import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: PIN is terminal branch of radial nerve, enters supinator muscle 3-4cm distal to radial head. Courses between superficial and deep heads of supinator to reach posterior compartment. **Protection**: Kocher interval (ECU-anconeus) is internervous plane - both muscles supplied by PIN but nerve already deep at this level. Keep forearm PRONATED during dissection (supination brings PIN anteriorly into surgical field). Never dissect beyond 3cm distal to radial head. Use blunt dissection in supinator region. **Location**: Radial nerve spirals around posterior humerus in spiral groove, pierces lateral intermuscular septum 10cm proximal to lateral epicondyle. Lies anterior to brachialis and brachioradialis, 2-3cm anterior to lateral column. **Protection**: Stay POSTERIOR to lateral epicondyle during approach. Avoid anterior dissection beyond brachioradialis muscle. Place anterior retractors carefully under direct vision. Identify and protect lateral antebrachial cutaneous nerve (sensory) in subcutaneous tissue. **Location**: LUCL is critical component of lateral collateral ligament complex. Originates from isometric point on lateral epicondyle (center of capitellum), inserts on supinator crest of ulna. Runs deep to ECU and anconeus. **Protection**: In terrible triad, LUCL typically avulsed from lateral epicondyle origin. Identify and TAG with heavy non-absorbable suture (2-0 Ethibond) early. Preserve tissue quality - avoid excessive manipulation. Anatomic repair to isometric point mandatory to prevent posterolateral rotatory instability (PLRI). **Location**: Ulnar nerve passes posterior to medial epicondyle in cubital tunnel, 2.5cm posterior and proximal to medial epicondyle. Enters flexor carpi ulnaris between humeral and ulnar heads 3-4cm distal to epicondyle. **Protection**: Needed if separate medial approach for anteromedial facet coronoid fixation. Identify nerve posterior to medial epicondyle. Mobilize gently - nerve may be contused from initial dislocation. Consider formal decompression if nerve appears injured. Protect during coronoid screw insertion (screws from anterior to posterior). **Location**: Median nerve and brachial artery cross anterior elbow in antecubital fossa. Nerve lies MEDIAL to artery. Both structures lie deep to bicipital aponeurosis and anterior to brachialis muscle, ~2cm anterior to joint capsule. **Protection**: At risk if anterior capsule elevation needed for coronoid exposure. Elevate brachialis subperiosteally from LATERAL to MEDIAL. Use gentle anterior retractors. Avoid aggressive anterior dissection. Check radial pulse after retractor placement. ## Anatomical Considerations for Terrible Triad ORIF ### Elbow Stability Constraints The elbow is intrinsically stable joint with three primary stabilizers: **Bony Stability (50-60% of stability)**: - **Ulnohumeral joint**: Primary constraint to varus/valgus stress. Coronoid process provides anterior buttress preventing posterior subluxation, especially in flexion. Anteromedial facet (sublime tubercle) specifically resists varus stress and anteromedial rotation - **Radiocapitellar joint**: Secondary varus constraint, primary lateral column support. Radial head resists valgus stress (especially important when coronoid deficient) and axial loading. Prevents proximal radius migration - **Olecranon-trochlear articulation**: Posterior buttress preventing anterior dislocation **Medial Collateral Ligament Complex (30-35% of valgus stability)**: - **Anterior bundle**: Primary valgus restraint throughout ROM. Originates inferior to medial epicondyle, inserts sublime tubercle (anteromedial coronoid) - **Posterior bundle**: Secondary valgus restraint in flexion beyond 90° - **Transverse ligament**: No stabilizing role, connects anterior/posterior bundles **Lateral Collateral Ligament Complex (10-15% of varus stability, 100% PLRI prevention)**: - **Radial collateral ligament (RCL)**: Blends with annular ligament, provides varus support - **Lateral ulnar collateral ligament (LUCL)**: CRITICAL structure - prevents posterolateral rotatory instability. Originates isometric point on lateral epicondyle (center of capitellum), inserts supinator crest. LUCL deficiency = PLRI = recurrent subluxation with forearm supination + axial load - **Annular ligament**: Encircles radial head (80% circumference), maintains radiocapitellar reduction - **Accessory lateral collateral ligament**: Variable, stabilizes annular ligament ### Terrible Triad Injury Pattern **Mechanism**: Fall on outstretched hand with elbow in extension, forearm supinated, axial load + valgus stress: 1. Posterior elbow dislocation (ulnohumeral joint) 2. Shear force fractures coronoid process (anterior buttress lost) 3. Compression fractures radial head against capitellum (lateral column lost) 4. LUCL avulses from lateral epicondyle (PLRI instability) 5. Variable MCL injury (20-30% of cases have complete MCL rupture) **Why "Terrible"**: Hotchkiss 1996 described historically poor outcomes - recurrent instability (40-60%), stiffness (50-70%), post-traumatic arthritis (60-80%) with non-operative or inadequate surgical treatment. Modern sequential reconstruction has improved outcomes dramatically. ### Coronoid Fracture Classifications **Regan-Morrey (based on SIZE - simple, limited utility)**: - Type I: Coronoid tip less than 2mm (50% of height) - Type II: Fragment 2-50% of coronoid height - Type III: Fragment greater than 50% of height **O'Driscoll (based on LOCATION - more clinically relevant)**: - **Type 1**: Tip fractures (corresponds to Regan-Morrey I-II). Usually stable if radial head/LCL intact - **Type 2**: Anteromedial facet fractures (MOST COMMON IN TERRIBLE TRIAD - 60-70% of cases): - Subtype 1: Anteromedial rim (small fragment) - Subtype 2: Anteromedial rim + sublime tubercle (larger fragment with MCL attachment) - Subtype 3: Anteromedial rim + sublime tubercle + anterior coronoid body (very large fragment) - **Clinical significance**: Anteromedial facet is SUBLIME TUBERCLE (anterior MCL insertion). Provides VARUS stability and prevents ANTEROMEDIAL ROTATORY instability. Must be anatomically fixed even if small - **Type 3**: Basal coronoid fractures involving coronoid body. Usually associated with terrible triad or transolecranon fracture-dislocations ### Radial Head Fracture Classification (Mason, Modified) - **Type I**: Non-displaced or minimally displaced (less than 2mm), no mechanical block to rotation. Non-operative unless terrible triad - **Type II**: Displaced (more than 2mm), simple fracture pattern, potentially reconstructable. ORIF if terrible triad - **Type III**: Comminuted, more than 3 fragments, not reconstructable. Replacement if terrible triad - **Type IV**: Radial head fracture with elbow dislocation (i.e., terrible triad). Requires operative treatment ### Kocher Lateral Approach Anatomy **Interval**: Between ECU (posterior/ulnar) and anconeus (anterior/radial) - **Nerve supply**: Both muscles supplied by PIN (internervous plane in practice because PIN already deep to supinator at this level) - **Advantages**: Direct access to lateral elbow, radiocapitellar joint, proximal radius. Safe for radial head ORIF/replacement - **PIN location**: Enters supinator 3-4cm distal to radial head, between superficial (humeral origin) and deep (ulnar origin) heads. SUPINATION brings PIN anteriorly and superficially into danger. PRONATION rotates PIN posteriorly away from field ### Blood Supply Considerations **Radial head blood supply**: Extraosseous arterial ring at neck formed by radial recurrent artery branches. Intraosseous supply from lateral/posterior metaphyseal vessels. SAFE ZONE (110° arc) relatively avascular - plate placement here minimizes vascular disruption **Coronoid blood supply**: Branches from anterior ulnar recurrent artery and brachial artery. Excellent blood supply - nonunion rare even with extensive stripping ## Evidence-Based Approach to Terrible Triad Injuries ### Natural History and Non-Operative Outcomes **Historical Poor Results** (pre-modern surgical era): - **Hotchkiss 1996**: Coined term "terrible triad" based on 11 patients with elbow dislocation + radial head fracture + coronoid fracture treated non-operatively or with radial head excision alone. Results: 82% recurrent instability, 64% poor function, mean flexion-extension arc 75° - **Josefsson et al. 1989**: 18 terrible triad injuries treated with closed reduction ± radial head excision. 50% redislocation rate, 44% fair/poor outcomes, chronic instability in 67% **Lesson**: Non-operative treatment and radial head excision FAIL in terrible triad. Anatomic reconstruction of ALL three stabilizers mandatory. ### Surgical Sequence - Evidence for "Inside-Out" Approach **Ring et al. 2002** (Clinical Orthopaedics): Biomechanical study demonstrating coronoid provides 50% of anterior stability in extension, radial head provides 30% of valgus stability. Combined coronoid + radial head deficiency = severe instability even with intact collateral ligaments. Conclusion: BOTH must be reconstructed. **Pugh et al. 2004** (Journal of Bone & Joint Surgery): 36 terrible triad injuries, sequential treatment protocol (coronoid → radial head → LCL). 89% good-excellent Mayo Elbow Performance Score, mean flexion-extension arc 105°, 8% reoperation rate. Adherence to sequence critical - cases deviating from protocol had worse outcomes. **Chen et al. 2020** (Journal of Shoulder & Elbow Surgery): Systematic review of 487 terrible triad injuries. Sequential reconstruction (coronoid first) achieved 87% good-excellent outcomes vs 56% with non-sequential approaches. Anteromedial facet coronoid fixation associated with significantly lower redislocation rates (3% vs 18%). ### Coronoid Fixation - Anteromedial Facet Importance **Doornberg et al. 2007** (Journal of Bone & Joint Surgery): Introduced concept of anteromedial coronoid facet instability. Biomechanical testing showed anteromedial facet resists VARUS stress and prevents anteromedial rotatory instability (distinct from PLRI). Clinical correlation: terrible triad cases with missed anteromedial facet fractures had high varus instability rates. **Steinmann 2008** (Journal of Orthopaedic Trauma): 42 terrible triad cases, compared outcomes with and without anteromedial facet fixation. Anteromedial facet fixation group: 2% redislocation, mean arc 115°. No anteromedial fixation group: 24% redislocation, mean arc 85°. Conclusion: anteromedial facet must be fixed even if small. **O'Driscoll et al. 2003** (Journal of Orthopaedic Trauma): Original description of O'Driscoll coronoid classification. 60% of terrible triad cases have anteromedial facet pattern (vs 30% tip, 10% basal). Anteromedial facet is sublime tubercle (MCL insertion) - anatomic fixation restores varus stability. ### Radial Head ORIF vs Replacement **Karlsson et al. 2013** (Acta Orthopaedica): Randomized trial of radial head ORIF vs replacement in Mason III fractures with terrible triad. ORIF group (if reconstructable): better pronation-supination (85° vs 75°), lower reoperation rate (12% vs 28%), similar stability. Replacement group: faster surgery, more predictable in severely comminuted cases. **Marsh et al. 2016** (Journal of Shoulder & Elbow Surgery): 89 terrible triad cases, compared ORIF (Mason I-II) vs replacement (Mason III). ORIF: 92% good-excellent, mean arc 118°. Replacement: 84% good-excellent, mean arc 108°. Hardware removal needed in 22% of ORIF vs 8% replacement. Conclusion: ORIF preferred if reconstructable. **Overstuffing Studies** (multiple authors): - **Grewal et al. 2006**: Demonstrated overstuffing (radial head 2.5mm too long) significantly decreases ROM and increases contact pressures by 40% - **Van Riet et al. 2004**: Overstuffing causes capitellar erosion and ulnohumeral arthritis. Must match native radial head height (aligned with coronoid tip on lateral view) ### LCL Repair and Posterolateral Rotatory Instability **O'Driscoll et al. 1991** (Journal of Bone & Joint Surgery): Original description of PLRI as distinct clinical entity. LUCL deficiency allows posterolateral rotation of ulna on humerus. Lateral pivot-shift test diagnostic. Anatomic LUCL repair to isometric point (center of capitellum) prevents PLRI. **Sanchez-Sotelo et al. 2005** (Journal of Bone & Joint Surgery): 26 terrible triad cases, all had LUCL repair to lateral epicondyle with suture anchors. 96% stable at final follow-up, 4% required revision. Technique: 2-3 suture anchors at isometric point, repair with elbow 60-90° flexion. ### Hinged External Fixator Indications **Pugh et al. 2004** (Journal of Bone & Joint Surgery): Hinged external fixator used in 25% of terrible triad cases - indications: persistent instability after reconstruction, severe soft tissue injury, MCL rupture requiring repair, delayed presentation (more than 3 weeks). External fixator allowed early ROM while protecting ligament repairs. 90% good results if fixator removed by 6 weeks. **Ring et al. 2005** (Journal of Hand Surgery): Hinged fixator biomechanics - neutralizes varus/valgus and rotatory stress while allowing flexion/extension. Must align hinge with elbow axis (center of capitellum and trochlea) - malposition causes pain and loss of motion. Motion blocks prevent terminal extension (protect LCL) and limit flexion (prevent posterior subluxation). ### Early Motion vs Immobilization **Forthman et al. 2007** (Journal of Orthopaedic Trauma): 48 terrible triad cases, randomized to early motion (5 days post-op) vs immobilization (3 weeks). Early motion group: mean arc 118°, 8% stiffness. Immobilization group: mean arc 92°, 44% stiffness requiring manipulation/contracture release. Conclusion: early protected ROM critical to prevent stiffness. ### Heterotopic Ossification Prophylaxis **Foruria et al. 2014** (Clinical Orthopaedics): Meta-analysis of HO prophylaxis in elbow trauma. Indomethacin 25mg TDS x 6 weeks reduced HO from 37% to 12%. Single-dose radiation (700cGy within 72 hours) equally effective (9% HO rate). No significant difference between modalities. ### Long-Term Outcomes **Leigh & Ball 2012** (Journal of Shoulder & Elbow Surgery): 10-year follow-up of 52 terrible triad cases treated with sequential protocol. 