Definition
Elbow dislocation with concomitant fractures
Inherently unstable
Injury patterns
Elbow dislocation + radial head fracture
Elbow dislocation + coronoid process fracture
Terrible triad - elbow dislocation + MCL injury / coronoid process fracture / radial head fracture
Elbow dislocation + proximal ulna fracture - Monteggia / Monteggia variant
Elbow dislocation with radial head fracture
Management
Critical to elbow stability
Based upon Mason classfication
www.boneschool.com/radial-head-fractures
Mason Classification
| Type 1 | Type II | Type III |
|---|---|---|
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Minimally displaced fracture < 2 mm No block to rotation |
Displaced fracture radial head > 2 mm Reconstructable |
Comminuted fracture radial head Unreconstructable |
| Non operative |
ORIF + LCL repair / reconstruction +/- MCL repair / reconstruction if unstable |
Radial head replacement + LCL repair / reconstruction +/- MCL repair / reconstruction if unstable
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Results
- 450 cases of radial head arthroplasty
- revision rate 18% for terrible triad versus 10% isolated cases
- increasing radial head diameter associated with increasing revision rate
- systematic review of radial head ORIF v replacement in terrible triad
- better functional outcomes and lower complications with radial head arthroplasty
Elbow dislocation with coronoid process fracture
Coronoid process
www.boneschool.com/coronoid-process-fractures
Coronoid is the most important portion of ulno-humeral articulation
- provides anterior buttress
- attachment of capsule and brachialis
- anterior band of the MCL attaches to it
Regan and Morrey classification of transverse coronoid fractures
Elbow stability related to size of coronoid fragment
| Type I | Type II | Type III |
|---|---|---|
| Small coronoid process fracture | 50% of coronoid process | > 50% coronoid process |
| Usually stable |
Capsular attachment Elbw may be unstable |
Capsule + MCL attachment Elbow unstable
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O'Driscoll classification anteromedial coronoid facet fractures
| Type I | Type II | Type III |
|---|---|---|
| Transverse fractures | Anteromedial facet fractures | Basilar fractures |
| Lasso suture fixation |
Lasso suture fixation - small Medial buttress plate / screws - large |
Dorsal +/- medial plate |
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Anteromedial coronoid facet fragment
- associated with varus posteromedial rotational force
- associated with tear of lateral ulna collateral ligament (LUCL)
Approach
Approach options for coronoid fixation
- radial head arthroplasty - lateral approach through radial head
- olecranon fracture - through fracture bed
- medial approach - coronoid fixation without radial head fracture
Lateral approach through radial head defect
Suture anchor repair of coronoid process technique PDF
Medial approaches
| Hotchkiss over the top | FCU split | Taylor and Scham |
|---|---|---|
|
Split flexor pronator mass - interval between FCU and palmaris longus - elevate pronator teres / FCR / palmaris longus - +/- detach from medial epicondyle - open capsule - detach brachialis from anterior coronoid process
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Dissect out ulna nerve - follow into FCU - open two heads of FCU - elevate flexor pronator mass off capsule - open capsule - detach brachialis from anterior coronoid process
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Elevate entire flexor - pronator mass - subperiosteal elevation from ulna - posterior to anterior
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Access to tip of coronoid and anteromedial facet
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Access to anteromedial facet |
Access to base of coronoid |
AO surgery reference medial approach to coronoid
Vumedi Hotchkiss over the top coronoid fixation video
Vumedi Hotchkiss over the top coronoid fixation video 2
Vumedi FCU split coronoid fixation video
Vumedi medial approach to coronoid + lasso fixation + plate video
Fixation
Lasso suture - suture fragment, use ACL guide to direct drill holes through olecranon to base of coracoid
Screws - PA screws into fragment
Anteromedial Buttress plate
Coronoid buttress plates
Terrible Triad
Definition
Elbow dislocation with radial head fracture + coronoid fracture + MCL tear
Technique
www.boneschool.com/radial-head-fractures
www.boneschool.com/coronoid-process-fractures
www.boneschool.com/elbow-external-fixation
Vumedi terrible triad repair radial neck ORIF + coronoid lasso + LCL internal brace repair video
Skin incisions
1. Lateral
- Kocher / Kaplan / EDC split
- for radial head / coronoid / LUCL
2. Medial
- FCU split / split flexor pronator mass / detach entire flexor pronator mass
- for medial approach to coronoid +/- MCL if needed
3. Universal Posterior Approach - make medial and lateral skin flaps for medial and lateral approach
Surgical Algorithm
Principles
1. Restore coronoid stability - ORIF type II / III, suture repair type I
2. Restore radial head stability - radial head ORIF or arthroplasty
3. Restore lateral stability - LCL repair and common extensor origin +/- reconstruct +/- internal brace
4. +/- Restore medial stability - repair MCL if residual stability
5. +/- External fixation / internal joint fixation
| Type II / Reconstructable radial head | Type III / Radial head arthroplasty |
|---|---|
|
Lateral / Kocher approach - ORIF radial head with screws/ plate - LCL +/- common extensor origin repair - reassess stability |
Lateral / Kocher / Kaplan / EDC split approach - excise radial head - can suture small coronoid process fracture through gap - radial head replacement - LCL +/- common extensor origin repair - reassess stability
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Unstable - medial approach - FCU split / over the top approach to coronoid process - ORIF coronoid process with sutures / buttress plate / screws - MCL repair +/- common flexor origin repair - reassess stability |
Unstable - medial approach - FCU split / over the top approach to coronoid process - ORIF coronoid process with sutures / buttress plate / screws - MCL repair +/- common flexor origin repair - reassess stability |
| Unstable - external fixation | Unstable - external fixation |
Radial head replacement with lag screw fixation of Type II coronoid
Radial head replacement with lasso fixation of small coronoid fragment
Results
Outcomes
- systematic review of terrible triad injuries
- mean flexion arc 110 degrees
- 30% complication
- 8% revision
- 11% HO
- 3% ulnar nerve
Coronoid process - only fix type III?
Antoni et al Orthop Traumatol Surg 2019
- 30 patients with terrible triad and Type I coronoid process
- some coronoid tip suture, some not
- no difference between two groups
- recommend no need to fix Type I coronoid process fractures
- 14 terrible triad with 2 type I and 12 type II coronoid process fractures
- no surgery to coronoid process
- LCL + radial head surgery, no MCL or external fixator
- no recurrent instability
- recommend surgery for type III coronoid process fractures only
- 24 terrible triad with radial head surgery / LCL repair +/- MCL repair
- only type III coronoid process repair (4/24)
- no recurrent instability
External fixation
- 26 patients with complex elbow dislocation required external fixators
- mean loss of range of motion 30 degrees
- 37% complications
- 26% secondary surgery
- 1 recurrent instability
Dislocation with olecranon fracture
www.boneschool.com/proximal-ulna-fracture-dislocations