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Terrible Triad Elbow Fracture

Categories
  • Elbow
  • Joint/Tendon
Tags
  • Elbow injury
Elbow

Upper Limb Anatomy

Right shoulder and arm, posterior view
Right shoulder and arm, posterior view

Right shoulder and arm, posterior view

Normal Upper Limb Anatomy
Triceps Brachii Muscle
Upper Limb Anatomy (Arm)
Muscles of the Forearm
Muscles of the Forearm
Upper Limb Anatomy (Nerve)
Medial aspect of right forearm

Medial aspect of right forearm

Left Brachial plexus

Left Brachial plexus

Nerves Posterior to Elbow Joint

Posterior view of right elbow

Posterior view of right elbow

Blood supply around the elbow joint

Blood supply and anastomosis

Blood supply and anastomosis around the right elbow. Anterior view

Elbow Joint

Elbow joint structural stability structures

Elbow joint structural stability structures

Left Arm

Left arm
Left arm
Humerus

Radial head/neck fractures

The triangular structure of distal humerus at elbow joint provides structural strength.

Anterior view right distal humerus bone

Anterior view right distal humerus bone

Rotation around throchlear axis

The elbow joint is a hinge joint with axis of rotation around throchlear axis

Extensor muscles

Extensor muscles

Resisted finger flexion

Flexor muscles

Bone Structure
Haversion bone system

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

Posterolateral elbow dislocation with radial neck and coronoid fractures

Elbow Joint Structural Stability Structures

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

Mason-Johnston Classification of radial head fractures

AO Classification of Proximal Radius and Ulnar Fractures

AO classification of proximal Radius and Ulnar fractures

Regan and Morrey Classification of Coronoid Fracture

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

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

Forearm in neutral

Lateral Collateral Ligament Repair

Lateral Collateral ligament repair

Coronoid Fixation Repair Options

Coronoid fixation options include:

  • Suture, suture anchor fixation
  • Lag screws
  • Plate fixation (rare)
Coronoid fixation repair options

Elbow External Fixator

Elbow external fixator

Hinged elbow external fixator

Surgery Technique

Surgery
Jones et al treatment algorithm

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

Surgery Radial heal/neck repair
  • 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

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.

Coronoid fracture fixation

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.

Elbow external fixator

Safe Zones for Pin Sites for External Fixator around Elbow Joint

Safe zones for pin sites

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

Arm sling

Hand grip exercises with arm in splint

Hand grip exercises with arm in splint

Strength exercises only performed after union

Strength exercises only performed after union

Download ASSIC Performance Fingerprint or Strength & Conditioning apps for rehab guideline routines or create own under professional supervision

apple app store  google play store

References

  1. 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.
  2. Traumatic elbow injuries: what the orthopedic surgeon wants to know. Sheehan S.E. Radiographics 33(3(: 869-888.
  3. 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.
  4. 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.
  5. 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.
  6. Classifications in Brief: Mayo classification of olecranon fractures. Sullivan CW, Desai K. Clin Orthop Relat Res. 2019 Apr;477(4): 908-910.
  7. Elbow fractures. Midtgaard KS, Ruzbarsky JJ, Hackett TR, Viola RW. Clin Sports Med. 2020 Jul;39(3): 623-636.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. Complex elbow dislocations and the “terrible triad” injury. Allistair D R Jones, Robert W Jordan. Open Orthop J. 2017 Nov 30;11: 1394-1404.

Contributor:

Dr N J Kauta

Learn More

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