WEBVTT 00:00:00.000 --> 00:00:02.500 Did you know that a seemingly simple fall onto 00:00:02.500 --> 00:00:05.620 an outstretched arm, a common everyday accident, 00:00:06.139 --> 00:00:09.320 can unleash one of the most devastating and complex 00:00:09.320 --> 00:00:12.019 patterns of orthopedic injury? It really can. 00:00:12.460 --> 00:00:15.519 One so challenging to manage that it was historically 00:00:15.519 --> 00:00:19.039 and perhaps justifiably labeled the terrible 00:00:19.039 --> 00:00:22.059 triad. That's the one. Today we ask, are these 00:00:22.059 --> 00:00:24.800 injuries still as formidable? And how has our 00:00:24.800 --> 00:00:26.780 understanding and treatment evolved to tackle 00:00:26.780 --> 00:00:29.519 this specific kind of chaos in the elbow joint? 00:00:30.230 --> 00:00:33.350 Welcome to the deep dive where we transform stacks 00:00:33.350 --> 00:00:35.969 of information into clear actionable insights. 00:00:36.670 --> 00:00:39.189 I'm your host and in this deep dive we're tackling 00:00:39.189 --> 00:00:41.770 that historically ominous terrible triad of the 00:00:41.770 --> 00:00:44.539 elbow. a very significant injury. This is a dive 00:00:44.539 --> 00:00:46.939 shaped specifically by the collection of articles 00:00:46.939 --> 00:00:49.179 and research you, our dedicated listeners, shared 00:00:49.179 --> 00:00:51.859 with us. To help navigate the intricate anatomy, 00:00:52.320 --> 00:00:54.539 complex mechanics and challenging treatment pathways 00:00:54.539 --> 00:00:57.079 detailed in these sources, I'm thrilled to be 00:00:57.079 --> 00:00:59.479 joined by an expert with a profound ability to 00:00:59.479 --> 00:01:02.640 synthesize dense medical literature into accessible, 00:01:02.960 --> 00:01:05.180 practical understanding. It's a privilege to 00:01:05.180 --> 00:01:07.230 have you with us today. Thank you. It's a pleasure 00:01:07.230 --> 00:01:10.950 to be here. These injuries are certainly a significant 00:01:10.950 --> 00:01:13.930 challenge in orthopedics, and the sources you've 00:01:13.930 --> 00:01:16.629 provided offer a really comprehensive look at 00:01:16.629 --> 00:01:19.269 where we stand in managing them today. And that 00:01:19.269 --> 00:01:22.269 understanding is precisely our mission. Because, 00:01:22.409 --> 00:01:24.489 as the sources make clear, this isn't just a 00:01:24.489 --> 00:01:27.010 collection of random broken bones. No, not at 00:01:27.010 --> 00:01:29.370 all. It's a specific, predictable pattern of 00:01:29.370 --> 00:01:32.349 failure in a joint built for both stability and 00:01:32.349 --> 00:01:35.790 complex motion. Exactly. A delicate balance easily 00:01:35.790 --> 00:01:38.150 disrupted. So let's jump straight into the fundamental 00:01:38.150 --> 00:01:40.430 questions setting the stage for our deep dive. 00:01:41.049 --> 00:01:44.090 If someone were to ask you, what exactly is a 00:01:44.090 --> 00:01:47.450 terrible triad injury? Beyond the scary name. 00:01:47.680 --> 00:01:50.680 What are the three absolute core components that 00:01:50.680 --> 00:01:53.340 define it? Right. The triad refers to the three 00:01:53.340 --> 00:01:55.480 key elements that must be present simultaneously. 00:01:56.420 --> 00:01:58.459 Firstly, you have a posterior elbow dislocation. 00:01:58.459 --> 00:02:00.579 Okay. Secondly, a fracture of the radial head 00:02:00.579 --> 00:02:03.280 or the neck. Right, the radius bone. And thirdly, 00:02:03.500 --> 00:02:05.579 a fracture of the coronoid process of the ulna. 00:02:05.680 --> 00:02:08.300 The ulna. Yeah. It's the combination of this 00:02:08.300 --> 00:02:11.379 dislocation with those specific bony injuries 00:02:11.379 --> 00:02:15.789 that creates the Well, the profound instability 00:02:15.789 --> 00:02:18.069 characteristic of the terrible triad. So it's 00:02:18.069 --> 00:02:20.210 the dislocation plus the radial head fracture 00:02:20.210 --> 00:02:22.530 plus the coronoid fracture. Got it. That's the 00:02:22.530 --> 00:02:25.030 definition. Second question. You mentioned a 00:02:25.030 --> 00:02:28.550 simple fall can cause this. What is the specific 00:02:28.550 --> 00:02:32.030 mechanism, the typical scenario that brings these 00:02:32.030 --> 00:02:34.229 three components together in such a damaging 00:02:34.229 --> 00:02:37.009 way? Well, the classic mechanism described in 00:02:37.009 --> 00:02:39.229 the sources as accounting for around 60 % of 00:02:39.229 --> 00:02:42.550 cases is a fall onto an outstretched arm. Right, 00:02:42.629 --> 00:02:45.270 the fail injury. Precisely. The critical forces 00:02:45.270 --> 00:02:48.629 involved are axial loading that's force traveling 00:02:48.629 --> 00:02:51.210 up the arm through the radius. Okay. Combined 00:02:51.210 --> 00:02:53.310 with a valgus force, which is a bending force 00:02:53.310 --> 00:02:55.669 pushing the elbow inwards towards the midline 00:02:55.669 --> 00:02:58.150 of the body. Ah, okay. And external rotation 00:02:58.150 --> 00:03:01.129 or supination of the forearm relative to the 00:03:01.129 --> 00:03:04.330 humerus. So twisting outwards. Yes. Imagine planting 00:03:04.330 --> 00:03:06.370 your hand slightly lateral to your body as you 00:03:06.370 --> 00:03:08.889 fall. This often generates the necessary combination 00:03:08.889 --> 00:03:11.469 of forces to disrupt the elbow, typically starting 00:03:11.469 --> 00:03:13.389 from the lateral side and progressing inwards. 00:03:13.770 --> 00:03:18.270 Axial load, valgus, external rotation. That specific 00:03:18.270 --> 00:03:20.629 cocktail of forces from something as common as 00:03:20.629 --> 00:03:23.270 a fall is, well, it's quite sobering. It is indeed. 00:03:23.889 --> 00:03:26.389 And finally, going back to that name, why was 00:03:26.389 --> 00:03:29.169 this injury historically considered so terrible? 00:03:29.689 --> 00:03:32.280 What were the outcomes like in the past? Historically, 00:03:32.780 --> 00:03:34.819 yes, managing these injuries was fraught with 00:03:34.819 --> 00:03:37.500 difficulty, really quite problematic. How so? 00:03:37.680 --> 00:03:40.139 Even after they managed to reduce the dislocation 00:03:40.139 --> 00:03:42.819 and attempt some sort of fixation, the elbow 00:03:42.819 --> 00:03:45.840 often remained unstable or, perhaps more commonly, 00:03:46.419 --> 00:03:49.520 became severely stiff. Ah, stiffness. Exactly. 00:03:50.099 --> 00:03:52.219 The rates of complications like recurrent dislocation, 00:03:52.340 --> 00:03:54.240 the elbow just popping out again and significant 00:03:54.240 --> 00:03:56.819 loss of motion were very high. Surgeons really 00:03:56.819 --> 00:03:59.479 struggled to reliably restore stability and achieve 00:03:59.479 --> 00:04:01.560 good functional outcomes. Leading to long -term 00:04:01.560 --> 00:04:03.840 problems. Yes, leading to long -term disability 00:04:03.840 --> 00:04:06.830 for many patients. The name... truly reflected 00:04:06.830 --> 00:04:10.430 that historical difficulty and the high potential 00:04:10.430 --> 00:04:13.050 for a poor result. That historical context certainly 00:04:13.050 --> 00:04:14.969 underscores the challenge. It sounds like the 00:04:14.969 --> 00:04:17.269 fight against instability on one hand and stiffness 00:04:17.269 --> 00:04:20.209 on the other is absolutely central to this injury. 00:04:20.490 --> 00:04:22.629 That's the core dilemma. OK, let's unpack this 00:04:22.629 --> 00:04:24.889 further, diving into the details from the sources. 