8 November 2022 - Terrible Triad Injury of Elbow BN

Thursday, December 8th
2022
TERRIBLE TRIAD OF
ELBOW
Moderator: AO
Team I: ZA-RW-LE-FA-ZQ-BN
Theme: TRAUMA
SUPERVISOR :
Dr.Ira Nong, M.Kes, Sp.OT(K)
INTRODUCTION
 The terrible triad was named by Hotchkiss, because of historically poor
outcomes
 the terrible triad  Combination of an elbow dislocation, a radial head
fracture, and a coronoid process fracture has had a consistently poor
outcome
 Terrible  reccurent/persistent subluxation or disclocation, Chronic
instability, arthrosis and pain
Terrible Triad Injury of the Elbow: Current Concepts avaible at

https://journals.lww.com/jaaos/Fulltext/2009/03000/Terrible_Triad_Injury_of_the_Elbow__Current.3.aspx
INTRODUCTION
 Elbow dislocations
 Simple : Dislocation and capsuloligamentous injury with no fractures
 Complex : Dislocation with associated radial head and coronoid process
fractures

ANATOMY
 Consist of 3 bone
 Humerus
 Radius
 Ulna
 3 Joint
 Radiocapitellar
 Ulnohumeral
 Proximalradioulnal joint
Netter concise orthopaedic anatomy 9th edition

ANATOMY

 2 Stabilizer
 Primary stabilizers of the elbow are ulnohumeral articulation, the MCL, and the
LCL
 Secondary stabilizers include the radial head, joint capsule, and the common
flexor and extensor origin
 Ulnohumeral articulation : primary bony supporting structure in the flexion-
extension plane (30’ Flexion)

 Coronoid process provides substantial resistance to posterior subluxation or
dislocation  stabilizer for axial, varus, posteromedial and posterolateral
rotatory force.
 Small fracture involving 10% coronoid  effected elbow stability

MECHANISM OF INJURY
 The terrible triad injury is often caused by a fall on an outstretched
hand.
 O’Driscoll et al described an additional valgus stress and/or
posterolateral “roll-out” that occurs with this injury.

CLASSIFICATION

CLASSIFICATION
 Hotchkiss classification (matson + clinical examination and
intraoperative finding)
 Help guided treatment
 type I fractures are those dis-placed <2 mm, with no
mechanical block
 type II are those with >2 mm of displacement that are
repairable and may have a mechanical block to motion;
 type III are comminuted fractures that are judged to be
not repairable by radiographic or intraoperative findings
and that require excision or replacement.

CLASSIFICATION

CLASSIFICATION

CLINICAL FINDINGS
 Complain :
 Pain
 Clicking
 Locking of elbow in extension
 History : Mechanism of injury

IMAGING
 Radiographs
 Anteroposterior and lateral radiograps
 Check ulnohumeral and radiocapitellar joint congruity
 line drawn through center of radial neck should intersect the center of the
capitellum regardless of radiographic projection
 evaluate lateral radiograph for coronoid fracture
 Coronoid process closely viewed on AP and lateral image
 Lateral view  determine height of coronoid fracture

IMAGING
 Computed tomography (CT) is to identify fracture patterns,
comminution, and displacement
 Three-dimensional images can improve the visualization of fracture
fragments and their location, as well as fracture line propagation.

Mayo Clinic Department of Orthopedic Surgery, USA
TREATMENT PRINCIPLES
 Restore elbow stability
 Protect the reconstruction
 Allow early range of motion
 Stability and protection shoukd take precedence over motion
Mayo Clinic Department of Orthopedic Surgery, USA

TREATMENT
 OPERATIVE
 Open wound
 Neurovascular Injury
 NONOPERATIVE
 Specific criteria
 CT imaging :
 small nondisplaced or minimally displaced radial head or neck fracture that does not
cause a mechanical block to forearm rotation or elbow flexion/extension
 coronoid fracture must also be a small tip fragment.

