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    A Case of Terrible Triad Injury to the Elbow

    A fall from a ladder sends a 65-year-old male patient to the emergency department with left elbow pain. Following closed reduction of an elbow dislocation, imaging shows an unusually large anteromedial coronoid fragment requiring surgical fixation.

    Authors

    Alexander W. Aleem, MD, and Charles L. Getz, MD

    Disclosures

    The authors have no disclosures relevant to this article.

    Introduction

    Originally described by Hotchkiss, [1] a “terrible triad” injury of the elbow refers to a constellation of injuries in the elbow that include fractures of both the radial head and coronoid with resultant posterolateral dislocation of the elbow joint. [2,3]

    Most patients suffer this injury by falling on an outstretched, supinated arm with a valgus stress through the elbow. The “terrible” designation of these injuries is due to the fact that the elbow has lost all ligamentous and bony stability, leading to a high rate of recurrent instability if left untreated.

    Terrible triad injuries account for approximately 30% of all elbow dislocations. [3] They more commonly occur in adult men, with a peak incidence during the 4th decade of life. Concurrent ipsilateral injuries to the wrist, interosseous membrane of the forearm, and shoulder have been described.

    The goal of treatment of terrible triad injuries is to restore the bony and ligamentous restraints of the elbow to provide elbow stability. [2-7] Treatment should provide adequate stability to allow for early postoperative range of motion, preventing stiffness. Several treatment algorithms have been described, and should be tailored to each patient’s specific injury pattern.

    We present a case of a terrible triad with an unusually large anteromedial coronoid fragment that required fixation through a dual-incision approach.

    Case Presentation

    A 65-year-old male patient presents to the emergency department with a chief complaint of left elbow pain after falling off a ladder. He had no antecedent elbow pain or history of elbow instability.

    Per report from the emergency department, his elbow was dislocated and he underwent a closed reduction of the elbow prior to evaluation by orthopedic surgery.

    History and Physical Examination

    • History of diabetes mellitus and hypertension
    • Significant swelling and bruising of the left elbow; no open wounds
    • Tenderness to palpation across the entire elbow
    • Pain with any gentle range of motion
    • Motor and sensory function intact in the upper extremity

    Differential Diagnosis

    • Elbow fracture-dislocation: possible terrible triad, trans-olecranon fracture, or Monteggia fracture
    • Distal humerus fracture
    • Simple elbow dislocation

    Imaging

    Anteroposterior (AP) and lateral views of the elbow were obtained in the emergency department (Figure 1).

    • The AP radiograph demonstrates incongruity of the elbow joint and fracture of the coronoid.
    • The lateral radiograph shows persistent subluxation of the elbow with fractures of the radial head and coronoid

    Figure 1. Anteroposterior radiograph (left) demonstrates the elbow injury, and lateral radiograph (right) shows persistent subluxation with radial head and coronoid fractures.

    The fracture-dislocation underwent an attempted closed reduction in the emergency department, and a post-reduction CT scan was then obtained.

    The CT scan showed a large anteromedial fracture of the coronoid with a comminuted fracture of the radial head and persistent subluxation of the joint (Figure 2).

    Figure 2. Select CT slices and 3D reconstruction demonstrate a large anteromedial coronoid fracture (arrow) with persistent subluxation of the elbow.

    Diagnosis

    • Terrible triad

    Treatment

    The patient gave consent for surgery. He was scheduled for open reduction, internal fixation (ORIF) of the coronoid; ORIF (versus replacement) of the radial head; repair of the lateral collateral ligament; and possible repair of the medial collateral ligament.

    These procedures can be accomplished via an all lateral approach or dual incision lateral and medial approach.