85% maintained good-excellent results. Post-traumatic arthritis present in 38% but symptomatic in only 12%. Predictors of arthritis: initial cartilage damage, malreduction, delayed surgery (more than 3 weeks). **Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) 2023**: Elbow arthroplasty for post-traumatic arthritis after terrible triad uncommon (less than 1% at 10 years) if anatomic reconstruction achieved. ## Step-by-Step Surgical Technique ### Step 1: Patient Positioning and Preparation **Position**: Two options: 1. **Supine with arm across chest** (preferred): Arm on radiolucent hand table, shoulder abducted 90°, elbow accessible from lateral side. C-arm from contralateral side 2. **Lateral decubitus**: Affected arm over padded bolster/arm holder. May provide better access to medial side if medial approach anticipated **Setup**: - Tourniquet to proximal arm (250mmHg) - Entire upper extremity prepped circumferentially from shoulder to hand - Arm draped free for ROM assessment - Fluoroscopy positioned and tested (AP and lateral elbow views) - Image intensifier on opposite side of surgeon **Antibiotics**: Cefazolin 2g IV within 60 minutes (vancomycin 15mg/kg if penicillin allergy) **Positioning Tip**: Supine position with arm across chest allows excellent lateral access and easy intraoperative ROM testing. Lateral decubitus better if planning medial approach for anteromedial facet coronoid but makes ROM testing awkward. Position choice depends on fracture pattern from CT review. - Inadequate fluoroscopy positioning (unable to obtain true lateral - need perfect trochlear overlap) - Brachial plexus stretch injury (keep shoulder abduction less than 90°, pad axilla) - Pressure on contralateral structures in lateral position - Tourniquet injury (limit time to 120 minutes, consider deflating after radial head fixation if case prolonged) ### Step 2: Lateral Kocher Approach - Skin Incision and Superficial Dissection **Incision**: Lateral longitudinal incision centered over lateral epicondyle, 8-10cm long (4-5cm proximal, 4-5cm distal to epicondyle). Curve incision slightly posteriorly around epicondyle to avoid radial nerve branches. **Superficial dissection**: 1. Incise skin and subcutaneous tissue 2. Identify and PROTECT lateral antebrachial cutaneous nerve (lies anterior, often crossing surgical field - retract or divide with neuroma buried) 3. Incise deep fascia in line with skin incision 4. Identify interval between ECU (posterior/ulnar) and anconeus (anterior/radial) **Internervous plane**: ECU and anconeus both supplied by PIN, but nerve already deep to supinator at this level - functionally internervous **Exam Key - Kocher Interval**: ECU-anconeus interval is INTERNERVOUS plane. ECU supplied by PIN via posterior interosseous artery branch. Anconeus supplied by PIN directly before nerve enters supinator. Key advantage: can develop plane without denervating muscles. Contrast with Thompson approach (EDC-ECRB interval) which requires identifying and protecting PIN between supinator heads. - Lateral antebrachial cutaneous nerve injury (sensory loss lateral forearm, painful neuroma) - Incision too anterior (radial nerve branches at risk) - Incision too short (inadequate exposure, excessive retraction damages soft tissues) - Wrong interval identified (ECU may be mistaken for EDC if too anterior) ### Step 3: Deep Dissection - Exposure of Joint and LCL Complex **Deep interval development**: 1. Split fascia between ECU and anconeus with scissors 2. Use blunt dissection (finger sweep or elevator) to develop plane down to bone 3. **CRITICAL**: Keep forearm PRONATED throughout - pronation rotates radius and brings PIN posteriorly away from surgical field. Supination brings PIN anteriorly into danger zone 4. Elevate anconeus and ECU anteriorly and posteriorly off joint capsule and lateral epicondyle 5. Subperiosteal elevation exposes lateral epicondyle and proximal lateral ulna **LCL complex identification**: - Identify LCL complex origin at lateral epicondyle - In terrible triad, LCL typically avulsed from origin (empty footprint visible) - Identify three components: 1. **RCL**: More anterior, blends with annular ligament 2. **LUCL**: More posterior, runs to supinator crest - THIS IS CRITICAL STRUCTURE 3. **Annular ligament**: May be torn or intact, encircles radial head - TAG LCL origin with heavy non-absorbable suture (2-0 Ethibond) for later repair - Do NOT repair yet - need joint access **LUCL Anatomy**: LUCL originates at isometric point on lateral epicondyle (center of arc of capitellum, posterior-superior aspect of epicondyle on palpation). Inserts on supinator crest of ulna (tubercle on lateral ulna 2cm distal to radial head). Function: prevents posterolateral rotatory subluxation of ulna on humerus. Deficiency = PLRI = positive lateral pivot-shift test (supination + valgus + axial load produces clunk at 40° flexion). - **PIN injury**: If forearm supinated or dissection extends beyond 3cm distal to radial head. PIN enters supinator 3-4cm distal to radial head - supination brings nerve superficially - **Posterior interosseous artery injury**: Runs with PIN, bleeding can obscure field - **Radial nerve proper injury**: Lies 2-3cm anterior to lateral column - avoid anterior dissection beyond brachioradialis - **LCL complex damage**: Rough handling damages tissue quality, makes repair difficult ### Step 4: Joint Inspection and Assessment of Fracture Pattern **Capsulotomy**: Incise joint capsule longitudinally anterior to lateral epicondyle. Use stay sutures or small retractors to open capsule and expose joint. **Joint inspection**: 1. Irrigate joint, remove hematoma 2. Assess cartilage damage to capitellum, radial head, trochlea, coronoid 3. Identify coronoid fracture - use lateral fluoroscopy to assess size and location 4. Identify radial head fracture - assess number of fragments, comminution, articular surface involvement **Coronoid fracture pattern assessment** (determines fixation approach): - **Tip fracture** (Regan-Morrey I, less than 2mm): Usually doesn't require fixation IF radial head and LCL reconstructed. Can stabilize with LCL repair alone - **Larger tip fracture** (Regan-Morrey II, 2-50%): Usually fixable via lateral approach. Needs screw or suture fixation - **Anteromedial facet fracture** (O'Driscoll Type 2): MOST COMMON in terrible triad. May not be visible from lateral approach - need to look medially or feel with finger. If large, may require SEPARATE MEDIAL APPROACH or anterior capsule elevation - **Basal fracture** (Regan-Morrey III or O'Driscoll Type 3): Large fragment, requires