00:04:25.490 --> 00:04:28.310 To truly appreciate what goes wrong in a terrible 00:04:28.310 --> 00:04:30.970 triad, we first need to understand the normal 00:04:30.970 --> 00:04:34.069 elbow, its incredibly complex anatomy, and how 00:04:34.069 --> 00:04:36.480 it achieves stability. Absolutely. Yeah. You 00:04:36.480 --> 00:04:38.160 can't fix it if you don't understand how it's 00:04:38.160 --> 00:04:41.019 supposed to work. The elbow is far more sophisticated 00:04:41.019 --> 00:04:44.180 than a simple hinge. Right. As the sources detail, 00:04:44.620 --> 00:04:47.439 it's actually a single joint capsule containing 00:04:47.439 --> 00:04:50.360 three articulations. The humeral nerve joint, 00:04:50.920 --> 00:04:53.980 the radiocapitular joint, and the proximal radial 00:04:53.980 --> 00:04:56.379 nerve joint. Three joints in one capsule. Yes. 00:04:56.839 --> 00:04:59.879 It's described as a trochleogene lemoid joint. 00:05:00.079 --> 00:05:02.920 Trochleogene lemoid. Quite a mouthful. It is. 00:05:03.079 --> 00:05:05.160 It basically means it's primarily a hinge, but 00:05:05.160 --> 00:05:08.019 it also allows rotation. So the hinge part is 00:05:08.019 --> 00:05:10.160 where? That's the main articulation, the humeralnar 00:05:10.160 --> 00:05:11.980 joint. The trochlea of the humerus, which is 00:05:11.980 --> 00:05:14.439 shaped a bit like a spool, articulates with the 00:05:14.439 --> 00:05:17.160 greater sigmoid notch of the ulna. This gives 00:05:17.160 --> 00:05:19.620 you the primary hinge motion flexion and extension. 00:05:20.240 --> 00:05:22.399 And it's inherently quite stable due to the way 00:05:22.399 --> 00:05:24.779 the bones fit together, especially in full extension 00:05:24.779 --> 00:05:27.279 and near full flexion. And the rotation comes 00:05:27.279 --> 00:05:29.259 from the radiocapitalar joint. Is that right? 00:05:29.740 --> 00:05:32.339 Precisely. This is where the radial head, which 00:05:32.339 --> 00:05:35.360 has a sort of concave, articular surface, rotates 00:05:35.360 --> 00:05:38.360 against the capitolum of the humerus, the rounded 00:05:38.360 --> 00:05:41.000 end of the humerus on the lateral side. This 00:05:41.000 --> 00:05:44.060 allows for pronation and supination, turning 00:05:44.060 --> 00:05:47.120 your palm down and up. The proximal radial nar 00:05:47.120 --> 00:05:49.420 joint, where the radial head also contacts the 00:05:49.420 --> 00:05:51.939 ulna, is critical for this rotation, too. And 00:05:51.939 --> 00:05:54.019 it's mainly stabilized by the anular ligament. 00:05:54.240 --> 00:05:56.680 Okay, so bending and twisting are both happening 00:05:56.680 --> 00:05:59.399 here. The sources particularly highlight the 00:05:59.399 --> 00:06:02.160 coronoid process and the radial head as key bony 00:06:02.160 --> 00:06:04.970 players in the terrible triad. What are their 00:06:04.970 --> 00:06:07.670 specific roles in normal stability? They are 00:06:07.670 --> 00:06:11.670 absolutely crucial osseous stabilizers, the bony 00:06:11.670 --> 00:06:14.209 parts providing stability. Right. The coronoid 00:06:14.209 --> 00:06:16.230 process, which is a projection on the front of 00:06:16.230 --> 00:06:19.509 the ulna, acts as an anterior buttress. It's 00:06:19.509 --> 00:06:21.829 vital for preventing the ulna from sliding backwards 00:06:21.829 --> 00:06:24.389 on the humerus, especially as the elbow flexes 00:06:24.389 --> 00:06:26.910 beyond about 30 degrees. So it stops it dislocating 00:06:26.910 --> 00:06:30.649 backwards in flexion. Essentially, yes. What's 00:06:30.649 --> 00:06:32.790 particularly significant and often fractured 00:06:32.790 --> 00:06:35.189 in the terrible triad is a specific part of the 00:06:35.189 --> 00:06:38.790 coronoid called the sublime tubercle. It's on 00:06:38.790 --> 00:06:41.850 the antiromedial aspects. Antiromedial, front 00:06:41.850 --> 00:06:44.750 and inside. Correct. And this is the primary 00:06:44.750 --> 00:06:47.589 attachment site for the crucial anterior bundle 00:06:47.589 --> 00:06:50.029 of the medial collateral ligament, the MCL. Ah, 00:06:50.069 --> 00:06:52.420 so... Fracturing the cornoid isn't just losing 00:06:52.420 --> 00:06:54.180 a piece of bone. You're potentially detaching 00:06:54.180 --> 00:06:57.319 a major ligament at the same time. Exactly. Especially 00:06:57.319 --> 00:06:59.360 if it's a significant fragment involving that 00:06:59.360 --> 00:07:02.560 sublime tubercle or the wider anti -romedial 00:07:02.560 --> 00:07:04.860 facet as described by the odriscal classification 00:07:04.860 --> 00:07:07.160 we'll probably come on to. Okay. Then you have 00:07:07.160 --> 00:07:09.240 the radial head. Well, the humoral inner joint 00:07:09.240 --> 00:07:11.279 is the main stabilizer in the bending plane. 00:07:11.860 --> 00:07:13.959 The radial head plays a vital secondary role. 00:07:14.459 --> 00:07:17.589 Secondary. How so? particularly against valgus 00:07:17.589 --> 00:07:20.709 stress, that inward bending force, and also against 00:07:20.709 --> 00:07:23.790 rotational instability. It contributes up to 00:07:23.790 --> 00:07:26.829 30 % of the resistance to valgus forces. 30%. 00:07:26.829 --> 00:07:30.129 That's significant. It is. And crucially, it's 00:07:30.129 --> 00:07:32.949 also a primary bony restraint to something called 00:07:32.949 --> 00:07:36.829 post -relateral rotatory instability, or PLRI. 00:07:37.269 --> 00:07:39.810 It helps prevent that abnormal outward twisting 00:07:39.810 --> 00:07:42.889 of the radius and ulna on the humerus. Wow. Up 00:07:42.889 --> 00:07:47.269 to 30 % of valgus resistance. That's a huge contribution 00:07:47.269 --> 00:07:49.449 for a bone we often just think about for rotation. 00:07:49.930 --> 00:07:52.290 It really highlights how interconnected these 00:07:52.290 --> 00:07:54.250 structures are. Absolutely. Everything works 00:07:54.250 --> 00:07:57.209 together. What about the main ligamentous stabilizers 00:07:57.209 --> 00:07:59.790 then, the soft tissues? The static stabilizers, 00:08:00.449 --> 00:08:02.850 the ligaments and the capsule are arguably even 00:08:02.850 --> 00:08:04.670 more critical for stability, especially against 00:08:04.670 --> 00:08:07.360 sudden forces. Right. On the medial side, The 00:08:07.360 --> 00:08:09.199 inside, you have the medial collateral ligament, 00:08:09.360 --> 00:08:12.259 or MCL complex. This is the primary restraint 00:08:12.259 --> 00:08:15.100 of algus stress. It also resists internal rotation 00:08:15.100 --> 00:08:17.879 stress. It has three bundles described. The anterior 00:08:17.879 --> 00:08:20.040 bundle is the strongest. It's taught from 0 to 00:08:20.040 --> 00:08:22.040 60 degrees of flexion. The main working range. 00:08:22.300 --> 00:08:24.680 Often, yes. Then the posterior bundle is taught 00:08:24.680 --> 00:08:27.540 in deeper flexion, say 60 to 120 degrees. And 00:08:27.540 --> 00:08:29.439 there's a transverse ligament, which is generally 00:08:29.439 --> 00:08:32.230 considered less functionally important. And you 00:08:32.230 --> 00:08:34.610 mentioned the anterior bundle attaches to the 00:08:34.610 --> 00:08:37.129 cornoid. Yes, it attaches right onto that sublime 00:08:37.129 --> 00:08:40.029 tubercle of the cornoid. This connection makes 00:08:40.029 --> 00:08:42.429 injuries to that part of the cornoid, particularly 00:08:42.429 --> 00:08:44.570 destabilizing for the medial side. Right, you 00:08:44.570 --> 00:08:46.789 lose the bone and the ligament anchor. And on 00:08:46.789 --> 00:08:50.230 the lateral side, that LCL complex seems key 00:08:50.230 --> 00:08:52.629 in the mechanism you described earlier. Yes, 00:08:52.710 --> 00:08:54.490 absolutely. The lateral -collateral ligament 00:08:54.490 --> 00:08:57.269 complex is the primary restraint to that poster 00:08:57.269 --> 00:09:00.690 lateral rotatory instability, the PLRI. It originates 00:09:00.690 --> 00:09:03.070 from the lateral epicondyle of the humerus, the 00:09:03.070 --> 00:09:05.570 bony prominence on the outside. Okay. Traditionally, 00:09:05.610 --> 00:09:07.509 it's described as having several components. 00:09:08.230 --> 00:09:10.470 The radial collateral ligament, the annular ligament, 00:09:10.590 --> 00:09:13.129 which we mentioned stabilizes the proximal radial 00:09:13.129 --> 00:09:15.929 lunar joint. Right. The accessory lateral collateral 00:09:15.929 --> 00:09:18.429 ligament, and the key one, the lateral ulnar 00:09:18.429 --> 00:09:21.590 collateral ligament, the LUCL. The LUCL is frequently 00:09:21.590 --> 00:09:23.830 mentioned in the sources as being paramount. 