Terrible Triad Elbow Injury with Coronal Shear Trochlea Fracture
Lee Hunter MD, MBA (Hunter Medical Founder and Chief Medical Officer)
October 2016
30 YO RHDM Terrible Triad Elbow Injury with Coronal Shear Trochlear Fracture
So called “terrible triad” injuries of the elbow (radial head fracture, coronoid fracture, with elbow dislocation) can be difficult to repair and achieve a satisfactory outcome. The anatomic complexity of the elbow can make visualization and secure repair of the coronoid fracture particularly challenging. Humeral shear fractures are quite seldom encountered with these injuries, but when present can make these injuries even more complicated to treat.
The Case
The patient fell down steps at his home, injuring his left elbow. He was seen in the local ER the day of his injury, and presented to my office two days later with x-rays and a CT scan(see below). These studies showed a displaced, comminuted radial head fracture, a widely displaced coronoid avulsion fracture, and a displaced coronal shear fracture involving the entire trochlea, with the coronoid process subluxed into the trochlea fracture gap. The skin about the elbow was healthy and neurovascular exam was normal.
The surgical procedure was performed utilizing the ElbowLOC® Arm Positioning Systemin supine mode with one surgical assistant.An olecranon osteotomy was performed and the ulnar nerve decompressed. The radial head fragments were floating loose in the joint, and were removed and the joint space irrigated free of small fracture debris. The proximal ulna was retracted and the trochlea fracture easily exposed, reduced and secured with multiple headless screws. The coronoid fracture and anterior capsule were stabilized with sutures passed through the intact coronoid using an ACL drill guide. The radial head was then replaced. Interestingly, as the elbow was not completely dislocated, much of the lateral collateral ligament was intact. The ulnar collateral ligament was intact as well. Physical therapy was started three days post op, and follow up office x-rays10 days post op are shown below.
The ElbowLOC® Arm Positioning System was used in this procedure to stabilize the humerus vertically while supporting the forearm; creating a stable platform for exposure, manipulation, and stabilization of the various injuries. As the forearm is only supported, not “captured”, by the ElbowLOC® the surgeon maintains unrestricted ability to rotate the forearm and manipulate the elbow joint without having to adjust the positioner or alter the surgical orientation. These benefits save a great deal of intraoperative time and frustration in challenging cases like this.
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!