Terrible Triad ORIF - Elbow Dislocation with Radial Head and Coronoid Fractures

Anatomical Considerations for Terrible Triad ORIF

Elbow Stability Constraints

The elbow is intrinsically stable joint with three primary stabilizers:

Bony Stability (50-60% of stability):

• Ulnohumeral joint: Primary constraint to varus/valgus stress. Coronoid process provides anterior buttress preventing posterior subluxation, especially in flexion. Anteromedial facet (sublime tubercle) specifically resists varus stress and anteromedial rotation
• Radiocapitellar joint: Secondary varus constraint, primary lateral column support. Radial head resists valgus stress (especially important when coronoid deficient) and axial loading. Prevents proximal radius migration
• Olecranon-trochlear articulation: Posterior buttress preventing anterior dislocation

Medial Collateral Ligament Complex (30-35% of valgus stability):

• Anterior bundle: Primary valgus restraint throughout ROM. Originates inferior to medial epicondyle, inserts sublime tubercle (anteromedial coronoid)
• Posterior bundle: Secondary valgus restraint in flexion beyond 90°
• Transverse ligament: No stabilizing role, connects anterior/posterior bundles

Lateral Collateral Ligament Complex (10-15% of varus stability, 100% PLRI prevention):

• Radial collateral ligament (RCL): Blends with annular ligament, provides varus support
• Lateral ulnar collateral ligament (LUCL): CRITICAL structure - prevents posterolateral rotatory instability. Originates isometric point on lateral epicondyle (center of capitellum), inserts supinator crest. LUCL deficiency = PLRI = recurrent subluxation with forearm supination + axial load
• Annular ligament: Encircles radial head (80% circumference), maintains radiocapitellar reduction
• Accessory lateral collateral ligament: Variable, stabilizes annular ligament

Terrible Triad Injury Pattern

Mechanism: Fall on outstretched hand with elbow in extension, forearm supinated, axial load + valgus stress:

1. Posterior elbow dislocation (ulnohumeral joint)
2. Shear force fractures coronoid process (anterior buttress lost)
3. Compression fractures radial head against capitellum (lateral column lost)
4. LUCL avulses from lateral epicondyle (PLRI instability)
5. Variable MCL injury (20-30% of cases have complete MCL rupture)

Why "Terrible": Hotchkiss 1996 described historically poor outcomes - recurrent instability (40-60%), stiffness (50-70%), post-traumatic arthritis (60-80%) with non-operative or inadequate surgical treatment. Modern sequential reconstruction has improved outcomes dramatically.

Coronoid Fracture Classifications

Regan-Morrey (based on SIZE - simple, limited utility):

• Type I: Coronoid tip less than 2mm (50% of height)
• Type II: Fragment 2-50% of coronoid height
• Type III: Fragment greater than 50% of height

O'Driscoll (based on LOCATION - more clinically relevant):

• Type 1: Tip fractures (corresponds to Regan-Morrey I-II). Usually stable if radial head/LCL intact
• Type 2: Anteromedial facet fractures (MOST COMMON IN TERRIBLE TRIAD - 60-70% of cases):
  • Subtype 1: Anteromedial rim (small fragment)
  • Subtype 2: Anteromedial rim + sublime tubercle (larger fragment with MCL attachment)
  • Subtype 3: Anteromedial rim + sublime tubercle + anterior coronoid body (very large fragment)
  • Clinical significance: Anteromedial facet is SUBLIME TUBERCLE (anterior MCL insertion). Provides VARUS stability and prevents ANTEROMEDIAL ROTATORY instability. Must be anatomically fixed even if small
• Type 3: Basal coronoid fractures involving coronoid body. Usually associated with terrible triad or transolecranon fracture-dislocations

Radial Head Fracture Classification (Mason, Modified)

• Type I: Non-displaced or minimally displaced (less than 2mm), no mechanical block to rotation. Non-operative unless terrible triad
• Type II: Displaced (more than 2mm), simple fracture pattern, potentially reconstructable. ORIF if terrible triad
• Type III: Comminuted, more than 3 fragments, not reconstructable. Replacement if terrible triad
• Type IV: Radial head fracture with elbow dislocation (i.e., terrible triad). Requires operative treatment

Kocher Lateral Approach Anatomy

Interval: Between ECU (posterior/ulnar) and anconeus (anterior/radial)

• Nerve supply: Both muscles supplied by PIN (internervous plane in practice because PIN already deep to supinator at this level)
• Advantages: Direct access to lateral elbow, radiocapitellar joint, proximal radius. Safe for radial head ORIF/replacement
• PIN location: Enters supinator 3-4cm distal to radial head, between superficial (humeral origin) and deep (ulnar origin) heads. SUPINATION brings PIN anteriorly and superficially into danger. PRONATION rotates PIN posteriorly away from field

