Terrible Triad of the Elbow : Wheeless' Textbook of Orthopaedics

- Discussion:
- terrible triad: (RHF + MCL + coronoid process frx) + elbow dislocation
- in this injury there is little to keep the elbow reduced;

         - general operative considerations:
                 1) radial head: repair or replacement of the radial head (see ORIF or radial head)
                       - concomitant excision of radial head and coronoid process is not performed since it may result in marked instability;
                         - if operative repair is not possible, then radial head replacement is necessary;
                                 - in this case, lateral approach affords exposure to the coronoid;
                 2) LCL: repair of the lateral ulnar collateral ligament (LUCL) of the elbow
                 3) coronoid frx repair of the coronoid process frx with one of two techniques
                         - medial approach:
                                 - if the radial head is not excised, the coronoid is approached medially;
                                 - simultaneous fixation of the coronoid process and repair of the common flexor muscle and MCL
                                          injury were performed through an anteromedial incision;
           - in the report by Ring D, et al, the authors note that these fractures are very unstable and prone to
                                 numerous complications;
   - they recommend careful identification of the coronoid fracture, and CT is used if there is a question of coronoid frx;
   - they recommend radial head fixation or replacement, repairing the lateral collateral ligament, and in some cases
                                 performing IF of the coronoid fracture;
                         - reference:
                                 - Posterior Dislocation of the Elbow with Fractures of the Radial Head and Coronoid
                                 - Fixation of the Coronoid Process in Elbow Fracture-Dislocations
                                 - Terrible Triad Injuries of the Elbow: Does the Coronoid Always Need to Be Fixed?

4) flexor tendon origin open repair or reattachment of the brachialis is usually necessary;

- Intraoperative Considerations:
   - in the report by McKee MD, et al., the authors recommend:
         - coronoid process frx:
- fixation of the coronoid fragement and/or anterior capsule (suture fixation is required more often than screw fixation);
- in some cases coronoid fracture fragment will be incarcerated within the joint;
- often in cases of coronoid frx, radial head will be comminuted and will be require excision, which allows full exposure of coronoid frx;
                  - ref:
                                 -Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique.
         - radial head:
- ORIF of radial head or replacement of the radial head; (most require radial head replacement);
- repair of the lateral collateral ligament; (see posterolateral instability)
- LCL is typically avulsed off the humeral attachement;
- look for posterolateral bare area off of the humeral attachment;
- repair of the medial collateral ligament or application of hinged fixator;
                  - references:
                          - Radial head replacement or repair for the terrible triad of the elbow: which procedure is better?
         - hanging arm test: (from Garrigues, et al )
                  - intraoperative stability of the elbow can be tested with use of the hanging arm test;
                  - performed w/ elbow in full extension w/ forearm supinated (the position of maximal instability) and bump under upper arm;
                  - wt of arm creates subluxating force;
                  - lateral flouro images demonstrate if the elbow remains reduced during this maneuver;
                  - if the elbow remains concentrically located while hanging in this position, it is stable.
                  - it is performed after each critical aspect of pathoanatomy was addressed
                  - if there is absence of an increased ulnohumeral distance known as the drop sign
                  - ref:
                                 - Terrible Triad Injuries of the Elbow: Does the Coronoid Always Need to Be Fixed?
                                 - Fixation of the Coronoid Process in Elbow Fracture-Dislocations
         - hinged fixator:
                  - Good Functional Recovery of Complex Elbow Dislocations Treated With Hinged External Fixation: A Multicenter Prospective Study

- Post Operative Care:
- Critical time period for recovery of range of motion after surgical treatment of complex elbow instability: Prospective study on 76 patients.
- Single-staged Treatment Using a Standardized Protocol Results in Functional Motion in the Majority of Patients With a Terrible Triad Elbow Injury