terrible triad of the elbow - bonefix | orthopaedic | dr. vasu...
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Terrible triad of the elbow
Vasu PaiVasu Pai
? “Terrible triad of the elbow"? Terrible triad of the elbow
• Posterior dislocation of the elbow
• + Fractures of the radial head+ Fractures of the radial head
F f id• + Fracture of coronoid process
• Uncommon injury 5% of dislocation
ProblemsProblems
• Difficulties Rarity of injury• Exposure
h b l• Achieving stability• .
• Poor outcome Recurrent instability
[15% to 35%]•
Stiffness
Th f bli h d hi i j• There are few published reports on this injury • Jupiter and Ring, MckeeJupiter and Ring, Mckee
PATHOGENESISPATHOGENESISI Disruption of the stabilizing lateral soft‐tissue structures
a. Avulsion of the lateral epicondyle 60%Mid b t t 35%c. Midsubstance rupture 35%
d. Ulnar detachment of LCL ?
Need Repair. Morrey : Isometric point
II Coronoid type I fracture with extensive anterior capsule [Controversy] Not required to repair• Regan and Morrey[1992] Type I not important for stabilityRegan and Morrey[1992] Type I not important for stability• Beingessner [2007] Cadaveric study: not important
Always repair• Mckee/Pugh [2004] ImportantMckee/Pugh [2004] Important• King [1993], Terada [2000]
The location of the capsule insertions well within the Type I region and the most coronoid tip fractures included disruption of the anterior capsule.
• JSE Volume 449: 259Volume 449: 259‐‐261, 2006261, 2006
•
d l h d f ll dIII Radial head fracture: Usually comminuted
1. Open reduction and internal fixation: Best when possible
2. Excision of head of the radius2. Excision of head of the radius
High evidence of instability [Morrey]
High evidence of Osteoarthritis [Josephson]
3 R l3. Replacement
Silicon replacement [Synovitis]Silicon replacement [Synovitis]
Metal prosthesis : uniblock or modularMetal prosthesis : uniblock or modular
Pugh, Mckee, Ring
Our standard protocolOur standard protocol
R d i f h di l i• Reduction of the dislocation
• ORIF or Replacement of radial head• ORIF or Replacement of radial head
• Repair anterior capsule to coronoid• Repair anterior capsule to coronoid
• Repair lateral structuresRepair lateral structures
• Brace for 4 weeks
• Early ROM at ten days in the brace
Terrible triadTerrible triad
In a Cadaveric elbow study.
Excision of the radial head Fully destabilized the elbowsExcision of the radial head Fully destabilized the elbowsand removal of the coronoid
Excision of the radial head Posterolateral rotatory laxity of 19°d i d ll l liAnd repaired collateral ligaments
Replace head, reconstruct C ll t l R i id F ll t bilitCollaterals, Repair coronoid Full stability
• Terrible triad: could not be stabilized by radial head replacement alone, butTerrible triad: could not be stabilized by radial head replacement alone, but additional coronoid reconstruction restored stability.
•Elbow JBJS 86 A: 975
Materials and methods
• Methods• Methods• 4 patients [2005‐2006]
d l[ ] k [ ] b [ ]• Dunedin Hospital[1], Hawkes Bay[2], Gisborne [1]
• Single Surgeon [VP]
• All had standard protocol
• A fracture of the anterior chip fracture of the coronoid process
• Grossly comminuted fracture of the radius and posterior dislocationGrossly comminuted fracture of the radius and posterior dislocation
I patient 36 M [ MNJ]I patient 36 M [ MNJ] 21/7/1971
Following Closed ReductionFollowing Closed Reduction
ExposureExposure• A direct lateral incision• A direct lateral incision
• Patient supine; Forearm in pronation
• Between FCU and anconeus
• The detachment of the lateral ll l li i " l " fcollateral ligament in a "sleeve" of
tissue, leaving a characteristic "bare spot" on the posterolateral aspect of the distal humerus
• Annular ligament is divided• anterior to anconeus•
Exposure of radial head
• A portion of the common extensor origin‐lateral ligament complex can beligament complex can be seen hanging down from the bare lateral condyle.y
• One big portion of the head g p
Excision of radial headExcision of radial head• All the fragments of the radial head• All the fragments of the radial head
were removed
• The radial neck was divided aboveThe radial neck was divided above the bicipital tuberosity. The saw cut (with an oscillating saw) was made above the tuberosity
• Trial components are implanted, and then the elbow is put through a range of motion to determine the size that best restores joint stability.
• The definitive components are then insertedinserted.