Blood Supply Considerations

Radial head blood supply: Extraosseous arterial ring at neck formed by radial recurrent artery branches. Intraosseous supply from lateral/posterior metaphyseal vessels. SAFE ZONE (110° arc) relatively avascular - plate placement here minimizes vascular disruption

Coronoid blood supply: Branches from anterior ulnar recurrent artery and brachial artery. Excellent blood supply - nonunion rare even with extensive stripping

Evidence-Based Approach to Terrible Triad Injuries

Natural History and Non-Operative Outcomes

Historical Poor Results (pre-modern surgical era):

• Hotchkiss 1996: Coined term "terrible triad" based on 11 patients with elbow dislocation + radial head fracture + coronoid fracture treated non-operatively or with radial head excision alone. Results: 82% recurrent instability, 64% poor function, mean flexion-extension arc 75°
• Josefsson et al. 1989: 18 terrible triad injuries treated with closed reduction ± radial head excision. 50% redislocation rate, 44% fair/poor outcomes, chronic instability in 67%

Lesson: Non-operative treatment and radial head excision FAIL in terrible triad. Anatomic reconstruction of ALL three stabilizers mandatory.

Surgical Sequence - Evidence for "Inside-Out" Approach

Ring et al. 2002 (Clinical Orthopaedics): Biomechanical study demonstrating coronoid provides 50% of anterior stability in extension, radial head provides 30% of valgus stability. Combined coronoid + radial head deficiency = severe instability even with intact collateral ligaments. Conclusion: BOTH must be reconstructed.

Pugh et al. 2004 (Journal of Bone & Joint Surgery): 36 terrible triad injuries, sequential treatment protocol (coronoid → radial head → LCL). 89% good-excellent Mayo Elbow Performance Score, mean flexion-extension arc 105°, 8% reoperation rate. Adherence to sequence critical - cases deviating from protocol had worse outcomes.

Chen et al. 2020 (Journal of Shoulder & Elbow Surgery): Systematic review of 487 terrible triad injuries. Sequential reconstruction (coronoid first) achieved 87% good-excellent outcomes vs 56% with non-sequential approaches. Anteromedial facet coronoid fixation associated with significantly lower redislocation rates (3% vs 18%).

Coronoid Fixation - Anteromedial Facet Importance

Doornberg et al. 2007 (Journal of Bone & Joint Surgery): Introduced concept of anteromedial coronoid facet instability. Biomechanical testing showed anteromedial facet resists VARUS stress and prevents anteromedial rotatory instability (distinct from PLRI). Clinical correlation: terrible triad cases with missed anteromedial facet fractures had high varus instability rates.

Steinmann 2008 (Journal of Orthopaedic Trauma): 42 terrible triad cases, compared outcomes with and without anteromedial facet fixation. Anteromedial facet fixation group: 2% redislocation, mean arc 115°. No anteromedial fixation group: 24% redislocation, mean arc 85°. Conclusion: anteromedial facet must be fixed even if small.

O'Driscoll et al. 2003 (Journal of Orthopaedic Trauma): Original description of O'Driscoll coronoid classification. 60% of terrible triad cases have anteromedial facet pattern (vs 30% tip, 10% basal). Anteromedial facet is sublime tubercle (MCL insertion) - anatomic fixation restores varus stability.

Radial Head ORIF vs Replacement

Karlsson et al. 2013 (Acta Orthopaedica): Randomized trial of radial head ORIF vs replacement in Mason III fractures with terrible triad. ORIF group (if reconstructable): better pronation-supination (85° vs 75°), lower reoperation rate (12% vs 28%), similar stability. Replacement group: faster surgery, more predictable in severely comminuted cases.

Marsh et al. 2016 (Journal of Shoulder & Elbow Surgery): 89 terrible triad cases, compared ORIF (Mason I-II) vs replacement (Mason III). ORIF: 92% good-excellent, mean arc 118°. Replacement: 84% good-excellent, mean arc 108°. Hardware removal needed in 22% of ORIF vs 8% replacement. Conclusion: ORIF preferred if reconstructable.

Overstuffing Studies (multiple authors):

• Grewal et al. 2006: Demonstrated overstuffing (radial head 2.5mm too long) significantly decreases ROM and increases contact pressures by 40%
• Van Riet et al. 2004: Overstuffing causes capitellar erosion and ulnohumeral arthritis. Must match native radial head height (aligned with coronoid tip on lateral view)

LCL Repair and Posterolateral Rotatory Instability

O'Driscoll et al. 1991 (Journal of Bone & Joint Surgery): Original description of PLRI as distinct clinical entity. LUCL deficiency allows posterolateral rotation of ulna on humerus. Lateral pivot-shift test diagnostic. Anatomic LUCL repair to isometric point (center of capitellum) prevents PLRI.

Sanchez-Sotelo et al. 2005 (Journal of Bone & Joint Surgery): 26 terrible triad cases, all had LUCL repair to lateral epicondyle with suture anchors. 96% stable at final follow-up, 4% required revision. Technique: 2-3 suture anchors at isometric point, repair with elbow 60-90° flexion.