    All Lateral Approach

    Advantages

    • Single incision minimizes soft tissue dissection
    • Obtain access to the coronoid fragment through a lateral window by removing the radial head
    • Minimal risk to surrounding neurovascular structures

    Disadvantages

    • Cannot access the anteromedial side of the coronoid, which may lead to inadequate fixation
    • Cannot address potential medial collateral ligament injuries

    Dual Incision Lateral and Medial Approach

    Advantages

    • Obtain access to the medial and lateral sides of joint
    • Assess injury to the medial collateral ligament
    • Easier access to the coronoid fragment

    Disadvantages

    • Ulnar nerve at risk
    • More soft tissue dissection

    We prefer a dual incision lateral and medial approach, as we believe the advantages outweigh the disadvantages.

    Surgical Procedure

    Place the patient in the supine position with a hand table and non-sterile tourniquet. Position the C-arm at the end of the hand table. The patient should receive general anesthesia and a preoperative nerve block.

    Make the first incision on the lateral side, taking care to avoid creating large skin flaps.

    • A traumatic injury usually results in fascial disruption. Either a Kocher (posterolateral) approach through the anconeus and extensor carpi ulnaris or a Kaplan (lateral) approach through the extensor digitorum communis and extensor carpi radialis longus can be used to gain access to the joint.
    • Evacuate any hematoma and then evaluate the lateral collateral ligaments, which are usually torn off the humeral side.
    • Evaluate the radial head once access has been gained into the joint. In general, replacement is recommended instead of ORIF if there is significant comminution of the radial head or if 1 of the fragments is in more than 2 pieces.
    • Assess the coronoid fragment once the radial head has been removed to determine the optimum treatment. If the fracture is not too large, it can be fixed through a lateral window.
    • Radial head replacement vs. ORIF: Replacement will ensure the joint is not overstuffed; ORIF is generally reserved for simple fractures that are amenable to 2 or 3 mini fragment screws.

    Next, move to the medial side.

    • The incision should be centered on the medial epicondyle.
    • Unroof the ulnar nerve; there’s no need to transpose.
    • Elevate the upper two thirds of the flexor-pronator mass off the medial epicondyle to access medial elbow joint.
    • The coronoid can now be accessed.
    • Perform ORIF of the coronoid: Screws or an anteromedial plate can be used, with a plate being appropriate for larger fragment pieces. Good fixation is necessary in the sublime tubercle and distally into the ulna.
    • Once ORIF is complete, assess the medial collateral ligament.

    The lateral collateral ligament, which is usually avulsed off the humeral side, can be repaired after the bony injuries have been fixed.

    • A non-absorbable suture can be used to incorporate the ligament with the capsule and common extensors.
    • Ensure that the ligament is repaired back to the isometric point on the lateral epicondyle (center of capitellum).
    • Bone tunnels (our preferred technique) or anchors can be used.

    Assess joint stability once the lateral side is fixed, using clinical assessment and fluoroscopy to confirm stability.

    • Medial collateral ligaments (MCL) may need to be repaired if the joint is still unstable.
    • Consider using a static external fixator for stabilization if the joint remains unstable after MCL repair.

    Once the procedure is complete, the arm is immobilized in 90 degrees of flexion and full pronation.

    Postoperative Course

    Immediate Postoperative Period

    The patient tolerated the procedure well without complications. He was discharged home on postoperative day 1 with instructions to remain non-weight-bearing in a splint and sling.

    First Postoperative Visit, 2 Weeks After Surgery

    The splint and staples were removed. Radiographs showed a stable joint (Figure 3). As a result, the patient was allowed to start physical therapy consisting of:

    • Passive and active assisted elbow flexion and extension with the forearm in pronation
    • Passive and active assisted pronation and supination with the elbow at 90 degrees of flexion

    Figure 3. Two-week postoperative lateral radiograph (left) shows concentrically reduced elbow joint. Radiocapitellar lateral radiograph (right) demonstrates concentric elbow joint and coronoid hardware.

    The patient was provided a resting elbow splint made for 90 degrees of flexion and neutral rotation, and he was advised not to do any strengthening exercises yet.