00:09:24.129 --> 00:09:27.269 Is it the single most important lateral structure? 00:09:27.610 --> 00:09:30.330 Well, the LUCL is certainly often considered 00:09:30.330 --> 00:09:32.509 the main functional component of the lateral 00:09:32.509 --> 00:09:35.269 complex. Disruption of this ligament is consistently 00:09:35.269 --> 00:09:38.210 associated with PLRI. OK, however, it's maybe 00:09:38.210 --> 00:09:41.210 a bit more nuanced. Some biomechanical studies 00:09:41.210 --> 00:09:43.769 suggest that the entire complex functions more 00:09:43.769 --> 00:09:46.990 as a single unit, originating from a common footprint 00:09:46.990 --> 00:09:49.669 on the lateral epicondyle and inserting onto 00:09:49.669 --> 00:09:52.950 the ulna. Like a sheet of tissue. Sort of, highlighting 00:09:52.950 --> 00:09:55.570 the concept of a continuous capsule ligamentous 00:09:55.570 --> 00:09:58.500 complex. There's also a thickening of the post 00:09:58.500 --> 00:10:01.120 -relateral capsule, often referred to as the 00:10:01.120 --> 00:10:04.019 Osborne Cotteral Ligament, which also contributes 00:10:04.019 --> 00:10:06.580 to stability, acting as a check grain against 00:10:06.580 --> 00:10:09.200 post -relateral rotation and varus angulation. 00:10:09.379 --> 00:10:11.919 Varus is the outward bending. Correct, the opposite 00:10:11.919 --> 00:10:14.460 of valgus. So while the L -U -C -L is crucial, 00:10:14.580 --> 00:10:16.899 it operates within this broader complex lateral 00:10:16.899 --> 00:10:19.600 network. It's not just acting alone. That level 00:10:19.600 --> 00:10:21.559 of detail is really helpful. It's not just one 00:10:21.559 --> 00:10:23.620 simple rope holding things together. It's more 00:10:23.620 --> 00:10:26.169 like a woven structure. A good analogy. And you 00:10:26.169 --> 00:10:28.350 also mentioned the joint capsule itself. Yes. 00:10:28.590 --> 00:10:30.909 The anterior and posterior capsules are also 00:10:30.909 --> 00:10:33.049 important contributors to overall stability. 00:10:33.909 --> 00:10:35.990 The anterior capsule provides some secondary 00:10:35.990 --> 00:10:38.710 restraint to valgus stress and also contains 00:10:38.710 --> 00:10:41.509 nerve endings contributing to proprioception, 00:10:42.009 --> 00:10:44.149 the sense of joint position. So it tells your 00:10:44.149 --> 00:10:47.250 brain where your elbow is. In part, yes. And 00:10:47.250 --> 00:10:50.179 both capsules are typically torn. quite extensively 00:10:50.179 --> 00:10:53.159 in elbow dislocations. And finally, the muscles. 00:10:53.539 --> 00:10:56.259 The dynamic stabilizers, yes. The muscles crossing 00:10:56.259 --> 00:10:59.259 the joint, like the aconius, triceps, brachialis, 00:10:59.620 --> 00:11:02.379 and the common flexor and extensor origins. By 00:11:02.379 --> 00:11:04.340 providing compressive forces across the joint 00:11:04.340 --> 00:11:07.340 during contraction and contributing to proprioception, 00:11:07.799 --> 00:11:10.200 they add another layer of stability, especially 00:11:10.200 --> 00:11:12.960 during active movement. It's incredible how many 00:11:12.960 --> 00:11:15.279 different elements have to work in perfect harmony. 00:11:15.519 --> 00:11:17.700 The specific shakes of the bones, the tensile 00:11:17.700 --> 00:11:19.899 strength of the ligaments, the integrity of the 00:11:19.899 --> 00:11:21.940 capsule, and the coordinated action of the muscles. 00:11:22.100 --> 00:11:24.879 It's a truly intricate system, built for stability 00:11:24.879 --> 00:11:27.399 during load bearing, but also for remarkable 00:11:27.399 --> 00:11:30.149 mobility for function. And when you disrupt key 00:11:30.149 --> 00:11:33.529 players from multiple categories like this, bone, 00:11:33.710 --> 00:11:37.129 ligament, capsule. You get the profound multiplanar 00:11:37.129 --> 00:11:39.970 instability seen in a terrible triad. It's not 00:11:39.970 --> 00:11:42.629 just one structure failing. It's a catastrophic 00:11:42.629 --> 00:11:45.990 cascading failure involving bony blocks, critical 00:11:45.990 --> 00:11:47.870 ligaments, and the surrounding capsular support. 00:11:48.190 --> 00:11:49.929 Which brings us back to the mechanism again, 00:11:49.990 --> 00:11:51.990 but perhaps in more detail now we understand 00:11:51.990 --> 00:11:55.870 the anatomy. How do those specific forces you 00:11:55.870 --> 00:11:58.730 described, the axial load, valgus stress, external 00:11:58.730 --> 00:12:01.909 rotation, how do they specifically create this 00:12:01.909 --> 00:12:04.649 pattern of simultaneous bony and ligamentous 00:12:04.649 --> 00:12:07.169 damage? This is where the concept of the Hori 00:12:07.169 --> 00:12:09.549 circle comes into play, which the source has 00:12:09.549 --> 00:12:12.029 mentioned. It describes the predictable sequence 00:12:12.029 --> 00:12:14.789 of injury progression around the elbow. The Hori 00:12:14.789 --> 00:12:17.490 circle sounds like a map of destruction. In a 00:12:17.490 --> 00:12:20.259 way, yes. It typically starts laterally and spirals 00:12:20.259 --> 00:12:22.600 around the elbow medially as the dislocating 00:12:22.600 --> 00:12:25.200 forces continue and overcome each stabilizer 00:12:25.200 --> 00:12:28.080 in turn. So stage one? Stage one involves the 00:12:28.080 --> 00:12:29.840 disruption of the lateral -collateral ligament 00:12:29.840 --> 00:12:33.100 complex. This initiates the instability, allowing 00:12:33.100 --> 00:12:35.960 the radius and ulna to start rotating post -relaterally 00:12:35.960 --> 00:12:38.000 relative to the humerus. The outward twisting 00:12:38.000 --> 00:12:40.279 starts? Correct. If the force continues, you 00:12:40.279 --> 00:12:42.539 progress to stage two. This involves carrying 00:12:42.539 --> 00:12:45.610 of the anterior and posterior capsules. The joint 00:12:45.610 --> 00:12:48.909 is now actively dislocating or subluxating. But 00:12:48.909 --> 00:12:51.850 the medial side, the MCL, might still be intact, 00:12:52.149 --> 00:12:55.309 providing some sort of unstable hinge. However, 00:12:55.509 --> 00:12:57.830 in the terrible triad, the forces are usually 00:12:57.830 --> 00:13:00.110 higher. Pushing it further. Exactly. Pushing 00:13:00.110 --> 00:13:03.230 into stage three, where the medial collateral 00:13:03.230 --> 00:13:05.889 ligament is also disrupted. Now you've lost stability 00:13:05.889 --> 00:13:08.669 on both sides, plus the capsule. And the bony 00:13:08.669 --> 00:13:10.850 fractures are a consequence of this progression. 00:13:11.029 --> 00:13:13.840 When do they happen? Precisely. The terrible 00:13:13.840 --> 00:13:17.000 triad is considered an osseous extension, a bony 00:13:17.000 --> 00:13:19.720 consequence of this stage three disruption of 00:13:19.720 --> 00:13:21.940 the whole right circle. Right. As these severe 00:13:21.940 --> 00:13:24.659 forces overcome the lateral ligaments, then the 00:13:24.659 --> 00:13:27.200 capsule, and finally the medial ligament, the 00:13:27.200 --> 00:13:29.740 bones themselves start to fail under the stress. 00:13:30.259 --> 00:13:32.659 The radial head is forcefully impacted against 00:13:32.659 --> 00:13:34.860 the capitellum causing it to fracture. Stashed 00:13:34.860 --> 00:13:37.980 against the humerus. Effectively, yes. Simultaneously, 00:13:38.279 --> 00:13:41.279 as the ulma is displaced posteriorly, the coronoid 00:13:41.279 --> 00:13:43.559 process acting as that anterior buttress and 00:13:43.559 --> 00:13:46.500 also the anchor for the MCL is sheared off or 00:13:46.500 --> 00:13:48.480 fractured as it collides with the trochlea of 00:13:48.480 --> 00:13:50.200 the humerus. So it gets knocked off from behind. 