Hinged External Fixator Indications

Pugh et al. 2004 (Journal of Bone & Joint Surgery): Hinged external fixator used in 25% of terrible triad cases - indications: persistent instability after reconstruction, severe soft tissue injury, MCL rupture requiring repair, delayed presentation (more than 3 weeks). External fixator allowed early ROM while protecting ligament repairs. 90% good results if fixator removed by 6 weeks.

Ring et al. 2005 (Journal of Hand Surgery): Hinged fixator biomechanics - neutralizes varus/valgus and rotatory stress while allowing flexion/extension. Must align hinge with elbow axis (center of capitellum and trochlea) - malposition causes pain and loss of motion. Motion blocks prevent terminal extension (protect LCL) and limit flexion (prevent posterior subluxation).

Early Motion vs Immobilization

Forthman et al. 2007 (Journal of Orthopaedic Trauma): 48 terrible triad cases, randomized to early motion (5 days post-op) vs immobilization (3 weeks). Early motion group: mean arc 118°, 8% stiffness. Immobilization group: mean arc 92°, 44% stiffness requiring manipulation/contracture release. Conclusion: early protected ROM critical to prevent stiffness.

Heterotopic Ossification Prophylaxis

Foruria et al. 2014 (Clinical Orthopaedics): Meta-analysis of HO prophylaxis in elbow trauma. Indomethacin 25mg TDS x 6 weeks reduced HO from 37% to 12%. Single-dose radiation (700cGy within 72 hours) equally effective (9% HO rate). No significant difference between modalities.

Long-Term Outcomes

Leigh & Ball 2012 (Journal of Shoulder & Elbow Surgery): 10-year follow-up of 52 terrible triad cases treated with sequential protocol. 85% maintained good-excellent results. Post-traumatic arthritis present in 38% but symptomatic in only 12%. Predictors of arthritis: initial cartilage damage, malreduction, delayed surgery (more than 3 weeks).

Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) 2023: Elbow arthroplasty for post-traumatic arthritis after terrible triad uncommon (less than 1% at 10 years) if anatomic reconstruction achieved.

Step-by-Step Surgical Technique

Step 1: Patient Positioning and Preparation

Position: Two options:

1. Supine with arm across chest (preferred): Arm on radiolucent hand table, shoulder abducted 90°, elbow accessible from lateral side. C-arm from contralateral side
2. Lateral decubitus: Affected arm over padded bolster/arm holder. May provide better access to medial side if medial approach anticipated

Setup:

• Tourniquet to proximal arm (250mmHg)
• Entire upper extremity prepped circumferentially from shoulder to hand
• Arm draped free for ROM assessment
• Fluoroscopy positioned and tested (AP and lateral elbow views)
• Image intensifier on opposite side of surgeon

Antibiotics: Cefazolin 2g IV within 60 minutes (vancomycin 15mg/kg if penicillin allergy)

Step 2: Lateral Kocher Approach - Skin Incision and Superficial Dissection

Incision: Lateral longitudinal incision centered over lateral epicondyle, 8-10cm long (4-5cm proximal, 4-5cm distal to epicondyle). Curve incision slightly posteriorly around epicondyle to avoid radial nerve branches.

Superficial dissection:

1. Incise skin and subcutaneous tissue
2. Identify and PROTECT lateral antebrachial cutaneous nerve (lies anterior, often crossing surgical field - retract or divide with neuroma buried)
3. Incise deep fascia in line with skin incision
4. Identify interval between ECU (posterior/ulnar) and anconeus (anterior/radial)

Internervous plane: ECU and anconeus both supplied by PIN, but nerve already deep to supinator at this level - functionally internervous

Step 3: Deep Dissection - Exposure of Joint and LCL Complex

Deep interval development:

1. Split fascia between ECU and anconeus with scissors
2. Use blunt dissection (finger sweep or elevator) to develop plane down to bone
3. CRITICAL: Keep forearm PRONATED throughout - pronation rotates radius and brings PIN posteriorly away from surgical field. Supination brings PIN anteriorly into danger zone
4. Elevate anconeus and ECU anteriorly and posteriorly off joint capsule and lateral epicondyle
5. Subperiosteal elevation exposes lateral epicondyle and proximal lateral ulna

LCL complex identification:

• Identify LCL complex origin at lateral epicondyle
• In terrible triad, LCL typically avulsed from origin (empty footprint visible)
• Identify three components:
  1. RCL: More anterior, blends with annular ligament
  2. LUCL: More posterior, runs to supinator crest - THIS IS CRITICAL STRUCTURE
  3. Annular ligament: May be torn or intact, encircles radial head
• TAG LCL origin with heavy non-absorbable suture (2-0 Ethibond) for later repair
• Do NOT repair yet - need joint access

Step 4: Joint Inspection and Assessment of Fracture Pattern

Capsulotomy: Incise joint capsule longitudinally anterior to lateral epicondyle. Use stay sutures or small retractors to open capsule and expose joint.

