M/C)– all directions and divergent
dislocations can occur
• Beware patterns other than posterior/posterolateral – can be more unstable
after reduction
• Mechanism of Injury
• Partially flexed elbow
• Axial load, supination, and valgus
• Varus mechanisms also described
• Medial ligamentous injuries in most cases
SIMPLE DISLOCATION
21. UNSTABLE AFTER REDUCTION
• Uncommon in simple dislocations
• May require soft tissue reconstruction
• Do what needs to be done to hold a concentric
reduction
• Splint in more flexion
• External fixator – static vs hinged
• Elbow cross pinning
• Internal fixator
31. Valgus stability-MCL and Radial head
Importance: Valgus force
Primary stabilisers – anterior bundle of MCL
Secondary stabilisers- Radial Head
So,whenever excise the radial head in case of MCL rupture- no
resist to valgus force- valgus instability
32. Radial head
communited
fracture
Radial head
excised
Intact
intraosseous
membrane
Radial head
excised
Ruptured
intraosseous
membrane
Radius migrated
proximally-
causing damage
to elbow joint,
Ulna move
towards distally-
causing damage
to ulnocarpal jt.
So, whenever Radial
head fracture
Always look for
DRUJ
Disruption/intraoss
eous membrane
damage
ESSEX LOPRESSETI #
33. UNSTABLE RADIAL HEAD #
No MCL + Radial head excision = valgus instability =
Early osteoarthritis
UNSTABLE RADIAL HEAD FRACTURE
34. DECISION MAKING
• Fragment number
• Displacement
• Articular surface
• Age and bone quality
• Dislocation
• Ass. Ligamentous injury
• Ass. Elbow fractures
DECISION MAKING
37. RADIAL HEAD AND NECK- SAFE ZONE
• 240° of circumference
articulates with ulna at
lesser sigmoid notch
• ~90-100 ° arc of safe
hardware placement
Caput et al recommended using the radial styloid and listers
tubercle as guides
43. COMMINUTED RADIAL HEAD FRACTURE
ROLE OF THE RADIAL HEAD ARTHROPLASTY
▪ Excision will lead to instability
▪ Functional spacer
▪ Creates stability by increasing radial length & restoring valgus restraint
48. ▪ Direct visualization
▪ Most accurate way to
determine appropriate head
size
▪ Radial head should be just
at or proximal to radial
notch of the ulna
▪ Intra-op Fluoro
• Needs to be assessed in
flexion and extension
• Less reliable • > 6mm
overstuffing must be present
to consistently be seen on
fluoro
RADIAL HEAD FRACTURE-OVERSTUFFING
49. POST-OP PROTOCOL
▪ For all stabilized fxs and dislocations regardless of fixation
• Initially
• Immobilization for 10-14 days
• Secondarily
• Early ACTIVE range of motion
• Allows dynamic stabilizers to help hold reduction of joint
▪ Will reduce pseudosubluxations
• Limits elbow stiffness
• Some limit active shoulder abduction if LUCL was repaired
50. APPROACHES
• KAPLAN APPROACH
• KOCHER APPROACH
• EDC Split
• Modified Boyd
• Posterior approach
• Elevate LUCL from lateral epicondyle
• Can be used for combined olecranon/radial head
fxs
RARELY USED APPROACH
51. KOCHER APPROACH
Plane Between ECU and anconeus
Most often utilized for radial head
• Interval
• Anconeus – Radial Nerve
• ECU – PIN
• 5cm incision from lateral epicondyle distally
• Angled posteriorly 30-45 degrees
• Often deep soft tissues will be disrupted by injury
52. • Damage to LUCL
• Stay on anterior half of radial
head
• Damage to PIN
• Pronate the arm to move nerve
distally
• Carefully dissect distal to annular
ligament
KOCHER PITFALLS
53. • Distal extension becomes dorsal
Thompson approach
• More often used for radial neck/proximal
radial shaft fxs
• Interval
• ECRB – Radial nerve or PIN (variable) •
EDC – PIN
10cm incision from lateral epicondyle to
Lister’s Tubercle
KAPLAN APPROACH
60. PROXIMAL ULNA - ANTERIOR
CORONOID
•Anterior capsule
•Brachialis
•Anterior bundle of MCL
•Anteromedial facet of coronoid
▪ Fx propagation into this region
may cause functional MCL
incompetancy
65. OLECRANON FRACTURE
Mechanism of Injury
• Acute Tension overload: Tension applied by
the triceps with flexion of the elbow
• Direct Trauma
• Chronic overload: eg. stress fractures seen
commonly with osteopaenic or pediatric
patients
66.
