Terrible Triad of Elbow

 Introduction  - 

Originally described in 1996 by Hotchkiss, the terrible triad of the elbow constitutes a highly unstable form of fracture-dislocation consisting of elbow dislocation with concomitant radial head or neck and coronoid process fractures. 

Relevant Anatomy

◎ Radial Head-

○ Resists posterolateral rotatory instability

○ Resists Valgus strain to the elbow

◎ Coronoid-

○ Forms the buttress for the ulno-humeral joint

○ Prevents posterior subluxation with elbow from full flexion to 30 degree 

◎ Medial collateral ligament

* Anterior bundle

      - most important for stability, 

      - restraint to valgus and posteromedial rotatory instability 

      - insertion on sublime tubercle (anteromedial facet of coronoid)

* Posterior bundle 

* Transverse ligament

◎ Lateral collateral ligament

       - Insertion on supinator crest distal to lesser sigmoid notch 

      - the primary restraint to posterolateral rotatory instability 

      - Avulsion from lateral condyle when injured 

- Components

               Lateral ulnar collateral ligament (most important for stability) 

               Radial collateral ligament 

               Annular ligament 

              Accessory ligament 

Mechanism and Presentation

◎ Fall on outstretched hand that is in mild flexion 

◎ Valgus stress at elbow 

◎ Forearm supination

*  Evaluation in ED - 

○ X-rays 

○ NV status 

○ Elbow reduction in ED 

○ Appropriate immobilisation in above elbow back slab 

○ Confirm NV status again 

○ Repeat X-rays 

○ Check for distal radio-ulnar joint injury (Essex Lopresti injury)

○ CT scan thereafter (can happen from the ward/ED)

Radiographs and definition

◎ Damage/Fracture to radial head       

◎ Damage/Fracture to coronoid 

◎ Elbow dislocation

◎ Get pre and post reduction x-rays 

◎ Forearm and wrist x-rays - if distal radioulnar joint injury is suspected

Typical images of a reduced elbow with Terrible Triad injury - 

Treatment (conservative)

• Indication -

•  Ulno-humeral and radio-capitellar joints well reduced 
•  Radial head # must not meet surgical indications 
• Small coronoid (mayo type 1) # 
• elbow should be sufficiently stable to allow early ROM

Protocol- 

• 1 week of immobilization (at 90 degree) 

• Active assisted motion initiated with the splint on. 

• ROM from full flexion to progressive extension. Full extension is done around 6-week time. 

• Strengthening after 6 weeks

Radial Head Surgical indications

Mason classification  

◎ Mason Type II with mechanical block

◎ Mason Type III where ORIF feasible

◎ Presence of other complex ipsilateral elbow injuries

Coronoid fracture 

◎ Transverse fractures (Mayo type I) 

◎ Anteromedial facet fractures (Mayo type II) 

◎ Basilar fractures (Mayo type III)

Management (Surgical)

◎ Indication - Terrible triad injury with

• unstable radial head fracture (meeting surgical indications)  
• type II/III coronoid fracture
• Posterior skin incision advantageous
• Radial head- 

              ○ Radial head ORIF indicated in constructible fractures 

              ○ Radial head arthroplasty/excision in severely comminuted # radial head

• Coronoid-

             ○Can be fixed through radial head defect laterally 

             ○ FCU split approach for isolated coronoid # 

             ○ Mayo type 1- suture anchor/suture tunnel in unstable elbow 

            ○ Mayo type 2- suture / buttress plate in larger fragment 

            ○ Mayo type 3- Lag screw +/- buttress plate

• LCL repair 

         ○ usually avulsed from origin on lateral epicondyle 

         ○ reattach with suture anchors or trans-osseous sutures 

         ○ 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 

        ○ repairs are performed with elbow at 90 degrees of flexion

• MCL repair

       ○ Indicated if instability on examination after LCL and fracture fixation,  Especially with extension beyond 30 degrees

       ○ Persistent posteromedial instability following radial head replacement/repair and LCL repair in the setting of Type I/II coronoid fracture should be managed with MCL repair

• Hinged fixators- when instability is noted after complete bone and soft tissue repair

Post Operative

• Immobilize in flexion with forearm pronation to provide stability against posterior

subluxation

• If both MCL and LCL were repaired, elbow in flexion and forearm neutral rotation