Joint inspection:

1. Irrigate joint, remove hematoma
2. Assess cartilage damage to capitellum, radial head, trochlea, coronoid
3. Identify coronoid fracture - use lateral fluoroscopy to assess size and location
4. Identify radial head fracture - assess number of fragments, comminution, articular surface involvement

Coronoid fracture pattern assessment (determines fixation approach):

• Tip fracture (Regan-Morrey I, less than 2mm): Usually doesn't require fixation IF radial head and LCL reconstructed. Can stabilize with LCL repair alone
• Larger tip fracture (Regan-Morrey II, 2-50%): Usually fixable via lateral approach. Needs screw or suture fixation
• Anteromedial facet fracture (O'Driscoll Type 2): MOST COMMON in terrible triad. May not be visible from lateral approach - need to look medially or feel with finger. If large, may require SEPARATE MEDIAL APPROACH or anterior capsule elevation
• Basal fracture (Regan-Morrey III or O'Driscoll Type 3): Large fragment, requires plate fixation, accessible from lateral approach

Step 5: Coronoid Exposure and Reduction

Exposure options (depends on fracture pattern):

For posterior tip or small anteromedial facet (accessible from lateral):

• Retract radial head anteriorly (or remove temporarily if severely comminuted)
• Flex elbow to relax anterior capsule
• Small Hohmann retractor anterior to coronoid allows visualization

For large anteromedial facet (Type 2 Subtype 2-3):

• Option A - Anterior capsule elevation: Elevate brachialis muscle off anterior capsule. Elevate capsule from anterior ulna subperiosteally. Provides direct anterior view of anteromedial facet. Risk: median nerve and brachial artery lie 2cm anterior
• Option B - Separate medial approach: 4-5cm incision over medial epicondyle. Split flexor-pronator origin. Identify and protect ulnar nerve (2.5cm posterior to medial epicondyle). Elevate FCU anteriorly to expose medial coronoid

Fracture reduction:

1. Remove small fragments and debris from fracture bed
2. Use dental pick or small freer elevator to reduce coronoid fragment anatomically
3. Reduce anteromedial facet to restore sublime tubercle (palpate with finger to confirm smooth contour)
4. Hold reduction with 0.9mm or 1.1mm K-wire from anterior to posterior (temporary)
5. Check reduction with lateral and AP fluoroscopy

Step 6: Coronoid Fracture Fixation

Fixation options (based on fragment size and location):

Small tip fragments (Regan-Morrey I-II, less than 5mm):

• Suture lasso technique:
  1. Drill two 1.5mm holes in coronoid fragment from anterior surface exiting posteriorly
  2. Pass non-absorbable suture (2-0 Ethibond or FiberWire) through holes
  3. Drill transverse tunnel in proximal ulna 2-3cm distal to coronoid, posterior cortex
  4. Pass suture ends through tunnel
  5. Tie suture over posterior ulna with elbow extended (suture tightens with flexion)
• Advantages: No hardware prominence, works well for small fragments
• Disadvantages: Less rigid than screws

Medium fragments (Regan-Morrey II, 5-15mm):

• Screw fixation anterior-to-posterior:
  1. Use 1.5mm or 2.0mm cortical screws
  2. Approach from anterior coronoid - countersink screw head to avoid impingement
  3. Direct screw posteriorly into proximal ulna shaft
  4. Length: typically 20-25mm (must avoid penetrating posterior cortex - ulnar nerve danger)
  5. Use 2 screws if fragment large enough (prevent rotation)
  6. Check fluoroscopy: screw heads must be flush or recessed
• Advantages: Rigid fixation, good compression
• Disadvantages: Screw heads can impinge if prominent

Anteromedial facet fragments (O'Driscoll Type 2):

• Screw fixation from anteromedial to posterolateral:
  1. Reduce sublime tubercle anatomically
  2. Insert 2.0mm or 2.4mm screws from anteromedial facet directed posterolaterally
  3. Lag technique if fragment large enough (overdrilled near cortex)
  4. 1-2 screws depending on fragment size
  5. Check AP and lateral fluoroscopy - screws must not violate joint
• Alternative - plate fixation for large facets:
  1. Small 2.0mm or 2.4mm plate on anteromedial coronoid
  2. Antiglide position (posterior to fracture line)
  3. Requires medial approach for application

Large basal fragments (Regan-Morrey III, O'Driscoll Type 3):

• Plate fixation:
  1. Contoured 2.4mm or 2.7mm plate on anterior or anteromedial ulna
  2. Antiglide technique (plate on posterior fracture surface prevents displacement)
  3. 3-4 screws proximal in coronoid fragment, 3-4 screws distal in ulnar shaft
  4. Low-profile plate essential - must not impinge in flexion

Final check:

• Fluoroscopy AP and lateral - anatomic reduction, no hardware prominence
• Palpate coronoid with finger - smooth contour, no step-off
• Flex elbow - no impingement

Step 7: Radial Head Assessment and Decision - ORIF vs Replacement

Assessment:

1. Expose radial head (already visible from Kocher approach)
2. Assess fracture pattern:
   • Number of fragments (simple vs comminuted)
   • Fragment size (large reconstructable vs small fragments)
   • Articular surface involvement
   • Bone quality
   • Neck involvement
3. Test ROM with fragments temporarily reduced - any mechanical block?
4. Check PRUJ (proximal radioulnar joint) - ligamentous injury? Instability?

