Updated: 7/11/2021

Terrible Triad Injury of Elbow

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  • summary
    • Terrible Triad Injury of Elbow is a traumatic injury pattern of the elbow characterized by elbow dislocation, radial head/neck fracture, and a coronoid fracture.
    • Diagnosis can be made with plain radiographs of the elbow. CT studies are helpful for surgical planning. 
    • Treatment is generally ORIF versus radial head arthroplasty, LCL reconstruction, coronoid ORIF, and possible MCL reconstruction.
  • Etiology
    • Characterized by presence of
      • elbow dislocation (often associated with posterolateral dislocation or LCL injury )
      • radial head or neck fracture
      • coronoid fracture
    • Pathophysiology
      • mechanism
        • fall on extended arm that results in a combination of
          • valgus, axial, and posterolateral rotatory forces
            • produces posterolateral dislocation
      • pathoanatomy
        • structures of elbow fail from lateral to medial
          • LCL disrupted first
          • anterior capsule injured next
          • possible MCL disruption
  • Anatomy
    • Radial head
      • a primary restraint to posterolateral rotatory instability (PLRI)
      • secondary valgus stabilizer
      • forearm in neutral rotation, lateral portion of articular margin devoid of cartilage
        • roughly between radial styloid and listers tubercle
    • Coronoid process
      • provides an anterior and varus buttress to ulnohumeral joint
      • resists posterior subluxation beyond 30 deg of flexion
      • fracture fragment typically has some anterior capsule attached
        • useful in repair
    • Medial collateral ligament
      • three components
        • anterior bundle
          • most important to stability, restraint to valgus and posteromedial rotatory instability
            • inserts on sublime tubercle (anteromedial facet of coronoid)
            • specifically inserts 18.4mm dorsal to tip of coronoid process
        • posterior bundle
        • transverse ligament
    • Lateral collateral ligament
      • inserts on supinator crest distal to lesser sigmoid notch
      • the primary restraint to posterolateral rotatory instability
      • four components
        • lateral ulnar collateral ligament (most important for stability)
        • radial collateral ligament
        • annular ligament
        • accessory collateral ligament
      • when injured is usually avulsed off of the lateral epicondyle
  • Presentation
    • Symptoms
      • patients complain of pain, clicking and locking with elbow in extension
    • Physical exam
      • possible varus / valgus instability patterns
      • distal radial ulnar joint must be evaluated for possible Essex-Lopresti injury
  • 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
      • need prereduction and postredcution films
      • consider PA and lateral films of wrist and forearm when indicated
    • CT
      • often utilized for better evaluation 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
          • radial head fx must not meet surgical indications
          • coronoid fx must be small
          • elbow should be sufficiently stable to allow early ROM
        • technique
          • one week of immobilization followed by progressive ROM
          • active motion initiated with resting splint at 90 degrees and forearm pronation, avoiding terminal extension
          • static progressive extension splinting at night after 4-6 weeks
          • strengthening protocol after 6 weeks
    • Operative
      • ORIF versus radial head arthroplasty, LCL reconstruction, coronoid ORIF, possible MCL reconstruction
        • indications
          • terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation
          • coronoid fractures involving less than 10% of the coronoid do not confer elbow stability in cadaveric studies and therefore do not require repair
            • should instability persist after addressing the radial head and the LCL complex in the presence of a small coronoid fracture, the next best step is MCL reconstruction
  • Techniques
    • ORIF vs replacement of radial head, coronoid ORIF, LCL reconstruction, and possible MCL reconstruction
      • approach
        • posterior skin incision advantageous
          • allows access to both medial and lateral aspect of elbow
          • lower risk of injury to cutaneous nerves
          • more cosmetic
      • technique
        • radial head ORIF vs. arthroplasty
          • radial head ORIF indicated if non comminuted fractures that involve < 40% articular surface
            • 1.5, 2.0, or 2.4mm countersunk screws
            • plate if necessary; 2.0 plates cause minimal loss of motion even when placed on radial neck
            • plate position should be posterolateral
              • safe zone: 90-110 arc from radial styloid to Lister's tubercle with arm in neutral rotation
          • radial head arthroplasty indicated for comminuted radial head fxs (> 3 pieces)
            • 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 ligamentously injured elbows
            • if <25% head damaged or fragments not reconstructable and nonarticulating, can excise fractured portion if elbow stable (rarely indicated)
        • coronoid ORIF
          • can be fixed through radial head defect laterally
          • sutures, suture anchors, screws, or rarely plate fixation.
            • suture passed through 2 drill holes
            • posterior to anterior lag screws if fragment large
            • basal coronoid fxs (rare) fixed with anteromedial or medial plate on proximal ulna
              • FCU split approach preferred for rare isolated coronoid fractures
        • 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 after LCL and fracture fixation, especially with extension beyond 30 degrees
      • postoperative
        • elbow fixators - hinged or static
          • consider when instability is noted after complete bone and soft tissue repair
        • immobilization
          • can 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
        • rehabilitation
          • initiate active ROM exercises 48 hours after surgery to improve functional outcomes
  • 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
    • Post-traumatic stiffness
      • very common complication
      • initiate early ROM to prevent
    • Heterotopic ossification
      • consider prophylaxis in pts with head injury or in setting of revision surgery
    • Post-traumatic arthritis
      • due to chondral damage at time of injury and/or residual instability
  • Prognosis
    • Historically poor outcomes secondary to
      • persistent instability
      • stiffness
      • arthrosis
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(SBQ18TR.10) During a trauma conference, a hand surgeon presents a case of a 25-year-old male who injured his elbow while roller skating. While describing the patient's radiographs, he reports that this injury is associated with valgus posterolateral rotatory instability. Which of the following images is most likely the patient's radiograph?

