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

What is a Terrible Triad? Elbow dislocation Coronoid fracture 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 “Posterolateral rotatory instability”

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

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

Medial Collateral Ligament Anterior bundle Posterior bundle Transverse 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

Posterior dislocation & radial head fracture Injury Patterns Posterior dislocation & radial head fracture

Injury Patterns Posterior dislocation & radial head fracture Posterior dislocation, radial head & coronoid fractures “Terrible Triad”

Injury Patterns Posterior dislocation & radial head fracture Posterior dislocation, radial head & coronoid fractures “Terrible Triad” Transolecranon fracture-dislocations Anterior Posterior

Terrible Triad Injuries Patient 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 stairs

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 Anteromedial facet fractures are located between the sublime tubercle and the tip of the coronoid process

Classification: Coronoid Fractures Regan & Morrey Type 1 tip Type 2 < 50% May be stable Type 3 > 50% usu very UNstable

Classification: Coronoid fractures O’Driscoll Classification Type I: tip Type II: anteromedial facet Type III: base

Terrible Triad –Treatment Protocol 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

Surgical Planning: Approaches What’s injured? Radial head only Radial head type 1 coronoid 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

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

Radial Head Fixation - Safe Zone 100 degree arc centered laterally with the forearm in neutral position.

Comminuted Radial Head Fracture Role of the Radial Head Arthroplasty Excision will lead to instability Functional 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 Pronator FCU Ulnar Nerve Medial Epicondyle FCU Medial Epicondyle Nerve Ulnohumeral joint reduced

Terrible Triad: Persistent Instability ? Hinges Uniplanar Lateral Frame Multiplanar Compass Hinge

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

Incision Midline Posterior

Surgical Approach Options

Lateral: Kocher Approach Anconeus – 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 Coronoid Exposure of: Coronoid Sublime tubercle MCL Proximal ulna MCL reconstruction or repair ORIF AM facet of coronoid Buttress plating of coronoid

Posteromedial Approach to Coronoid Necessitates ulnar nerve exposure and transposition Palpate 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 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 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 If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@ota.org Return to Upper Extremity Index