Terrible triad of the elbow

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This document discusses the terrible triad injury of the elbow, which involves fractures of the radial head and coronoid process along with disruption of the lateral collateral ligament complex. It begins by noting that these injuries are typically seen by trauma and orthopaedic surgeons. It then outlines the anatomy and stabilizers of the elbow joint. The remainder describes an algorithmic approach to managing terrible triad injuries, focusing on restoring the coronoid, replacing the radial head, and repairing the lateral ligament complex while protecting surrounding soft tissues and nerves. Key steps include using fluoroscopy, considering prosthetic replacement for comminuted fractures, and having fixation devices available depending on the injury and stability.

Terrible Triad of the Elbow
International Trauma Symposium
Prof. Mohamed A. Imam
MD, MSc (Orth)(Hons), D.SportMed, Ph.D., FRCS (Tr. and Orth.)
Consultant Trauma and Orthopaedic Surgeon, Rowley Bristow Orthopaedic Centre, Chertsey,
UK
Email: Info@theArmDoc.co.uk
@MoAImam

Who sees these injuries?
Does it matter??

Approach to instability
• Understand anatomy
• Pattern recognition
• Algorithm for management

Radial head
Coronoid
Lateral ligament complex
MCL - anterior bundle
Common flexor and extensor
origin
Primary stabilisers
MCL - anterior bundle
Coronoid
Lateral ligament complex
Olecranon
Secondary stabilisers
Radial head
Common flexor and
extensor origin
Anterior capsule
Elbow Stability

The Interosseous Ligament
The quadrate ligament of Denucé is the most
proximal aspect of the interosseous membrane
and is located just distal to the annular
ligament.
This quadrate ligament reinforces the
inferior aspect of the elbow capsule and
contributes to stability by securing the proximal
radius to the radial notch.

Copyright Dr Gregory Bain and Max Crespi)

Watts et al, 2019
Three column model of osseous elbow stability

Terrible Triad Algorithm
Assess/Restore
Coronoid
Restore Radial Head
Restore Lateral
Ligamentous complex
Restore Medial
soft tissue
Ex-fix

Radial Head replacement Height
Height
Resected
Head
UHJ
Gapping
Ulna
variance
Coronoid

PEARLS AND PITFALLS
• Protection of the posterior interosseous nerve
Pronation of the forearm moves the posterior interosseous nerve away
from the operative field during posterior approaches. Dissection should
remain subperiosteally.
• Comminution
We have a low threshold for arthroplasty in the setting of comminution.
• Fluoroscopy
A fluoroscopy unit should be available for examination under anesthesia
before sterile preparation.

$PEARLS AND PITFALLS • Hardware Prosthetic radial head replacement should be discussed with the patient as an option and should be available in the room should the fracture prove to be comminuted. A hinged external fixator should be available if instability may be an issue. • Examination A thorough fluoroscopic examination is the most important factor in deciding what treatment is appropriate. To obtain a true lateral view, we recommend abducting the arm and externally rotating the shoulder while placing the elbow on the image intensifier.$

Email: Info@TheArmDoc.co.uk
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