00:13:50.460 --> 00:13:53.500 Or sheared off by the force. So it's a progressive 00:13:53.500 --> 00:13:56.279 failure of the soft tissues culminating in these 00:13:56.279 --> 00:13:58.559 specific bony injuries occurring at the points 00:13:58.559 --> 00:14:01.799 of maximum stress or weakest structure. What's 00:14:01.799 --> 00:14:03.700 really insightful from the sources is that the 00:14:03.700 --> 00:14:06.080 bony injuries aren't just random events. They 00:14:06.080 --> 00:14:08.820 are a direct result of the extreme forces tearing 00:14:08.820 --> 00:14:11.600 through the stabilizing soft tissues in that 00:14:11.600 --> 00:14:14.879 specific lateral to medial sequence. That sequential 00:14:14.879 --> 00:14:17.700 failure from lateral to medial, with the bony 00:14:17.700 --> 00:14:20.159 fractures being the sort of final breaking points, 00:14:20.740 --> 00:14:23.580 that paints a very clear albeit brutal picture 00:14:23.580 --> 00:14:26.399 of the forces at play. It does. It helps understand 00:14:26.399 --> 00:14:28.750 why these three injuries occur together. OK, 00:14:28.909 --> 00:14:31.690 so a patient presents after this type of fall, 00:14:31.909 --> 00:14:33.950 their elbow is maybe obviously dislocated or 00:14:33.950 --> 00:14:36.470 just looks severely injured. How do clinicians 00:14:36.470 --> 00:14:39.389 confirm the terrible triad diagnosis and understand 00:14:39.389 --> 00:14:41.830 the full extent of the damage? Well, a high index 00:14:41.830 --> 00:14:44.009 of suspicion is absolutely vital, especially 00:14:44.009 --> 00:14:46.169 in the context of any elbow dislocation. Yeah. 00:14:46.250 --> 00:14:48.450 You assume it could be this until proven otherwise. 00:14:48.769 --> 00:14:51.629 The initial clinical evaluation involves a thorough 00:14:51.629 --> 00:14:54.980 assessment. Beyond any obvious deformity, you're 00:14:54.980 --> 00:14:57.659 looking carefully for swelling, bruising, and 00:14:57.659 --> 00:15:00.340 gently palpating for tenderness, which might 00:15:00.340 --> 00:15:03.179 indicate specific fracture sites or ligamentous 00:15:03.179 --> 00:15:06.259 injury points. And critically. Critically, a 00:15:06.259 --> 00:15:08.659 neurovascular examination is non -negotiable. 00:15:09.279 --> 00:15:11.500 You must check the radial pulse and capillary 00:15:11.500 --> 00:15:14.000 refill and assess nerve function, sensation, 00:15:14.259 --> 00:15:17.100 and motor power, particularly for the ulnar nerve. 00:15:17.659 --> 00:15:20.200 Why the ulnar nerve specifically? It runs right 00:15:20.200 --> 00:15:23.259 behind the medial epicondyle, so it's very vulnerable 00:15:23.259 --> 00:15:25.159 to being stretched or even trapped during the 00:15:25.159 --> 00:15:27.759 dislocation or by fracture fragments around the 00:15:27.759 --> 00:15:30.440 medial elbow. Assessing instability clinically 00:15:30.440 --> 00:15:32.769 can be very difficult in the acute setting. because 00:15:32.769 --> 00:15:35.230 of pain and muscle guarding, though sometimes 00:15:35.230 --> 00:15:37.289 gross instability is horribly obvious. Is there 00:15:37.289 --> 00:15:39.750 anything else you look for clinically, any associated 00:15:39.750 --> 00:15:42.470 injuries? Yes, always. Always remember the potential 00:15:42.470 --> 00:15:44.610 for associated injuries, particularly distal 00:15:44.610 --> 00:15:47.509 ones. Specifically, in the context of a radial 00:15:47.509 --> 00:15:50.429 head fracture with elbow instability, you absolutely 00:15:50.429 --> 00:15:52.950 must examine the distal radial solnar joint down 00:15:52.950 --> 00:15:55.110 at the wrist. The wrist joint. Why? Because the 00:15:55.110 --> 00:15:57.570 interosseous membrane, a strong sheet connecting 00:15:57.570 --> 00:16:00.809 the radius and ulna along their length, can transmit 00:16:00.809 --> 00:16:04.230 force. A severe radial head injury, especially 00:16:04.230 --> 00:16:06.610 if it's comminuted or involves the neck, can 00:16:06.610 --> 00:16:09.590 disrupt this membrane and also injure the DRUJ 00:16:09.590 --> 00:16:12.629 ligaments at the wrist. Ah, that's the S. exlipresti 00:16:12.629 --> 00:16:14.889 injury. Exactly. That's the S. exlipresti injury. 00:16:15.610 --> 00:16:17.929 And missing it can have severe functional consequences 00:16:17.929 --> 00:16:21.049 later on, like wrist pain and instability and 00:16:21.049 --> 00:16:23.490 proximal migration of the radius. That's a critical 00:16:23.490 --> 00:16:25.610 point. An elbow injury could be directly linked 00:16:25.610 --> 00:16:28.110 to a significant wrist problem. And then imaging. 00:16:28.629 --> 00:16:31.500 That must be key. Imaging is fundamental, yes. 00:16:31.899 --> 00:16:33.559 Plane radiographs are always the first step. 00:16:33.639 --> 00:16:35.779 Standard AP and lateral views are essential. 00:16:36.419 --> 00:16:38.779 If the elbow is dislocated on arrival, you ideally 00:16:38.779 --> 00:16:41.740 need films before reduction and definitely after 00:16:41.740 --> 00:16:44.500 reduction to confirm concentric reduction of 00:16:44.500 --> 00:16:47.019 both the humeralnar and radiocapitalar joints. 00:16:47.179 --> 00:16:49.600 How do you check that concentricity? On the lateral 00:16:49.600 --> 00:16:51.759 view. A line drawn through the center of the 00:16:51.759 --> 00:16:54.120 radial neck should always pass through the center 00:16:54.120 --> 00:16:56.059 of the capitellum, regardless of the flexion 00:16:56.059 --> 00:16:59.360 angle. Any deviation suggests subluxation or 00:16:59.360 --> 00:17:02.620 malalignment. Radiographs can identify the dislocation 00:17:02.620 --> 00:17:05.000 and often show the significant radial head or 00:17:05.000 --> 00:17:07.700 coronoid fractures, but... But they have limitations. 00:17:07.839 --> 00:17:10.099 Yes. They're often limited in showing complex 00:17:10.099 --> 00:17:12.980 bony detail, subtle displacement, or the exact 00:17:12.980 --> 00:17:15.759 size and shape of fragments, especially the coronoid. 00:17:16.210 --> 00:17:18.490 So x -rays give you the initial picture, but 00:17:18.490 --> 00:17:21.089 for the full story, what else is needed? That's 00:17:21.089 --> 00:17:24.170 where computed tomography, the CT scan, becomes 00:17:24.170 --> 00:17:26.700 absolutely invaluable. It's almost mandatory 00:17:26.700 --> 00:17:29.579 in complex elbow fracture dislocations like the 00:17:29.579 --> 00:17:32.380 terrible triad. Why is CT so crucial here? CT 00:17:32.380 --> 00:17:34.859 provides detailed cross -sectional images and 00:17:34.859 --> 00:17:37.339 crucially allows for 3D reconstruction. This 00:17:37.339 --> 00:17:39.740 is vital for precisely characterizing the fracture 00:17:39.740 --> 00:17:42.359 patterns. For example? For example, the size, 00:17:42.539 --> 00:17:45.039 shape, location, and displacement of the coronoid 00:17:45.039 --> 00:17:47.259 fragment, which can be much more complex than 00:17:47.259 --> 00:17:49.759 it appears on x -ray, particularly those tricky 00:17:49.759 --> 00:17:52.759 intramedial facet fractures. It also details 00:17:52.759 --> 00:17:54.900 the comminution and displacement of the radial 00:17:54.859 --> 00:17:58.140 head fracture any articular step off and helps 00:17:58.140 --> 00:18:00.299 identify any small bone fragments that might 00:18:00.299 --> 00:18:02.539 be trapped within the joint. So it's like a blueprint 00:18:02.539 --> 00:18:05.740 for surgery. Exactly. This detailed 3D blueprint 00:18:05.740 --> 00:18:07.799 is essential for accurate surgical planning. 00:18:08.400 --> 00:18:11.000 Fluoroscopy using live x -ray under anesthesia 00:18:11.000 --> 00:18:14.259 is also often used intraoperatively to dynamically 00:18:14.259 --> 00:18:17.259 assess the stability after the bony and ligamentous 00:18:17.259 --> 00:18:19.380 repairs have been performed. Right, so the CT 00:18:19.380 --> 00:18:22.259 scan is the key to truly understanding the specific 00:18:22.259 --> 00:18:25.079 anatomy of the bony damage, which plain x -rays 00:18:25.079 --> 00:18:28.200 might easily miss. Combining that detailed imaging 00:18:28.200 --> 00:18:30.140 with the clinical picture allows you to confirm 00:18:30.140 --> 00:18:32.839 the diagnosis and plan the next steps. Precisely. 