Elbow dislocations and terrible triad

1. Elbow Dislocations and Terrible Triad
Dr. Mohammad Mahdi Shater
Orthopedic Surgery Resident
Baqiyatallah University of Medical Sciences
‫الرحیم‬ ‫الرحمن‬ ‫اهلل‬ ‫بسم‬
Rockwood and Green's Fractures in Adults 9th Edition

2. Simple Elbow Dislocation
Introduction to Simple Elbow Dislocation
• A simple elbow dislocation is one in which there are no associated fractures
• second most commonly dislocated joint in the adult
• Sport injury
• Sex
• In high energy trauma
• Soft tissue injury
• Mechanism
• Associated injury
• Signs and symptoms
• Imaging
• Classification
• Pathoanatomy

3. Simple Elbow Dislocation
Nonoperative Treatment of Simple Elbow Dislocation
• Indication and contraindication
• Drop sign

4. Simple Elbow Dislocation
Operative Treatment of Simple Elbow Dislocation
• Indication and contraindication
• Technique
• Postoprative care

5. Simple Elbow Dislocation
Surgical Pitfalls and Preventions And Outcomes
• Residual instability
• Elbow stiffness
• Nerve palsy

6. Simple Elbow Dislocation
Complication

7. Simple Elbow Dislocation
Operative Treatment of Simple Elbow Dislocation
• Algorithm

8. Radial Head Fractures
Introduction to Radial Head Fractures
• most common fractures of the elbow
• Sex
• Age
• Associated injury
• Essex-lopresti

9. Assessment of Radial Head Fractures
• Low/high energy trauma
• Mechanism of trauma
• Associated injury
• Sign and symptom
• Imaging
• Classification(Mason, Broberg and morrey, Mayo-Mason)
• Anatomy

10. Treatment Options for Radial Head Fracture
Nonoperative Treatment of Radial Head Fractures
• Indication and relative contraindication
• Technique
• Outcomes

11. Operative Treatment of Radial Head Fractures
• Indication/contraindication

12. Operative Treatment of Radial Head Fractures
• Arthroscopic Excision of Radial Head Fragments
• Pitfall
• Excision of large radial head fragment leading to instability or clicking
• Poor visualization at arthroscopy
• Neurovascular injury
• Failure to remove loose fragments
• Outcomes
•

13. Operative Treatment of Radial Head Fractures
• Open Radial Head Excision
• Surgical Approach
• Pitfall
• Elbow or forearm instability
• Posterior interosseous nerve injury
• Retained fragments of radial head
• Outcomes
•

14. Operative Treatment of Radial Head Fractures
• ORIF
• Technique
• Postoperative care
• Pitfall
• Fixation failure
• tiffness
• Posterior interosseous nerve injury
• Avascular necrosis
• Outcomes

15. Operative Treatment of Radial Head Fractures
• ORIF
• Technique
• Postoperative care
• Pitfall
• Fixation failure
• tiffness
• Posterior interosseous nerve injury
• Avascular necrosis
• Outcomes

16. Operative Treatment of Radial Head Fractures
• Radial Head Arthroplasty
• Pitfall
• Incorrect implant size
• Radial head implant maltracking
• Radial neck fracture
• Stiffness
• Posterior interosseous nerve palsy
• Prosthesis failure
• Outcomes

17. Radial Head Fractures: Common Adverse
Outcomes and Complications
• Posttraumatic arthritis
• Stiffness
• Symptomatic nonunion, malunion, or avascular necrosis
• Elbow and/or forearm instability

18. Algorithm

19. Coronoid Fractures
• Introduction
• Classification(Regan–Morrey, O'Driscoll )

20. Terrible Triad Injuries of the Elbow
• Introduction (fracture of the radial head and coronoid and an elbow dislocation )
• Mechanisms(fall onto an outstretched arm, with supination, valgus, and axial-directed force )
• Associated Injuries(wrist, other in high energy)
• Sign and symptom(NVE,skin,wrist)
• Imaging(AP,Lat,CT)
• Classification(Terrible triad injuries are subclassified by the pattern of radial head and coronoid
fractures )
• Pathoanatomy

21. Nonoperative Treatment of Terrible Triad Injuries
• Terrible triad injuries can successfully be treated nonoperatively if the following criteria are
met: (1) the radial head fracture does not cause a mechanical block to motion; (2) the
coronoid fracture is small (Regan Morrey type 1 or 2); (3) the elbow joint is congruent
following a closed reduction; and (4) there is a stable arc of motion to 30 degrees of flexion.

22. Nonoperative Treatment of Terrible Triad Injuries
• Technique
• Outcomes

23. Operative Treatment of Terrible Triad Injuries
• Most patients with terrible triad injuries require surgical management to achieve a stable
congruous reduction of the elbow allowing early motion. Residual subluxation of the elbow
following a closed reduction or residual instability precluding early motion is an indication for
surgery. Displaced radial head fractures blocking motion or incarcerated fracture fragments
in the articulation are also indications for surgery.
• Surgery may occasionally be contraindicated in patients whose medical comorbidities place
them at an unacceptable risk as well as in patients with nonfunctional upper extremities due
to neurologic or other impairments.

