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Terrible triad - elbow
- 1. Terrible Triad - Elbow
- 3. 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
- 6. Stabilizers of elbow • Primary stabilizers Ulnohumeral joint MCL -( Ant. Bundle) LCL - • Secondary stabilizers Radiohumeral joint Capsule Origin of flexor & extensor tendons Dynamic stabilizers - Muscle crossing elbow Anconeus Brachialis Triceps
- 7. Simple dislocations • Universal disruption of the LCL • MCL partially or completely torn Bony congruence • Secondary stabilizers intact • Recurrent instability rare
- 8. Complex fracture dislocations transolecranon fracture dislocation posterior Monteggiadislocation, radial head, coronoid TERRIBLE TRIAD
- 9. Terrible Triad • Elbow dislocation • Coronoid fracture • Radial head fracture
- 11. The “terrible triad“ • Subluxation—ligamentous injury • Coronoid fracture • Radial head fracture • Primary and secondary stabilizers disrupted • Recurrent instability the rule
- 12. Why terrible • Recurrent / persistent subluxation or dislocation • Chronic instability • Arthrosis and pain
- 13. 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
- 14. 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
- 15. Mechanism of injury • Fall on outstretched hand • Axial load, supination & Valgus stress
- 16. Stages I Ulnar lateral collateral ligament disruption II Anterior and posterior soft issue disruption with coronoid under trochlea III a Intact MCL anterior band III b Ruptured MCL anterior band III c All soft tissue stripped
- 17. Terrible triad - Presentation • Pain • Clicking • Locking of elbow in extension • Varus instability • Valgus instability – ( If MCL injured )
- 18. What are the Dilemna • Surgical techniques challenging • Debate in surgical steps • Choices in management
- 19. 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
- 20. 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%)
- 21. • Baseline neural examination • 20% patient – Terrible ulnar nerve palsy
- 22. • High risk of developing heterotopic ossification
- 23. Management • Dislocated elbow – reduce in emergency dept • Unstable – Do not perform rpt rereduction • Plan under anaesthesia
- 24. Imaging • X- rays – Ap and lateral • Ct scan – Include 3D reconstruction
- 25. 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
- 26. Standard treatment protocols Pugh 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
- 27. Aim of management • Ulnohumeral joint reduced – 4 - 6 weeks • Prevent injury and treatment related complication
- 28. 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 flexion IMMOBILIZE IN 90 Deg FLEXION
- 29. •Planning operative treatment of terrible triad
- 30. Positioning • Arm on hand table • Rotate the shoulder and work on either side
- 31. Approach • Posterior approach - Lateral flap - Medial flap – ulnar nerve / MCL
- 32. Operative treatment • Work on primarily lateral side • Work from “outside” to “inside” LCL / common extensor Radial head fracture Coronoid fracture
- 33. Operative treatment • Stabilize in reverse order “inside” to “outside’’ • Repair coronoid Repair / replace radial head reattach common extensor/LCL
- 34. Lateral Interval • Kocher ‘s - ECU and anconeus • Boyd’s - Ulna and anconeus • Kaplan- Extensor elevated off the ridge “ AVAILABLE WINDOW”
- 35. 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
- 36. 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
- 37. Medial Interval • Medial - Between the two head FCU - Over the top - Hotchkis
- 38. Approach • Medial and lateral approach - Large repairable radial head in the way
- 39. 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
- 40. 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
- 41. 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
- 42. Radial Head - ORIF • One / Two part articular fracture • Entire head – one piece • Preserve head when possible
- 43. Radial Head – Excise / replace Fracture < 25% Osteoporotic Extraarticular Elbow stable Elbow Unstable Excise Replace
- 44. Radial head – Fix / replace • Operative repair / replacement - similar short term result ( 7 year) • Limited size ( 23 pt .)
- 45. Do not excise without replacement • Restore radial head • If not possible replace • Repair lateral collateral lig • Orif of coronoid
- 46. 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
- 47. Radial Head Fixation - Safe Zone
- 48. Radial head replacement • Plane of radial head – 0.9 mm proximal to lateral edge of coronoid • Preop x- rays of opposite elbow
- 49. Radial head replacement • Overstuffing – early joint degeneration • Understuffing – Valgus instability • Intraop – visible ulnohumeral gap – suggests radial lengthening.
