a summary of the pertinent elbow anatomy, mechanism of injury, primary and secondary stabilizers of the elbow, and treatment options of elbow terrible triad

1. ““Terrible Triad”Terrible Triad”
Fracture-Dislocations of the ElbowFracture-Dislocations of the Elbow
Presented byPresented by
DR.Yasser BarakatDR.Yasser Barakat
Under Supervision ofUnder Supervision of
Dr. Hussain AlgawahmedDr. Hussain Algawahmed

2. What is a Terrible Triad?What is a Terrible Triad?
1.1. Elbow dislocationElbow dislocation
2.2. Coronoid fractureCoronoid fracture
3.3. Radial head fractureRadial head fracture

3. Elbow AnatomyElbow Anatomy

4. Coronoid ProcessCoronoid Process
• AnteriorlyAnteriorly
• Articulates with trochleaArticulates with trochlea
• Brachialis insertionBrachialis insertion
• LaterallyLaterally
• Lesser semilunar notch articulatesLesser semilunar notch articulates
with radial headwith radial head
• MediallyMedially
• Attachment of anterior fibers of MCLAttachment of anterior fibers of MCL

5. LateralLateral Collateral LigamentCollateral Ligament

6. MedialMedial Collateral LigamentCollateral Ligament

7. Proximal Ulna - AnteriorProximal Ulna - Anterior
CoronoidCoronoid
•Anterior capsuleAnterior capsule
•BrachialisBrachialis
•Anterior bundle of MCLAnterior bundle of MCL
•Anteromedial facet ofAnteromedial facet of
coronoidcoronoid
Fx propagation into thisFx propagation into this
region may causeregion may cause
functional MCLfunctional MCL
incompetancyincompetancy

8. Medial Muscular AnatomyMedial Muscular Anatomy

9. Lateral Muscular Anatomy

10. Ulnohumeral joint
MCL ( Ant. Bundle)
LCL
Stabilizers of the Elbow:
Primary

11. Radiohumeral joint
Capsule
Origin of flexor & extensor tendons
Stabilizers of the Elbow:
Secondary

12. Muscle crossing elbow:
Anconeus
Brachialis
Triceps
Stabilizers of the Elbow:
Dynamic

13. Injury PatternsInjury Patterns
•Posterior dislocation & radial head fracturePosterior dislocation & radial head fracture

14. Injury PatternsInjury Patterns
Posterior dislocation, radial head & coronoid fracturesPosterior dislocation, radial head & coronoid fractures
““Terrible TriadTerrible Triad””

15. Injury PatternsInjury Patterns
Transolecranon fracture-dislocationsTransolecranon fracture-dislocations
AnteriorAnterior
PosteriorPosterior

16. Terrible Triad Injuries:Terrible Triad Injuries: Mechanism of InjuryMechanism of Injury
• Fall on an outstretched handFall on an outstretched hand
• Axial loadAxial load
• Relative elbow extensionRelative elbow extension
• ValgusValgus
• Forearm rotationForearm rotation
• SupinationSupination

17. StagesStages
I LUCL disruption
II Anterior and posterior soft issue
disruption (+coronoid)
III a Intact MCL anterior band
III b Ruptured MCL anterior band
III c All soft tissue stripped

18. ImagingImaging
• X- rays – AP + LateralX- rays – AP + Lateral
• CT scan – IncludeCT scan – Include 3D3D reconstructionreconstruction AFTERAFTER
REDUCTIONREDUCTION

19. 47 yo trip and fall down stairs47 yo trip and fall down stairs

20. Terrible Triad Fracture-DislocationTerrible Triad Fracture-Dislocation
• What is so terrible about it?What is so terrible about it?
• Extremely unstableExtremely unstable
• Loss of joint congruencyLoss of joint congruency
• InstabilityInstability
• Fracture fragments are usually quite smallFracture fragments are usually quite small
• Difficult to repairDifficult to repair
• Patients don’t routinely do “well”Patients don’t routinely do “well”
• Unaware of the magnitude of theUnaware of the magnitude of the
injury for the elbowinjury for the elbow
• Residual instabilityResidual instability
• StiffnessStiffness