QID: 211210
FIGURES:
1

Figure A

1%

(20/1533)

2

Figure B

1%

(12/1533)

3

Figure C

4%

(56/1533)

4

Figure D

12%

(179/1533)

5

Figure E

81%

(1244/1533)

L 5 A

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(OBQ13.232) A young gymnast fell awkwardly onto an outstretched hand during a competition. At the time of impact, his forearm was positioned in supination. Axial and posterolateral forces were loaded along the forearm into the elbow and the elbow underwent a significant valgus thrust. What injury pattern is most likely to result from the combination of these forces at the elbow?

QID: 4867
1

Extension-type supracondylar fracture

7%

(336/4636)

2

Flexion-type supracondylar fracture

1%

(57/4636)

3

Anterior olecranon fracture dislocation

0%

(20/4636)

4

Coronoid fracture, olecranon fracture and elbow dislocation

3%

(152/4636)

5

Coronoid fracture, radial head fracture and elbow dislocation

87%

(4028/4636)

L 2 B

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(OBQ12.250) 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?

QID: 4610
FIGURES:
1

Radial head replacement

13%

(721/5407)

2

Radial head ORIF

11%

(589/5407)

3

Capsular plication

1%

(47/5407)

4

Lateral collateral ligament complex repair or reconstruction

64%

(3476/5407)

5

Medial collateral ligament complex reconstruction

10%

(547/5407)

L 3 B

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

QID: 2981
1

Radial tuberosity

1%

(16/2169)

2

3mm distal to the tip of the coronoid

15%

(315/2169)

3

Anteromedial process of the coronoid

79%

(1718/2169)

4

Medial border of the olecranon fossa

3%

(57/2169)

5

Radial side of ulna at origin of annular ligament

3%

(57/2169)

L 2 C

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(SBQ06TR.39) A 25-year-old Norwegian amateur curler slips on the ice, falling onto an outstretched right elbow. He is taken to the local teaching hospital and radiographs demonstrate a significantly comminuted radial head fracture and coronoid base fracture. His elbow is reduced and splinted. To restore stability and allow early range of motion, which of the following will most likely need to be performed in most cases?

QID: 2651
1

Radial head fixation or replacement

0%

(6/1354)

2

Radial head fixation or replacement and coronoid fixation

5%

(69/1354)

3

Radial head fixation or replacement, coronoid fixation, and lateral ulnar collateral ligament (LUCL) repair

82%

(1110/1354)

4

Radial head fixation or replacement, coronoid fixation, LUCL and medial ulnar collateral ligament (MUCL) repair

9%

(117/1354)

5

Radial head fixation or replacement, coronoid fixation, LUCL and MUCL repair, and application of a hinged fixator

4%

(48/1354)

L 2 C

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(SBQ06TR.4) A 58-year-old right-hand-dominant computer programmer trips and falls onto his right arm. He reports right arm pain and that his elbow felt "sloppy". His initial lateral radiograph is shown in Figure A. The orthopedic junior resident counsels him that he will likely need a radial head arthroplasty, ligament repair, and possible fixation of the ulna. What factor would most significantly affect the decision to surgically address the ulna fracture?

QID: 2616
FIGURES:
1

Degree of radial head comminution

1%

(25/1842)

2

The deforming force acting on the avulsed fracture fragment

2%

(37/1842)

3

Size of fragment and elbow stability after radial head replacement

92%

(1692/1842)

4

The degree of fracture displacement

2%

(46/1842)

5

Patient age and bone quality

1%

(20/1842)

L 1 B

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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?

QID: 192
1

closed reduction and early range of motion

1%

(11/1625)

2

radial head resection and lateral collateral ligament reconstruction

0%

(7/1625)

3

radial head resection and coronoid open reduction internal fixation

2%

(37/1625)

4

radial head arthroplasty and coronoid open reduction internal fixation

9%

(140/1625)

5

radial head arthroplasty, coronoid open reduction internal fixation, and lateral collateral ligament repair

87%

(1414/1625)

L 1 B

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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?

QID: 938
FIGURES:
1

extension and pronation

2%

(24/975)

2

extension and supination

5%

(49/975)

3

extension and neutral rotation

5%

(45/975)

4

flexion and pronation

49%

(480/975)

5

flexion and supination

38%

(369/975)

L 4 C

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(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?

QID: 1013
1

Early passive range-of-motion in a hinged elbow brace

0%

(4/932)

2

Application of a static spanning external fixator for 6 weeks

1%

(6/932)

3

Radial head excision, coronoid excision, and repair of the lateral ulnar collateral ligament and medial collateral as needed

1%

(5/932)

4

Radial head excision, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed

12%

(108/932)

5

Radial head replacement, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed

85%

(795/932)

L 1 A

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