• Active ROM exercises 48 hours after surgery 

Complications

• Instability- more common following type I or II coronoid fractures 

• Failure of internal fixation- more common following repair of radial neck fractures

           - poor vascularity leading to osteonecrosis and non-union

• Post-traumatic stiffness 

• Heterotopic ossification

          - prophylaxis in pts with head injury or in setting of revision surgery

• Post-traumatic arthritis

References -

  - Ring D, Jupiter JB, Zilberfarb J. "Terrible Triad Injuries of the Elbow." *J Orthop Trauma.* 2024.  

  - O’Driscoll SW. "Posterolateral Rotatory Instability of the Elbow." *J Hand Surg.* 2023.  

Thank You 

CARPAL BONE ALIGNMENT MEASUREMENT

▪︎ The  following  are  the  most  frequently used  measurements  to  define  carpal  bone  alignment- 

1) LC  angle :  This  is  helpful  to  quantify  midcarpal  misalignment. 

• A  normal  LC  angle  should  be  0  ±  15  degrees  with  the wrist  in  neutral . 

2) SL angle : one  of  the  major  determinants  of  SL  dissociation.

• Normal  values  range  from  30  to  60  degrees  (average, 47 degrees).

•Although  angles  greater  than  80  degrees  indicate  SL  ligament  disruption,  lower  readings  do  not  rule  out this  pathology. Values  less  than  30  degrees  are  not  unusual for  patients  with  STT  joint  osteoarthritis.

3) RL  angle :  This  gives  objective  evidence  of  the  dorsal  or palmar  tilt  of  the  lunate.  

•The  normal  RL  angle  should  be  0 ±  15  degrees.

4)  Ulnar Variance : Ulnar  variance  is  usually  measured  on  standard  PA  radiographs,  although  lateral  radiographic  projections  also  offer very accurate readings.  

• When  the   ulna  is  shorter  than  the  radius,  the  ulnar  variance is  negative,  and  when  longer,  it  is  positive.   

5) Carpal Height Ratio :  This  is  another  parameter  in  the  evaluation  of  carpal  collapse.

6) Ulnar  translocation  ratio :  In  some  instability  conditions, there  is  an  ulnar  shift  of  the  carpal  bones.  The  amount  of translocation  can  be  quantified  using  a  variety  of  techniques. 

Very commonly used  technique measures the perpendicular distance from the center of the head of the capitate to a line from the radial styloid, which extends distally and parallel to the longitudinal axis of the radius. The carpal translocation ratio (calculated as the ratio of this distance to the length of the third metacarpal) in normal wrists is 0.28 ± 0.03.

FROSCH POSTEROLATERAL APPROACH KNEE

INTRODUCTION 

* At least 7% of all tibial plateau fractures lie in the region of the posterolateral corner. Fractures in this region, usually cannot be adequately treated by using a lateral or anterolateral approach due to coverage by the fibular head and ligamentous structures in the corner region of the popliteus muscle. 

• To minimize this problem, a lateral approach  was described by Lobenhoffer et al.With this approach, a fibular osteotomy and detachment of the joint capsule and meniscotibial ligaments from the lateral tibial plateau  allow for the exposure and examination of the posterolateral joint surfaces of tibia. 

• Lobenhoffer approach provides a good view of the posterolateral corner of the tibial plateau but leads to extensive trauma of soft tissue there.

• Isolated posterior approaches allow for fragment fixation but visual control of fracture reduction is limited. 

* Therefore a modified surgical technique for the treatment of posterolateral tibial plateau fracture was introduced. Frosch described this posterolateral approach for fracture reduction and fixation combined with a lateral arthrotomy to visually control the fracture alignment and the joint surface. 

SURGICAL TECHNIQUE- 

 POSITION- 

• Patient lies in a lateral position. 

• Knee is supported by thick rolled pillow because the weight of the leg itself apply varus stress which causes the joint gap to be laterally opened. 

INCISION-

• An approximately 15 cm long posterolateral skin incision is required. Fibula head is used as an anatomical landmark. 

•Incision starts 3 cm above the joint line and follows the fibula in a distal direction. 

