Surgical Approaches for

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Surgical Approaches for Terrible Triad
Fracture-Dislocations of the Elbow

• Michael J. Medvecky, MD
• Seth Dodds, MD
• Created May 2011

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What is a Terrible Triad?

• Elbow dislocation
• Coronoid fracture
• Radial head fracture

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Terrible Triad Injuries Mechanism of Injury

• Fall on an outstretched hand
• Axial load
• Relative elbow extension
• Valgus
• Forearm rotation
• Supination

The ultimate Posterolateral rotatory
instability
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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 dont routinely do well
• Unaware of the magnitude of the injury for the
  elbow
• Residual instability
• Stiffness

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Lateral Collateral Ligament

• Radial collateral ligament
• Lateral ulnar collateral ligament
• Annular ligament

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Medial Collateral Ligament

• Anterior bundle
• Posterior bundle
• Transverse 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
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Lateral muscular anatomy
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Injury Patterns

• Posterior dislocation radial head fracture

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Injury Patterns

• Posterior dislocation radial head fracture
• Posterior dislocation, radial head coronoid
  fractures
• Terrible Triad

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Injury Patterns

• Posterior dislocation radial head fracture
• Posterior dislocation, radial head coronoid
  fractures
• Terrible Triad
• Transolecranon fracture-dislocations
• Anterior
• Posterior

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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 stairs
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Radial Head FracturesModified - Mason
Classification

• Type I nondisplaced
• No block to forearm rotation, displacement lt 2mm
• Type II displaced
• Internal fixation possible
• Type III displaced, severely comminuted
• Judged to be irreparable
• Type IV fracture dislocation

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Classification Coronoid Fractures

• Regan Morrey
• Type 1 tip
• Type 2 lt 50
• May be stable
• Type 3 gt 50
• usu very UNstable

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Classification Coronoid fractures

• ODriscoll Classification
• Type I tip
• Type II anteromedial facet
• Type III base

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Terrible Triad Treatment Protocol McKee, Pugh,
Schemitsch,et al JBJS(A) 04

• 36 consecutive patients treated
• Fix or suture coronoid
• Repair / replace radial head
• Repair LCL
• If still unstable, repair MCL
• If still unstable, hinged ex-fix

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Surgical Planning Approaches

• Whats 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 common proximal ulna
fracture exposes coronoid tip
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Internal fixation

• 3 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 heads
• Secure radial head to neck with 2.0 or 2.7
  L-shaped plates or mini blade plates

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Radial Head Fixation - Safe Zone
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Comminuted Radial Head FractureRole of the
Radial Head Arthroplasty

• Excision will lead to instability
• Functional spacer
• Creates stability by increasing radial length
  restoring valgus restraint

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Terrible Triad Medial Instability ?

• Repair MCL
• Reconstruct through bone tunnels
• Suture Anchors
• Palmaris autograft or allograft tendon
• Repair muscle origins

Pronator
FCU
Medial Epicondyle
Nerve
Ulnohumeral joint reduced
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Terrible Triad Persistent Instability ?

• Hinges

Uniplanar Lateral Frame
Multiplanar Compass Hinge
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Surgical Planning

• Positioning 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

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Incision Midline Posterior
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Surgical Approach Options
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Lateral Kocher Approach

• Anconeus ECU interval

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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

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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

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Anteromedial Approach to Coronoid

• Medial supracondylar ridge
• Pronator teres - brachialis interval
• Incise anterior 1/2 flexor-pronator mass
• Anterior capsule

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Anteromedial Approach to Coronoid

• Medial supracondylar ridge
• Pronator teres - brachialis interval
• Incise anterior 1/2 flexor-pronator mass
• Anterior capsule

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Anteromedial Approach to Coronoid

• Medial supracondylar ridge
• Pronator teres - brachialis interval
• Incise anterior 1/2 flexor-pronator mass
• Anterior capsule

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Posteromedial Approach to Coronoid

• Exposure of
• Coronoid
• Sublime tubercle
• MCL
• Proximal ulna
• MCL reconstruction or repair
• ORIF AM facet of coronoid
• Buttress plating of coronoid

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Posteromedial Approach to Coronoid

• Necessitates ulnar nerve exposure and
  transposition
• Palpate sublime tubercle
• Incise FCU ulnar attachment distal to sublime
  tubercle and proceed proximally -gt anterior
  bundle of MCL.

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CASES
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40 F thrown from horse
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Radial head coronoid fractures s/p dislocation
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Terrible Triad Injuries Rehab

• Rehab
• Stiffness vs. Instability
• Cautious
• Posterior 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 supineactive against gravity

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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

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Questions ?
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Conclusions
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