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Ortopedia M-boi Mirim CASE REPORT Dr. Sergio Rowinski

Elbow Terrible Triad

MEDICAL HISTORY

healthy

saleswoman in shoe store

R.S.F., female, 32 years old

MEDICAL HISTORY

30/Jan/2009

right arm got “stuck” into handrail

when she stood up, elbow was with intense swelling and

pain

fall from stairs, at work

MEDICAL HISTORY

elbow had evident clinical deformity

very intense pain taken to hospital

analgesia + X-rays

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AP X-ray Dislocated elbow ...

Radial head fracture

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Lateral X-rayCoronoid fracture

Coronoid fracture +

Radial head fracture +

Elbow dislocation

= TERRIBLE TRIAD !!

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Immediate post-reduction X-rays

SEQUENCE ...

Ask for a CT

better comprehend the fracture

specially radial head fracture

After 1 hour, CT was ready

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3D CT - elbow dislocated during exam

Radial head fracture

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3D CT - lateral view

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3D CT - Medial view

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Radial head fracture Coronoid fracture

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New reduction

Prepare for surgery in 3 days

SEQUENCE ...

Elbow capsule tears in this orderO’DRISCOLL mechanism

Understanding the lesions to know what to do

Sure

radial head fracture

Lateral ligamentary complex

radial head ANATOMY must be re-established

sutured/reconstructed

IDEALLY ARTICULATED EXT FIX

Coronoid fracture

depends on the size of the fragment

Maybe

repair medial ligaments

Synthesis

Prosthesis

Surgical stepsIdentify and

evaluate radial head fracture

Repair/reconstruct Lateral ligaments

Synthesis or prosthesis

Test for stability

Stable

Cast, if articulatedext fix not possible

Unstable

Maybe repair medial ligaments

What about coronoid ????

Regan and Morrey classification

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When to fix ???

• TYPE I - no need to fix

• TYPE II - fix in Terrible Triad (still some controversy)

• TYPE III - all of them

What about radial head ????Mason’s classification

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Fix or Replace

• TYPE I - conservative. In Terrible Triad, fix

• TYPE II - fix

• TYPE III/IV - both options possible

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Fix or Replace

• TYPE III/IV - better results with REPLACEMENT

Present case - Surgery - 12/feb/2009

Synthesis ???

NO ...

Good fixation ???

NO ...

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Prosthesis ...

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Identify lateral ligament

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Immediate post-op Lat view

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Immediate post-op AP view

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01 week post-op

04 months post-op

Clinical results - 06 months post-op

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Clinical results - 06 months post-op