Terrible triad of the elbow

Case contributed by Leo Martinez

Presentation

Patient was involved in a motorcycle accident. Patient pressed the front brake and flipped over the handlebars. Patient fell on her outstretched bilateral arms.

Patient Data

Age: 40 years
Gender: Female

Elbow radiograph

x_ray

Single view lateral projection of the right elbow obtained during admission to the emergency department demonstrates posterior elbow dislocation, comminuted displaced fracture of the coronoid process, and comminuted intra-articular displaced fracture of the radial head. 

Post-reduction elbow x-ray

x_ray

Frontal and lateral radiographic projections of the right elbow were obtained after a closed reduction attempt in the emergency department. There is a near-anatomical alignment of the elbow joint, comminuted displaced fracture of the coronoid process, and comminuted intra-articular displaced fracture of the radial head. 

Post-reduction CT

ct

Computed tomography images of the right elbow were obtained after a closed reduction attempt. There is persistent posterior elbow dislocation, intra-articular fracture of the volar aspect of the radial head, and mildly displaced fracture of the coronoid process. There are small intra-articular osseous fragments in the medial aspect of the elbow joint measuring up to 6 mm and small elbow joint effusion.

ORIF

Fluoroscopy

Intraoperative fluoroscopic images during open reduction and internal fixation (ORIF) of complex fracture-dislocation of the right elbow. Intraarticular radial head fragments were identified and removed.  Retrieved fragments of the native radial head comprised 90% of the circumference of the radial head. The coronoid fragment was not identified, but instead, the anterior capsule was tagged with a suture through two drill holes made in the ulna and exiting at the coronoid. The recovered radial head fragments were predrilled twice and pinned in place on the drill holes, and then passed for the screw to be further drilled in the radial head.  There was evidence of a tendency toward subluxation of the radial head laterally.  A drill hole was made in the lateral epicondyle, and a suture anchor was placed bringing the collateral ligament down to the bone and bringing the capsule together. 

Case Discussion

Elbow dislocations are one of the most common large joint dislocations in adults. Complex elbow dislocations (fracture-dislocations) usually required open reduction and internal fixation of associated injuries. This case illustrates a complex dislocation of the right elbow with associated coronoid process and radial head fracture previously described as the "terrible triad of the elbow" due to the poor outcome associated with the combination of these injuries. 

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