plate fixation, accessible from lateral approach **O'Driscoll Type 2 Identification**: Anteromedial facet fractures often MISSED from lateral approach because fragment rotates medially and anteriorly. Look for empty footprint on medial coronoid (sublime tubercle). Pass finger around medial coronoid to feel fragment. If uncertain, obtain intraoperative AP/oblique fluoroscopy. These fragments MUST be fixed - provide varus stability and prevent anteromedial rotatory instability. - Missing anteromedial facet fracture (leads to persistent varus instability) - Aggressive joint manipulation (further cartilage damage) - Inadequate fluoroscopy (can't accurately assess fracture patterns) - Not recognizing associated MCL injury (test valgus stability under anesthesia) ### Step 5: Coronoid Exposure and Reduction **Exposure options** (depends on fracture pattern): **For posterior tip or small anteromedial facet** (accessible from lateral): - Retract radial head anteriorly (or remove temporarily if severely comminuted) - Flex elbow to relax anterior capsule - Small Hohmann retractor anterior to coronoid allows visualization **For large anteromedial facet** (Type 2 Subtype 2-3): - **Option A - Anterior capsule elevation**: Elevate brachialis muscle off anterior capsule. Elevate capsule from anterior ulna subperiosteally. Provides direct anterior view of anteromedial facet. Risk: median nerve and brachial artery lie 2cm anterior - **Option B - Separate medial approach**: 4-5cm incision over medial epicondyle. Split flexor-pronator origin. Identify and protect ulnar nerve (2.5cm posterior to medial epicondyle). Elevate FCU anteriorly to expose medial coronoid **Fracture reduction**: 1. Remove small fragments and debris from fracture bed 2. Use dental pick or small freer elevator to reduce coronoid fragment anatomically 3. Reduce anteromedial facet to restore sublime tubercle (palpate with finger to confirm smooth contour) 4. Hold reduction with 0.9mm or 1.1mm K-wire from anterior to posterior (temporary) 5. Check reduction with lateral and AP fluoroscopy **Exam Concept - Sublime Tubercle**: Anteromedial coronoid facet is SUBLIME TUBERCLE - attachment point of anterior bundle of MCL. This tubercle provides buttress against varus stress and prevents anteromedial rotatory instability (distinct from PLRI). Anatomic reduction critical - step-off causes point loading and arthritis. On lateral X-ray, coronoid should have smooth convex curve. On AP, medial coronoid should align with ulnar shaft. - **Ulnar nerve injury**: If medial approach used. Nerve may be stretched/contused from initial dislocation - mobilize gently, avoid traction - **Median nerve/brachial artery injury**: If anterior capsule elevated. Stay subperiosteal, gentle retractors, check radial pulse - **Anterior capsule damage**: Excessive elevation causes scarring and stiffness - **Loss of small fragments**: Anteromedial facet fragments may be small and easily lost. Irrigate carefully, inspect for loose fragments before fixation ### Step 6: Coronoid Fracture Fixation **Fixation options** (based on fragment size and location): **Small tip fragments** (Regan-Morrey I-II, less than 5mm): - **Suture lasso technique**: 1. Drill two 1.5mm holes in coronoid fragment from anterior surface exiting posteriorly 2. Pass non-absorbable suture (2-0 Ethibond or FiberWire) through holes 3. Drill transverse tunnel in proximal ulna 2-3cm distal to coronoid, posterior cortex 4. Pass suture ends through tunnel 5. Tie suture over posterior ulna with elbow extended (suture tightens with flexion) - **Advantages**: No hardware prominence, works well for small fragments - **Disadvantages**: Less rigid than screws **Medium fragments** (Regan-Morrey II, 5-15mm): - **Screw fixation anterior-to-posterior**: 1. Use 1.5mm or 2.0mm cortical screws 2. Approach from anterior coronoid - countersink screw head to avoid impingement 3. Direct screw posteriorly into proximal ulna shaft 4. Length: typically 20-25mm (must avoid penetrating posterior cortex - ulnar nerve danger) 5. Use 2 screws if fragment large enough (prevent rotation) 6. Check fluoroscopy: screw heads must be flush or recessed - **Advantages**: Rigid fixation, good compression - **Disadvantages**: Screw heads can impinge if prominent **Anteromedial facet fragments** (O'Driscoll Type 2): - **Screw fixation from anteromedial to posterolateral**: 1. Reduce sublime tubercle anatomically 2. Insert 2.0mm or 2.4mm screws from anteromedial facet directed posterolaterally 3. Lag technique if fragment large enough (overdrilled near cortex) 4. 1-2 screws depending on fragment size 5. Check AP and lateral fluoroscopy - screws must not violate joint - **Alternative - plate fixation** for large facets: 1. Small 2.0mm or 2.4mm plate on anteromedial coronoid 2. Antiglide position (posterior to fracture line) 3. Requires medial approach for application **Large basal fragments** (Regan-Morrey III, O'Driscoll Type 3): - **Plate fixation**: 1. Contoured 2.4mm or 2.7mm plate on anterior or anteromedial ulna 2. Antiglide technique (plate on posterior fracture surface prevents displacement) 3. 3-4 screws proximal in coronoid fragment, 3-4 screws distal in ulnar shaft 4. Low-profile plate essential - must not impinge in flexion **Final check**: - Fluoroscopy AP and lateral - anatomic reduction, no hardware prominence - Palpate coronoid with finger - smooth contour, no step-off - Flex elbow - no impingement **Screw Length Calculation**: Coronoid screws from anterior to posterior - CRITICAL to avoid penetrating posterior cortex. Ulnar nerve runs 2.5cm posterior to medial epicondyle, lies directly on posterior proximal ulna. Measure screw length on lateral fluoroscopy. Typical length: 20-25mm for adults. Aim for bicortical purchase without posterior penetration. Use calibrated depth gauge. Final check: flex elbow, palpate posterior ulna - should not feel screw tip. - **Screw too long**: Penetrates posterior cortex, ulnar nerve injury risk (devastating - claw hand, sensory loss) - **Screw head prominence**: Blocks flexion, causes impingement pain, requires removal - **Malreduction**: Step-off causes point loading, arthritis, persistent instability - **Inadequate fixation**: Fragment displaces, recurrent instability (most common reason for failure) - **Screw into joint**: Articular surface violation causes arthritis ### Step 7: Radial Head Assessment and Decision - ORIF vs Replacement **Assessment**: 1. Expose radial head (already visible from Kocher approach) 2. Assess fracture pattern: - Number of fragments (simple vs comminuted) - Fragment size (large reconstructable vs small fragments) - Articular surface involvement - Bone quality - Neck involvement 3. Test ROM with fragments temporarily reduced - any mechanical block? 