- 51. Coronoid fracture • Classification - Regan and Moorey - O’ Driscoll
- 52. Coronoid Fracture – Regan & Moorey Classification • Type 1 - # tip • Type 2 - < 50 % • Type 3 - >50%
- 53. Classification: Coronoid fractures •O’Driscoll Classification •Type I: tip •Type II: anteromedial facet •Type III: base
- 54. Coronoid fractures—nonoperative treatment Type I • Usually early motion Type II • Early motion, unless unstable • Internal fixation if associated injuries
- 55. Coronoid fractures—surgical treatment Type III • Internal fixation • Screw or anterior plate • Reconstruction with bone bone graft (tip of olecranon)
- 56. Coronoid fracture – Associated condition • Posteromedial rotatory instability • Posterolateral rotatory instability • Terrible triad • Large fracture of olecranon
- 57. Test for posterolateral instability
- 58. • Large coronoid fracture- olecranon frac dislocation • Small transverse fracture – Terrible triad The average height 39 % ( 19% - 59 % ) • Anteromedial facet fracture – varus posteromedial
- 59. Coronoid fracture • Small fragments – Type 1 • Fix with suture - #5 non absorbale suture
- 62. Type 1 & 2 – No fixation Repair / replacement of radial head and LUCL complex – stable elbow
- 63. Coronoid fracture • Type 2 ( < 50%) • Type 3 ( >50%) Fix with screw passed from ulnar cortex Large fragement – plate fixation – medial approach
- 64. Coronoid fracture • Approach – lateral – Thru the fracture radial head • Large fragment – separate medial approach
- 65. Lateral Collateral Ligament Complex • Avulsed from lateral condyle along with common extensor • Unstable elbow to varus test • Local bruising
- 66. Lateral Collateral ligament • Repair done elbow – 90 deg • MCL intact forearm – pronated • MCL injured – forearm supinated
- 67. Lateral Collateral ligament • Repair with suture anchors • Transosseous tunnels
- 68. Medial Collateral ligament • After repairing radial head • Coronoid • LCL • Test elbow stability – Fluoroscopically • Elbow unstable from 30 to 130 – repair MCL
- 69. Terrible Triad: Medial Instability ? – Repair MCL – Reconstruct through bone tunnels • Suture Anchors • Palmaris autograft or allograft tendon – Repair muscle origins Ulnohumeral joint reduced
- 71. Hanging arm test • Check intraop stability of elbow • Elbow in full extension , • forearm supinated • Bump under the arm
- 72. Hinge / static fixator • After repairing radial head • Coronoid • LCL • MCL Elbow still unstable – Hinge / static fixator Ulnohumeral transfixation – inferior option
- 75. Hinge / static fixator • Static fixator – removed at 3 weeks • Hinge Fixator – remove at 6 – 8 weeks
- 77. 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
- 78. Post op Rehabiliattion • Begin Range of motion - 2 – 5 days • Stable arc of motion – intraop determined • Resting splint – 6 weeks • Night splint - 12 weeks
- 81. Complications • Instability • Failure of internal fixation • Post traumatic stiffness • Heterotopic ossification • Post traumatic arthritis
- 82. 32-year-old male, fell from roof • Left elbow injury • Neurovascular structure intact • Closed injury • Moderate swelling
- 83. CT scan
- 84. 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
- 85. 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
- 88. 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
- 89. 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
- 90. Terrible Triad • Only patients with INSTABILITY had CORONOID fractures (4 patients)
- 91. 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
- 92. The “terrible triad”—coronoid fracture surgical technique Repair • Anterior capsule may be captured by nonabsorbable sutures • Screw or small plate
- 93. The “terrible triad”—radial head surgical technique Repair or replace • After coronoid repair • May need to subluxate elbow to insert prosthesis
- 94. 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
- 95. Radial Head fracture • Mason Classification • Hotchkiss modification