TREATMENT
 Nonoperative
 Immidiatly closed reduction, followed by CT Scan
(congruency of the elbow )
 initial period of immobilization at 90° of flexion in a
splint for 7 to 10 days with isometric biceps and triceps
muscle contraction
 Static progressive extension splinting at night after 4-6
weeks
 Strengthening protocol after 6 weeks
 Weekly clinical and radiograph followup every week in
first 4 weeks
OPERATIVE
 Indications:
 Unstable radial head fracture,
 Type III coronoid fracture
 Associated elbow dislocation

TECHNIQUE
 Posterior Approach
 Acces from outside to inside
 Common extensor  radial head fracture  coronoid
 Stablize from inside to outside
 Coronoid radial head repair or release  reattach common extensor/LCL
 3 technique
 Kocher (ECU and anconeus)
 Boyd (ulna and anconeus)
 Kaplan (extensor)

KOCHER
WHEN NEED MEDIAL
APPROACHED?
 Plate coronoid fracture
 Transpose ulnar nerve
 Repair or reconstruct MCL

RADIAL HEAD FIXATION
(SAFE ZONE)
Forearm in neutral, safe zone located 65’ anterior and 45’ posterior
CORONOID FRACTURE
 Type 1
 Fix with suture
CORONOID FRACTURE
 Type 2 (<50% body)
 Screw passed from ulna cortex
CORONOID FRACTURE
• Type 3 (>50% body)
– Plate fixation with medial approach
LATERAL COLLATERAL
-LIGAMENT
Repair with suture anchor COMPLEX
- Transosseous tunnels
OPERATIVE
 After fix
 Radial head
 Coronoid
 LCL
 Cek elbow stability by fluoroscophy

 If elbow unstable 30’-130’  repair MCL
 Repair by contruction bone tunnels with :
 Suture anchor
 Allograft tendon
OPERATIVE
 After repair
 Coronoid
 Radial head
 LCL
 MCL
 Elbow still unstable : Hinge/static fixator application

COMPLICATIONS
 Posttraumatic stiffness
 Instability (type I or II coronoid fractures)
 Failure of internal fixation (Radial neck fractures) poor
vascularity leading to osteonecrosis and nonunion
 Heterotopic ossification
 Posttraumatic arthritis
 Malunion, nonunion
 Infection

QUESTION
QUESTION 1
A 25-year-old Norwegian amateur curler slips on the ice, falling onto an
outstretched right elbow. He is taken to the local teaching hospital and
radiographs demonstrate a significantly comminuted radial head fracture and
coronoid base fracture. His elbow is reduced and splinted. To restore stability
and allow early range of motion, which of the following will most likely need to
be performed in most cases?
A. Radial head fixation or replacement
B. Radial head fixation or replacement and coronoid fixation
C. Radial head fixation or replacement, coronoid fixation, and lateral ulnar
collateral ligament (LUCL) repair
D. Radial head fixation or replacement, coronoid fixation, LUCL and medial
ulnar collateral ligament (MUCL) repair
E. Radial head fixation or replacement, coronoid fixation, LUCL and MUCL
repair, and application of a hinged fixator
QUESTION 1
A 25-year-old Norwegian amateur curler slips on the ice, falling onto an
outstretched right elbow. He is taken to the local teaching hospital and
radiographs demonstrate a significantly comminuted radial head fracture
and coronoid base fracture. His elbow is reduced and splinted. To
restore stability and allow early range of motion, which of the following
will most likely need to be performed in most cases?
A. Radial head fixation or replacement
B. Radial head fixation or replacement and coronoid fixation
C. Radial head fixation or replacement, coronoid fixation, and
lateral ulnar collateral ligament (LUCL) repair
D. Radial head fixation or replacement, coronoid fixation, LUCL and
medial ulnar collateral ligament (MUCL) repair
E. Radial head fixation or replacement, coronoid fixation, LUCL and
MUCL repair, and application of a hinged fixator
 ANSWER C
 The patient has sustained a "terrible triad" injury, classically involving a radial
head fracture, coronoid fracture, and elbow dislocation. These often involve
LUCL injuries and a traumatic injury in the radiocapitellar joint. Stability is
achieved with radial head replacement (or fixation), coronoid fixation (in cases
with a large coronoid fracture), and lateral soft tissue repair.
Posterolateral rotatory instability (PLRI) following a terrible triad injury is

