Terrible Triad Injury of Elbow

Author: Joshua Blomberg

Topic updated on 01/26/13 12:20pm

Introduction

A traumatic injury pattern of the elbow characterized by
- posterolateral dislocation
- radial head fx
- coronoid fracture
Mechanism is fall on extended arm that leads to
- valgus stress produces posterolateral dislocation
- structures of elbow fail from lateral to medial
  - anterior bundle of MCL last to fail
  - LCL disrupted in most cases

Anatomy

Radial head
- forearm in neutral rotation, lateral portion of articular margin devoid of cartilage
- provides anterior and valgus buttress
Coronoid process
- provides an anterior and varus buttress
Medial collateral ligament
- Anterior bundle, posterior bundle, and transverse ligament components
- Anterior bundle most important to stability, restraint to valgus and posteromedial rotatory instability
  - inserts on sublime tubercle (anteriomedial facet of coronoid)
  - sublime tubercle is 18.4mm dorsal to tip of coronoid process
Lateral collateral ligament
- inserts on supinator crest distal to lesser sigmoid notch
- restraint to varus and posterolateral rotatory instability
- two components
  - lateral ulnar collateral ligament (most important for stability)
  - lateral radial collateral ligament
    - attaches to annular ligament

Presentation

Symptoms
- patients complain of clicking and locking with elbow in extension
Physical exam
- varus instability
- may show valgus instability if injury to MCL

Imaging

Radiographs
- evaluate for concentricity of ulnohumeral and radiocapitellar joints
- line drawn through center of radial neck should intersect the center of the capitellum regardless of radiographic projection
- evaluate lateral radiograph for coronoid fracture
CT
- better evaulation of coronoid fracture
- 3D imaging for determining fracture line propagation

Treatment

Nonoperative
- immobilize in 90 deg of flexion for 7-10 days
  - indications (rare)
    - ulnohumeral and radiocapitellar joints must be concentrically reduced
    - elbow must should extend to 30 degrees before becoming unstable
    - CT must show insignificant radial head/neck fx, no block to motion
    - coronoid fx limited to tip
  - 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
- acute radial head stabilization, coronoid ORIF, and LCL reconstruction, MCL reconstuction if needed
  - indications
    - terrible triad elbow injury that includes a unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation

Techniques

Acute radial head stabilization, coronoid ORIF, and LCL reconstruction, MCL reconstuction if needed
- approach
  - posterior skin incision advantagous
    - allows acess to both medial and lateral aspect of elbow
    - lower risk of inury to cutaneous nerves
    - more cosmetic
- technique
  - radial head ORIF vs. arthroplasty
    - radial head arthroplasty indicated for comminuted radial head fracture
      - use of modular prosthesis preferable
      - sizing based on fragments removed from elbow
      - implant should articulate 2mm distal to the tip of the coronoid process
      - radial head resection without replacement is NOT indicated in presence of Essex-Lopresti lesion or in young active patient
    - it <25% head damaged or fragments not reconstructable and nonarticulating, can excise if elbow stable (rarely indicated)
    - radial head ORIF indicated if non comminuted with good bone stock and fracture involves < 40% articular surface
      - 1.5, 2.0, or 2.4mm countersunk screws
      - plating if necessary; 2.0 plates cause minimal loss of motion even when placed in PRUJ
  - coronoid ORIF
    - can be fixed through radial head defect laterally
    - fix with suture passed through 2 drill holes, or posterior to anterior lag screws if fragment large
    - basal coroind fxs (rare) fixed with anteromedial or medial plate on proximal ulna
  - LCL repair
    - usually avulsed from origin on lateral epicondyle
    - reattach with suture anchors or transosseous sutures
      - must be reattached at center of capitellar curvature on lateral epicondyle
    - if MCL is intact, LCL is repaired with forearm in pronation
    - if MCL injured, LCL is repaired with forearm in supination to avoid medial gapping due to overtightening
    - repairs are performed with elbow at 90 degrees of flexion
  - MCL repair
    - indicated if instability on exam, especially with extension beyond 30 degrees
  - instability after complete bone and soft tissue repair indicates need for hinged elbow fixator application
  - postoperative
    - immobilize elbow in flexion with forearm pronation to provide stability against posterior subluxation
    - if both MCL and LCL were repaired, splint in flexion and neutral rotation.