67. CLASSIFICATION
Many Classifications:
– Colton
– Morrey
– Schatzker
– AO/ASIF
– OTA
Criteria
– Displacement
– Direction of fracture
– Degree of comminution
– Percent involvement
– Associated injuries
69. TREATMENT -AIM
Restoration of elbow motion and prevention
of stiffness
– Goal is to begin early ROM
• Restoration and preservation of the elbow
extensor mechanism.
• Restoration of the articular surface.
• Prevention of complications.
70. TREATMENT METHOD
• Non operative method
• Operative method
• Excision of olecranon and triceps repair
• Open reduction with internal fiaxtion
• TBW with pins or intramedullary
screws
• Plate
73. VARUS ANGULATION
Proximally the ulna
demonstrates ~ 12 degrees
varus angulation
– The articular surface
extends beyond the “joint
space” visualized on the
lateral radiograph
74. SURGICAL ANATOMY
• Coronoid process: preserve
height
– Coronoid Height ~ 2 x Olecranon
height
– Tip of Coronoid to tip of
Olecranon subtends angle of ~30
degrees from long axis of ulnar
shaft
Articular cartilage
– Sigmoid notch of ulna: bare
spot centrally between tip and
coronoid
– Pearl: Beware of narrowing
sigmoid fossa when treating
comminuted olecranon fx’s.
75. TBW
For most simple, transverse,
non-comminuted fractures
• Use 18- or 20-gauge steel
wire or small braided cable.
– Be sure wires cross over
dorsal cortex.
– 2 smaller (22 gauge) wires
may be less prominent
• May use with either parallel
K-wires or an
intramedullary screw
76.
77.
78.
79. For simple and transverse fracture fracture
If fracture goes beyond the coronoid,TBW
principle not work
80. INTRAMEDULLARY SCREWS
Need to add tension band
wire
• Long/large screw required
– 6.5mm cancellous
– 85-110 mm long
• Risk of shortening…
osteopaenic bone, oblique
fracture and comminution
87. WHAT IS A TERRIBLE TRIAD?
1. Elbow dislocation
2. Coronoid fracture
3. Radial head fracture
88. TERRIBLE TRIAD INJURIES: MECHANISM OF
INJURY
▪ Fall on an outstretched hand
▪ Axial load
▪ Relative elbow extension
▪ Valgus
▪ Forearm rotation
▪ Supination
The ultimate
“Posterolateral rotatory instability”
89. TERRIBLE TRIAD FRACTURE-
DISLOCATION
▪ What is so terrible about it?
▪ Extremely unstable
▪ Loss of joint congruency
▪ Instability
▪ Fracture fragments are usually quite small
▪ Difficult to repair
▪ Patients don’t routinely do “well”
▪ Unaware of the magnitude of the injury
for the elbow
▪ Residual instability
▪ Stiffness
90. TERRIBLE TRIAD INJURIES
PATIENT AND INJURY ASSESSMENT
• Patient evaluation
▪ Associated injuries
▪ Mechanism of injury
▪ Soft tissue status
▪ Radiographs (possible traction views)
▪ Post-reduction CT w/ 3D recons
• Operative timing
▪ As urgently as possible but during the
daytime
▪ Pre-op planning for appropriate equipment
95. TERRIBLE TRIAD –TREATMENT PROTOCOL
(MCKEE, PUGH, SCHEMITSCH,ET AL JBJS(A) ’04)
▪ 36 consecutive patients treated:
1. Fix or suture coronoid
2. Repair / replace radial head
3. Repair LCL
4. If still unstable, repair MCL
5. If still unstable, hinged ex-fix
96. SURGICAL PLANNING: APPROACHES
▪What’s injured?