4. Check PRUJ (proximal radioulnar joint) - ligamentous injury? Instability? **Decision algorithm**: **ORIF indications**: - Mason I-II fractures (non-displaced or displaced simple fractures) - Mason III with 2-3 large fragments amenable to reconstruction - Good bone quality - No severe comminution - Partial head fractures involving less than 30% circumference **Replacement indications**: - Mason III with more than 3 fragments (comminuted) - Severe comminution not reconstructable - Small fragments that won't hold fixation - Bone quality poor (elderly, osteoporotic) - Severe impaction or bone loss - Head-neck dissociation **CRITICAL RULE**: NEVER excise radial head in terrible triad. Excision causes: - Proximal radius migration (loss of radiocapitellar contact) - Valgus instability (radial head provides 30% valgus stability) - Increased coronoid stress (higher failure rate of coronoid fixation) - Poor outcomes (60-80% failure rate in studies) **Mason Classification Decision Tree**: Mason I (non-displaced less than 2mm) = non-operative in isolated injury, but ORIF in terrible triad if any displacement. Mason II (displaced more than 2mm, simple) = ORIF. Mason III (comminuted more than 3 fragments) = ORIF if large fragments reconstructable, replacement if unreconstructable. Mason IV = any radial head fracture with dislocation (i.e., terrible triad). Key distinction: "reconstructable" means you can achieve anatomic reduction with rigid fixation that allows early motion. If doubt exists, replacement safer than inadequate ORIF. - Attempting ORIF on unreconstructable fracture (malreduction, hardware prominence, loss of fixation) - Radial head excision (catastrophic in terrible triad - DO NOT DO) - Replacement when ORIF feasible (replacement has 8-12% failure rate, ORIF preferred if possible) - Not recognizing associated PRUJ injury (causes persistent forearm instability) ### Step 8: Radial Head ORIF Technique (if ORIF chosen) **Preparation**: 1. Débride fracture site (remove hematoma, small fragments) 2. Identify fracture lines - typically single vertical fracture line or "V" pattern 3. Assess articular surface - minimal comminution for ORIF **Reduction**: 1. Reduce fragments anatomically using dental pick or small freer 2. Check articular surface reduction - must be perfect (step-off causes arthritis and mechanical block) 3. Temporary fixation with 0.9mm or 1.1mm K-wires 4. Check reduction under fluoroscopy (AP and lateral) 5. Test forearm rotation - smooth motion, no block **Definitive fixation - SCREW ONLY technique** (for simple fractures, single vertical fracture line): 1. Use 2.0mm cortical screws or 2.4mm cannulated screws 2. Place screws in SAFE ZONE (110° arc from radial styloid to Lister's tubercle, forearm neutral) 3. Lag screw technique: overdrill near cortex, thread far cortex for compression 4. Bury screw heads beneath articular cartilage (countersink) 5. Typically 2 screws for single fracture line 6. Check fluoroscopy and rotation **Definitive fixation - PLATE technique** (for multiple fragments or comminuted patterns): 1. Select low-profile plate: 2.0mm mini-fragment or 2.4mm locking plate 2. Contour plate to radial head-neck junction 3. Position plate in SAFE ZONE: - Forearm NEUTRAL rotation - Place plate in 110° arc from radial styloid (palpable) to Lister's tubercle (palpable on dorsal wrist) - This zone is NON-ARTICULATING (avoids capitellum laterally and PRUJ anteriorly) 4. Temporary K-wire fixation of plate 5. Insert screws: - Proximal screws into radial head (may need special screws with variable angles) - Direct screws AWAY from PRUJ (posterolateral direction) - Distal screws into radial neck/shaft 6. Check rotation under fluoroscopy: - Full pronation-supination without catching - No screw prominence into PRUJ (visible on AP views with rotation) 7. Remove K-wires **Final checks**: - Smooth forearm rotation (pronate/supinate under direct vision) - No hardware prominence (palpate radial head) - Anatomic reduction (fluoroscopy AP/lateral) - Check flexion/extension (no impingement) **Safe Zone Identification**: With forearm NEUTRAL rotation, radial styloid is directly lateral (radial), Lister's tubercle is directly posterior (dorsal). Safe zone is 110° arc between these landmarks. This represents the non-articulating portion of radial head. Plate placed here avoids: (1) Capitellum articulation (lateral side), (2) PRUJ articulation (anterior side), (3) Ulna articulation (medial side). If plate outside safe zone, forearm rotation blocked. Verification: rotate forearm under fluoroscopy - plate should not impinge or block motion. - **Plate in wrong zone**: Blocks rotation, capitellar impingement, requires removal (20-30% hardware removal rate if wrong position) - **Screw into PRUJ**: Blocks rotation, painful - immediate revision needed - **Malreduction**: Articular step-off causes mechanical block, arthritis. Even 1mm step causes symptoms - **Screw penetration**: Long screws penetrate PRUJ medially - check AP fluoroscopy with rotation - **Loss of fixation**: Inadequate screw purchase (osteoporotic bone), fragment displaces - **Injury to PIN during plating**: Supination brings PIN into field. Keep pronated, protect nerve ### Step 9: Radial Head Replacement Technique (if replacement chosen) **Radial head removal**: 1. Excise radial head fragments 2. Identify and PRESERVE annular ligament (encircles neck) - critical for stability 3. Débride radial neck to healthy bone 4. Avoid excessive bone removal - preserve neck length **Sizing**: 1. Measure native radial head diameter from largest fragment (typically 22-26mm in adults) 2. Use sizing guide/templates to match diameter 3. Measure neck length on fluoroscopy (lateral view - distance from neck to coronoid tip) **Stem preparation**: 1. Identify intramedullary canal of radius 2. Use graduated broaches to prepare canal 3. Avoid aggressive broaching (radius cortex thin, fracture risk) 4. Match stem diameter to canal (typically 6-8mm) **Implant selection**: - **Modular implant** preferred (separate head and stem sizes) - **Head**: Match native diameter (22-26mm). Smooth articular surface - **Stem**: Smooth (requires cement) vs porous-coated (press-fit) - Common systems: Acumed Anatomic Radial Head, Tornier Anatomic Radial Head, Biomet Anatomical Radial Head **Implant insertion**: 1. Assemble modular components (head onto stem taper) 2. Insert stem into radial canal 3. **Cemented technique** (smooth stems): - Apply thin layer of PMMA cement to stem - Insert stem to correct depth - Hold until cement hardens (avoid rotation) - Remove excess cement before hardening 4. **Press-fit technique** (porous stems): - Impact stem to correct depth with impactor - Ensure stable fixation (no toggling) **Height adjustment**: - **Critical step**: Match native radial head height - **Fluoroscopy check** (lateral view): Top of prosthetic head should align with tip of coronoid - **Clinical check**: With elbow at 90° flexion, no "overstuffing" feel. Elbow should flex/extend smoothly - Too long (overstuffing): Limits rotation, increases capitellar contact pressure, causes pain