Repair: I Fix the coronoid
The deepest structure the coronoid is addressedThe deepest structure, the coronoid, is addressed first
The coronoid fragment with the capsule [Type I]
Type‐II or III 1 or 2 small‐fragment (3.0 or 3.5‐mm) lag screws from the posterior surface of the ulna [O l t f th di l id ][Or a plate from the medial side]
LCL repairLCL repair
R i th LCLRepair the LCL:• suture anchors.
In the center of rotation of the elbow laterally, located at the center of the capitellar circumference in pthe lateral condyle.
Ch k t i d ti A 20° t 130°• Check concentric reduction : Arc 20° to 130°
Valgus instability alone is usually well tolerated t ti l d i t i di ti f f th i lpostoperatively and is not an indication for further surgical
intervention
• A residual posterior or posterolateral instability is not acceptable.
• Perform a repair of the medial structures or apply a hinged external fixator to the elbow
Case 2: AW 6/3/1972Case 2: AW 6/3/1972
III case mono blockIII case mono block
Materials and methodMaterials and method
Case 1Case 1 LabourerLabourer M 28YM 28Y FallFall GG10 10 --125125
NoneNone
TeacherTeacher M 32YM 32Y BikeBike GG1010--130130
Radial N Radial N neuropraxianeuropraxia
Bush workBush work M 28M 28 FallFall GG1010--130130
NoneNone
EngineerEngineer M 34M 34 BikeBike 2020--100100 Limitation Limitation of ROMof ROM
Reported studiesReported studies
NN T f RT f R OO C li iC li iNoNo Type of RxType of Rx Out comeOut come ComplicationsComplications
RingRing 1111 Radius: ORIF 5, Excise 4Radius: ORIF 5, Excise 4Cornoid: not repairedCornoid: not repairedLCL repaired in 3 LCL repaired in 3
4/11: G4/11: G--EE 5 post op disloctn5 post op disloctn1each: arthrosis, 1each: arthrosis, synostosis, synostosis, deformitydeformitydeformitydeformity
Pugh and Pugh and MckeeMckee
3636 Radius: ORIF or ReplaceRadius: ORIF or ReplaceCoronoid: RepairCoronoid: RepairLCL R i dLCL R i d
FF--E:112E:112°° ±± 1111°°Rotation 136Rotation 136°° ±± 1616°°..
2 synostosis2 synostosis1 recurrent 1 recurrent i t biliti t bilitLCL: RepairedLCL: Repaired
[6MCL; 2 hinged brace][6MCL; 2 hinged brace]28/36: G28/36: G--EE instabilityinstability
PopovicPopovic 1111 Floating radial head replacementFloating radial head replacement 8/11 E8/11 E--GG --
PaiPai 44[type I][type I] Radius: Radial headRadius: Radial head 3/4 E3/4 E--GG 1 Neuropraxia of 1 Neuropraxia of R di l NR di l NCornoid: RepairedCornoid: Repaired
LCL repairedLCL repaired1Fair1Fair Radial NRadial N
SummarySummaryIn a “Terrible triad” Coronoid fracture repair is important irrespective of theIn a Terrible triad Coronoid fracture repair is important irrespective of the
size. The type I [smaller fractures]The type I [smaller fractures] associated with elbow instability should now be regarded as the most troublesome. [Cf Type II and III]
Radial head: should be fixed or replaced.
• Resection of the radial head:• Resection of the radial head:• Instability [Ring]
• Late osteoarthritis [Josefsson CORR246]• Late osteoarthritis [Josefsson CORR246]
Our protocolOur protocol
(1) R l f h di l h d• (1) Replacement of the radial head,
(2) Fi i f h id f i• (2) Fixation of the coronoid fragment or anterior capsule: Anchoring stitch [Mitek]
•(3) Repair of the LCL: Anchoring stitch [Mitek]
• (4) This allows early mobilizationearly mobilization, enhancing the functional outcomefunctional outcome.
If elbow is still unstableIf elbow is still unstable
• Persistent elbow instability in spite of repair of the coronoid, radial head, and lateral collateral ligament, the literature has suggested:lateral collateral ligament, the literature has suggested:
• A brief period of hinged external fixation• MCL repair
Th i i f i i h li h l• There is scarce information in the literature to help define optimal treatment
• Choosing the ideal treatment between replacement i l fi i f h di l h d b diffi lor internal fixation of the radial head can be difficult.
• In unfixable radial head fracture with dislocation, replacement of the head is appropriate. However, l t lt t il bllong term results are not available.