Complications

Instability
- more common following type I or II coronoid fractures
Failure of internal fixation
- most common following repair of radial neck fractures
  - poor vascularity leading to osteonecrosis and nonunion
Posttraumatic stiffness
- very common
- initiate early ROM to prevent
Heterotopic ossification
- consider prophylaxis in pts with head injury or in setting of revision surgery
Posttraumatic arthritis
- due to chondral damage at time of injury and/or residual instability

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Qbank (5 Questions)

TAG

(OBQ09.168) At the elbow, the anterior bundle of the medial collateral ligament inserts at which site? Topic

Review Topic

1. Radial tuberosity
2. 3mm distal to the tip of the coronoid
3. Anteromedial process of the coronoid
4. Medial border of the olecranon fossa
5. Radial side of ulna at origin of annular ligament

PREFERRED RESPONSE ▶

DISCUSSION: The anterior bundle of the medial collateral ligament of the elbow inserts at the anteromedial process of the coronoid, also known as the sublime tubercle. Fractures at this site have been shown to have worse results with nonoperative treatment, due to increased rates of instability and post-traumatic arthrosis.

The referenced articles by Ring and Steinmann are great reviews of the topic of coronoid fractures. They review the diagnosis, treatment options, rehabilitation, and outcomes of these injuries. They focus on the importance of the coronoid in elbow stability, especially with base fractures, or ones that involve the sublime tubercle.

Illustration A depicts the anterior bundle of the MCL insertiing at the sublime tubercle.

Illustrations: A

REFERENCES:

1. Steinmann SP. Coronoid process fracture. J Am Acad Orthop Surg. 2008;16:519-529 PMID:18768709 (Link to Abstract)

2. Ring D. Fractures of the coronoid process of the ulna. J Hand Surg Am. 2006;31:1679- 1689 PMID:17145391 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD, Michael Hughes MD,

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(OBQ06.81) A 35-year-old woman presents with an elbow injury which includes a coronoid fracture involving more than 50%, a comminuted radial head fracture, and an elbow dislocation. What is the most appropriate treatment? Topic

Review Topic

1. closed reduction and early range of motion
2. radial head resection and lateral collateral ligament reconstruction
3. radial head resection and coronoid open reduction internal fixation
4. radial head arthroplasty and coronoid open reduction internal fixation
5. radial head arthroplasty, coronoid open reduction internal fixation, and lateral collateral ligament repair

PREFERRED RESPONSE ▶

DISCUSSION: A terrible triad of the elbow includes dislocation of the elbow with associated fractures of the radial head and the coronoid process. Ring et al. stressed that these injuries are prone to complications and advised against resection of the radial head due to instability, and instead recommended a radial head replacement if too comminuted for ORIF. Coronoid fractures compromise elbow stability as well and require open reduction and internal fixation as with the lateral collateral ligament. McKee et al. showed stable elbows in 34/36 with mean Mayo elbow score of 88 when the standard protocol of coronoid ORIF, radial head repair/replacement, and LCL repair were employed.

REFERENCES:

1. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551 PMID:11940613 (Link to Abstract)

2. McKee MD, Pugh DM, Wild LM, et al: Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures: Surgical technique. J Bone Joint Surg Am 2005;87:22-32 PMID:15743844 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Derek Moore,

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(OBQ05.52) You are planning operative treatment of the injury shown in figure A. If the MCL is intact, in what position should the elbow and forearm be splinted at the end of the case? Topic

Review Topic

FIGURES: A

1. extension and pronation
2. extension and supination
3. extension and neutral rotation
4. flexion and pronation
5. flexion and supination

PREFERRED RESPONSE ▶

DISCUSSION: A terrible triad elbow injury consists of an elbow dislocation with fractures of the radial head and coronoid. Neale et al (Presentation at the 23rd Annual Meeting of the American Society of Biomechanics, University of Pittsburgh; October 21-23, 1999) showed that the coronoid is clearly a primary stabilizer of the elbow, with the radial head being a secondary stabilizer. When moving from flexion to extension, the elbow dislocated at higher angles of flexion with increasing amount of coronoid loss and with loss of the radial head. Therefore, the elbow is more stable in flexion due to the support provided by the coronoid and radial head. Dunning et al (Clin Orthop 2001;388:118-124) investigated the contribution of forearm position to the stability of a lateral collateral ligament deficient elbow. They determined that varus and valgus laxity was significantly less with the forearm in pronation than in supination. They speculated that the internal rotation torque applied to the wrist to maintain the forearm in pronation may cause the ulna to pivot about the intact soft tissues on the medial side of the elbow and close the gap on the lateral side. The most stable position is flexion with forearm pronation. If both the MCL and LCL are repaired, newer recommendations from Mathew et al. are for splinting in flexion and neutral rotation.