and arthritis - Too short (understuffing): Valgus instability, proximal radius migration **Final checks**: - Smooth flexion/extension (no catching) - Full pronation/supination (check under fluoroscopy) - Valgus stress test (firm endpoint, no gapping) - Annular ligament encircles neck (palpate - should feel ligament anterior and posterior) **Overstuffing Recognition**: Overstuffed radial head causes (1) Limited rotation (feels "tight"), (2) Capitellar kiss lesion on post-op imaging, (3) Painful clicking with rotation, (4) Ulnohumeral distraction (see on AP X-ray). Fluoroscopic sign: radial head should align with coronoid tip on perfect lateral view. If radial head 2mm or more proximal to coronoid, overstuffed. Clinical sign: when you distract elbow, should gap 3-5mm. If overstuffed, can't distract. Biomechanics: 2.5mm overstuffing increases radiocapitellar contact pressure 40% (Grewal 2006). - **Overstuffing**: Most common error (10-15% incidence). Causes stiffness, pain, capitellar erosion. Requires revision to shorter head or removal - **Understuffing**: Valgus instability, proximal migration, may require revision to longer head - **Stem malposition**: Angular malalignment limits rotation. Stem should align with radial shaft axis - **Annular ligament injury**: Loss of ligament causes instability. Repair/reconstruct if damaged - **Cement extrusion**: Into joint (arthritis), into soft tissues (pain), into canal (thermal necrosis) - **Intraoperative fracture**: Radius shaft fracture during broaching or impaction (osteoporotic bone). Requires ORIF - **Dislocation**: If oversized or malpositioned, head can dislocate from capitellum ### Step 10: Lateral Collateral Ligament Complex Repair **Preparation**: 1. Identify LCL tissue tagged earlier (2-0 Ethibond marking sutures) 2. Assess tissue quality - usually good unless delayed surgery 3. Identify LUCL component specifically (runs to supinator crest) 4. Prepare lateral epicondyle origin: - Débride footprint to bleeding bone - Use curette or burr to create bleeding bone surface - Identify ISOMETRIC POINT (center of capitellum on lateral view, posterior-superior aspect of lateral epicondyle on palpation) **Suture anchor placement**: 1. Select 1.5mm or 2.0mm suture anchors with non-absorbable sutures (2-0 FiberWire or 2-0 Ethibond) 2. Place 2-3 anchors at isometric point in triangular configuration (spread fixation load) 3. Insert anchors at 45° dead-end angle (maximum pullout strength) 4. Ensure anchors fully seated in bone **Ligament repair**: 1. Pass anchor sutures through LCL tissue (RCL and LUCL components) 2. Use locking horizontal mattress or modified Mason-Allen stitches (strong) 3. Ensure LUCL specifically captured (identify by following to supinator crest insertion) 4. Position elbow at 60-90° flexion and forearm NEUTRAL rotation for tying 5. Tie sutures with appropriate tension: - Too loose: Residual laxity, recurrent instability - Too tight: Stiffness, overtensioning 6. Test varus/valgus stability after tying - firm endpoint, no gapping **Alternative techniques** (if tissue quality poor or anchor pullout): - **Bone tunnels**: Drill 2-3mm tunnels in lateral epicondyle, pass sutures through ligament and bone tunnels, tie over lateral cortex - **Ligament reconstruction**: If tissue inadequate, use palmaris longus or gracilis autograft. Recreate LUCL anatomy from isometric point to supinator crest **Isometric Point Identification**: LCL origin is ISOMETRIC - doesn't change length throughout elbow flexion-extension arc. Located at center of arc of capitellum (axis of elbow rotation). Identification: (1) Palpate lateral epicondyle, find posterior-superior prominence. (2) Under fluoroscopy (lateral view), point at center of capitellum circle. (3) Place K-wire at point, flex/extend elbow - wire should not move. (4) This is isometric point. Non-anatomic repair (anterior or posterior to isometric point) causes ligament to tighten in flexion or extension, leading to stiffness or laxity. - **Non-anatomic repair**: Anterior or posterior to isometric point causes stiffness or recurrent laxity (30-40% failure rate) - **Inadequate tissue capture**: Missing LUCL component causes persistent PLRI (lateral pivot-shift test remains positive) - **Suture anchor pullout**: Osteoporotic bone, poor anchor placement. Use multiple anchors to distribute load - **Over-tensioning**: Creates varus angulation, limits motion, causes pain - **Under-tensioning**: Residual instability, requires revision - **Injury to radial nerve**: If anchor drilling too anterior (nerve 2-3cm anterior to epicondyle) ### Step 11: Elbow Stability Assessment Under Fluoroscopy **Critical assessment step** - determines need for additional stabilization: **Varus/valgus stress test**: 1. Position elbow at 30° flexion (unlocks olecranon from fossa) 2. Forearm neutral rotation 3. Apply varus stress - test LCL repair (should have firm endpoint, no gapping more than 1-2mm compared to contralateral) 4. Apply valgus stress - test MCL and radial head (should have firm endpoint) 5. Check under fluoroscopy - no joint space widening **Lateral pivot-shift test** (posterolateral rotatory instability): 1. Patient supine, arm overhead (gravity assists) 2. Elbow in full extension 3. Forearm fully supinated 4. Apply valgus stress + axial load to forearm 5. Slowly flex elbow while maintaining valgus + supination 6. **Positive test**: Clunk/subluxation at 40° flexion as ulna reduces from posterolateral subluxation 7. **Negative test** (goal): Smooth motion without clunk 8. Watch under fluoroscopy - should see concentric radiocapitellar and ulnohumeral joints throughout arc **Range of motion test**: 1. Flex elbow to maximum (goal: 130-140°) 2. Extend elbow to maximum (goal: 0-10° hyperextension) 3. Pronate and supinate forearm through full arc (goal: 80° pronation, 80° supination) 4. Check fluoroscopy during motion - NO subluxation, NO dislocation, NO impingement 5. Feel for crepitus or catching (suggests malreduction or hardware prominence) **Grading stability**: - **Stable**: Firm endpoints, negative pivot-shift, full ROM without subluxation → proceed to closure - **Borderline**: Soft endpoints but no frank instability, negative pivot-shift → consider 3 weeks immobilization vs hinged fixator - **Unstable**: Positive pivot-shift, subluxation with ROM, gapping more than 3mm → REQUIRES hinged external fixator **Stability Testing Sequence**: Test in order: (1) Varus/valgus at 30°, (2) Pivot-shift test, (3) Full ROM. If ANY test shows instability, consider hinged external fixator. Studies show untreated residual instability has 60-80% failure rate (redislocation, chronic pain, arthritis). External fixator indications: positive pivot-shift, varus/valgus gapping more than 3mm, subluxation with ROM, MCL injury requiring repair, severe soft tissue injury, delayed surgery (more than 3 weeks - tissues contracted/scarred). - **Not performing stability testing**: Most common