•Before the popliteal fossa is dissected a lateral standard arthrotomy is performed.

EXPOSURE- 

•The iliotibial tract is incised from the dorsal side and the dorsal fibers are detached from the Gerdy's tubercle. Thereafter, the lateral capsule is incised and the meniscotibial ligament is dissected approximately 2mm away from its insertion in the tibia, parallel to the joint surface.

•The entire lateral tibial plateau, including the posterolateral corner can be viewed by using this lateral arthrotomy. 

•For manipulation of the posterolateral fragment an additional posterolateral exposure of the fragments is necessary.

• Both approaches are performed through one skin incision. 

• After direct incision of the fascia, the peroneal nerve is exposed to the rear edge of the biceps femoris muscle. The nerve should be carefully dissected and gently mobilized for protection during the operation. 

• Blunt dissection of the popliteal fossa is initially performed between the lateral head of gastrocnemius and soleus and inspection begins on the muscle belly of soleus. 

• Popliteal vessels and the popliteus muscle are exposed.The popliteal vessels are protected by the lateral head of gastrocnemius which is retracted by a Langenbeck retractor. 

•Inferior genicular vessels are ligated only if necessary. 

•At distal edge of the popliteal muscle, it is pulled back towards the medial and cranial direction. Then the muscle is carefully detached from the dorsal surface of the fibula. 

•The soleus muscle  should be detached distally until the peroneal nerve at the fibular neck enters into the musculature. The peroneal nerve should not be detached after it enters into the musculature because muscle branches leading off in a atypical fashion can be easily damaged.

FIXATION- 

•Posterolateral fragments are manipulated and reduced from the dorsal side with a raspatory or with pointed reduction forceps. 

•Fragments after reduction are held in place using K wires. 

•Plain radiographs need to be performed intraoperatively. 

*After fracture reduction, a conventional radius, T plate can be pinched off with lateral gutters so that a two-hole L-plate is obtained. To buttress the fracture, the plate can be slightly under countered and dorsally fixed with conventional screws. 

The lateral edge of the plate lies immediately next to the fibular Head.

ADVANTAGES- 

1) Visual control of the reduction of the fracture is achieved through a conventional lateral standard arthrotomy, which is accomplished through the same skin incision. The anatomical reduction of the fracture and internal fixation are performed from the dorsal side. Therefore as a result of the modified posterolateral approach, the fragments are not denuded. 

2) The avoidance of fibula osteotomy in most patients with posterolateral tibial plateau fractures is an advantage. 

3) Damage to the upper tibiofibular joint and nerve injuries caused by an oscillating saw blade can be avoided by using the presented technique. 

4) Minimal soft tissue damage compared to Lobenhoffer posterolateral approach with fibular osteotomy. 

Limitation of the modified posterolateral approach - 

 1) It cannot be extended distally because of the trifurcation vessels that traverse the interosseous membrane approximately 5 cm below the joint line. However, because the lateral tibial metaphysis has a posterior inclination angle of approximately 45 degree and the posterolateral split fracture segment is usually less than 4 cm in cortical length, this limitation seems to have no problem in practice. 

2) Difficult to address additional medial plateau fractures when the patient is lying in the lateral position. 

3) Iatrogenic injuries of blood vessels can occur if the posterolateral plate is placed too far distally. 

4) Precise knowledge of the anatomy of the posterolateral corner is required. 

REMPLISSAGE PROCEDURE

The term 'Remplissage' means  'to fill in'.

• 1st described in 2007 by Wolf et al (1) as an adjunct to the arthroscopic anterior stabilisation procedure of the shoulder in order to address a large engaging Hill-

Sach's defect. 

•This technique has been reported to be effective in reducing the incidence of recurrent anterior shoulder instability, when used along with arthroscopic Bankart repair .

Indication- 

• This technique is performed when the Hill-Sachs lesion is very large and engaging the anterior glenoid with little overhead movement (i.e. dislocating very easily due to the large Hill-Sachs lesion, as well as the Bankart lesion). In these situations a Bankart repair alone may not be sufficient. Thus the development of the remplissage technique.

Operative Technique- 

 • The arthroscope is placed through the anterior portal to view the Hill-Sach's lesion on the posterior aspect of the

humeral head. Through the posterior portal, a burr is introduced to decorticate the Hill-Sach's lesion. 

