Right shoulder and arm, posterior view
Terrible Triad Elbow Fracture
Upper Limb Anatomy
Medial aspect of right forearm
Left Brachial plexus
Nerves Posterior to Elbow Joint
Posterior view of right elbow
Blood supply around the elbow joint
Blood supply and anastomosis around the right elbow. Anterior view
Elbow joint structural stability structures
Left Arm
Radial head/neck fractures
The triangular structure of distal humerus at elbow joint provides structural strength.
Anterior view right distal humerus bone
The elbow joint is a hinge joint with axis of rotation around throchlear axis
Extensor muscles
Flexor muscles
Haversion bone system
Terrible Elbow Triad Injury
Terrible Triad Injury of the Elbow Joint
The terrible triad elbow injury is a traumatic elbow injury characterized by elbow dislocation, radial head/neck fracture and a coronoid fracture.
Mechanism: fall on extended arm with an axial, valgus and posterolateral complex disruption producing a posterolateral elbow dislocation.
Posterolateral elbow dislocation with radial neck and coronoid fractures
Elbow Joint Structural Stability Structures
Terrible Triad Injury of the Elbow Joint
Presentation:
- Pain
- Swelling
- Deformity
- Clicking and locking
Clinically:
- Bone tenderness
- Varus/valgus instability
- Exclude Essex-Lopresti injury
Investigations:
- X-ray: X-ray elbow and include wrist joint when clinically indicated. Assess joint congruency.
- CT: for intra-articular fracture evaluation and surgical planning
Mason-Johnston Classification of Radial Head Fractures
AO Classification of Proximal Radius and Ulnar Fractures
Regan and Morrey Classification of Coronoid Fracture
Type Ⅰ: avulsion tip
Type Ⅱ: single or comminuted fracture involving < 50% of coronoid
Type Ⅲ: single or comminuted fracture involving > 50% of coronoid
Management
Non-surgical management is seldom done with immobilization in a splint/cast for closed fractures provided:
- Reduced elbow
- Radial head fracture doesn’t meet surgery recommendations for fixation
- Insignificantly small coronoid fracture
Options
- Splint for one week with progressive increasing elbow range of motion while limiting full extension until after 4-6 weeks
Surgery:
- Fixation options: radial head replacement or radial head fixation with repair of collateral ligament and coronoid fracture fixation for fractures >10% of the coronoid
Radial head/neck fracture surgery considerations with Terrible Triad injury
Surgery considerations for radial head/neck injury associated with Terrible Triad. ORIF coronoid and lateral elbow ligament complex.
Safe Zone for Radial Neck ORIF
Lateral Collateral Ligament Repair
Coronoid Fixation Repair Options
Coronoid fixation options include:
- Suture, suture anchor fixation
- Lag screws
- Plate fixation (rare)
Elbow External Fixator
Hinged elbow external fixator
Surgery Technique
Jones et al treatment algorithm for surgical treatment of terrible triad elbow injuries (2017)
Surgery Radial Heal/Neck Repair or Replacement in Terrible Triad Injury
- Lateral approach (Kocher/Kaplan)
- Surgery considerations for radial head/neck injury associated with Terrible Triad. ORIF coronoid and lateral elbow ligament complex.
Lateral Collateral Ligament Repair
- LCL repaired and sutured to lateral epicondyle through bone tunnels or anchor fixation
- With elbow at 90° flexion the LCL is repaired with forearm in pronation if MCL is intact or forearm in supination if torn MCL
Coronoid Fracture Fixation
Coronoid fixation options include:
- Suture, suture anchor fixation
- Lage screws
- Plate fixation (rare)
Approach: Through site of radial head/neck fracture or lateral approach. Medial approach additional option. A medial over-the-top, Taylor and Scham or FCU split approach may be used.
Fracture reduction and screw fixation for large fracture fragments. Type fractures may require a Lasso technique by suture fixation of Brachialis muscle/tendon complex and securing it by tie fixation after passing it to through olecranon bone tunnels.
Elbow External Fixator
Hinged external fixator can supplement unstable elbow fracture ORIF and ligament repair.
Safe Zones for Pin Sites for External Fixator around Elbow Joint
Arc for safe zone for application of external fixator pins of right arm
Post Operative Rehabilitation
- Immobilization in arm splint 3-4 weeks: maintain hand gripping exercises
- After fracture healing with radiologically callous formation gravity eliminated exercises are performed
- No load bearing exercises until fracture union
Arm sling
Hand grip exercises with arm in splint
Strength exercises only performed after union
Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision
References
- A comparative Biomechanical Analysis of 2 Double-Row, Distal Triceps Tendon Repairs. Matthew A Dorweiler, Rufus O Van Dyke, Robert C Siska, Michael A Boin and Mathew J DiPaola. The Orthopaedic Journal of Sports Medicine May 2017, 5(5): 23259671177080.
- Traumatic elbow injuries: what the orthopedic surgeon wants to know. Sheehan S.E. Radiographics 33(3(: 869-888.
- A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Johnston GW. Ulster Med J 31: 51-56.
- Management of severely comminuted distal radius fractures. David M Brogan, Marc J Richard, David Ruch, Sanjeev Kakar. J Hand Surg Am. 2015 Sep; 40(9): 1905-14.
- Surgical management for olecranon fractures in adults: a systematic review and meta-analysis. Koziarz A, Woolnough T, Oitment C, Nath S, Johal H. Orthopedic. 2019 Mar 1;42(2): 75-82.
- Classifications in Brief: Mayo classification of olecranon fractures. Sullivan CW, Desai K. Clin Orthop Relat Res. 2019 Apr;477(4): 908-910.
- Elbow fractures. Midtgaard KS, Ruzbarsky JJ, Hackett TR, Viola RW. Clin Sports Med. 2020 Jul;39(3): 623-636.
- Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures. Petra Grahn, Tero Hämäläinen, Yrjänä Nietosvaara, Matti Ahonen. Acta Orthop. 2021 Feb;92(1): 114-119.
- A narrative review on avulsion fractures of the upper limb and lower limbs. Christopher Vannabouathong, Olufemi R Ayeni, Mohit Bhandari. Clin Med Insights Arthritis Musculoskelet Disord. 2018;11: 1179544118809050.
- Outcome after ORIF of capitellar and trochlear fractures. JH Dubberley, KJ Faber, JC Macdermid, SD Patterson, GH King. J Bone Joint Surg Am. Vol. 88 2006: 46-54.
- Coronal plane partial articular fractures of the distal humerus: current concept in management. DE Ruchelsman, NC Tejwani, YW Kwon, KA Egol. J Am Acad Orthop Surg. Vol 16 2008: 716-728.
- Complex elbow dislocations and the “terrible triad” injury. Allistair D R Jones, Robert W Jordan. Open Orthop J. 2017 Nov 30;11: 1394-1404.
