Subacute Triad Reconstruction

Lee Hunter MD, MBA

Hunter Medical Founder and Chief Medical Officer

August 2018

 

Elbow triad fracture/dislocations are serious injuries that almost always require surgical treatment to restore elbow stability and lessen the risk of post-traumatic arthritis.  These injuries can vary in complexity but are made more difficult to manage by a delay in treatment or reduction of the elbow joint.

 

38 YOF WITH SUBACUTE UNREDUCED TRIAD INJURY

The patient was a high school softball coach who fell at practice backwards onto her outstretched arm and sustained the injury shown on the X-ray below. Neurovascular exam was normal, and her skin healthy. She was given IV sedation and her elbow reduced in the ER just a couple of hours after her injury, with a posterior splint applied. Post reduction X-rays confirmed the reduction. She presented to my office two weeks later, where an interval CT scan in her long arm splint revealed recurrent dislocation with a comminuted radial head fracture as shown below. The CT was performed two days after her injury. Given the severity of her injury, delayed presentation, and increased BMI, I was concerned about the quality of her lateral soft tissue envelope in particular. For that reason, I chose to perform a lateral collateral ligament reconstruction with a palmaris longus autograft, in addition to radial head replacement and coronoid fracture repair.

 

The Procedure

   The patient was placed in the supine position utilizing the ElbowLOC® Arm Positioning System. A standard posterior approach was made. The radial head fragments were loose and were removed. Non-absorbable sutures were passed through the anterior capsule immediately adjacent to the coronoid fracture and passed dorsally through drill holes in the ulna metaphysis. A radial head replacement was inserted. A palmaris longus autograft was harvested and secured as a looped graft using 5.5 mm tenodesis screws.  The patient’s post op course was uneventful. The patient had normal forearm rotation, no pain, and an ulno-humeral arc of motion of 10 > 135 degrees at 10 weeks post op. Her 4 month follow up X-rays are below.

 

Supine patient positioning and a posterior approach allows excellent surgical exposure and access to the elbow joint for triad injuries. The ElbowLOC Supine Positioner stabilizes the humerus vertically, and gives the surgeon independent control of the elbow joint. This markedly simplifies placement of tunnels for collateral ligament reconstruction, not to mention drilling and suture passage for the coronoid fracture repair.

 

This case is another great example of how the ElbowLOC® simplifies and accelerates procedural times for many elbow surgeries and makes surgery easier for the surgeon, patient, and staff!

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