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Ex-fix the elbow
3%
49/1568
Placement of Steinmann pin across the joint for 2 weeks followed by removal
1%
15/1568
Repair of the medial ulnar collateral ligament
84%
1315/1568
Splint elbow in 90 degrees of flexion in pronation
6%
100/1568
Splint elbow in 90 degrees of flexion in supination
5%
81/1568
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This patient has sustained a terrible triad elbow injury. With persistent elbow instability following radial head arthroplasty, anterior capsule/coronoid repair, and LUCL repair, MCL repair may be warranted. Terrible triad injuries include an elbow dislocation, radial head or neck fracture, and coronoid fracture. A valgus, axial, and posterolateral rotatory force results in posterolateral elbow instability. With this injury, the structures of the elbow predictably fail in a lateral to medial direction, with the LUCL failing first, followed by the anterior capsule and possibly the MCL. Repair of the MCL is indicated if instability on exam is evident after LUCL and fracture fixation, especially with extension beyond 30 degrees. Matthew et al. reviews fracture-dislocations of the elbow. They report that due to the displacement of the radial head and coronoid process, these terrible triad injuries result in an inherently unstable elbow necessitating surgical fixation . They conclude that a systematic approach for treatment and rehabilitation results in better outcomes and infers elbow stability. Steinmann et al. reviews the importance of the coronoid process to provide ulnohumeral joint stability. They report that despite much attention being focused on treatment of radial head fractures and lateral ligament reconstruction, addressing the coronoid fracture may be critical to reestablish elbow stability. They conclude that the surgical approach to address the coronoid fracture may be influenced by both the condition of the radial head and intraoperative stress testing. Ring et al. reports on the surgical management of radial head fractures. They report that complex fractures of the radial head are prone to early failure, nonunion, and poor forearm rotation following operative fixation. They conclude that use of radial head arthroplasty for complex fractures of the radial head may be beneficial. Pugh et al. reports on their protocol for elbow fracture-dislocations which includes radial head ORIF or arthroplasty, ORIF of the coronoid, and repair of the LUCL, repair of the MCL, and/or application of a hinged external fixator. They report with use of this surgical protocol sufficient elbow stability is restored to early postoperative elbow motion is permitted. They conclude that MCL repair is often not needed but should be performed in the persistently unstable elbow. Figures A&B are the AP and lateral radiographs of the elbow demonstrating a terrible triad injury. Illustration A demonstrates the failing of the elbow structures from lateral to medial. Incorrect Answers: Answer 1: An ex-fix is most commonly used following persistent elbow instability after surgical management of the radial head, coronoid/anterior capsule, LUCL, and MCL Answer 2: Placement of a Steinmann pin may help ensure elbow stability, but is typically reserved in refractory cases of elbow instability as it prevents postoperative elbow motion and violates cartilage Answers 4&5: With persistent elbow instability following surgical management of the radial head, coronoid/anterior capsule, and LUCL, operative intervention of the MCL is often indicated to infer elbow stability
1.7
(3)
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