elbow trauma

Question 1

what is a terrible triad?

Answer 1

elbow dislocation
coronoid fracture
radial head fracture

elbow dislocations are based on the direction of the distal fragment

Question 2

how do you manage a terrible triad?

Answer 2

Approach
- posterior utility approach with thick skin flaps
- kocher interval - ecu (pin) and anconeus (radial nerve)
- FCU split

Position
supine and arm board

Sequence of fixation
LATERAL
1. remove radial head fragments
2. fix coronoid fracture - screw or sxuture repair - large anteromedial fix from medial side
3. radial head fixation (3 or less fragments)/ replacement
4. LCL repair

MEDIAL
+/- anteromedial fixation
MCL repair if needed

Persistent instability
- hinged external fixator

Post-op immobilisation
- flexion/ pronation
- neutral if LCL and MCl repaired

Risk of posterolateral instability

Question 3

what are the stabilisers of the elbow?

Answer 3

Static Stabilisers
PRIMARY
- ulnohumeral joint
- anterior bundle of MCL
- LCL complex

SECONDARY
- radiocapitellar joint
- joint capsule
- origin of flexors and extensors

Dynamic stabilisers
muscles crossing the elbow applying compressive forces
- anconeus
- brachialis
- triceps

Question 4

Biceps tendon rupture
- risk factors
- op vs non-op management

Answer 4

Risk factors
- smoking - x 7 risk
- steroids
- watershed zone

Non-op
- loss of flexion (30%) and supination (40%)

Operative
- 1 vs 2 incision techniques
- single incision- risk of LACN and PIN
- dual incision - risk of heterotopic ossification and radioulnar syntoses

Single incision:
- modified henry’s approach - pronator teres and brachioradialis
- supination to protect PIN
- identify distal tendon - kessler or whip
- endobutton - radial tuberosity

Chronic Biceps rupture
- allograft or autograft

Partial biceps rupture
- complete rupture and repair