21. Radial Head Fractures:Radial Head Fractures:
Modified -Modified - MasonMason ClassificationClassification
• Type IType I: non-displaced: non-displaced
• No block to forearm rotation,No block to forearm rotation,
displacement < 2mmdisplacement < 2mm
• Type IIType II: displaced: displaced
• Internal fixation possibleInternal fixation possible
• Type IIIType III: displaced, severely: displaced, severely
comminutedcomminuted
• Judged to be irreparableJudged to be irreparable
• Type IVType IV: fracture + dislocation: fracture + dislocation

22. Classification: Coronoid FracturesClassification: Coronoid Fractures
• Regan & MorreyRegan & Morrey
• Type 1Type 1 tiptip
• Type 2Type 2 < 50%< 50%
• Type 3Type 3 > 50%> 50%

23. Classification: Coronoid fracturesClassification: Coronoid fractures
• O’Driscoll ClassificationO’Driscoll Classification
• Type I:Type I: tiptip
• Type II:Type II: anteromedial facetanteromedial facet
• Type III:Type III: basebase

24. ManagementManagement

25. Critical Components to AchieveCritical Components to Achieve
Treatment GoalsTreatment Goals
• Obtaining and maintaining a concentricObtaining and maintaining a concentric
reductionreduction
• ManagementManagement of coronoidof coronoid & radial head& radial head
fracture if presentfracture if present
• Early range of motionEarly range of motion

26. TREATMENTTREATMENT
Conservative:
Indications (rare)
• Ulnohumeral and radiocapitellar joints must be
concentrically reduced
• Elbow should extend to at least 30 degrees before
becoming unstable
• CT must show insignificant radial head/neck fx., no
block to motion
• Coronoid fx. limited to tip.

27. TechniqueTechnique
•Immobilize in 90 deg.of flexion for 7-10 days
•active motion initiated with resting splint at 90 degrees, avoiding
terminal extension
•static progressive extension splinting at night after 4-6 weeks
•strengthening protocol after 6 weeks

28. OperativeOperative
1. Fix or suture coronoid
2. Repair / replace radial head
3. Repair LUCL
4. If still unstable, repair MCL
5. If still unstable, hinged ex-fix

29. Surgical Planning: ApproachesSurgical Planning: Approaches
• What’s injured?What’s injured?
• Radial head onlyRadial head only
• Radial headRadial head
• type 1 coronoidtype 1 coronoid
• Radial headRadial head
• type 2 or 3 coronoidtype 2 or 3 coronoid
• Proximal ulna / olecranonProximal ulna / olecranon
• Medial Approach Needed if:Medial Approach Needed if:
• plate coronoid fractureplate coronoid fracture
• transpose ulnar nervetranspose ulnar nerve
• repair or reconstruct MCLrepair or reconstruct MCL
Radial head replacement &Radial head replacement &
common proximal ulna fracturecommon proximal ulna fracture
exposes coronoid tipexposes coronoid tip

30. Radial Head FixationRadial Head Fixation
• 3 steps:3 steps:
1.1. Repair radial headRepair radial head
2.2. Secure radial head to theSecure radial head to the
radial neckradial neck
3.3. Avoid impingement ofAvoid impingement of
plates during forearmplates during forearm
rotation.rotation.

31. Radial Head Fixation - Safe ZoneRadial Head Fixation - Safe Zone

32. Comminuted Radial HeadComminuted Radial Head
FractureFracture
Role of the Radial Head ArthroplastyRole of the Radial Head Arthroplasty
• Excision will lead toExcision will lead to instabilityinstability
• Functional spacerFunctional spacer
• Creates stability by increasingCreates stability by increasing
radial length & restoring valgusradial length & restoring valgus
restraintrestraint

33. Terrible Triad:Terrible Triad: Medial Instability ?Medial Instability ?
• Repair MCLRepair MCL
• Reconstruct through bone tunnelsReconstruct through bone tunnels
• Suture AnchorsSuture Anchors
• Palmaris autograft orPalmaris autograft or allograft tendonallograft tendon
• Repair muscle originsRepair muscle origins Pronator
Pronator
FCUFCU
NerveNerve
Medial Epicondyle
Medial Epicondyle
FCUFCU
UlnarUlnar
NerveNerve
Medial Epicondyle
Medial Epicondyle
UlnohumeralUlnohumeral
joint reducedjoint reduced

