elbow

1. TERRIBLE TRIAD

2. • ELBOW DISLOCATION
• CORONOID FRACTURE
• RADIAL HEAD FRACTURE

3. WHY TERRIBLE ?
• Recurrent / persistent subluxation or dislocation.
• Chronic instability.
• Arthrosis and pain.

4. Mechanism of Injury
• Fall on outstretched hand
• Axial load, supination & Valgus stress

5. STAGES
1. Ulnar lateral collateral ligament disruption
2. Anterior and posterior soft tissue disruption with coronoid under
trochlea
3. A. Intact MCL anterior band
B. Ruptured MCL anterior band
C. All soft tissue stripped

6. Terrible Triad Presentation
• Pain
clicking
• Locking of elbow in extension
• Varus instability
• Valgus instability (If MCL injuried)

7. Critical Component to Achieve Treatment Goal
• Obtaining band maintaining a concentrically reduced articulation
• Mamnagement of coronoid & radial head fracture if oresent
• Early range of motion
• Unstable elbow with wrist injury – High risk of compartement
syndrome
• 20% PATIENT – Terrible ulnar nerve palsy
• High risk of developing heterocopic ossification

8. Management
• Dislocated elbow
Reduce in emergency department
• Unstable
Do not perform repeat reduction
• Plan under anaesthesia

9. Pathoanatomy
• Capsuloligamentous injury
• Avulsion of flexor & extensor musle from epicondyle
• Coronoid fracture – transverse fragment with anterior capsule
attached, involves 30% of height
• Radial head – anteroateral of entire radial head

10. Standard treatment protocols
• 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