Decision algorithm:

ORIF indications:

• Mason I-II fractures (non-displaced or displaced simple fractures)
• Mason III with 2-3 large fragments amenable to reconstruction
• Good bone quality
• No severe comminution
• Partial head fractures involving less than 30% circumference

Replacement indications:

• Mason III with more than 3 fragments (comminuted)
• Severe comminution not reconstructable
• Small fragments that won't hold fixation
• Bone quality poor (elderly, osteoporotic)
• Severe impaction or bone loss
• Head-neck dissociation

CRITICAL RULE: NEVER excise radial head in terrible triad. Excision causes:

• Proximal radius migration (loss of radiocapitellar contact)
• Valgus instability (radial head provides 30% valgus stability)
• Increased coronoid stress (higher failure rate of coronoid fixation)
• Poor outcomes (60-80% failure rate in studies)

Step 8: Radial Head ORIF Technique (if ORIF chosen)

Preparation:

1. Débride fracture site (remove hematoma, small fragments)
2. Identify fracture lines - typically single vertical fracture line or "V" pattern
3. Assess articular surface - minimal comminution for ORIF

Reduction:

1. Reduce fragments anatomically using dental pick or small freer
2. Check articular surface reduction - must be perfect (step-off causes arthritis and mechanical block)
3. Temporary fixation with 0.9mm or 1.1mm K-wires
4. Check reduction under fluoroscopy (AP and lateral)
5. Test forearm rotation - smooth motion, no block

Definitive fixation - SCREW ONLY technique (for simple fractures, single vertical fracture line):

1. Use 2.0mm cortical screws or 2.4mm cannulated screws
2. Place screws in SAFE ZONE (110° arc from radial styloid to Lister's tubercle, forearm neutral)
3. Lag screw technique: overdrill near cortex, thread far cortex for compression
4. Bury screw heads beneath articular cartilage (countersink)
5. Typically 2 screws for single fracture line
6. Check fluoroscopy and rotation

Definitive fixation - PLATE technique (for multiple fragments or comminuted patterns):

1. Select low-profile plate: 2.0mm mini-fragment or 2.4mm locking plate
2. Contour plate to radial head-neck junction
3. Position plate in SAFE ZONE:
   • Forearm NEUTRAL rotation
   • Place plate in 110° arc from radial styloid (palpable) to Lister's tubercle (palpable on dorsal wrist)
   • This zone is NON-ARTICULATING (avoids capitellum laterally and PRUJ anteriorly)
4. Temporary K-wire fixation of plate
5. Insert screws:
   • Proximal screws into radial head (may need special screws with variable angles)
   • Direct screws AWAY from PRUJ (posterolateral direction)
   • Distal screws into radial neck/shaft
6. Check rotation under fluoroscopy:
   • Full pronation-supination without catching
   • No screw prominence into PRUJ (visible on AP views with rotation)
7. Remove K-wires

Final checks:

• Smooth forearm rotation (pronate/supinate under direct vision)
• No hardware prominence (palpate radial head)
• Anatomic reduction (fluoroscopy AP/lateral)
• Check flexion/extension (no impingement)

Step 9: Radial Head Replacement Technique (if replacement chosen)

Radial head removal:

1. Excise radial head fragments
2. Identify and PRESERVE annular ligament (encircles neck) - critical for stability
3. Débride radial neck to healthy bone
4. Avoid excessive bone removal - preserve neck length

Sizing:

1. Measure native radial head diameter from largest fragment (typically 22-26mm in adults)
2. Use sizing guide/templates to match diameter
3. Measure neck length on fluoroscopy (lateral view - distance from neck to coronoid tip)

Stem preparation:

1. Identify intramedullary canal of radius
2. Use graduated broaches to prepare canal
3. Avoid aggressive broaching (radius cortex thin, fracture risk)
4. Match stem diameter to canal (typically 6-8mm)

Implant selection:

• Modular implant preferred (separate head and stem sizes)
• Head: Match native diameter (22-26mm). Smooth articular surface
• Stem: Smooth (requires cement) vs porous-coated (press-fit)
• Common systems: Acumed Anatomic Radial Head, Tornier Anatomic Radial Head, Biomet Anatomical Radial Head

Implant insertion:

1. Assemble modular components (head onto stem taper)
2. Insert stem into radial canal
3. Cemented technique (smooth stems):
   • Apply thin layer of PMMA cement to stem
   • Insert stem to correct depth
   • Hold until cement hardens (avoid rotation)
   • Remove excess cement before hardening
4. Press-fit technique (porous stems):
   • Impact stem to correct depth with impactor
   • Ensure stable fixation (no toggling)

Height adjustment:

• Critical step: Match native radial head height
• Fluoroscopy check (lateral view): Top of prosthetic head should align with tip of coronoid
• Clinical check: With elbow at 90° flexion, no "overstuffing" feel. Elbow should flex/extend smoothly
• Too long (overstuffing): Limits rotation, increases capitellar contact pressure, causes pain and arthritis
• Too short (understuffing): Valgus instability, proximal radius migration

Final checks:

• Smooth flexion/extension (no catching)
• Full pronation/supination (check under fluoroscopy)
• Valgus stress test (firm endpoint, no gapping)
• Annular ligament encircles neck (palpate - should feel ligament anterior and posterior)

Step 10: Lateral Collateral Ligament Complex Repair

Preparation:

1. Identify LCL tissue tagged earlier (2-0 Ethibond marking sutures)
2. Assess tissue quality - usually good unless delayed surgery
3. Identify LUCL component specifically (runs to supinator crest)
4. Prepare lateral epicondyle origin:
   • Débride footprint to bleeding bone
   • Use curette or burr to create bleeding bone surface
   • Identify ISOMETRIC POINT (center of capitellum on lateral view, posterior-superior aspect of lateral epicondyle on palpation)

Suture anchor placement:

1. Select 1.5mm or 2.0mm suture anchors with non-absorbable sutures (2-0 FiberWire or 2-0 Ethibond)
2. Place 2-3 anchors at isometric point in triangular configuration (spread fixation load)
3. Insert anchors at 45° dead-end angle (maximum pullout strength)
4. Ensure anchors fully seated in bone

Ligament repair:

1. Pass anchor sutures through LCL tissue (RCL and LUCL components)
2. Use locking horizontal mattress or modified Mason-Allen stitches (strong)
3. Ensure LUCL specifically captured (identify by following to supinator crest insertion)
4. Position elbow at 60-90° flexion and forearm NEUTRAL rotation for tying
5. Tie sutures with appropriate tension:
   • Too loose: Residual laxity, recurrent instability
   • Too tight: Stiffness, overtensioning
6. Test varus/valgus stability after tying - firm endpoint, no gapping

Alternative techniques (if tissue quality poor or anchor pullout):

• Bone tunnels: Drill 2-3mm tunnels in lateral epicondyle, pass sutures through ligament and bone tunnels, tie over lateral cortex
• Ligament reconstruction: If tissue inadequate, use palmaris longus or gracilis autograft. Recreate LUCL anatomy from isometric point to supinator crest

Step 11: Elbow Stability Assessment Under Fluoroscopy

Critical assessment step - determines need for additional stabilization:

Varus/valgus stress test:

1. Position elbow at 30° flexion (unlocks olecranon from fossa)
2. Forearm neutral rotation
3. Apply varus stress - test LCL repair (should have firm endpoint, no gapping more than 1-2mm compared to contralateral)
4. Apply valgus stress - test MCL and radial head (should have firm endpoint)
5. Check under fluoroscopy - no joint space widening

Lateral pivot-shift test (posterolateral rotatory instability):

1. Patient supine, arm overhead (gravity assists)
2. Elbow in full extension
3. Forearm fully supinated
4. Apply valgus stress + axial load to forearm
5. Slowly flex elbow while maintaining valgus + supination
6. Positive test: Clunk/subluxation at 40° flexion as ulna reduces from posterolateral subluxation
7. Negative test (goal): Smooth motion without clunk
8. Watch under fluoroscopy - should see concentric radiocapitellar and ulnohumeral joints throughout arc

Range of motion test:

1. Flex elbow to maximum (goal: 130-140°)
2. Extend elbow to maximum (goal: 0-10° hyperextension)
3. Pronate and supinate forearm through full arc (goal: 80° pronation, 80° supination)
4. Check fluoroscopy during motion - NO subluxation, NO dislocation, NO impingement
5. Feel for crepitus or catching (suggests malreduction or hardware prominence)

Grading stability:

• Stable: Firm endpoints, negative pivot-shift, full ROM without subluxation → proceed to closure
• Borderline: Soft endpoints but no frank instability, negative pivot-shift → consider 3 weeks immobilization vs hinged fixator
• Unstable: Positive pivot-shift, subluxation with ROM, gapping more than 3mm → REQUIRES hinged external fixator

Step 12: Hinged External Fixator Application (if unstable)

Indications (if ANY present, consider fixator):

