Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky,...
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Transcript of Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky,...
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 The ultimate ““Posterolateral rotatory instabilityPosterolateral rotatory instability””
Terrible Triad Fracture-DislocationWhat 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 Radial collateral ligament • Lateral ulnar collateral ligamentLateral ulnar collateral ligament• Annular ligament Annular ligament
Medial Collateral Ligament
• Anterior bundleAnterior bundle• Posterior bundlePosterior bundle• Transverse bundleTransverse 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 anatomyLateral muscular anatomy
Injury Patterns•Posterior dislocation &
radial head fracture
Injury PatternsPosterior dislocation &
radial head fracture
Posterior dislocation, radial head & coronoid
fractures– “Terrible Triad”
Injury PatternsPosterior dislocation &
radial head fracture
Posterior dislocation, radial head & coronoid
fractures– “Terrible Triad”
Transolecranon fracture-dislocations
– Anterior– Posterior
Terrible Triad InjuriesPatient 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 47 yo trip and fall down stairsstairs
Radial Head Fractures:Modified - Mason ClassificationType 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 fracturesO’Driscoll ClassificationType I: tip
Type II: anteromedial facetType III: base
Terrible Triad –Treatment ProtocolMcKee, 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: ApproachesWhat’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 & Radial head replacement & common proximal ulna fracture common proximal ulna fracture exposes coronoid tipexposes coronoid tip
Internal fixation3 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 headsSecure 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 ArthroplastyExcision 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 originsPronatorPronator
FCUFCU
NerveNerve
Medial Epicondyle
Medial Epicondyle
FCUFCU
Ulnar Ulnar NerveNerve
Medial Epicondyle
Medial Epicondyle
Ulnohumeral Ulnohumeral joint reducedjoint reduced
Terrible Triad: Persistent Instability ?
Hinges
Uniplanar Lateral FrameUniplanar Lateral Frame Multiplanar Compass HingeMultiplanar Compass Hinge
Surgical PlanningPositioning: 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 ApproachAnconeus – 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 CoronoidExposure of:
• Coronoid
• Sublime tubercle
• MCL
• Proximal ulna
MCL reconstruction or repair
ORIF AM facet of coronoid
Buttress plating of coronoid
Posteromedial Approach to CoronoidNecessitates 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
– CautiousPosterior 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
Return to Return to Upper ExtremityUpper Extremity
IndexIndex
E-mail OTA E-mail OTA about about
Questions/CommentsQuestions/Comments
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