Journal club on terrible triad injury of elbow joint.

Journal Club on “TREATMENT STRATEGY OF TERRIBLE

TRIAD OF ELBOW”

Presented By : Dr. Vipendra Singh

MODERATORSDr. Abhishek PathakDr. Mohd. Zuber

Presenting a Journal Club on“Treatment strategy of terrible triad of the

elbow: Experience in Shanghai 6th People’s Hospital”

Authors : Chi Zhang, Biao Zhong, Cong-feng LuoStudy conducted at 6th People’s Hospital,

Shanghai, China Level IV studyPublished in Journal “Injury” in 2014.

Introduction

Terrible Triad Injury of the Elbow• Elbow Dislocation• Radial Head Fracture• Coronoid Process Fracture

Why is Terrible Triad Injury Important?

• Because along with the fractures, this leads to the injury to the Lateral Collateral Ligament (LCL) Complex.

• Sometimes Medial Collateral Ligament (MCL) complex may also fail.

• This renders the elbow in an inherently unstable state and invariably requires surgical intervention.

• Due to the complexity of injury, outcomes are generally poor and associated with long term complications like joint stiffness, instability, pain and arthritis.

Objectives

• The purpose of this study is to report the outcomes of a modified Surgical technique as compared to the established standard surgical protocol for the repair of terrible triad of the elbow injuries.

Materials and Methods

• Twenty-one cases of elbow dislocation associated with fractures of the radial head and coronoid process were identified as terrible triad of the elbow injuries at the Shanghai 6th People’s Hospital between July 2008 and January 2011.

• All the patients were operated using a modified surgical technique and followed up over a period of 24 -48 months.

Investigations

• All routine blood investigation were done along with radiographs.

• Computed tomography (CT) was routinely used in cases of terrible triad injuries before surgery to identify fracture patterns, comminution, and displacement which may not be evident on plain radiographs.

• MRI was done for the assessment of soft tissue injuries.

Classification

Radial head fracture was classified according to Mason Classification

• Type I : non-displaced radial head fractures (or small marginal fractures);

• Type II : partial articular fractures with displacement (>2 mm);

• Type III : comminuted fractures involving the entire radial head.

Soft tissue injuries were categorised into three types.

• Type I : soft-tissue injuries were lateral collateral ligament (LCL) complex injuries without MCL injury; there was rupture or avulsion of the LCL from the lateral epicondyle, as well as the common extensor tendon and posterior capsule).

• Type II soft-tissue injuries were LCL complex injuries with MCL injury, but with the continuity of the MCL remaining complete.

• Type III soft-tissue injuries were LCL complex injuries with MCL body rupture or avulsion from the medial humeral attachment.

Operative Procedure

• Approach : Lateral approach for radial head and a separate Anteromedial approach for coronoid process.

• Operative Steps :1. Radial head was repaired (not replaced) first using

cannulated screws.2. LCL complex was then temporarily sutured to the

supra-lateral condyle to provide provisional stability to elbow joint.

3. This helps in restoring the articulation of the humero-ulnar joint and facilitates reduction and fixation of coronoid fracture.

4. Next, an anteromedial skin incision was made and an ‘‘over the top’’ approach was used to expose most of the coronoid fracture.

5. After reduction, 3 mm cannulated screws and/or a T-type buttress plate was used for fixation of the coronoid fracture.

6. Once bony reconstruction was complete, the LCL complex injury, in which the lateral ligament complex was detached from the humerus was repaired by direct suturing using non-absorbable sutures.

7. Stability assessment is done with emphasis on that• There should be no posterior or posterolateral

instability in flexion-extension movement.• There should be no valgus instability.

STANDARD PROTOCOL MODIFIED PROTOCOL

POSTERIOR APPROACH FOR ELBOW JOINT LATERAL AND ANTEROMEDIAL APPROACH

REDUCE AND FIX CORONOID FRACTURE FIRST

FIX THE RADIAL HEAD FIRST

REPLACE THE RADIAL HEAD WITH A METAL PROSTHESIS

REPAIR THE RADIAL HEAD

APPLY A HINGED EXTERNAL FIXATOR IF RESIDUAL INSTABILITY PERSISTS.

NOT PREFFERED

• Post operative Management :

• All the patients were given a hinged plastic brace with elbow at 90⁰ of flexion for 6 weeks.

• Supervised physiotherapy was begun on the second day after surgery for all patients with gradual increase in the range of motion.

EVALUATION

• Radiography was used for identification of synostosis, heterotopic ossification, and joint congruency.

• The Mayo Elbow Performance Score (MEPS)

was used for assessment of functional recovery.

RESULTS

• All the patients, except one, had solid osseous union on the final follow-up radiographs without any evidence of elbow instability.

• The mean MEPS was 95.2 points (range, 85–100 points), with 19 excellent cases and 2 good cases.

COMPLICATIONS :

• Heterotopic ossification : 2 cases; does not require re-surgery.

• Non union : 1 case; patient was asymptomatic with no limitation of forearm rotation.

• Infection : 1 case; superficial infection, healed uneventfully after surgical debridement and antibiotic therapy.

• Ulnar Neuropathy : 1 case

SUMMARY

• The results of this study indicate that the modified surgical technique we have described results in good to excellent outcomes for the treatment of terrible triad of the elbow injuries with minimal complications or morbidity.

STUDY Outcome InferenceRodriguez-Martin J et alOutcomes after terrible triads of the elbow treated with the current surgical protocols. A review. Int Orthop 2011;35:851–60.

Overall flexion extension arc : 111.48 Averaged flexion : 132.58Forearm rotation : 135.58MEPS : 85.6 points

Modified protocols have better results

Egol KA et al Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Bull NYU Hosp Jt Dis 2007;65:263–70.

Average flexion extension : 109 Average pronation supination arc : 128 Grip strength averaged 72% of the contralateral extremity, MEPS : 81 points

Modified protocols have better results

Leigh WB et al Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg 2012;21:1336–41.

No significant difference exists in outcome related to elbow function in radial head repair or radial head replacement group

Radial head replacement has no particular benefit

McKee MD et alStandard surgical protocol to treat elbow dislocations with radial head and coronoid fractures : J Bone Joint Surg Am 2005;87(Suppl. 1 (Pt. 1)):22–32.

Soft-tissue healing is not adequate despite restoration of the anatomical centre of rotation of the elbow by the hinged external fixator.

Hinged external fixator has certain disadvantages on soft tissue healing.

Study Outcome Inference

Garrigues GE et al Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am 2011;93:1873

Greater stability with fewer complications was achieved with use of the suture lasso technique for coronoid fracture fixation.

Suture lasso technique gives better results than butress plate or screws.

Reichel LM et al Anterior approach for operative fixation of coronoid fractures in complex elbow instability. Tech Hand Surg 2012;16:98– 104

accurate and stable internal fixation was achieved with anteroposterior screws and a buttress plate by an anterior approach in which brachialis muscle was split at its midline

Anterior approach could be a better alternative.

Studies in opposition of the current study.

THANK YOU