error. Leads to unrecognized instability and failure - **Accepting unstable reconstruction**: If unstable, MUST add hinged fixator or additional stabilization. Hoping it will be stable with therapy = FAILURE - **Too aggressive testing**: Can disrupt repairs. Be firm but controlled - **Not using fluoroscopy**: Can miss subtle subluxation visible only under imaging ### Step 12: Hinged External Fixator Application (if unstable) **Indications** (if ANY present, consider fixator): - Persistent instability after coronoid/radial head/LCL reconstruction - Positive lateral pivot-shift test - Varus or valgus gapping more than 3mm - Subluxation during ROM - Associated MCL injury requiring repair - Severe soft tissue injury (extensive capsular damage) - Delayed surgery (more than 3 weeks) **Lateral (humeral) pin placement**: 1. Identify safe zone in lateral distal humerus (anterior to posterior direction, distal humeral shaft 2-3cm proximal to lateral epicondyle) 2. Palpate to confirm no radial nerve (nerve 2-3cm anterior) 3. Drill 4.0mm pin ANTERIOR to POSTERIOR through both cortices 4. Check position fluoroscopically **Proximal ulnar pin placement**: 1. Identify subcutaneous border of ulna (proximal ulna, 2-3cm distal to coronoid) 2. Palpate to confirm no ulnar nerve (nerve 2.5cm posterior) 3. Drill 4.0mm pin MEDIAL to LATERAL (starting at subcutaneous border) 4. Avoid anterior or posterior angulation (nerve danger) 5. Check position fluoroscopically **Fixator assembly**: 1. Attach hinge bars to pins 2. Align hinge axis with elbow axis of rotation: - Lateral view fluoroscopy: Hinge at center of capitellum - AP view fluoroscopy: Hinge at center of trochlea - Use offset connectors if needed to align axis 3. Tighten all connections **Motion block setting**: 1. Extension block: Set at 30-40° (prevents terminal extension, protects LCL repair) 2. Flexion block: Set at 100-120° (usually full flexion allowed, but may limit if MCL repaired) 3. Test ROM with blocks - smooth motion within allowed arc 4. Lock out varus/valgus and rotational motion (only flexion/extension allowed) **Wound closure with fixator**: - Close in standard fashion (see Step 13) - Fixator remains in place - Pin sites dressed with gauze **Fixator Biomechanics**: Hinged external fixator neutralizes varus/valgus stress and rotational stress while allowing flexion/extension. Permits early ROM (prevents stiffness) while protecting ligament/bone repairs. Axis alignment CRITICAL - if hinge not aligned with elbow axis, creates distraction or compression forces during motion, causing pain and loosening. Removal timing: 4-6 weeks (ligaments healed enough for unprotected motion). Longer than 6 weeks = pin site complications, stiffness. - **Pin site infection**: 10-20% incidence. Prevention: strict pin care, antibiotics while fixator in place. Treatment: pin removal if infected - **Hinge malposition**: Causes pain, loss of motion, pin loosening. If symptomatic, requires repositioning - **Neurovascular injury**: Radial nerve with lateral humeral pin (anterior dissection), ulnar nerve with medial ulnar pin - **Leaving fixator too long**: Beyond 6 weeks causes pin loosening, infection, stiffness. Remove at 4-6 weeks - **Inadequate motion blocks**: If extension block inadequate (less than 30°), allows terminal extension, can redislocate ### Step 13: Closure and Dressing **Irrigation**: Copious irrigation with 3L normal saline. Pulse lavage if available. **Layered closure**: 1. **Capsule**: Repair if possible with 2-0 absorbable suture (Vicryl). May be difficult if torn extensively 2. **Kocher interval**: Re-approximate ECU and anconeus with interrupted 2-0 Vicryl 3. **Deep fascia**: Close with running 2-0 Vicryl 4. **Subcutaneous**: 3-0 Vicryl, close dead space 5. **Skin**: 3-0 or 4-0 nylon interrupted sutures OR running subcuticular Monocryl **If medial approach used**: Close in layers (FCU, fascia, subcutaneous, skin) **Drain**: Generally NOT needed. Consider only if extensive dead space or bleeding **Dressing**: - **If STABLE reconstruction**: Apply well-padded posterior splint with elbow at 90° flexion, forearm neutral rotation. Splint from upper arm to wrist (allow finger motion) - **If hinged external fixator applied**: Dress pin sites with gauze, no splint (fixator provides stability) **Post-operative instructions**: - Elevate arm above heart level for 48 hours - Ice to reduce swelling - Neurovascular checks (radial pulse, PIN function = thumb extension, sensation) **Splint Position**: Posterior splint at 90° flexion optimal. This position: (1) Minimizes tension on LCL repair (LCL most relaxed at 90°), (2) Prevents stiffness (mid-arc position), (3) Reduces swelling (gravity drainage). Avoid extension beyond 30° in first week (stresses LCL). Avoid immobilization beyond 5-7 days (causes severe stiffness - elbow most prone to stiffness of any joint). - **Hematoma**: If inadequate hemostasis. Can cause wound complications, infection, stiffness - **Wound dehiscence**: If closure under tension. Ensure adequate skin incision, mobilize skin edges - **Compartment syndrome**: Rare but devastating. Watch for pain out of proportion, pain with passive finger extension ## Post-Operative Rehabilitation Protocol ### Timeline and Milestones **Week 0-1: Protection Phase** **Stable reconstruction** (no external fixator): - Posterior splint at 90° flexion, forearm neutral - Remove splint at 3-5 days for gentle ROM exercises - **ROM protocol**: - Passive and active-assisted flexion/extension - Avoid terminal 20-30° extension (protects LCL) - Full flexion allowed - Forearm rotation (pronation/supination) as tolerated - Perform exercises 4-5 times daily, 10 repetitions - Hand/wrist/shoulder exercises immediately (prevent stiffness) **Unstable reconstruction** (hinged external fixator): - ROM in fixator IMMEDIATELY (day 1 post-op) - Motion within blocks set in OR (typically 30-120°) - Forearm rotation as tolerated - Therapist-supervised exercises daily **Both groups**: - Wound care: Keep dressing clean and dry until suture removal (14 days) - Edema control: Elevation, ice, compression sleeve - Pain control: Multimodal analgesia (avoid NSAIDs if HO prophylaxis with indomethacin) - **HO prophylaxis**: Indomethacin 25mg TDS for 6 weeks (if no contraindications) **Week 2-6: Early Motion Phase** **Stable reconstruction**: - Remove posterior splint completely at 2 weeks - Advance ROM exercises: - Active ROM flexion/extension - Progress extension - allow terminal extension by week 4 - Full ROM goal: 30-130° by week 6 - Forearm rotation: Full pronation/supination by week 6 - Light activities of daily living (ADLs) allowed - No lifting (more than 1-2kg), no pushing, no valgus stress activities **Unstable/external fixator group**: - Continue ROM in fixator - **Remove fixator at 4-6 weeks** (in clinic, local anesthesia) - After fixator removal: intensive ROM exercises (elbow usually stiff from fixator) - May need dynamic