3. Elbow anatomy—coronoid process
• Anterior aspect of the
greater sigmoid notch
– Articulates with trochlear
– Brachialis insertion
• Laterally
– Lesser semilunar notch
articulates with radial
head
• Medially
– Attachment of anterior
fibers of MCL
11. The “terrible triad“
• Subluxation—ligamentous injury
• Coronoid fracture
• Radial head fracture
• Primary and secondary stabilizers disrupted
• Recurrent instability the rule
12. Why terrible
• Recurrent / persistent subluxation or
dislocation
• Chronic instability
• Arthrosis and pain
13. 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
14. The “terrible triad“
Ring et al (2002) J Bone Joint Surg Am
• 11 patients with terrible triad
– 4 radial head resection, 5 radial head ORIF
– None of the coronoid fractures fixed
• 5 patients redislocated in postoperative splint
– All radial head resections dislocated acutely
• 1 total elbow performed
• 9 out of 10 with native elbow developed arthrosis
15. Mechanism of injury
• Fall on outstretched hand
• Axial load, supination & Valgus stress
16. Stages
I Ulnar lateral collateral
ligament disruption
II Anterior and posterior
soft issue disruption with
coronoid under trochlea
III a Intact MCL anterior
band
III b Ruptured MCL anterior
band
III c All soft tissue stripped
17. Terrible triad - Presentation
• Pain
• Clicking
• Locking of elbow in extension
• Varus instability
• Valgus instability – ( If MCL injured )
18. What are the Dilemna
• Surgical techniques challenging
• Debate in surgical steps
• Choices in management
19. Critical components to achieve treatment goals
• Obtaining and
maintaining
a concentrically
reduced
articulation
• Management of
coronoid & radial head
fracture if present
• Early range of motion
20. Examination
• Unstable elbow with wrist injury - High risk of
compartment syndrome
• Combined distal radius and elbow fracture –
9/59 ( 15%)
• Isolated distal radius # - 3/869 ( .3%)
22. • High risk of developing heterotopic
ossification
23. Management
• Dislocated elbow – reduce in emergency dept
• Unstable – Do not perform rpt rereduction
• Plan under anaesthesia
24. Imaging
• X- rays – Ap and lateral
• Ct scan – Include 3D reconstruction
25. Pathoanatomy
• Capsuloligamentous injury
• Avulsion of flexor & extensor muscle from
epicondyle
• Coronoid fracture – transverse fragment with
anterior capsule attached, involves 30% of height
• Radial head – anterolateral or entire radial head
26. Standard treatment protocols
Pugh DMW, et al (2004) J Bone Joint Surg Am
• Fixation or replacement of radial head
• Fixation of coronoid fracture
• Repair of associated capsular and lateral soft-tissue
injuries
• Evaluation of stability and repair of MCL as necessary
• Adjuvant hinged external fixation if residual instability
27. Aim of management
• Ulnohumeral joint reduced – 4 - 6 weeks
• Prevent injury and treatment related
complication
28. Non operative treatment
• Small coronoid and radial head fracture
• Concentrically reduced ulnohumeral and
radiocapitellar joint
• Ct scan – insignificant fracture
• Elbow unstable in only < 30 deg flexion
IMMOBILIZE IN 90 Deg
FLEXION
32. Operative treatment
• Work on primarily lateral side
• Work from “outside” to “inside”
LCL / common extensor Radial head fracture Coronoid
fracture
33. Operative treatment
• Stabilize in reverse order
“inside” to “outside’’
• Repair coronoid Repair / replace radial
head reattach common extensor/LCL
34. Lateral Interval
• Kocher ‘s - ECU and
anconeus
• Boyd’s - Ulna and
anconeus
• Kaplan- Extensor
elevated off the ridge
“ AVAILABLE
WINDOW”
36. 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
39. 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
40. Surgical protocol
• Fixation / replacement radial head
• Fixation of coronoid fracture – if possible
• Repair of associated capsule and collateral
ligament
In recalcitrant cases
• Repair of MCL
• Adjuvant hinged fixator
PUGH et al 2004
41. Radial Head Fractures:
Modified - Mason Classification
•Type I: nondisplaced
– No block to forearm rotation, displacement < 2mm
•Type II: displaced
– Internal fixation possible
•Type III: displaced, severely comminuted
– Judged to be irreparable
•Type IV: fracture + dislocation
42. Radial Head - ORIF
• One / Two part articular fracture
• Entire head – one piece
• Preserve head when possible
44. Radial head – Fix / replace
• Operative repair / replacement - similar short
term result ( 7 year)
• Limited size ( 23 pt .)
45. Do not excise without replacement
• Restore radial head
• If not possible replace
• Repair lateral collateral lig
• Orif of coronoid
46. Safe Zone – Radial Heal ORIF
• Forearm neutral
rotation – mark AP
diameter radial head
• Safe zone – 65 deg.
anterior and 45 deg.
Posterior to this mark
68. Medial Collateral ligament
• After repairing radial head
• Coronoid
• LCL
• Test elbow stability – Fluoroscopically
• Elbow unstable from 30 to 130 – repair MCL
69. Terrible Triad: Medial Instability ?
– Repair MCL
– Reconstruct through bone tunnels
• Suture Anchors
• Palmaris autograft or allograft tendon
– Repair muscle origins
Ulnohumeral joint
reduced
70.
71. Hanging arm test
• Check intraop stability of elbow
• Elbow in full extension ,
• forearm supinated
• Bump under the arm
72. Hinge / static fixator
• After repairing radial head
• Coronoid
• LCL
• MCL
Elbow still unstable – Hinge / static fixator
Ulnohumeral transfixation – inferior option
73.
74.
75. Hinge / static fixator
• Static fixator – removed at 3 weeks
• Hinge Fixator – remove at 6 – 8 weeks
76.
77. Post op Rehabiliattion
• Position of immobilization
• MCL intact &LCL repaired – 90 deg flexion /full
pronation
• MCL & LCL repaired – splint in neutral
• LCL repaired & MCL unrepaired – 90 deg
flexion and full supination
78. Post op Rehabiliattion
• Begin Range of motion - 2 – 5 days
• Stable arc of motion – intraop determined
• Resting splint – 6 weeks
• Night splint - 12 weeks
84. Approach
• Fix the coronoid? What technique?
• Radial head fix or replace?
• How do you repair collateral ligaments:
– Drill holes or suture anchors
• What are the sequence of events for
treatment
85. Treatment
• Posterior approach
• Pieced together radial head on
back table
• Suture anchor in coronoid base
• Fix head to plate
• Weave sutures through LCL
• Run sutures in capsule over
coronoid
86.
87.
88. 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
89. Summary
• Complex bony and soft-tissue injury
• Will lead to unstable elbow if not properly
treated
• Requires coronoid process stability
• Radial head fixation or replacement
• LCL repair
93. The “terrible triad”—radial head
surgical technique
Repair or replace
• After coronoid repair
• May need to subluxate elbow to insert
prosthesis
94. Final check for stability
• Excessive valgus instability repair MCL
• If unstable in progressive extension or the
fixation is tenuous
– Hinged external fixation
– Splint in flexion and plan staged capsular release
