1. 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

2. What is a Terrible Triad?
Elbow dislocation
Coronoid fracture
Radial head fracture

3. 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”

4. 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

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

6. Medial Collateral Ligament
Anterior bundle
Posterior bundle
Transverse bundle

7. 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

8. Medial Muscular Anatomy

9. Lateral muscular anatomy

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

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

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

13. 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

14. 47 yo trip and fall down stairs

15. 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

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

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

18. 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

19. 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

20. 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

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

22. 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

23. 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

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

25. 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

26. Incision Midline Posterior

27. Surgical Approach Options

28. Lateral: Kocher Approach
Anconeus – ECU interval

29. 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

30. 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

31. Anteromedial Approach to Coronoid
Medial supracondylar ridge
Pronator teres - brachialis interval
Incise anterior 1/2 flexor-pronator mass
Anterior capsule

32. Anteromedial Approach to Coronoid
Medial supracondylar ridge
Pronator teres - brachialis interval
Incise anterior 1/2 flexor-pronator mass
Anterior capsule

33. Anteromedial Approach to Coronoid
Medial supracondylar ridge
Pronator teres - brachialis interval
Incise anterior 1/2 flexor-pronator mass
Anterior capsule

34. 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

35. 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.

36. CASES

37. 40 F thrown from horse

40. Radial head & coronoid fractures s/p dislocation

42. 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

43. 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

44. Questions ?

45. Conclusions
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