00:18:33.099 --> 00:18:35.589 Diagnosis and planning are paramount. Okay, once 00:18:35.589 --> 00:18:37.710 the diagnosis is made, you're faced with this 00:18:37.710 --> 00:18:40.329 really challenging multi -component problem. 00:18:41.009 --> 00:18:43.789 The dislocation, the radial head fracture, the 00:18:43.789 --> 00:18:46.369 coronoid fracture, and the extensive ligamentous 00:18:46.369 --> 00:18:49.980 disruption. The sources discuss various classification 00:18:49.980 --> 00:18:53.160 systems for the bony injuries. How do these systems 00:18:53.160 --> 00:18:56.259 help surgeons make sense of this chaos and, crucially, 00:18:56.680 --> 00:18:59.339 guide treatment decisions? Classification is 00:18:59.339 --> 00:19:02.200 absolutely vital, yes. It helps standardize description 00:19:02.200 --> 00:19:04.500 and guide surgical management because different 00:19:04.500 --> 00:19:06.839 fracture patterns behave differently biomechanically 00:19:06.839 --> 00:19:08.940 and often require different fixation strategies. 00:19:10.000 --> 00:19:12.319 For coronoid fractures, the traditional classification 00:19:12.319 --> 00:19:15.160 is the Regan -Mori system. It's based simply 00:19:15.160 --> 00:19:17.240 on the height of the fragment seen on the lateral 00:19:17.240 --> 00:19:20.259 x -ray view. Type 1 is just the tip, type 2 is 00:19:20.259 --> 00:19:22.799 less than 50 % of the coronoid height, and type 00:19:22.799 --> 00:19:25.420 3 is more than 50 % of the height. Seems straightforward, 00:19:25.619 --> 00:19:27.480 but the source has noted a limitation there. 00:19:27.640 --> 00:19:29.619 Yes, the main limitation of Regan -Mori is that 00:19:29.619 --> 00:19:31.819 it doesn't adequately capture the crucial three 00:19:31.819 --> 00:19:34.400 -dimensional location of the fracture, particularly 00:19:34.400 --> 00:19:36.660 those involving the anteromedial facet. The bit 00:19:36.660 --> 00:19:40.329 where the MCL attaches? Exactly. Those anteromedial 00:19:40.329 --> 00:19:43.009 facet fractures can be highly destabilizing, 00:19:43.250 --> 00:19:45.349 even if they aren't particularly large in height 00:19:45.349 --> 00:19:48.250 on the lateral view. The odriscal classification 00:19:48.250 --> 00:19:50.609 addresses this much better. How does odriscal 00:19:50.609 --> 00:19:53.269 work? It categorizes fractures based on their 00:19:53.269 --> 00:19:56.130 anatomical location. Type 1 involves the tip, 00:19:56.549 --> 00:19:59.569 type 2 involves the anteromedial facet, and type 00:19:59.569 --> 00:20:02.869 3 involves the base of the coronoid. and there 00:20:02.869 --> 00:20:05.049 are subtypes within those. And that's more useful 00:20:05.049 --> 00:20:07.390 surgically. Yes, the adriscal system is generally 00:20:07.390 --> 00:20:09.430 considered more useful for surgical decision 00:20:09.430 --> 00:20:12.089 -making because it directly relates the specific 00:20:12.089 --> 00:20:14.710 fracture pattern to the injured ligament attachment 00:20:14.710 --> 00:20:17.789 like the MCL on the antiremedial facet and therefore 00:20:17.789 --> 00:20:20.890 informs the necessary fixation strategy and surgical 00:20:20.890 --> 00:20:23.170 approach. That makes sense. Location dictates 00:20:23.170 --> 00:20:25.650 strategy. And for the radial head fracture, what 00:20:25.650 --> 00:20:28.109 systems are used there? The Mason classification 00:20:28.109 --> 00:20:30.910 is the classic system, widely known. It's based 00:20:30.910 --> 00:20:33.430 purely on the radiological appearance. Type 1 00:20:33.430 --> 00:20:36.089 is non -displaced. Type 2 is displaced, but generally 00:20:36.089 --> 00:20:38.569 considered repairable, often causing a mechanical 00:20:38.569 --> 00:20:42.609 block to motion. And type 3 is combinated, shattered 00:20:42.609 --> 00:20:44.690 into multiple pieces, typically not repairable. 00:20:45.069 --> 00:20:47.890 Johnson later added type 4 for any radial head 00:20:47.890 --> 00:20:50.150 fracture associated with an elbow dislocation, 00:20:50.490 --> 00:20:52.289 which is, of course, the pattern we see in a 00:20:52.289 --> 00:20:54.430 terrible triad. And the Hotchkiss modification, 00:20:54.529 --> 00:20:57.650 how does that refine Mason? The Hotchkiss modification 00:20:57.650 --> 00:21:00.150 builds on Mason by incorporating clinical findings 00:21:00.150 --> 00:21:03.589 and explicitly guiding treatment. It helps distinguish 00:21:03.589 --> 00:21:06.750 between fractures that might, very rarely, be 00:21:06.750 --> 00:21:09.650 treated non -surgically. Type 1, less than 2 00:21:09.650 --> 00:21:11.990 millimeter displacement, no block. OK. Those 00:21:11.990 --> 00:21:14.410 suitable for open reduction and internal fixation, 00:21:15.230 --> 00:21:18.289 or RIF type 2, more than 2 millimeter displacement, 00:21:18.849 --> 00:21:20.769 causing a block but still repairable. Right. 00:21:21.049 --> 00:21:24.150 And those requiring replacement, usually an arthroplasty. 00:21:24.569 --> 00:21:27.250 Type 3 committed, not repairable. This is a more 00:21:27.250 --> 00:21:29.690 clinically oriented and treatment -focused classification. 00:21:30.190 --> 00:21:32.430 Are there any systems mentioned that try to classify 00:21:32.430 --> 00:21:34.950 the entire injury pattern, taking into account 00:21:34.950 --> 00:21:37.549 both the bones and the ligaments? Yes, the wants 00:21:37.549 --> 00:21:40.450 at all. Reddington classification is mentioned 00:21:40.450 --> 00:21:42.529 in the sources. It's based on the three -column 00:21:42.529 --> 00:21:45.630 concept of the elbow, a lateral column, a middle 00:21:45.630 --> 00:21:48.309 ulnar column, and a medial column. It classifies 00:21:48.309 --> 00:21:51.390 complex fracture dislocations based on which 00:21:51.390 --> 00:21:53.589 columns and their associated key ligaments are 00:21:53.589 --> 00:21:57.039 injured. In this system, a type C injury essentially 00:21:57.039 --> 00:21:59.640 aligns with the terrible triad pattern, involving 00:21:59.640 --> 00:22:02.680 significant disruption of both lateral and medial 00:22:02.680 --> 00:22:05.220 stability structures. So it helps frame the overall 00:22:05.220 --> 00:22:08.259 instability pattern. So using these classification 00:22:08.259 --> 00:22:11.180 systems helps translate the complex imaging findings 00:22:11.180 --> 00:22:13.680 into categories that directly inform the treatment 00:22:13.680 --> 00:22:16.009 plan. What does that treatment plan typically 00:22:16.009 --> 00:22:18.450 look like? Is non -surgical management ever a 00:22:18.450 --> 00:22:20.809 realistic option for such an inherently unstable 00:22:20.809 --> 00:22:23.509 injury? For the vast, vast majority of terrible 00:22:23.509 --> 00:22:26.130 triad injuries, surgical management is necessary. 00:22:26.809 --> 00:22:28.809 Non -surgical treatment is only appropriate in 00:22:28.809 --> 00:22:31.210 extremely rare and select cases that meet very 00:22:31.210 --> 00:22:33.930 strict criteria. Such as? The elbow must be perfectly 00:22:33.930 --> 00:22:36.130 concentric, perfectly reduced after the initial 00:22:36.130 --> 00:22:38.799 reduction. The radial head and coronoid fractures 00:22:38.799 --> 00:22:41.000 must be very small and judged to be inherently 00:22:41.000 --> 00:22:43.319 stable. And critically, there must be enough 00:22:43.319 --> 00:22:46.140 inherent stability to allow immediate, protected 00:22:46.140 --> 00:22:48.759 early range of motion without any risk of the 00:22:48.759 --> 00:22:51.599 elbow subluxating or re -dislocating. So very 00:22:51.599 --> 00:22:54.720 specific circumstances. Extremely specific. Even 00:22:54.720 --> 00:22:57.619 then, it involves maybe a week or so of immobilization, 00:22:57.920 --> 00:23:00.200 followed by a very cautious restricted motion 00:23:00.200 --> 00:23:03.369 protocol. Essentially, if there's any significant 00:23:03.369 --> 00:23:06.029 displacement of the fractures or any ongoing 00:23:06.029 --> 00:23:08.930 concern for instability, surgery is indicated, 00:23:09.630 --> 00:23:12.269 which is most cases. So surgery is definitely 00:23:12.269 --> 00:23:14.490 the mainstay. What's the overarching goal of 00:23:14.490 --> 00:23:17.309 the surgery, then? The primary goal, the absolute 00:23:17.309 --> 00:23:19.730 key, is to restore enough stability to permit 00:23:19.730 --> 00:23:22.230 early motion. Why is early motion so important? 