    Second Postoperative Visit, 6 Weeks After Surgery

    The patient reported that he was not in pain and that he was satisfied with the procedure and the progress he had made. His active range of motion was 45 to 90 degrees of flexion, with passive flexion to 120 degrees. Supination and pronation were limited to 15 degrees each.

    Radiographs showed a reduced fracture with a small amount of heterotopic ossification at the radial neck.

    The resting elbow split was discontinued and the patient was progressed to more aggressive physical therapy, including:

    • All range of motion without limits
    • All phases of strengthening with a 10-pound weight limit

    Third Postoperative Visit, 3 Months After Surgery

    At the final postoperative visit, the patient was very pleased with his progress. His elbow range of motion was 20 to 140 degrees of flexion, 50 degrees of supination, and 60 degrees of pronation.

    Radiographs were unchanged from the 6-week visit (Figure 4). No mechanical block to motion was felt, so resection of the heterotopic ossification was not indicated.

    Figure 4. Three-month postoperative lateral radiograph (left) shows healed coronoid fracture, maintained elbow joint reduction, and a small amount of heterotopic ossification. Anteroposterior radiograph (right) demonstrates healed fractures and concentric elbow reduction.

    The patient was instructed to do 1 more month of supervised physical therapy and then to gradually return to activities as tolerated.

    Potential Postoperative Complications

    Although this patient did well following surgery, there are postoperative complications of which surgeons should be aware:

    • Infection
    • Neurovascular injury: Ulnar nerve at increased risk in medial approaches; radial nerve/posterior interosseous nerve at increased risk in lateral approaches
    • Compartment syndrome
    • Heterotopic ossification: Consider using indomethacin as prophylaxis postoperatively, but may delay bony union; resection reserved for when heterotopic mechanically blocks motion or is impinging neurovascular structures
    • Recurrent immediate postoperative instability: Consider prolonged immobilization or placement of external fixator; may require revision surgery to repair/reconstruct ligaments; may also be due to non-union of fracture fragments
    • Post-traumatic contracture/stiffness, which may require surgical release
    • Post-traumatic osteoarthritis; can be difficult to manage as many patients are young/high demand and not good candidates for total elbow arthroplasty
    • Chronic instability caused by non-union/malunion of bony fragments and/or incompetency of ligamentous complexes; may require reconstruction of all offending structures

    Author Information

    Alexander W. Aleem, MD, is a shoulder and elbow fellow with The Rothman Institute, Philadelphia, Pennsylvania. Charles L. Getz, MD, is a board-certified shoulder and elbow specialist with The Rothman Institute, Philadelphia, Pennsylvania.

    Shoulder Reconstruction Section Editor, Rothman Institute Grand Rounds

    Luke S. Austin, MD

    References

    1. Hotchkiss RN. Fractures and dislocations of the elbow. In: Court-Brown C, Heckman JD, Koval KJ, Wirth MA, Tornetta P, Bucholz RW, eds. Rock-wood and Green’s Fractures in Adults. Philadelphia, PA: Lippincott-Raven; 1996.
    2. Bohn K, Ipaktchi K, Livermore M, Cao J, Banegas R. Current treatment concepts for “terrible triad” injuries of the elbow. Orthopedics. 2014;37(12):831-837.
    3. van Riet RP, Morrey BF. Documentation of associated injuries occurring with radial head fracture. Clin Orthop Relat Res. 2008;466(1):130-134.
    4. Doornberg JN, Ring D. Coronoid fracture patterns. J Hand Surg Am. 2006;31(1):45-52.
    5. Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg Am. 2006;88(10):2216-2224.
    6. Garrigues GE, Wray WH, 3rd, Lindenhovius AL, Ring DC, Ruch DS. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am. 2011;93(20):1873-1881.
    7. Watters TS, Garrigues GE, Ring D, Ruch DS. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Clin Orthop Relat Res. 2014;472(7):2128-2135.