usually caused by a fall on an extended arm that produces a valgus, axial,
and rotatory force. The mechanism of injury begins laterally and moves
medially. Hence, the LUCL fails first, followed by the anterior capsule (or
coronoid), and lastly the MUCL. Even following fixation, patients often lose
some degree of their flexion-extension arc, may develop post-traumatic
arthritis, or most commonly may have persistent instability. The radial head is
a primary restraint to PLRI and must be either replaced with a prosthesis or
fixed in the setting of a terrible triad injury. Replacement is typically chosen
when the radial head is in more than 3 fragments. Coronoid fractures should
be fixed when they involve >30-50% of the coronoid base. However, the best
way to determine if coronoid fixation is necessary is with an intraoperative
fluoroscopic examination.
QUESTION 2
At the elbow, the anterior bundle of the medial collateral ligament inserts at
which site?
A. Radial tuberosity
B. 3mm distal to the tip of the coronoid
C. Anteromedial process of the coronoid
D. Medial border of the olecranon fossa
E. Radial side of ulna at origin of annular ligament
QUESTION 2
At the elbow, the anterior bundle of the medial collateral
ligament inserts at which site?
A. Radial tuberosity
B. 3mm distal to the tip of the coronoid
C. Anteromedial process of the coronoid
D. Medial border of the olecranon fossa
E. Radial side of ulna at origin of annular ligament
ANSWER C
• The anterior bundle of the medial collateral ligament of the elbow inserts at
the anteromedial process of the coronoid, also known as the sublime
tubercle. Fractures at this site have been shown to have worse results with
nonoperative treatment, due to increased rates of instability and post-
traumatic arthrosis.
The referenced articles by Ring and Steinmann are great reviews of the topic
of coronoid fractures. They review the diagnosis, treatment options,
rehabilitation, and outcomes of these injuries. They focus on the importance
of the coronoid in elbow stability, especially with base fractures, or ones that
involve the sublime tubercle.
QUESTION 3
 A 58-year-old right-hand-dominant computer programmer trips and falls onto his right
arm. He reports right arm pain and that his elbow felt "sloppy". His initial lateral
radiograph is shown in Figure A. The orthopedic junior resident counsels him that he
will likely need a radial head arthroplasty, ligament repair, and possible fixation of the
ulna. What factor would most significantly affect the decision to surgically address the
ulna fracture?
A. Degree of radial head comminution
B. The deforming force acting on the avulsed fracture fragment
C. Size of fragment and elbow stability after radial head replacement
D. The degree of fracture displacement
E. Patient age and bone quality
QUESTION 3
 A 58-year-old right-hand-dominant computer programmer trips and falls onto his right
arm. He reports right arm pain and that his elbow felt "sloppy". His initial lateral
radiograph is shown in Figure A. The orthopedic junior resident counsels him that he
will likely need a radial head arthroplasty, ligament repair, and possible fixation of the
ulna. What factor would most significantly affect the decision to surgically address the
ulna fracture?
A. Degree of radial head comminution
B. The deforming force acting on the avulsed fracture fragment
C. Size of fragment and elbow stability after radial head replacement
D. The degree of fracture displacement
E. Patient age and bone quality
ANSWER C
The size of the fragment and degree of elbow instability following radial head
fixation or replacement most often determines the intraoperative decision on
coronoid fragment fixation.
The radial head is a secondary restraint to posterolateral rotatory instability

(PLRI) of the elbow, while the coronoid provides an anterior and varus buttress
to the ulnohumeral joint, resisting posterior dislocation. The medial ulnar
collateral ligament attaches to the anteromedial facet of the coronoid, so large
medial facet fractures may displace and cause varus posteromedial instability
(PMRI). However, in terrible triad injuries (causing PLRI), small coronoid tip
fractures are more common. These are typically left as they most often do not
contribute to elbow instability. Therefore in most cases, radial head
replacement and lateral ligamentous repair are sufficient to restore stability.
However larger coronoid base fractures may require fixation in order to
stabilize the elbow. In these cases, the coronoid fracture may be addressed
through the lateral window after radial head resection and before the trial
implant is assessed. The anterior capsule can be tied down to the ulna or if the
fracture is large enough, it may sometimes tolerate internal fixation.
Conversely, a buttress plate for the coronoid may be applied via a medial
approach in the setting of a large coronoid base fracture as in PMRI.
THANK YOU

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Thursday, December 8th

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Netter concise orthopaedic anatomy 9th edition

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

 History : Mechanism of injury

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Mayo Clinic Department of Orthopedic Surgery, USA

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

 Cek elbow stability by fluoroscophy

 Elbow still unstable : Hinge/static fixator application

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Terrible Triad Injury of the Elbow: Current Concepts avaible at

Posterolateral rotatory instability (PLRI) following a terrible triad injury is

The radial head is a secondary restraint to posterolateral rotatory instability

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