We describe the treatment of terrible triad elbow fracture-dislocation with a systematic approach that includes fixation of the coronoid with the lasso technique.
Step 1: Patient Positioning
Position the patient supine with a tourniquet applied and the arm extended on a hand-table.
Step 2: Surgical Approach
Make the deep lateral exposure through the Kocher interval or through a traumatic posterolateral defect.
Step 3: Coronoid Lasso
Pass a suture over the coronoid fragment and through the anterior aspect of the capsule, drill the ulnar tunnels, pass and tie the sutures.
Step 4: Repair or Replacement of the Radial Head
Using a prosthesis that is too large can lead to overstuffing; choose the minor axis of the radial head to determine the size of the prosthetic radial head.
Step 5: Repair of the Lateral Ulnar Collateral Ligament
Weave heavy, braided suture through the ligament substance or through drill-holes in the ulna.
Step 6: Hanging Arm Test
Extend the elbow over a stack of towels under the upper arm; if the elbow remains stable with the weight of the hanging forearm, no further operative intervention is required.
Step 7: Medial Collateral Ligament (MCL) Repair or External Fixation (Rarely Needed)
In the rare cases in which instability persists, repair the MCL or apply external fixation.
Step 8: Rehabilitation
Tell the patient to strictly avoid abduction of the shoulder so as not to create a varus stress on the lateral ulnar collateral ligament repair.
We recently reported on a retrospective series of forty terrible triad elbow fracture-dislocations14.
What to Watch For
Pitfalls & Challenges