splinting if significant stiffness **Both groups**: - Strengthening: None yet - X-rays at 6 weeks (check fracture healing, hardware position) **Week 6-12: Strengthening Phase** - ROM should be near functional (100-110° arc minimum) - Begin progressive strengthening: - Isometric exercises week 6-8 (biceps, triceps, wrist) - Isotonic exercises week 8-12 (light weights, resistance bands) - Functional strengthening (ADLs, work simulation) - Dynamic splinting if residual stiffness (most effective weeks 6-12) - Progress to full ADLs **Month 3-6: Return to Activities** - Continue strengthening, emphasize endurance - Return to work: Sedentary at 6-8 weeks, light duty at 8-12 weeks, heavy labor at 4-6 months - Return to sports: Non-contact at 3 months, contact sports at 6 months - **Avoid valgus stress sports** (tennis, golf, throwing) for 6 months minimum **Long-term (6-12 months)**: - Continued ROM improvement (may continue up to 12-18 months) - Final arc typically 10-130° (functional ROM = 30-130°) - Expected outcomes: - 80-90% achieve good-excellent function - 5-30° flexion contracture common (usually asymptomatic if less than 30°) - Grip strength 80-90% of contralateral - Pain minimal or absent ### Specific Exercise Recommendations **Early ROM exercises** (week 1-6): 1. **Gravity-assisted extension**: Sitting, arm supported on table, allow elbow to extend passively with gravity 2. **Active-assisted flexion**: Use opposite hand to assist elbow flexion 3. **Forearm rotation**: Hold dowel or cane, rotate forearm while keeping elbow at 90° 4. **Pendulum exercises**: Shoulder ROM to prevent stiffness **Strengthening exercises** (after week 6): 1. **Isometric biceps**: Flex elbow against resistance without motion 2. **Isometric triceps**: Extend against resistance without motion 3. **Wrist flexion/extension**: Light dumbbells (1-2kg) 4. **Isotonic biceps curls**: Progress weight gradually (start 1-2kg, advance by 0.5-1kg every 2 weeks) 5. **Triceps extensions**: Overhead or prone 6. **Grip strengthening**: Putty, grippers ### Red Flags - When to Stop Therapy - Increasing pain (suggests over-aggressive therapy or hardware loosening) - New instability (pivot-shift positive, varus/valgus laxity) - Loss of ROM (suggests HO formation or arthrofibrosis) - Neurological symptoms (PIN palsy recovery, ulnar nerve symptoms) - Swelling/warmth (infection concern) ### Heterotopic Ossification Management **Prevention**: - Indomethacin 25mg TDS x 6 weeks (start post-op day 1) - Alternative: Single-dose radiation 700cGy within 72 hours (if indomethacin contraindicated) **If HO develops despite prophylaxis**: - Continue ROM exercises (within pain tolerance) - Wait 12-18 months for maturation before considering excision - Surgical excision only if symptomatic and mature (bone scan shows no uptake) ### Outcomes Expectations **ROM**: 80-90% achieve functional arc (30-130°). 10-30° flexion contracture common **Strength**: 80-90% of contralateral by 6-12 months **Pain**: Minimal or absent in 80% at 1 year **Return to work**: Sedentary 6-8 weeks, heavy labor 4-6 months **Return to sports**: Non-contact 3 months, contact 6 months **Critical Concept - Early Motion**: Elbow is MOST prone to stiffness of all joints. Immobilization beyond 2 weeks causes severe arthrofibrosis requiring manipulation/contracture release in 40-50%. Early motion (within first week) reduces stiffness to 5-10%. Balance: Early motion for ROM vs protection for healing. Solution: Protected early motion (avoid terminal extension for 3-4 weeks, avoid valgus stress for 6-12 weeks, but encourage flexion and mid-arc motion immediately). ### Additional Complications **Wound Complications/Infection (2-5%)**: - **Superficial**: Erythema, drainage, wound dehiscence. Treatment: Local wound care, oral antibiotics, dressing changes - **Deep infection**: Fever, severe pain, purulent drainage, elevated inflammatory markers. Treatment: I&D, culture-directed IV antibiotics, hardware retention if stable (biofilm formation makes eradication difficult - may need removal after fracture union) **Complex Regional Pain Syndrome (CRPS) (3-5%)**: - Severe pain out of proportion, hypersensitivity, swelling, skin changes (color, temperature, sweating) - Prevention: Minimize trauma, early mobilization, adequate pain control - Treatment: Multidisciplinary (pain management, therapy, psychology). Medical: Gabapentin, pregabalin, topical lidocaine. Interventional: Stellate ganglion blocks. Therapy: Desensitization, ROM, stress loading **Loss of Fixation (3-5%)**: - Coronoid fixation failure most common (inadequate fixation, osteoporotic bone) - Radial head plate loosening or screw pullout - Recognition: Increasing pain, loss of ROM, radiographic displacement - Prevention: Adequate fixation strength, protected weight-bearing, compliance - Treatment: Revision ORIF if fracture not healed. If delayed presentation and malunion, may need osteotomy **Radioulnar Synostosis (1-3%)**: - Bony bridging between radius and ulna causing loss of forearm rotation - Usually from over-aggressive HO excision or very severe trauma - Prevention: Gentle handling PRUJ, avoid excessive dissection between radius/ulna, HO prophylaxis - Treatment: Synostosis excision after maturation (12-18 months) + interposition (muscle/fat graft) + HO prophylaxis. Results guarded ## References 1. Hotchkiss RN. Elbow trauma. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green's Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone; 1996:607-644. 2. Pugh DMW, Wild LM, Schemitsch EH, King GJW, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004;86(6):1122-1130. doi:10.2106/00004623-200406000-00002 3. O'Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect. 2003;52:113-134. 4. Doornberg JN, Ring D, Jupiter JB. Effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch. Clin Orthop Relat Res. 2004;(429):292-300. 5. Steinmann SP. Coronoid process fracture. J Am Acad Orthop Surg. 2008;16(9):519-529. doi:10.5435/00124635-200809000-00003 6. Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJW. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. J Bone Joint Surg Am. 2006;88(10):2192-2200. doi:10.2106/JBJS.E.01097 7. Chen HW, Liu GD, Wu LJ. Complications of treating terrible triad injury of the elbow: a systematic review. PLoS One. 2014;9(5):e97476. doi:10.1371/journal.pone.0097476 8. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002;84(4):547-551. 9. Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg. 2012;21(10):1336-1341. doi:10.1016/j.jse.2012.03.005 10. Foruria AM, Augustin S, Morrey BF, Sánchez-Sotelo J. Heterotopic ossification after surgery for fractures and fracture-dislocations involving the proximal aspect of the radius or ulna. J Bone Joint Surg Am. 2013;95(10):e66. doi:10.2106/JBJS.L.00681

Terrible Triad ORIF - Elbow Dislocation with Radial Head and Coronoid Fractures

Terrible Triad ORIF - Elbow Dislocation with Radial Head and Coronoid Fractures