34. Terrible Triad:Terrible Triad: Persistent Instability ?Persistent Instability ?
• Hinged elbow external fixatorHinged elbow external fixator
Uniplanar Lateral FrameUniplanar Lateral Frame Multiplanar Compass HingeMultiplanar Compass Hinge

35. Surgical PlanningSurgical Planning
• Positioning:Positioning:
supine vs lateralsupine vs lateral
• SupineSupine::
Better access and visualizationBetter access and visualization
of anterior joint & coronoidof anterior joint & coronoid
• LateralLateral
Facilitates ulnar length, lessensFacilitates ulnar length, lessens
needs for assistantsneeds for assistants

36. Surgical Approach OptionsSurgical Approach Options
Surgical approach:
• Midline Posterior
• Kocher (posterolateral) vs Kaplan (anterolateral)
• Anteromedial
• Posteromedial
• Percutaneous coronoid fixation

37. Lateral: Kocher ApproachLateral: Kocher Approach
• Anconeus – ECU intervalAnconeus – ECU interval

38. Lateral: Kaplan ApproachLateral: Kaplan Approach
•Anterior column exposureAnterior column exposure
• Supracondylar ridgeSupracondylar ridge
• Anterior to mid-axis ofAnterior to mid-axis of
radiocapitellar jointradiocapitellar joint
• Incise anterior capsuleIncise anterior capsule
• Exposes anteriorExposes anterior
coronoidcoronoid
• Replacement or fixationReplacement or fixation

39. Anteromedial Approach toAnteromedial Approach to
CoronoidCoronoid
•Medial supracondylar ridgeMedial supracondylar ridge
•Pronator teres - brachialisPronator teres - brachialis
intervalinterval
•Incise anterior 1/2 flexor-Incise anterior 1/2 flexor-
pronator masspronator mass
•Anterior capsuleAnterior capsule

40. Posteromedial Approach toPosteromedial Approach to
CoronoidCoronoid
Exposure of:Exposure of:
• CoronoidCoronoid
• Sublime tubercleSublime tubercle
• MCLMCL
• Proximal ulnaProximal ulna
•MCL reconstruction or repairMCL reconstruction or repair
•ORIF AM facet of coronoidORIF AM facet of coronoid
•Buttress plating of coronoidButtress plating of coronoid
• Necessitates ulnar nerve exposure andNecessitates ulnar nerve exposure and
transpositiontransposition

41. CASESCASES

42. 40 F thrown from horse40 F thrown from horse

45. Radial head & coronoid fracturesRadial head & coronoid fractures
s/p dislocations/p dislocation

47. RehabilitationRehabilitation
• Stiffness vs. InstabilityStiffness vs. Instability
•Posterior splintPosterior splint
• 14 days post-op14 days post-op
•Guided rehab is essentialGuided rehab is essential
• Flexion first!Flexion first!
• Active and passiveActive and passive
• Active and passive forearm rotationActive and passive forearm rotation at 90at 90°°
• Begin extension at 3 weeks, active onlyBegin extension at 3 weeks, active only
• Start supine—active against gravityStart supine—active against gravity
• Hinged locked elbow brace is protectiveHinged locked elbow brace is protective

48. Terrible Triad Injuries:Terrible Triad Injuries: SummarySummary
• Not so TerribleNot so Terrible
• Isolated injury & cooperative patientIsolated injury & cooperative patient
• Stable repairs & motionStable repairs & motion
• Coronoid fixationCoronoid fixation
• Radial head arthroplasty vs. ORIFRadial head arthroplasty vs. ORIF
• LCL repairLCL repair
• TerribleTerrible
• Poor stability after repairs completePoor stability after repairs complete
• Multi-traumaMulti-trauma
• ICU stayICU stay
• Head injuriesHead injuries
• Non-weight bearing on lower extremitiesNon-weight bearing on lower extremities
• Uncooperative patientUncooperative patient

49. Questions ?Questions ?