00:23:22.549 --> 00:23:25.309 Because prolonged immobilization leads to severe 00:23:25.309 --> 00:23:28.029 stiffness, which, as we said, is the most common 00:23:28.029 --> 00:23:31.039 and often most debilitating complication. So, 00:23:31.039 --> 00:23:33.500 surgery aims to fix the bony fractures and repair 00:23:33.500 --> 00:23:35.480 the torn ligaments reliably enough that the patient 00:23:35.480 --> 00:23:38.259 can safely start moving the elbow actively within 00:23:38.259 --> 00:23:41.039 just a few days. OK. The sources describe the 00:23:41.039 --> 00:23:43.740 principle of inside outward, or perhaps more 00:23:43.740 --> 00:23:46.920 commonly, lateral to medial repair. This involves 00:23:46.920 --> 00:23:48.720 addressing the lateral structures first, then 00:23:48.720 --> 00:23:51.440 the bone, and finally addressing the medial side, 00:23:51.839 --> 00:23:54.940 only if instability persists, sequentially restoring 00:23:54.940 --> 00:23:57.519 stability. Let's delve into the surgical procedures 00:23:57.519 --> 00:23:59.640 mentioned in the soredices. What are the common 00:23:59.640 --> 00:24:01.700 approaches the incisions use to get to these 00:24:01.700 --> 00:24:04.440 structures? Surgeons typically use either separate 00:24:04.440 --> 00:24:06.740 approaches or sometimes a single larger approach, 00:24:06.740 --> 00:24:08.880 depending on the specific injury pattern and 00:24:08.880 --> 00:24:12.440 their preference. A direct lateral approach provides 00:24:12.440 --> 00:24:15.000 excellent access to the radial head and the LCL 00:24:15.000 --> 00:24:18.140 complex. Okay. A medial approach gives access 00:24:18.140 --> 00:24:21.339 to the MCL and also allows for fixation of some 00:24:21.339 --> 00:24:23.579 coronoid fractures, particularly those antiremedial 00:24:23.579 --> 00:24:26.789 facet ones. Right. Alternatively, a universal 00:24:26.789 --> 00:24:29.369 posterior approach, often using a technique that 00:24:29.369 --> 00:24:31.990 spares or reflects the triceps tendon, can allow 00:24:31.990 --> 00:24:34.250 access to both the medial and lateral columns 00:24:34.250 --> 00:24:37.089 through a single large incision. Some specific 00:24:37.089 --> 00:24:39.750 coronary fractures might even require an additional 00:24:39.750 --> 00:24:42.970 small anterior approach for fixation. The choice 00:24:42.970 --> 00:24:45.170 really depends on the surgeon's experience and 00:24:45.170 --> 00:24:47.670 the specific fractures needing fixation. And 00:24:47.670 --> 00:24:50.170 the specific techniques for fixing the bony and 00:24:50.170 --> 00:24:52.150 ligamentous injuries. Let's start with the radial 00:24:52.150 --> 00:24:54.980 head. Okay. For the radial head, if it's deemed 00:24:54.980 --> 00:24:57.099 repairable, generally fitting the Mason type 00:24:57.099 --> 00:25:00.119 two or Hotchkiss type two criteria, meaning usually 00:25:00.119 --> 00:25:02.299 less than three or four pieces, less than 40 00:25:02.299 --> 00:25:04.740 % of the articular surface involved and displaced. 00:25:04.940 --> 00:25:07.759 Then ORF. Yes. Then open reduction and internal 00:25:07.759 --> 00:25:11.059 fixation, O -R -A -F, is performed using small 00:25:11.059 --> 00:25:13.900 specialized screws and sometimes plates. The 00:25:13.900 --> 00:25:16.500 sources emphasize the importance of careful screw 00:25:16.500 --> 00:25:19.369 or plate placement within the safe zone. The 00:25:19.369 --> 00:25:21.670 safe zone, what's that? That's the post -relateral 00:25:21.670 --> 00:25:25.029 aspect of the radial head, roughly a 90 to 110 00:25:25.029 --> 00:25:27.950 degree arc measured from the radial styloid when 00:25:27.950 --> 00:25:30.559 the forearm is held in neutral rotation. Placing 00:25:30.559 --> 00:25:32.980 hardware here minimizes the risk of it impinging 00:25:32.980 --> 00:25:35.960 on the ulna or humerus during pronation and supination 00:25:35.960 --> 00:25:38.799 and reduces risk to the posterior interosseous 00:25:38.799 --> 00:25:41.319 nerve. Okay, crucial detail. What if the radial 00:25:41.319 --> 00:25:43.740 head is just too shattered to repair? Mason type 00:25:43.740 --> 00:25:46.380 3. If it's severely commended, Mason type 3, 00:25:46.539 --> 00:25:48.680 Haschges type 3, typically more than three or 00:25:48.680 --> 00:25:51.500 four fragments, basically irreparable, then it's 00:25:51.500 --> 00:25:53.460 usually replaced with a radial head arthroplasty. 00:25:53.640 --> 00:25:55.559 That's a metal implant that mimics the shape 00:25:55.559 --> 00:25:57.720 of the radial head. And sizing is important here. 00:25:57.839 --> 00:26:00.940 Absolutely critical. Sources stress that meticulous 00:26:00.940 --> 00:26:03.740 attention must be paid to implant sizing. An 00:26:03.740 --> 00:26:06.400 implant that is too long or over lengthened can 00:26:06.400 --> 00:26:09.299 cause significant pain, stiffness by overstuffing 00:26:09.299 --> 00:26:12.839 the joint, and wear on the capotella. An implant 00:26:12.839 --> 00:26:16.019 that is too short or undersized will simply not 00:26:16.019 --> 00:26:18.559 provide adequate stability. It won't restore 00:26:18.559 --> 00:26:20.859 the secondary valgus and rotational restraint. 00:26:21.420 --> 00:26:23.799 The goal is usually to seat the radial head implant 00:26:23.799 --> 00:26:26.700 approximately two millimeter distal to the tip 00:26:26.700 --> 00:26:29.259 of the native coronoid process. Right. And the 00:26:29.259 --> 00:26:31.180 sources were very clear about not just removing 00:26:31.180 --> 00:26:34.440 the radial head. Extremely clear. Radial head 00:26:34.440 --> 00:26:36.619 resection, just cutting it out and leaving nothing, 00:26:37.059 --> 00:26:39.900 is generally strongly contraindicated in unstable 00:26:39.900 --> 00:26:42.440 or dislocated elbows like the terrible triad. 00:26:42.559 --> 00:26:46.039 It removes a key secondary stabilizer, massively 00:26:46.039 --> 00:26:48.119 increasing the risk of proximal migration of 00:26:48.119 --> 00:26:50.680 the radius over time, leading to risk problems 00:26:50.680 --> 00:26:53.039 that Essex -Lepresti issue again. That's a really 00:26:53.039 --> 00:26:55.039 critical point about not just removing it if 00:26:55.039 --> 00:26:57.180 it's broken and the elbow's unstable. Okay, what 00:26:57.180 --> 00:26:59.160 about the coronoid fracture? How is that fixed? 00:26:59.599 --> 00:27:02.220 Coronoid fixation techniques vary quite a bit 00:27:02.220 --> 00:27:05.059 based on the fracture size and location, often 00:27:05.059 --> 00:27:08.079 guided by that otriscal classification. Smaller 00:27:08.079 --> 00:27:10.980 tip fractures, type 1, might be fixed with sutures 00:27:10.980 --> 00:27:13.740 passed through drill holes in the ulna or sometimes 00:27:13.740 --> 00:27:16.400 using suture anchors. Occasionally they can even 00:27:16.400 --> 00:27:18.599 be lassoed with sutures passed through a radial 00:27:18.599 --> 00:27:21.059 head implant if one is being used. And bigger 00:27:21.059 --> 00:27:23.400 fragments? Larger fragments, especially those 00:27:23.400 --> 00:27:26.160 involving the anti -remedial facet or the base 00:27:26.160 --> 00:27:28.960 of the coronoid, or Driscoll type 2 or 3, typically 00:27:28.960 --> 00:27:31.660 require more robust fixation with screws or even 00:27:31.660 --> 00:27:34.140 small plates for stability. These fractures can 00:27:34.140 --> 00:27:36.240 sometimes be quite challenging to access and 00:27:36.240 --> 00:27:39.240 fix directly, requiring specific surgical approaches. 