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
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Elbow Terrible Triad ORIF Orthobullets Team Trauma - Terrible Triad Injury of Elbow
QUESTIONS 1 of 21 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.201) A 35-year-old female fell while riding a motorcycle and sustained the left elbow injury shown in Figures A and B. Figures C and D are the CT scan and 3D reconstruction of the injury. After closed reduction, the elbow is unstable with valgus stress at 40 degrees of flexion. What is the most appropriate definitive treatment? QID: 213097 FIGURES: A B C D Type & Select Correct Answer 1 Radial head ORIF and MCL repair 8% (149/1776) 2 Radial head replacement and LUCL repair 5% (93/1776) 3 Radial head excision, coronoid ORIF, and LUCL repair 3% (45/1776) 4 Radial head replacement, coronoid ORIF, and LUCL repair 82% (1465/1776) 5 Radial head excision and LUCL repair 0% (8/1776) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ18.237) A 21-year-old football player is tackled as he falls onto an outstretched arm. He sustains the injury shown in Figure A. He undergoes successful operative treatment of his injury. In which order did his injury occur? QID: 213133 FIGURES: A Type & Select Correct Answer 1 MCL > LCL > anterior capsule 4% (78/1847) 2 MCL > anterior capsule > LCL 18% (330/1847) 3 anterior capsule > MCL > LCL 5% (85/1847) 4 LCL > anterior capsule > MCL 66% (1217/1847) 5 LCL > MCL > anterior capsule 5% (91/1847) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A B C D E Type & Select Correct Answer 1 Figure A 2% (27/1694) 2 Figure B 1% (14/1694) 3 Figure C 3% (59/1694) 4 Figure D 11% (190/1694) 5 Figure E 82% (1381/1694) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 Type & Select Correct Answer 1 Extension-type supracondylar fracture 7% (341/4721) 2 Flexion-type supracondylar fracture 1% (58/4721) 3 Anterior olecranon fracture dislocation 0% (20/4721) 4 Coronoid fracture, olecranon fracture and elbow dislocation 3% (156/4721) 5 Coronoid fracture, radial head fracture and elbow dislocation 87% (4102/4721) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A B Type & Select Correct Answer 1 Radial head replacement 13% (731/5482) 2 Radial head ORIF 11% (592/5482) 3 Capsular plication 1% (47/5482) 4 Lateral collateral ligament complex repair or reconstruction 64% (3535/5482) 5 Medial collateral ligament complex reconstruction 10% (549/5482) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ09.168) At the elbow, the anterior bundle of the medial collateral ligament inserts at which site? QID: 2981 Type & Select Correct Answer 1 Radial tuberosity 1% (17/2225) 2 3mm distal to the tip of the coronoid 14% (322/2225) 3 Anteromedial process of the coronoid 79% (1766/2225) 4 Medial border of the olecranon fossa 3% (57/2225) 5 Radial side of ulna at origin of annular ligament 3% (57/2225) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 Type & Select Correct Answer 1 Radial head fixation or replacement 0% (7/1526) 2 Radial head fixation or replacement and coronoid fixation 5% (75/1526) 3 Radial head fixation or replacement, coronoid fixation, and lateral ulnar collateral ligament (LUCL) repair 82% (1256/1526) 4 Radial head fixation or replacement, coronoid fixation, LUCL and medial ulnar collateral ligament (MUCL) repair 9% (131/1526) 5 Radial head fixation or replacement, coronoid fixation, LUCL and MUCL repair, and application of a hinged fixator 3% (52/1526) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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: A Type & Select Correct Answer 1 Degree of radial head comminution 1% (29/2070) 2 The deforming force acting on the avulsed fracture fragment 2% (39/2070) 3 Size of fragment and elbow stability after radial head replacement 92% (1911/2070) 4 The degree of fracture displacement 2% (47/2070) 5 Patient age and bone quality 1% (21/2070) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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 Type & Select Correct Answer 1 closed reduction and early range of motion 1% (12/1762) 2 radial head resection and lateral collateral ligament reconstruction 1% (9/1762) 3 radial head resection and coronoid open reduction internal fixation 2% (38/1762) 4 radial head arthroplasty and coronoid open reduction internal fixation 9% (151/1762) 5 radial head arthroplasty, coronoid open reduction internal fixation, and lateral collateral ligament repair 87% (1536/1762) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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: A Type & Select Correct Answer 1 extension and pronation 3% (27/1043) 2 extension and supination 5% (56/1043) 3 extension and neutral rotation 5% (51/1043) 4 flexion and pronation 49% (513/1043) 5 flexion and supination 37% (387/1043) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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 Type & Select Correct Answer 1 Early passive range-of-motion in a hinged elbow brace 0% (5/1022) 2 Application of a static spanning external fixator for 6 weeks 1% (7/1022) 3 Radial head excision, coronoid excision, and repair of the lateral ulnar collateral ligament and medial collateral as needed 0% (5/1022) 4 Radial head excision, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed 11% (113/1022) 5 Radial head replacement, open reduction internal fixation of the coronoid, and repair of the lateral ulnar collateral ligament and medial collateral as needed 86% (878/1022) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic
All Videos (4) Podcasts (1) Middle Atlantic Shoulder & Elbow Society Annual Meeting 2019 Complex Elbow Trauma and Instability: What's this about a terrible triad? - Matthew Ramsey, MD Matthew Ramsey Trauma - Terrible Triad Injury of Elbow B 8/4/2021 643 views 4.0 (1) Login to View Community Videos Login to View Community Videos 2018 Orthopaedic Summit Evolving Techniques Terrible Triad of the Elbow in 25 Year Old Gymnast: Repair LCL, Replace RH and Ignore Coronoid - Graham J. W. King, MD, MSc, FRCS (OSET 2018) Trauma - Terrible Triad Injury of Elbow A 8/12/2019 698 views 4.6 (5) Login to View Community Videos Login to View Community Videos 2016 Current Solutions in Orthopaedic Trauma Terrible Triad - Tricks for dealing with the unstable elbow - Mark A. Mighell, MD (CSOT #18, 2016) Mark A. Mighell Trauma - Terrible Triad Injury of Elbow A 2/21/2017 1566 views 4.8 (8) Trauma | Terrible Triad Injury of Elbow Trauma - Terrible Triad Injury of Elbow Listen Now 23:34 min 10/18/2019 960 plays 5.0 (2) See More See Less
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