Surgical Approaches for “Terrible Triad”

Fracture-Dislocations of the Elbow

Michael J. Medvecky, MDSeth 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 anatomy

Injury Patterns•Posterior dislocation &

radial head fracture

Injury PatternsPosterior dislocation &

radial head fracturePosterior dislocation,

radial head & coronoid fractures

– “Terrible Triad”

Injury PatternsPosterior dislocation &

radial head fracturePosterior 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 < 2mmType II: displaced

– Internal fixation possibleType III: displaced, severely comminuted

– Judged to be irreparableType 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 LCL4. 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 instabilityFunctional 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 origins

PronatorPronator

FCUFCU

NerveNerve

Medial EpicondyleMedial Epicondyle

FCUFCUUlnar Ulnar NerveNerve

Medial EpicondyleMedial 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 repairORIF AM facet of coronoidButtress plating of coronoid

Posteromedial Approach to CoronoidNecessitates ulnar nerve exposure and

transpositionPalpate 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

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