00:27:39.440 --> 00:27:42.180 Right. And finally, the torn ligaments, the LCL 00:27:42.180 --> 00:27:45.099 and maybe the MCL. The LCL complex is nearly 00:27:45.099 --> 00:27:48.200 always injured and requires repair. It's typically 00:27:48.200 --> 00:27:50.519 repaired by reattaching it anatomically back 00:27:50.519 --> 00:27:53.539 to its origin on the lateral epicondyle. Often, 00:27:53.759 --> 00:27:55.940 it's avulsed as a sleeve of tissue from the bone. 00:27:56.160 --> 00:27:58.599 How is it re -appatched? Suture anchors, small 00:27:58.599 --> 00:28:00.599 implants drilled into the bone with strong sutures 00:28:00.599 --> 00:28:02.880 attached, are commonly used to re -secure the 00:28:02.880 --> 00:28:05.000 ligament footprint back to the bone, typically 00:28:05.000 --> 00:28:07.240 centered around the axis of rotation near the 00:28:07.240 --> 00:28:09.220 center of the capitella curvature. And the forearm 00:28:09.220 --> 00:28:12.000 position matters during LCL repair? Yes, the 00:28:12.000 --> 00:28:14.380 forearm position during the LCL repair is important. 00:28:14.880 --> 00:28:17.099 Sources suggest repairing the LCL with the forearm 00:28:17.099 --> 00:28:21.160 held in pronation if the MCL is intact. Pronation 00:28:21.160 --> 00:28:23.559 tends to tighten the LCL and helps reduce that 00:28:23.559 --> 00:28:26.559 post -relateral rotation. And if the MCL is also 00:28:26.559 --> 00:28:29.160 torn? If the MCL is also significantly injured 00:28:29.160 --> 00:28:32.160 and requires repair, then the LCL is usually 00:28:32.160 --> 00:28:34.359 repaired with the forearm held in supination 00:28:34.359 --> 00:28:37.480 or perhaps neutral rotation to allow appropriate 00:28:37.480 --> 00:28:39.480 tensioning of both ligaments simultaneously. 00:28:40.000 --> 00:28:43.299 And is the MCL always repaired? Not always. The 00:28:43.299 --> 00:28:45.680 MCL itself is typically repaired only if the 00:28:45.680 --> 00:28:47.839 elbow remains unstable after fixing the bony 00:28:47.839 --> 00:28:51.269 injuries and repairing the LCL. Instability is 00:28:51.269 --> 00:28:54.130 often checked dynamically under anesthesia, particularly 00:28:54.130 --> 00:28:56.430 looking for gapping on the medial side when nevelgus 00:28:56.430 --> 00:28:59.089 stress is applied, especially in extension beyond 00:28:59.089 --> 00:29:02.170 30 degrees. If it's still unstable, then the 00:29:02.170 --> 00:29:05.250 MCL needs repair too. Okay, that's a lot of complex 00:29:05.250 --> 00:29:08.069 repair work. What if, even after fixing the bone 00:29:08.069 --> 00:29:10.150 and repairing the ligaments, the elbow still 00:29:10.150 --> 00:29:12.589 doesn't feel stable enough for that crucial early 00:29:12.589 --> 00:29:15.509 motion? That's a challenging situation, indicating 00:29:15.509 --> 00:29:18.960 persistent growth instability. In such cases, 00:29:19.400 --> 00:29:21.460 some form of supplementary stabilization might 00:29:21.460 --> 00:29:24.000 be required temporarily. Like what? This could 00:29:24.000 --> 00:29:27.039 involve applying a hinged external fixator. This 00:29:27.039 --> 00:29:29.279 is a frame outside the arm, connected by pins 00:29:29.279 --> 00:29:31.740 above and below the elbow, that allows controlled 00:29:31.740 --> 00:29:34.599 motion within a set range but protects the internal 00:29:34.599 --> 00:29:37.480 repairs by spanning the joint externally. Are 00:29:37.480 --> 00:29:40.380 there other options? Static external fixators 00:29:40.380 --> 00:29:43.390 rigidly hold the joint in one position. usually 00:29:43.390 --> 00:29:45.970 flexion, but carry a much higher risk of stiffness 00:29:45.970 --> 00:29:49.089 due to the complete immobilization. Internal 00:29:49.089 --> 00:29:51.809 joint stabilizer devices are also an option, 00:29:52.250 --> 00:29:54.029 implants placed across the joint internally, 00:29:54.569 --> 00:29:57.109 but they often require a second surgery for removal 00:29:57.109 --> 00:30:00.349 and have their own potential complications. Cross 00:30:00.349 --> 00:30:02.509 -kitting the humeral Nar joint in a reduced position 00:30:02.509 --> 00:30:05.109 with temporary wires is also mentioned in one 00:30:05.109 --> 00:30:07.309 source as a possibility for very short -term 00:30:07.309 --> 00:30:09.900 stability. But the goal is always to achieve 00:30:09.900 --> 00:30:12.180 enough primary stability from the internal repairs 00:30:12.180 --> 00:30:15.200 to allow that early motion if at all possible. 00:30:15.920 --> 00:30:18.319 It's clearly a very complex surgical undertaking 00:30:18.319 --> 00:30:21.299 involving multiple intricate repairs. The timing 00:30:21.299 --> 00:30:23.039 of the surgery is also something highlighted 00:30:23.039 --> 00:30:25.519 quite strongly in the sources. Yes, this seems 00:30:25.519 --> 00:30:27.900 to be a critical factor impacting the final outcome. 00:30:28.140 --> 00:30:30.839 Several sources emphasize that delayed surgery, 00:30:31.180 --> 00:30:33.220 particularly if it performed more than 14 days 00:30:33.220 --> 00:30:35.619 after the initial injury, is associated with 00:30:35.619 --> 00:30:38.119 significantly higher rates of stiffness and generally 00:30:38.119 --> 00:30:40.599 poorer functional outcomes compared to surgery 00:30:40.599 --> 00:30:42.859 performed within a shorter time frame. Sooner 00:30:42.859 --> 00:30:46.079 is better. Generally, yes. Surgery performed 00:30:46.079 --> 00:30:49.059 ideally within 24 hours up to perhaps 14 days 00:30:49.059 --> 00:30:52.009 seems preferable. Early anatomical reduction 00:30:52.009 --> 00:30:55.049 and scable fixation appear to interrupt the inflammatory 00:30:55.049 --> 00:30:57.730 and scarring processes that lead to severe joint 00:30:57.730 --> 00:31:00.710 contracture and potentially heterotopic ossification. 00:31:01.569 --> 00:31:03.990 Which means? Which means accurate and timely 00:31:03.990 --> 00:31:06.529 diagnosis, often requiring that prompt CT scanning 00:31:06.529 --> 00:31:09.509 we discussed, is key not just for planning the 00:31:09.509 --> 00:31:11.890 surgery, but for facilitating early surgical 00:31:11.890 --> 00:31:14.069 intervention to improve the chances of a good 00:31:14.069 --> 00:31:18.390 outcome. So diagnose quickly. operate comprehensively 00:31:18.390 --> 00:31:20.730 and in a timely manner, and then what? What's 00:31:20.730 --> 00:31:22.950 the crucial next step in the patient's journey 00:31:22.950 --> 00:31:25.910 towards regaining function? Post -operative rehabilitation. 00:31:26.250 --> 00:31:29.269 It is absolutely paramount and in many ways equally 00:31:29.269 --> 00:31:31.329 as challenging as the surgery itself. Why so 00:31:31.329 --> 00:31:33.230 challenging? It's a very delicate balancing act 00:31:33.230 --> 00:31:35.390 between protecting the surgical repairs, which 00:31:35.390 --> 00:31:37.789 need time to heal, and regaining motion to prevent 00:31:37.789 --> 00:31:40.549 stiffness. How is that balance managed initially? 00:31:40.970 --> 00:31:43.029 Initial immobilization is kept to an absolute 00:31:43.029 --> 00:31:46.240 minimum. usually just seven to 10 days. The elbow 00:31:46.240 --> 00:31:48.480 is typically held in a splinter brace at around 00:31:48.480 --> 00:31:51.140 90 degrees of flexion, potentially with specific 00:31:51.140 --> 00:31:54.079 forearm rotation pronation or neutral, depending 00:31:54.079 --> 00:31:56.299 on which ligaments were repaired and how. And 00:31:56.299 --> 00:31:59.299 after that brief period, what happens then? Early 00:31:59.299 --> 00:32:01.579 active motion is initiated very quickly, often 00:32:01.579 --> 00:32:03.940 within 48 hours or at least within a few days 00:32:03.940 --> 00:32:06.680 postoperatively, once the initial pain and swelling 00:32:06.680 --> 00:32:09.140 start to settle. Active motion, so the patient 00:32:09.140 --> 00:32:11.339 moves the elbow themselves? Yes, gentle active 00:32:11.339 --> 00:32:14.250 range of motion. Studies strongly support that 00:32:14.250 --> 00:32:16.289 initiating this as soon as stability permits 00:32:16.289 --> 00:32:18.690 significantly improves functional outcomes and 00:32:18.690 --> 00:32:21.069 is the best strategy we have to combat stiffness. 