24. Operative Treatment of Terrible Triad Injuries
• Open Reduction and Internal Fixation
• A systematic approach is important to address the critical components of this injury. This
includes fixation or replacement of the radial head, fixation of the coronoid fragment, and
repair of the LCL. The elbow is then evaluated intraoperatively for residual instability to
determine if MCL repair is required or rarely if an external fixator is needed.
• Surgical approach
• Technique
• Postoperative care

25. Operative Treatment of Terrible Triad Injuries
• Terrible Triad Injuries: Surgical Pitfalls and Preventions
• Residual instability
• Elbow stiffness
• Nerve palsy
• Outcomes
• Complication

26. Operative Treatment of Terrible Triad Injuries

27. Posteromedial Rotatory Instability of the Elbow
• Introduction
• Mechanism
• Associated Injury
• Sing and symptom
• Imaging
• Classification
• Subtype I involves the anteromedial rim only, subtype II involves the rim and tip, and subtype
III involves the rim and sublime tubercle, with or without involvement of the tip

28. Posteromedial Rotatory Instability of the Elbow
• Non operative treatment

29. Posteromedial Rotatory Instability of the Elbow
• Non operative treatment
• Technique
• Outcomes

30. Operative Treatment of Posteromedial Rotatory
Instability of the Elbow
• Most patients with PMRI require surgical management to achieve a stable elbow allowing
early motion. Residual subluxation or crepitus with motion suggests dynamic incongruity and
are indications for surgery.
• Open Reduction and Internal Fixation
• Restoration of varus posteromedial rotatory stability is achieved by internal fixation of the
coronoid and repair of the LCL. The sublime tubercle is fixed or the MCL is repaired if
injured. An external fixator is used to manage residual instability or to protect tenuous
internal fixation.
• Surgical Approach
• Postoperative Care

31. Operative Treatment of Posteromedial Rotatory
Instability of the Elbow
• Pitfall
• Residual instability
• Elbow stiffness
• Nerve palsy
• Outcomes
• Complication
• Elbow stiffness and heterotopic ossification
• Elbow subluxation or dislocation
• Elbow arthritis

32. Operative Treatment of Posteromedial Rotatory
Instability of the Elbow

33. Proximal Ulna Fractures
• Introduction
• Mechanisms of Injury
• Associated Injuries
• Signs and Symptoms
• Imaging
• Classification

34. Proximal Ulna Fractures
• Anterior fracture-dislocations of the olecranon have been termed
“transolecranon fracture-dislocations
• Mayo type III
• Posterior fracture-dislocations are typically posterior Monteggia lesions (Bado
type II). type IIA (fracture at the level of the coronoid process with the
coronoid as a separate fragment), IIB (fracture distal to the coronoid), IIC
(fracture through the diaphysis), and IID (complex fracture extending from the
olecranon to the diaphysis).

35. Nonoperative Treatment of Proximal Ulna
Fractures
Techniques
Typically, the elbow is splinted for 2 to 3 weeks and then gentle active-assisted flexion is started
avoiding active extension against gravity or resistance for the first 6 weeks after injury. At 6
weeks, the patient can begin active motion against gravity with resistive exercises started at 3
months.
Outcomes

36. Operative Treatment of Proximal Ulna Fractures
• Most proximal ulna fractures are treated surgically. Most fractures with
displacement and those associated with dislocations or elbow instability as
well as open fractures should be managed operatively

37. Operative Treatment of Proximal Ulna Fractures
• Olecranon Excision and Triceps Advancement
• Surgical Approach
• Postoperative Care
• The patient is placed into a long-arm splint in a semi-extended position to
protect the skin incision. Sutures are removed in 2 weeks and active and
active-assisted flexion and gravity-assisted extension are initiated. Active
extension begins at 6 weeks and strengthening at 3 months postoperatively
• Pitfall
• Elbow instability
• Outcomes

38. Operative Treatment of Proximal Ulna Fractures
• Olecranon Tension Band Wiring
• Surgical Approach
• Postoperative Care
• The patient is placed into a semi-extended position in a long-arm splint. The splint and
postoperative dressings are taken down 48 hours after surgery and the patient begins range
of motion exercises including active and active-assisted flexion and gravity-assisted
extension. Active exercises against gravity are started at 6 weeks with very gentle resistance
progressing to full resistive exercises at 3 months or when the fracture has united
• Pitfall
• Loss of fixation
• Prominent hardware
• Biceps tuberosity impingement and synostosis
• Ulnar/median nerve injury
• Outcomes

39. Operative Treatment of Proximal Ulna Fractures
• Olecranon Plating
• Surgical Approach
• Postoperative Care
• same as for tension band wiring
• Pitfall
• Failure of fixation with small proximal fragments
• Hardware in proximal radioulnar joint
• Outcomes

40. Open Reduction and Internal Fixation of Posterior
Monteggia Fractures

41. Open Reduction and Internal Fixation of Posterior
Monteggia Fractures
• Posterior Monteggia lesions in adults are a spectrum of injuries involving the
olecranon, coronoid, collateral ligaments, and radial head
• Surgical Approach
• Postoperative Care
• The elbow is splinted at 90 degrees of flexion with the forearm in neutral
rotation for 5 to 7 days. The splint is then removed and the patient is started
on range of motion exercises. These exercises include active and active-
assisted flexion and extension. Concomitant ligament injuries will direct the
rehabilitation plan as outlined in the section on operative treatment of elbow
dislocations. Active extension and extension against gravity begins at 6
weeks. Static progressive splinting may be used if the patient has stiffness
and the fracture has healed. At 3 months, a strengthening regimen is
instituted

42. Open Reduction and Internal Fixation of Posterior
Monteggia Fractures
• Pitfall

43. Open Reduction and Internal Fixation of Posterior
Monteggia Fractures
• Complication

44. Proximal Ulna Fractures

45. Posterior Monteggia Fractures