▪ Radial head only
▪ Radial head
▪ type 1 coronoid
▪ Radial head
▪ type 2 or 3 coronoid
▪ Proximal ulna / olecranon
●Medial Approach Needed if:
▪ plate coronoid fracture
▪ transpose ulnar nerve
▪ repair or reconstruct MCL
Radial head replacement &
common proximal ulna fracture
exposes coronoid tip
97. INTERNAL FIXATION
▪3 steps:
▪ Repair radial head
▪ Secure radial head to the radial neck
▪ Avoid impingement of plates during
forearm rotation.
▪Small K wires used provisionally.
▪“mini-fragment” screws (1.5 to
2.7 mm), countersink heads
▪Secure radial head to neck with
2.0 or 2.7 L-shaped plates or mini
blade plates
98. TERRIBLE TRIAD: MEDIAL INSTABILITY ?
▪ Repair MCL
▪ Reconstruct through bone tunnels
▪ Suture Anchors
▪ Palmaris autograft or allograft tendon
▪ Repair muscle origins
FC
U
Ulnar
Nerve
Ulnohumeral
joint reduced
103. LATERAL APPROACH: DEEP DISSECTION
• Access to anterior ulno-
humeral joint
▪ Elevate the extensors
▪ Stay superior to the LCL
▪ Able to visualize the PIN
• Arthrotomy
▪ Release of the lateral
capsule and annular
ligament
104. ANTEROMEDIAL APPROACH TO CORONOID
•Medial supracondylar ridge
•Pronator teres - brachialis interval
•Incise anterior 1/2 flexor-pronator
mass
•Anterior capsule
105. ANTEROMEDIAL APPROACH TO CORONOID
•Medial supracondylar ridge
•Pronator teres - brachialis interval
•Incise anterior 1/2 flexor-pronator
mass
•Anterior capsule
106. ANTEROMEDIAL APPROACH TO CORONOID
•Medial supracondylar ridge
•Pronator teres - brachialis interval
•Incise anterior 1/2 flexor-pronator mass
•Anterior capsule
107. POSTEROMEDIAL APPROACH TO
CORONOID
Exposure of:
• Coronoid
• Sublime tubercle
• MCL
• Proximal ulna
▪MCL reconstruction or repair
▪ORIF AM facet of coronoid
▪Buttress plating of coronoid
108. POSTEROMEDIAL APPROACH TO CORONOID
▪Necessitates ulnar nerve exposure and transposition
▪Palpate sublime tubercle
▪Incise FCU ulnar attachment distal to sublime tubercle and proceed proximally ->
anterior bundle of MCL.
109. TERRIBLE TRIAD INJURIES:
REHABILITATION
▪ Rehab
▪ Stiffness vs. Instability
▪ Cautious
▪ Posterior splint
▪ 14 days post-op
▪ Cuff and collar
▪ Guided rehab is essential
▪ Flexion first!
▪ Active and passive
▪ Active and passive forearm rotation at
90°
▪ Begin extension at 3 weeks, active only
▪ Start supine—active against gravity
110. TERRIBLE TRIAD INJURIES: SUMMARY
▪ Not so Terrible
▪ Isolated injury & cooperative patient
▪ Stable repairs & motion
▪ Coronoid fixation
▪ Radial head arthroplasty vs. ORIF
▪ LCL repair
▪ Terrible
▪ Poor stability after repairs complete
▪ Multi-trauma
▪ ICU stay
▪ Head injuries
▪ Non-weight bearing on lower extremities
▪ Uncooperative patient
