“Terrible Triad”

Fracture-Dislocations of the Elbow

Presenter
Dr. Bijay Mehta Moderator
Dr. Biplav Sapkota
 What is a Terrible Triad?
•Originally described by Hotchkiss

•Consists of :
1. Elbow dislocation

2. Coronoid fracture

3. Radial head fracture

Elbow Anatomy
Lateral Collateral Ligament
Medial Collateral Ligament
 Coronoid Process
• Anteriorly
• Articulates with
• trochlea Brachialis
insertion
• Laterally
• Lesser semilunar notch

articulates with radial head

• Medially
• Attachment of anterior fibers of
MCL
 Stabilizers of the Elbow: Primary

•Ulnohumeral joint

•MCL ( Ant. Bundle)

•LCL
 Stabilizers of the Elbow: Secondary

Radiohumeral joint

Capsule

Origin of flexor & extensor

tendons
 Stabilizers of the Elbow: Dynamic

Muscle crossing
elbow:
Ancone
us
Brachialis
Triceps
 Injury Patterns
•Posterior dislocation & radial head fracture
 Injury Patterns
Posterior dislocation, radial head & coronoid fractures
“Terrible Triad”
 Injury Patterns
Transolecranon fracture-dislocations
Anterior
Posterior
Terrible Triad Injuries: Mechanism of Injury
• Fall on an outstretched hand
• Axial load
• Relative elbow extension
• Valgus
• Forearm rotation
• Supination
 Stages
I. LUCL disruption

II.Anterior and posterior soft issue

disruption (+coronoid)

III.a Intact MCL anterior band

III b Ruptured MCL anterior band
III c All soft tissue stripped
 Imaging
• X- rays – AP + Lateral

• CT scan – Include 3D reconstruction AFTER

REDUCTION
 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
 Radial Head Fractures:
Modified - Mason Classification

• Type I: non-displaced
• 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
 Classification: Coronoid Fractures
• Regan & Morrey
• Type 1 tip
• Type 2 < 50%
• Type 3 > 50%
 Classification: Coronoid fractures
• O’Driscoll Classification
• Type I: tip
• Type II: anteromedial facet
• Type III: base
Management
 Critical Components to Achieve
Treatment Goals
• Obtaining and maintaining a concentric reduction

• Management of coronoid & radial head fracture if

present

• Early range of motion

 TREATMENT

Conservative:

Indications (rare)
• Concentric elbow following closed reduction

• Undisplaced Radial head # or displaced radial

head # without a block to rotation

• Regan and Morrey Type I coronoid #,undisplaced

type II and III #
 Technique
•Immobilize in 90 deg.of flexion for 7-10 days

•Active motion initiated with resting splint at 90 degrees,

avoiding terminal extension

•Static progressive extension splinting at night after 4-6

weeks

•Strengthening protocol after 6 weeks

Operative Management : Principles
1. Restore coronoid stability : Fix or suture coronoid

2. Restore radial head stability : Repair / replace radial

head

3. Restore lateral stability :Repair LUCL

4. If still unstable, repair MCL

5. If still unstable, hinged ex-fix

 Surgical Planning
• Positioning:
supine vs lateral
• Supine:
Better access and visualization
of anterior joint & coronoid
• Lateral
Facilitates ulnar length, lessens
needs for assistants
Surgical Planning: Approaches

•Best Approach: Controversial

•Choice depends on
• Fracture Pattern
• Type of Instability
• Soft tissue status
• Surgeon’s Experience
 Surgical Approach
Options
Surgical approaches:
•Midline Posterior
•Kocher (posterolateral) vs Kaplan
(anterolateral)
•Anteromedial
•Posteromedial
•Percutaneous coronoid fixation
 Lateral: Kocher Approach
• Anconeus – ECU interval
 Lateral: Kaplan Approach
•Anterior column exposure
• Supracondylar ridge
• Anterior to mid-axis of
radiocapitellar joint
• Incise anterior capsule
• Exposes anterior
coronoid
• Replacement or
fixation
 Coronoid # Management
• Type I # - Repaired by Suture anchors
• Type II and III- reduced and fixed with lag
screws
• Larger coronoid # - plates and screws
 Radial Head # Management
• If One or two fragments- reduce and fix
• If comminuted(3 or more fragments) –Excise
the head +/- Replacement
 Radial Head Fixation
• 3 steps:
1. Repair radial head
2. Secure radial head to the
radial neck
3. Avoid impingement of
plates during forearm
rotation.
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: Persistent Instability ?

• Hinged elbow external fixator

Uniplanar Lateral Frame Multiplanar Compass Hinge
 Post op Rehabilitation
• 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
 Post op Rehabilitation
• Begin Range of motion – 1 – 5 days(ususally
on 1st postop day)
• Full forearm rotation allowed with elbow 90
degree flexed
• Unrestricted Shoulder and wrist exercises
• Avoid terminal 30 degrees of extension for 4
weeks
 Complications
• Instability
• Failure of internal fixation
• Post traumatic stiffness
• Heterotopic ossification
• Post traumatic arthritis
 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 patient
Uncooperative
lower
extremities
 References:
• Rockwood and Green’s Fractures in Adults , 8th
Edition
• Campbell’s Operative Orthopaedics, 13th
Edition
• Apley and Solomon’s System of Orthopaedics
and Trauma, 10th Edition
• Various Websites
Thank You