• A triple-loaded large rotator cuff anchor is inserted into the Hill-Sach's defect through

the posterior portal. 

• Sutures are passed through the infraspinatus tendon and the posterior

capsule, which are then tied down with a 'parachute technique', hence successfully filling the defect on the humeral head.

Advantages - 

• The ability to make the Hill-Sach's defect

extra-articular, thereby eliminating engagement of the defect with the anterior glenoid rim. 

• It is ideally suited to instability patients who have large, engaging Hill-Sachs lesions and soft-tissue Bankart tears. These patients are known to have a higher failure rate after surgery than those with smaller lesions. The results of this technique in this difficult subset of traumatic anterior shoulder instability patients are significantly better (10% recurrence rate) than with an

arthroscopic Bankart repair alone (67% recurrence rate). 

Forearm and Wrist Fractures Eponym

Barton f.: an intraarticular fracture of the dorsal rim of the distal radius, usually resulting in subluxation of the radial carpal joint with the fracture site fragment.

chauffeur's f.: oblique fracture of the radial styloid caused by a twisting- or snapping-type injury; also called backfire f., Hutchinson f., and lorry driver's f.

chisel f.: incomplete, usually involving medial head of radius, with fracture line extending distally.

Colles f.: named prior to x-ray technology; implies a fracture of the distal radius, either articular or non-articular, with dorsal angulation of the distal fragment producing a silver fork deformity; generally associated with a fracture of the ulnar styloid.

Corner f.: a small bucket-handle-appearing fracture in the distal metaphyseal corner in a young child, often associated with child abuse.

de Quervain f.: combination of a wrist scaphoid fracture with volar dislocation of scaphoid fragment and lunate.

die-punch f.: an intraarticular fracture of the ulnar (volar) portion of the distal radius, usually caused by direct impaction of the lunate onto the lunate fossa of the distal radius.

Essex-Lopresti f.: a comminuted ¹radial head fracture with an injury to the ²distal radioulnar joint caused by disruption of the ³interosseous membrane, which can cause a proximal migration of the radius if the radial head is excised secondarily.

Galeazzi f.: typically a displaced fracture of the distal third or quarter of the radius with disruption of the distal radioulnar joint; called fracture of necessity because surgical fixation is required for reduction; also called a reverse Monteggia f., Dupuytren f., or Piedmont f.

Kocher f.: fracture of capitellum of distal humerus with possible displacement of fragment into joint.

Laugier f.: isolated fracture of the trochlea of the humerus at the elbow.

lead pipe f: typically in the forearm, a combination of greenstick fracture and torus fracture in the immature skeleton. Such fractures do not penetrate the entire shaft of the bone and have the appearance of a slightly bent lead pipe.

Lenteneur's f.: a distal radial fracture of the palmar rim, similar to Smith's type II fracture.

Monteggia f.: isolated fracture of proximal third of ulna, with anterior or posterior or lateral dislocation of radial head allowing angulation and overriding of ulnar fragments.

Moore f.: like a Colles f.; specifically, fracture of distal radius with dorsal displacement of ulnar styloid and impingement under annular ligament.

Mouchet f.: involves humeral capitellum.

Nightstick f.: undisplaced fracture of the ulnar shaft caused by a direct blow.

Piedmont f.: oblique f. usually at the proximal portion of distal third of the radius; obliquity runs from proximal ulnar to distal radial aspect, allowing distal fragments to be pulled into the ulna by the pronator quadratus muscle; fracture of necessity requiring

operative management.

Radial head f.: involves the most proximal part of the radius, a dish-shaped portion of bone.

radial styloid f.: involves distal radial tip of radius.

reverse Barton f.: dorsal displacement of carpus on radius, with associated fracture of dorsal articular surface of radius. The mechanism and appearance of this fracture are similar to those of a Colles f.

Skillern f.: open f. of distal radius associated with greenstick f. of distal ulna.

Smith f.: fracture of the distal radius in which the distal fragment is displaced volarly; also called reverse Colles f. This fracture was defined before the advent of radiography, and, classically, there are three types:

•Nonarticular

•Intraarticular; also called volar Barton f.

•Oblique nonarticular fracture near the joint line.