• Persistent instability after coronoid/radial head/LCL reconstruction
• Positive lateral pivot-shift test
• Varus or valgus gapping more than 3mm
• Subluxation during ROM
• Associated MCL injury requiring repair
• Severe soft tissue injury (extensive capsular damage)
• Delayed surgery (more than 3 weeks)

Lateral (humeral) pin placement:

1. Identify safe zone in lateral distal humerus (anterior to posterior direction, distal humeral shaft 2-3cm proximal to lateral epicondyle)
2. Palpate to confirm no radial nerve (nerve 2-3cm anterior)
3. Drill 4.0mm pin ANTERIOR to POSTERIOR through both cortices
4. Check position fluoroscopically

Proximal ulnar pin placement:

1. Identify subcutaneous border of ulna (proximal ulna, 2-3cm distal to coronoid)
2. Palpate to confirm no ulnar nerve (nerve 2.5cm posterior)
3. Drill 4.0mm pin MEDIAL to LATERAL (starting at subcutaneous border)
4. Avoid anterior or posterior angulation (nerve danger)
5. Check position fluoroscopically

Fixator assembly:

1. Attach hinge bars to pins
2. Align hinge axis with elbow axis of rotation:
   • Lateral view fluoroscopy: Hinge at center of capitellum
   • AP view fluoroscopy: Hinge at center of trochlea
   • Use offset connectors if needed to align axis
3. Tighten all connections

Motion block setting:

1. Extension block: Set at 30-40° (prevents terminal extension, protects LCL repair)
2. Flexion block: Set at 100-120° (usually full flexion allowed, but may limit if MCL repaired)
3. Test ROM with blocks - smooth motion within allowed arc
4. Lock out varus/valgus and rotational motion (only flexion/extension allowed)

Wound closure with fixator:

• Close in standard fashion (see Step 13)
• Fixator remains in place
• Pin sites dressed with gauze

Step 13: Closure and Dressing

Irrigation: Copious irrigation with 3L normal saline. Pulse lavage if available.

Layered closure:

1. Capsule: Repair if possible with 2-0 absorbable suture (Vicryl). May be difficult if torn extensively
2. Kocher interval: Re-approximate ECU and anconeus with interrupted 2-0 Vicryl
3. Deep fascia: Close with running 2-0 Vicryl
4. Subcutaneous: 3-0 Vicryl, close dead space
5. Skin: 3-0 or 4-0 nylon interrupted sutures OR running subcuticular Monocryl

If medial approach used: Close in layers (FCU, fascia, subcutaneous, skin)

Drain: Generally NOT needed. Consider only if extensive dead space or bleeding

Dressing:

• If STABLE reconstruction: Apply well-padded posterior splint with elbow at 90° flexion, forearm neutral rotation. Splint from upper arm to wrist (allow finger motion)
• If hinged external fixator applied: Dress pin sites with gauze, no splint (fixator provides stability)

Post-operative instructions:

• Elevate arm above heart level for 48 hours
• Ice to reduce swelling
• Neurovascular checks (radial pulse, PIN function = thumb extension, sensation)

Post-Operative Rehabilitation Protocol

Timeline and Milestones

Week 0-1: Protection Phase

Stable reconstruction (no external fixator):

• Posterior splint at 90° flexion, forearm neutral
• Remove splint at 3-5 days for gentle ROM exercises
• ROM protocol:
  • Passive and active-assisted flexion/extension
  • Avoid terminal 20-30° extension (protects LCL)
  • Full flexion allowed
  • Forearm rotation (pronation/supination) as tolerated
• Perform exercises 4-5 times daily, 10 repetitions
• Hand/wrist/shoulder exercises immediately (prevent stiffness)

Unstable reconstruction (hinged external fixator):

• ROM in fixator IMMEDIATELY (day 1 post-op)
• Motion within blocks set in OR (typically 30-120°)
• Forearm rotation as tolerated
• Therapist-supervised exercises daily

Both groups:

• Wound care: Keep dressing clean and dry until suture removal (14 days)
• Edema control: Elevation, ice, compression sleeve
• Pain control: Multimodal analgesia (avoid NSAIDs if HO prophylaxis with indomethacin)
• HO prophylaxis: Indomethacin 25mg TDS for 6 weeks (if no contraindications)

Week 2-6: Early Motion Phase

Stable reconstruction:

• Remove posterior splint completely at 2 weeks
• Advance ROM exercises:
  • Active ROM flexion/extension
  • Progress extension - allow terminal extension by week 4
  • Full ROM goal: 30-130° by week 6
  • Forearm rotation: Full pronation/supination by week 6
• Light activities of daily living (ADLs) allowed
• No lifting (more than 1-2kg), no pushing, no valgus stress activities

Unstable/external fixator group:

• Continue ROM in fixator
• Remove fixator at 4-6 weeks (in clinic, local anesthesia)
• After fixator removal: intensive ROM exercises (elbow usually stiff from fixator)
• May need dynamic splinting if significant stiffness

Both groups:

