Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky,...

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Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011

Transcript of Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky,...

Page 1: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Surgical Approaches for “Terrible Triad”

Fracture-Dislocations of the Elbow

Michael J. Medvecky, MD

Seth Dodds, MD

Created May 2011

Page 2: 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

Page 3: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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””

Page 4: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 5: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Lateral Collateral Ligament• Radial collateral ligament Radial collateral ligament • Lateral ulnar collateral ligamentLateral ulnar collateral ligament• Annular ligament Annular ligament

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Medial Collateral Ligament

• Anterior bundleAnterior bundle• Posterior bundlePosterior bundle• Transverse bundleTransverse bundle

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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

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Medial Muscular Anatomy

Page 9: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Lateral muscular anatomyLateral muscular anatomy

Page 10: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Injury Patterns•Posterior dislocation &

radial head fracture

Page 11: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Injury PatternsPosterior dislocation &

radial head fracture

Posterior dislocation, radial head & coronoid

fractures– “Terrible Triad”

Page 12: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Injury PatternsPosterior dislocation &

radial head fracture

Posterior dislocation, radial head & coronoid

fractures– “Terrible Triad”

Transolecranon fracture-dislocations

– Anterior– Posterior

Page 13: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

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47 yo trip and fall down 47 yo trip and fall down stairsstairs

Page 15: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 16: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Classification: Coronoid Fractures

Regan & Morrey

•Type 1 tip

•Type 2 < 50%– May be stable

•Type 3 > 50%– usu very UNstable

Page 17: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Classification: Coronoid fracturesO’Driscoll ClassificationType I: tip

Type II: anteromedial facetType III: base

Page 18: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 19: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 20: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 21: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Radial Head Fixation - Safe Zone

Page 22: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 23: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 24: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Terrible Triad: Persistent Instability ?

Hinges

Uniplanar Lateral FrameUniplanar Lateral Frame Multiplanar Compass HingeMultiplanar Compass Hinge

Page 25: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 26: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Incision Midline Posterior

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Surgical Approach Options

Page 28: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Lateral: Kocher ApproachAnconeus – ECU

interval

Page 29: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 30: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 31: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Anteromedial Approach to Coronoid

•Medial supracondylar ridge

•Pronator teres - brachialis interval

•Incise anterior 1/2 flexor-pronator mass

•Anterior capsule

Page 32: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Anteromedial Approach to Coronoid•Medial supracondylar ridge

•Pronator teres - brachialis interval

•Incise anterior 1/2 flexor-pronator mass

•Anterior capsule

Page 33: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Anteromedial Approach to Coronoid•Medial supracondylar ridge

•Pronator teres - brachialis interval

•Incise anterior 1/2 flexor-pronator mass

•Anterior capsule

Page 34: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Posteromedial Approach to CoronoidExposure of:

• Coronoid

• Sublime tubercle

• MCL

• Proximal ulna

MCL reconstruction or repair

ORIF AM facet of coronoid

Buttress plating of coronoid

Page 35: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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.

Page 36: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

CASES

Page 37: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

40 F thrown from horse

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Page 40: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Radial head & coronoid fractures s/p dislocation

Page 41: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.
Page 42: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 43: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

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

Page 44: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Questions ?

Page 45: Surgical Approaches for “Terrible Triad” Fracture-Dislocations of the Elbow Michael J. Medvecky, MD Seth Dodds, MD Created May 2011.

Conclusions

Return to Return to Upper ExtremityUpper Extremity

IndexIndex

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