Complex Elbow Injury by Dr Sergio Rowinski, Sao Paulo, Brazil.

1. 1
Ortope
CASE REPORT
Dr. Sergio Rowinski
Elbow Terrible Triad

2. MEDICAL HISTORY
healthy
saleswoman in shoe store
R.S.F., female, 32 years old

3. MEDICAL HISTORY
30/Jan/2009
right arm got “stuck” into handrail
when she stood up, elbow was
with intense swelling and pain
 fall from stairs,
at work

4. MEDICAL HISTORY
elbow had evident clinical deformity
very intense pain
taken to
hospital

analgesia + X-rays

5. 5
AP X-ray
Dislocated elbow ...
Radial head fracture

6. 6
Lateral X-ray
Coronoid fracture
Coronoid
fracture
+
Radial head
fracture
+
Elbow
dislocation
= TERRIBLE TRIAD !!

7. 7
Immediate post-reduction
X-rays

8. SEQUENCE ...
Ask for a
CT

better comprehend the fracture
specially radial head fracture
After 1 hour, CT was ready

9. 9
3D CT - elbow dislocated during exam
Radial head fracture

10. 10
3D CT - lateral view

11. 11
3D CT - Medial view

12. 12
Radial head fractureCoronoid fracture

13. 13
New reduction
Prepare for surgery
in 3 days
SEQUENCE ...

14. Elbow capsule tears in this order
O’DRISCOLL mechanism
O’DRISCOLL mechanism

15. Understanding the lesions to know
what to do
Sure 
radial head fracture
Lateral
ligamentary
complex

radial head
ANATOMY
must be re-
established
 sutured/reconstructed
IDEALLY  ARTICULATED EXT FIX
Coronoid fracture
 depends on the size of the
fragment
Maybe  repair medial ligaments
Synthesis
Prosthesis

16. Surgical steps
Identify and
evaluate radial head
fracture
Repair/reconstruct
Lateral ligaments

Synthesis or
prosthesis
 Test for stability
Stable
Cast, if articulated
ext fix not possible
Unstable
Maybe repair medial
ligaments

17. What about coronoid ????
Regan and Morrey classification

18. 18
When to fix ???
• TYPE I - no need to fix
• TYPE II - fix in Terrible Triad
(still some controversy)
• TYPE III - all of them

19. What about radial head ????
Mason’s classification

20. 20
Fix or Replace
• TYPE I - conservative. In Terrible Triad, fix
• TYPE II - fix
• TYPE III/IV - both options possible

21. 21

22. 22

23. 23

24. 24
Fix or Replace
• TYPE III/IV - better results with
REPLACEMENT

25. Present case - Surgery -
12/feb/2009
feb/2009

26. Synthesis ???
NO ...

27. Good fixation ???
NO ...

28. 28
Prosthesis ...

29. 29
Identify lateral ligament

31. 31
Immediate post-op Lat view

32. 32
Immediate post-op AP view

33. 33
01 week post-op

34. 04 months post-op

35. Clinical results - 06 months post-op

36. 36
Clinical results - 06 months post-op