REFERENCES:

1. Dunning CE, Zarzour ZD, Patterson SD, Johnson JA, King GJ. Muscle forces and pronation stabilize the lateral ligament deficient elbow. Clin Orthop Relat Res. 2001 Jul;(388):118-24. PMID:11451110 (Link to Abstract)

2. Boyer MI, Galatz LM, Borrelli J Jr, Axelrod TS, Ricci WM. Intra-articularfractures of the upper extremity: new concepts in surgical treatment. InstrCourse Lect. 2003;52:591-605. Review. PMID:12690885 (Link to Abstract)

3. Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg. 2009 Mar;17(3):137-51. PMID:19264707 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, Guillem Lomas MD,

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5.0

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TAG

(OBQ05.127) A 62-year-old man slips on ice and sustains an elbow dislocation. Post-reduction imaging reveals a highly comminuted radial head fracture and coronoid fracture through its base. What is the most appropriate treatment? Topic

Review Topic

1. Early passive range-of-motion in a hinged elbow brace
2. Application of a static spanning external fixator for 6 weeks
3. Radial head excision, coronoid excision, and repair of the lateral ulnar collateral ligament and medial collateral as needed
4. Radial head excision, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed
5. Radial head replacement, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed

PREFERRED RESPONSE ▶

DISCUSSION: The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and/or stiffness from prolonged immobilization. Therefore radial head replacement and open reduction internal fixation of the coronoid is the most appropriate treatment.

Pugh et al reported their experiences with this difficult population. Their protocol consisted of ORIF or replacement of the radial head, ORIF of the coronoid fracture, repair of the LCL and capsule, and repair of the MCL and/or hinged external fixation. Of the 36 cases, the outcome was graded as 28 excellent to good, 7 fair, and 1 poor. 8 cases required re-operation. The authors concluded that their surgical protocol restored sufficient elbow stability to allow early motion post-op, thereby enhancing the functional outcome. In fracture dislocation of the elbow with radial head and coronoid fracture, the radial head must be fixed or replaced to restore stability. The ORIF of coronoid fracture and radial head restores some valgus stability therefore MCL repair may not be needed. However, the varus stability must be restored by LCL repair.

REFERENCES:

1. Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB(eds): OKU Trauma 2. Rosemont, IL, AAOS, 2000

2. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004 Jun;86-A(6):1122-30. PMID:15173283 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, John Badylak MD,

Please Rate Educational Value!

4.0

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ABOS II: Terrible Triad Injury of Elbow

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Ring D. Fractures of the coronoid process of the ulna. J Hand Surg Am. 2006;31:1679- 1689 PMID:17145391 (Link to Abstract)
Steinmann SP. Coronoid process fracture. J Am Acad Orthop Surg. 2008;16:519-529 PMID:18768709 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Boyer MI, Galatz LM, Borrelli J Jr, Axelrod TS, Ricci WM. Intra-articularfractures of the upper extremity: new concepts in surgical treatment. InstrCourse Lect. 2003;52:591-605. Review. PMID:12690885 (Link to Abstract)
Dunning CE, Zarzour ZD, Patterson SD, Johnson JA, King GJ. Muscle forces and pronation stabilize the lateral ligament deficient elbow. Clin Orthop Relat Res. 2001 Jul;(388):118-24. PMID:11451110 (Link to Abstract)
Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg Am. 2007 Oct;32(8):1200-9. PMID:17923304 (Link to Abstract)
Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB(eds): OKU Trauma 2. Rosemont, IL, AAOS, 2000
Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg. 2009 Mar;17(3):137-51. PMID:19264707 (Link to Abstract)
McKee MD, Pugh DM, Wild LM, et al: Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures: Surgical technique. J Bone Joint Surg Am 2005;87:22-32 PMID:15743844 (Link to Abstract)
Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004 Jun;86-A(6):1122-30. PMID:15173283 (Link to Abstract)
Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551 PMID:11940613 (Link to Abstract)

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Terrible Triad Injury of Elbow

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