Surgical Approaches for “Terrible Triad”
Fracture-Dislocations of the Elbow
Michael J. Medvecky, MD
Seth Dodds, MD
Created May 2011
What is a Terrible Triad?
1. Elbow
dislocation
2. Coronoid fracture
3. Radial head
fracture
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”
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
Lateral Collateral Ligament
• Radial collateral ligament
• Lateral ulnar collateral ligament
• Annular ligament
Medial Collateral Ligament
• Anterior bundle
• Posterior bundle
• Transverse bundle
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
Medial Muscular Anatomy
Lateral muscular anatomy
Injury Patterns
•Posterior dislocation &
radial head fracture
Injury Patterns
Posterior dislocation &
radial head fracture
Posterior dislocation,
radial head & coronoid
fractures
– “Terrible Triad”
Injury Patterns
Posterior dislocation &
radial head fracture
Posterior dislocation,
radial head & coronoid
fractures
– “Terrible Triad”
Transolecranon fracturedislocations
– Anterior
– Posterior
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
47 yo trip and fall down stairs
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
Classification: Coronoid
Fractures
Regan & Morrey
•Type 1 tip
•Type 2 < 50%
– May be stable
•Type 3
> 50%
– usu very UNstable
Classification: Coronoid fractures
O’Driscoll Classification
Type I:
tip
Type II:
anteromedial facet
Type III:
base
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
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
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
Radial Head Fixation - Safe Zone
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
Terrible Triad: Medial Instability ?
– Repair MCL
– Reconstruct through bone tunnels
• Suture Anchors
• Palmaris autograft or allograft tendon
– Repair muscle origins
Ulnohumeral
joint reduced
Terrible Triad: Persistent Instability ?
Hinges
Uniplanar Lateral Frame
Multiplanar Compass Hinge
Surgical Planning
Positioning: supine vs lateral
– Supine:
• Better access and visualization of
anterior joint & coronoid
– Lateral
• facilitates ulnar length, lessens needs for
assistants
Surgical approach:
– Midline Posterior
– Kocher (posterolateral) vs Kaplan
(anterolateral)
– Anteromedial
– Posteromedial
– Percutaneous coronoid fixation
Incision Midline Posterior
Surgical Approach Options
Lateral: Kocher Approach
Anconeus – ECU
interval
Lateral: Kaplan Approach
•Anterior column exposure
– Supracondylar ridge
– Anterior to mid-axis of
radiocapitellar joint
– Utilize LCL tear
– Incise anterior capsule
– Exposes anterior coronoid
– Replacement or fixation
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
Anteromedial Approach to
Coronoid
•Medial supracondylar ridge
•Pronator teres - brachialis interval
•Incise anterior 1/2 flexor-pronator
mass
•Anterior capsule
Anteromedial Approach to
Coronoid
•Medial supracondylar ridge
•Pronator teres - brachialis interval
•Incise anterior 1/2 flexor-pronator
mass
•Anterior capsule
Anteromedial Approach to
Coronoid
•Medial supracondylar ridge
•Pronator teres - brachialis interval
•Incise anterior 1/2 flexor-pronator
mass
•Anterior capsule
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
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.
CASES
40 F thrown from horse
Radial head & coronoid fractures
s/p dislocation
Terrible Triad Injuries: Rehab
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
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
Questions ?
Conclusions
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