American Shoulder and Elbow Surgeons
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Average 4.1 of 74 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 26-year-old male sustains a fall from a ladder onto his outstretched right hand. He is evaluated in the emergency room and is found to have a closed injury to his elbow without evidence of neurovascular compromise. Plain radiographs are obtained and are shown in Figures A and B. During surgery a sequential approach is used to treat each element of this injury. Which part of the procedure is felt to add the most to rotatory stability?
Radial head replacement
Radial head ORIF
Lateral collateral ligament complex repair or reconstruction
Medial collateral ligament complex reconstruction
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The essential lesion that results in the most instability in a terrible triad injury of the elbow is rupture of the lateral collateral ligament. Repair of this lesion results in the greatest increase in elbow rotatory stability.
The key components of a terrible triad injury are a radial head fracture, coronoid fracture, dislocation of the ulnohumeral joint and disruption of the lateral collateral ligament complex. While restoration of the bony anatomy is important for static stability, the key primary stabilizer that needs to be addressed is the lateral collateral ligament complex. In acute injuries LCL repair may be possible. In chronic injury, LCL reconstruction would need to be considered.
Forthman et al. reviewed 34 patients with an elbow dislocation, 22 of 34 of which were terrible triad injuries. Open reduction internal fixation or radial head replacement (as appropriate) along with LCL repair was completed; the MCL was not surgically addressed. Seventeen of 22 had good or excellent results, indicating that MCL repair is not necessary.
Pugh et al. discuss their surgical protocol for addressing terrible triad injuries with 28/36 of their patients obtaining good or excellent results. Their inside out protocol is described as follows: 1) coronoid fracture ORIF (capsular repair), 2) radial head fracture ORIF or replacement 3) LCL complex repair (isometric point is center of capitellum), 4) reevaluation of stability; MCL repair or hinged fixator application
Jensen et.al in cadaveric studies have demonstrated that radial head replacement alone decreases varus laxity and external rotatory laxity to 14.6 & 14.8 degrees respectively. Isolated LCL repair neutralized varus laxity, suggesting that repair of this structure was more important thatn radial head replacement for gross stability of the elbow.
Figures A & B reveal a terrible triad injury with a posterolateral elbow dislocation, comminution of the radial head and injury to the coronoid process. Illustrations A & B demonstrate the post operative images for this particular patient who underwent open reduction, radial head replacement, and LCL primary repair. A video is attached that provides an overview of the terrible triad pathology.
Answers 1, 2: Radial head fractures need to be addressed during management of terrible triad injuries, but critical to restoration of stability is repair of the LCL complex.
Answer 3: Capsular plication may help with the operative management, but is not considered an essential step in restoring stability
Answer 5: The majority of these injury patterns may be addressed without repair or reconstruction of the medial collateral ligament complex
Forthman C, Henket M, Ring DC
J Hand Surg Am. 2007 Oct;32(8):1200-9. PMID: 17923304 (Link to Abstract)
Forthman, JHS 2007
Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD
J Bone Joint Surg Am. 2004 Jun;86-A(6):1122-30. PMID: 15173283 (Link to Abstract)
Pugh, JBJS 2004
Jensen SL, Olsen BS, Tyrdal S, Søjbjerg JO, Sneppen O
J Shoulder Elbow Surg. 2005 Jan-Feb;14(1):78-84. PMID: 15723017 (Link to Abstract)
Jensen, JSES 2005
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At the elbow, the anterior bundle of the medial collateral ligament inserts at which site?
3mm distal to the tip of the coronoid
Anteromedial process of the coronoid
Medial border of the olecranon fossa
Radial side of ulna at origin of annular ligament
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 inserting at the sublime tubercle.
J Am Acad Orthop Surg. 2008 Sep;16(9):519-29. PMID: 18768709 (Link to Abstract)
Steinmann, JAAOS 2008
J Hand Surg Am. 2006 Dec;31(10):1679-89. PMID: 17145391 (Link to Abstract)
Ring, JHS 2006
Average 4.0 of 27 Ratings
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?
closed reduction and early range of motion
radial head resection and lateral collateral ligament reconstruction
radial head resection and coronoid open reduction internal fixation
radial head arthroplasty and coronoid open reduction internal fixation
radial head arthroplasty, coronoid open reduction internal fixation, and lateral collateral ligament repair
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.
Ring D, Jupiter JB, Zilberfarb J.
J Bone Joint Surg Am. 2002 Apr;84-A(4):547-51. PMID: 11940613 (Link to Abstract)
Ring, JBJS 2002
Average 4.0 of 21 Ratings
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?
extension and pronation
extension and supination
extension and neutral rotation
flexion and pronation
flexion and supination
A terrible triad elbow injury consists of an elbow dislocation with fractures of the radial head and coronoid. After surgical repair, splinting in flexion and pronation is felt to help ensure reduction and aid stability. Flexion adds to the bony congruity of the elbow and the elbow is more stable in increasing degrees of flexion. Pronation tightens the medial ulnar collateral complex which acts like a sling to keep the radio-capitellar joint reduced.
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 the elbow was slowly brought into extension to find the point at which it becomes unstable, the degree of flexion needed to maintain stability was greater with progessive loss of coronoid 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 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.
Dunning CE, Zarzour ZD, Patterson SD, Johnson JA, King GJ
Clin. Orthop. Relat. Res.. 2001 Jul;(388):118-24. PMID: 11451110 (Link to Abstract)
Dunning, CORR 2001
Boyer MI, Galatz LM, Borrelli J Jr, Axelrod TS, Ricci WM.
Instr Course Lect. 2003;52:591-605. PMID: 12690885 (Link to Abstract)
Mathew PK, Athwal GS, King GJ
J Am Acad Orthop Surg. 2009 Mar;17(3):137-51. PMID: 19264707 (Link to Abstract)
Mathew, JAAOS 2009
Average 4.0 of 23 Ratings
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?
Early passive range-of-motion in a hinged elbow brace
Application of a static spanning external fixator for 6 weeks
Radial head excision, coronoid excision, and repair of the lateral ulnar collateral ligament and medial collateral as needed
Radial head excision, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed
Radial head replacement, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed
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.
Average 4.0 of 24 Ratings
Title: Terrible Triad - Tricks for dealing with the unstable elbow Authors: Mark...
Title: Terrible Triad Author: Jeffrey D. Stone, MD Duration: 21:50