• Strengthening: None yet
• X-rays at 6 weeks (check fracture healing, hardware position)

Week 6-12: Strengthening Phase

• ROM should be near functional (100-110° arc minimum)
• Begin progressive strengthening:
  • Isometric exercises week 6-8 (biceps, triceps, wrist)
  • Isotonic exercises week 8-12 (light weights, resistance bands)
  • Functional strengthening (ADLs, work simulation)
• Dynamic splinting if residual stiffness (most effective weeks 6-12)
• Progress to full ADLs

Month 3-6: Return to Activities

• Continue strengthening, emphasize endurance
• Return to work: Sedentary at 6-8 weeks, light duty at 8-12 weeks, heavy labor at 4-6 months
• Return to sports: Non-contact at 3 months, contact sports at 6 months
• Avoid valgus stress sports (tennis, golf, throwing) for 6 months minimum

Long-term (6-12 months):

• Continued ROM improvement (may continue up to 12-18 months)
• Final arc typically 10-130° (functional ROM = 30-130°)
• Expected outcomes:
  • 80-90% achieve good-excellent function
  • 5-30° flexion contracture common (usually asymptomatic if less than 30°)
  • Grip strength 80-90% of contralateral
  • Pain minimal or absent

Specific Exercise Recommendations

Early ROM exercises (week 1-6):

1. Gravity-assisted extension: Sitting, arm supported on table, allow elbow to extend passively with gravity
2. Active-assisted flexion: Use opposite hand to assist elbow flexion
3. Forearm rotation: Hold dowel or cane, rotate forearm while keeping elbow at 90°
4. Pendulum exercises: Shoulder ROM to prevent stiffness

Strengthening exercises (after week 6):

1. Isometric biceps: Flex elbow against resistance without motion
2. Isometric triceps: Extend against resistance without motion
3. Wrist flexion/extension: Light dumbbells (1-2kg)
4. Isotonic biceps curls: Progress weight gradually (start 1-2kg, advance by 0.5-1kg every 2 weeks)
5. Triceps extensions: Overhead or prone
6. Grip strengthening: Putty, grippers

Red Flags - When to Stop Therapy

• Increasing pain (suggests over-aggressive therapy or hardware loosening)
• New instability (pivot-shift positive, varus/valgus laxity)
• Loss of ROM (suggests HO formation or arthrofibrosis)
• Neurological symptoms (PIN palsy recovery, ulnar nerve symptoms)
• Swelling/warmth (infection concern)

Heterotopic Ossification Management

Prevention:

• Indomethacin 25mg TDS x 6 weeks (start post-op day 1)
• Alternative: Single-dose radiation 700cGy within 72 hours (if indomethacin contraindicated)

If HO develops despite prophylaxis:

• Continue ROM exercises (within pain tolerance)
• Wait 12-18 months for maturation before considering excision
• Surgical excision only if symptomatic and mature (bone scan shows no uptake)

Outcomes Expectations

ROM: 80-90% achieve functional arc (30-130°). 10-30° flexion contracture common Strength: 80-90% of contralateral by 6-12 months Pain: Minimal or absent in 80% at 1 year Return to work: Sedentary 6-8 weeks, heavy labor 4-6 months Return to sports: Non-contact 3 months, contact 6 months

Additional Complications

Wound Complications/Infection (2-5%):

• Superficial: Erythema, drainage, wound dehiscence. Treatment: Local wound care, oral antibiotics, dressing changes
• Deep infection: Fever, severe pain, purulent drainage, elevated inflammatory markers. Treatment: I&D, culture-directed IV antibiotics, hardware retention if stable (biofilm formation makes eradication difficult - may need removal after fracture union)

Complex Regional Pain Syndrome (CRPS) (3-5%):

• Severe pain out of proportion, hypersensitivity, swelling, skin changes (color, temperature, sweating)
• Prevention: Minimize trauma, early mobilization, adequate pain control
• Treatment: Multidisciplinary (pain management, therapy, psychology). Medical: Gabapentin, pregabalin, topical lidocaine. Interventional: Stellate ganglion blocks. Therapy: Desensitization, ROM, stress loading

Loss of Fixation (3-5%):

• Coronoid fixation failure most common (inadequate fixation, osteoporotic bone)
• Radial head plate loosening or screw pullout
• Recognition: Increasing pain, loss of ROM, radiographic displacement
• Prevention: Adequate fixation strength, protected weight-bearing, compliance
• Treatment: Revision ORIF if fracture not healed. If delayed presentation and malunion, may need osteotomy

Radioulnar Synostosis (1-3%):

• Bony bridging between radius and ulna causing loss of forearm rotation
• Usually from over-aggressive HO excision or very severe trauma
• Prevention: Gentle handling PRUJ, avoid excessive dissection between radius/ulna, HO prophylaxis
• Treatment: Synostosis excision after maturation (12-18 months) + interposition (muscle/fat graft) + HO prophylaxis. Results guarded