Terrible Triad - Elbow

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

Medial Collateral Ligament

Lateral Collateral Ligament

Stabilizers of elbow

• Primary stabilizers

Ulnohumeral jointMCL -( Ant. Bundle)LCL -

• Secondary stabilizers

Radiohumeral jointCapsuleOrigin of flexor & extensor

tendons

Dynamic stabilizers - Muscle crossing elbowAnconeusBrachialis

Triceps

Simple dislocations

• Universal disruption of the LCL

• MCL partially or completely torn

Bony congruence

• Secondary stabilizers intact

• Recurrent instability rare

Complex fracture dislocations

transolecranon fracture dislocation

posterior Monteggiadislocation, radial head, coronoid

TERRIBLE TRIAD

Terrible Triad

• Elbow dislocation • Coronoid fracture • Radial head fracture

The “terrible triad“• Subluxation—ligamentous injury

• Coronoid fracture

• Radial head fracture

• Primary and secondary stabilizers disrupted

• Recurrent instability the rule

Why terrible

• Recurrent / persistent subluxation or dislocation

• Chronic instability

• Arthrosis and pain

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

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

Mechanism of injury

• Fall on outstretched hand

• Axial load, supination & Valgus stress

Stages

I Ulnar lateral collateral ligament disruption

II Anterior and posterior soft issue disruption with coronoid under trochlea

III a Intact MCL anterior bandIII b Ruptured MCL anterior

bandIII c All soft tissue stripped

Terrible triad - Presentation

• Pain • Clicking• Locking of elbow in extension

• Varus instability• Valgus instability – ( If MCL injured )

What are the Dilemna

• Surgical techniques challenging

• Debate in surgical steps

• Choices in management

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

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%)

• Baseline neural examination

• 20% patient – Terrible ulnar nerve palsy

• High risk of developing heterotopic ossification

Management

• Dislocated elbow – reduce in emergency dept

• Unstable – Do not perform rpt rereduction

• Plan under anaesthesia

Imaging

• X- rays – Ap and lateral

• Ct scan – Include 3D reconstruction

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

Standard treatment protocolsPugh 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

Aim of management

• Ulnohumeral joint reduced – 4 - 6 weeks

• Prevent injury and treatment related complication

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 flexionIMMOBILIZE IN 90 Deg

FLEXION

•Planning operative treatment of terrible triad

Positioning

• Arm on hand table

• Rotate the shoulder and work on either side

Approach

• Posterior approach

- Lateral flap

- Medial flap – ulnar nerve / MCL

Operative treatment

• Work on primarily lateral side

• Work from “outside” to “inside”

LCL / common extensor Radial head fracture Coronoid fracture

Operative treatment

• Stabilize in reverse order “inside” to “outside’’

• Repair coronoid Repair / replace radial head reattach common extensor/LCL

Lateral Interval

• Kocher ‘s - ECU and anconeus

• Boyd’s - Ulna and anconeus

• Kaplan- Extensor elevated off the ridge

“ AVAILABLE WINDOW”

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

Medial Interval

• Medial

- Between the two head FCU

- Over the top - Hotchkiss

Approach

• Medial and lateral approach

- Large repairable radial head in the way

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

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

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

Radial Head - ORIF

• One / Two part articular fracture• Entire head – one piece

• Preserve head when possible

Radial Head – Excise / replace

Fracture < 25% Osteoporotic Extraarticular

Elbow stable Elbow Unstable

Excise Replace

Radial head – Fix / replace

• Operative repair / replacement - similar short term result ( 7 year)

• Limited size ( 23 pt .)

Do not excise without replacement

• Restore radial head • If not possible replace • Repair lateral collateral lig• Orif of coronoid

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

Radial Head Fixation - Safe Zone

Radial head replacement

• Plane of radial head – 0.9 mm proximal to lateral edge of coronoid

• Preop x- rays of opposite elbow

Radial head replacement

• Overstuffing – early joint degeneration

• Understuffing – Valgus instability

• Intraop – visible ulnohumeral gap – suggests radial lengthening.

Coronoid fracture

• Classification

- Regan and Moorey

- O’ Driscoll

Coronoid Fracture – Regan & Moorey Classification

• Type 1 - # tip

• Type 2 - < 50 %

• Type 3 - >50%

Classification: Coronoid fractures•O’Driscoll Classification•Type I: tip•Type II: anteromedial facet•Type III: base

Coronoid fractures—nonoperative treatment

Type I

• Usually early motion

Type II

• Early motion, unless unstable

• Internal fixation if associated injuries

Coronoid fractures—surgical treatment

Type III

• Internal fixation

• Screw or anterior plate

• Reconstruction with bone bone graft (tip of olecranon)

Coronoid fracture – Associated condition

• Posteromedial rotatory instability

• Posterolateral rotatory instability

• Terrible triad

• Large fracture of olecranon

Test for posterolateral instability

• Large coronoid fracture- olecranon frac

dislocation

• Small transverse fracture – Terrible triad The average height 39 % ( 19% - 59 % )

• Anteromedial facet fracture – varus posteromedial

Coronoid fracture

• Small fragments – Type 1

• Fix with suture - #5 non absorbale suture

Type 1 & 2 – No fixationRepair / replacement of radial

head and LUCL complex – stable elbow

Coronoid fracture

• Type 2 ( < 50%)• Type 3 ( >50%)

Fix with screw passed from ulnar cortex

Large fragement – plate fixation – medial approach

Coronoid fracture

• Approach – lateral – Thru the fracture radial head

• Large fragment – separate medial approach

Lateral Collateral Ligament Complex

• Avulsed from lateral condyle along with common extensor

• Unstable elbow to varus test

• Local bruising

Lateral Collateral ligament

• Repair done elbow – 90 deg

• MCL intact forearm – pronated• MCL injured – forearm supinated

Lateral Collateral ligament

• Repair with suture anchors

• Transosseous tunnels

Medial Collateral ligament

• After repairing radial head • Coronoid • LCL

• Test elbow stability – Fluoroscopically

• Elbow unstable from 30 to 130 – repair MCL

Terrible Triad: Medial Instability ?

– Repair MCL– Reconstruct through bone tunnels• Suture Anchors• Palmaris autograft or allograft tendon

– Repair muscle origins Pronator

FCU

Nerve

Medial Epicondyle

FCUUlnar Nerve

Medial Epicondyle

Ulnohumeral joint reduced

Hanging arm test

• Check intraop stability of elbow• Elbow in full extension ,• forearm supinated• Bump under the arm

Hinge / static fixator

• After repairing radial head • Coronoid • LCL• MCL

Elbow still unstable – Hinge / static fixator

Ulnohumeral transfixation – inferior option

Hinge / static fixator

• Static fixator – removed at 3 weeks

• Hinge Fixator – remove at 6 – 8 weeks

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

Post op Rehabiliattion

• Begin Range of motion - 2 – 5 days

• Stable arc of motion – intraop determined

• Resting splint – 6 weeks

• Night splint - 12 weeks

Complications

• Instability

• Failure of internal fixation

• Post traumatic stiffness

• Heterotopic ossification

• Post traumatic arthritis

32-year-old male, fell from roof

• Left elbow injury

• Neurovascular structure intact

• Closed injury

• Moderate swelling

CT scan

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

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

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

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

Terrible Triad

• Only patients with INSTABILITY had CORONOID fractures (4 patients)

The “terrible triad”—coronoid fracture surgical technique

Access

• Lateral if radial head out

• Medial-over the top for direct repair

• Indirect percutaneous from subcutaneous ulna

The “terrible triad”—coronoid fracture surgical technique

Repair

• Anterior capsule may be captured by nonabsorbable sutures

• Screw or small plate

The “terrible triad”—radial head surgical technique

Repair or replace

• After coronoid repair

• May need to subluxate elbow to insert prosthesis

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

Radial Head fracture

• Mason Classification

• Hotchkiss modification