00:32:21.950 --> 00:32:23.670 Patients are typically guided by a therapist 00:32:23.670 --> 00:32:25.789 through controlled flexion and extension within 00:32:25.789 --> 00:32:28.750 a safe prescribed arc of motion. Are there any 00:32:28.750 --> 00:32:31.750 specific movements or ranges to avoid initially 00:32:31.750 --> 00:32:34.910 to protect repairs? Yes. Often patients are advised 00:32:34.910 --> 00:32:37.609 to avoid achieving full or near full extension, 00:32:37.950 --> 00:32:40.690 particularly the last 30 degrees or so of extension 00:32:40.690 --> 00:32:43.039 for the first few weeks. typically around four 00:32:43.039 --> 00:32:45.559 weeks. Why avoid full extension? That terminal 00:32:45.559 --> 00:32:47.880 extension position can put significant stress 00:32:47.880 --> 00:32:51.039 on the healing LCL and potentially the MCL repairs, 00:32:51.720 --> 00:32:53.660 depending on the specific pattern of instability. 00:32:54.940 --> 00:32:56.920 Avoiding it helps protect the reconstruction 00:32:56.920 --> 00:32:59.579 during the early healing phase. Strengthening 00:32:59.579 --> 00:33:01.839 exercises are introduced much more gradually, 00:33:02.119 --> 00:33:04.079 usually starting around six to eight weeks post 00:33:04.079 --> 00:33:06.609 -op. What sort of strengthening? beginning with 00:33:06.609 --> 00:33:08.829 low resistance activities like gentle wall push 00:33:08.829 --> 00:33:11.329 -ups or weight bearing on the hands in a quadruped, 00:33:11.490 --> 00:33:14.509 all -force position, progressing slowly as tolerated 00:33:14.509 --> 00:33:17.029 and as healing progresses. This clearly requires 00:33:17.029 --> 00:33:19.930 close collaboration and expert guidance. Absolutely. 00:33:20.490 --> 00:33:23.150 A dedicated physiotherapist, ideally one experienced 00:33:23.150 --> 00:33:26.009 with complex elbow injuries, plays a vital role 00:33:26.009 --> 00:33:28.009 throughout the entire rehabilitation process. 00:33:28.349 --> 00:33:30.890 They guide the patient, monitor progress, adjust 00:33:30.890 --> 00:33:33.650 the program based on response, and manage expectations. 00:33:34.170 --> 00:33:36.650 And how is success measured? Functional outcomes 00:33:36.650 --> 00:33:39.089 are commonly tracked using validated questionnaires 00:33:39.089 --> 00:33:41.509 like the D -A -S -H score disabilities of the 00:33:41.509 --> 00:33:43.990 arm, shoulder, and hand, and the M -E -P -S, 00:33:44.130 --> 00:33:46.569 the male elbow performance score. M -E -P -S 00:33:46.569 --> 00:33:49.289 scores range from 0 to 100, with scores of 90 00:33:49.289 --> 00:33:51.569 -100 indicating an excellent functional result. 00:33:51.759 --> 00:33:54.119 Despite the best surgery and dedicated rehab, 00:33:54.660 --> 00:33:56.619 what are the potential setbacks or complications 00:33:56.619 --> 00:33:58.980 that patients and surgeons might still encounter? 00:33:59.839 --> 00:34:02.759 This injury sounds like it can fight back. Unfortunately, 00:34:03.039 --> 00:34:06.019 yes. Given the severity of the initial trauma 00:34:06.019 --> 00:34:08.800 and the complexity of the reconstruction, complications 00:34:08.800 --> 00:34:11.340 are relatively common, even with optimal management. 00:34:12.039 --> 00:34:14.699 Stiffness is arguably the most frequent significant 00:34:14.699 --> 00:34:17.780 complication. Stiffness again. Yes, reported 00:34:17.780 --> 00:34:20.880 incidences range from 5 % up to as high as 15 00:34:20.880 --> 00:34:23.840 % or even more in some series, requiring further 00:34:23.840 --> 00:34:26.420 intervention. It often presents as a significant 00:34:26.420 --> 00:34:29.440 loss of extension of flexion contracture. It 00:34:29.440 --> 00:34:31.519 can be caused by excessive scar tissue formation 00:34:31.519 --> 00:34:34.139 within and around the joint or by heterotopic 00:34:34.139 --> 00:34:37.119 ossification. Ulnar nerve irritation or entrapment 00:34:37.119 --> 00:34:39.820 is also a significant risk factor for pain and 00:34:39.820 --> 00:34:42.219 can contribute to limiting motion. Heterotopic 00:34:42.219 --> 00:34:44.280 ossification, that's the abnormal bone growth 00:34:44.280 --> 00:34:46.320 outside the normal skeleton you mentioned earlier. 00:34:46.719 --> 00:34:49.840 Yes, exactly. HO is a major concern after these 00:34:49.840 --> 00:34:52.980 complex elbow injuries. Its incidence in operatively 00:34:52.980 --> 00:34:55.920 treated terrible triads can be disturbingly high, 00:34:56.400 --> 00:34:58.940 reported up to 43 % radiographically in some 00:34:58.940 --> 00:35:01.239 studies, though not all of that is clinically 00:35:01.239 --> 00:35:03.980 significant. What causes it? HO seems associated 00:35:03.980 --> 00:35:06.199 with a severe of the initial soft tissue injury, 00:35:06.619 --> 00:35:08.719 the amount of tissue damage during surgery, prolonged 00:35:08.719 --> 00:35:11.400 immobilization, any associated nerve injury, 00:35:11.739 --> 00:35:14.019 infection, and significantly delayed surgical 00:35:14.019 --> 00:35:16.619 intervention seems to increase the risk. When 00:35:16.619 --> 00:35:19.780 does it appear? It typically appears radiographically 00:35:19.780 --> 00:35:22.340 within three to four weeks post -injury and can 00:35:22.340 --> 00:35:24.800 cause really severe restrictions in range of 00:35:24.800 --> 00:35:27.059 motion, potentially leading to ankylosis, which 00:35:27.059 --> 00:35:28.699 is complete fusion of the joint in the worst 00:35:28.699 --> 00:35:31.880 cases. Excision of the HO may be required later 00:35:31.880 --> 00:35:34.519 on, but that's a complex procedure itself with 00:35:34.519 --> 00:35:37.119 risks. Is there anything done to prevent HO? 00:35:37.400 --> 00:35:40.119 Sources discuss prophylaxis. like using anti 00:35:40.119 --> 00:35:42.780 -inflammatory drugs such as endomethacin. But 00:35:42.780 --> 00:35:44.980 note the evidence for its effectiveness specifically 00:35:44.980 --> 00:35:48.480 in traumatic elbow HO is still debated. Radiation 00:35:48.480 --> 00:35:51.219 prophylaxis is sometimes used, particularly after 00:35:51.219 --> 00:35:54.179 HO excision. But it's often considered too risky 00:35:54.179 --> 00:35:56.460 after the initial fracture surgery due to potential 00:35:56.460 --> 00:35:58.699 negative effects on fracture healing, though 00:35:58.699 --> 00:36:00.980 it is mentioned for severe burn patients with 00:36:00.980 --> 00:36:05.099 associated elbow injuries. So HO is a significant 00:36:05.099 --> 00:36:07.159 potential hurdle. What else is on the complication 00:36:07.159 --> 00:36:09.960 list after a terrible triad? surgery? Well, recurrent 00:36:09.960 --> 00:36:12.159 instability is another risk. This can happen 00:36:12.159 --> 00:36:14.860 if the initial surgical repairs fail, perhaps 00:36:14.860 --> 00:36:17.400 the fixation wasn't robust enough, or if subtle 00:36:17.400 --> 00:36:20.099 injuries, especially smaller coronoid fractures, 00:36:20.380 --> 00:36:22.960 were underestimated or inadequately fixed initially. 00:36:23.239 --> 00:36:25.159 Infection? Infection is a serious concern, especially 00:36:25.159 --> 00:36:27.440 with implants present. Rates have been reported 00:36:27.440 --> 00:36:30.940 up to 17 .5 % in some older series, which can 00:36:30.940 --> 00:36:33.739 be devastating, often requiring multiple further 00:36:33.739 --> 00:36:36.239 surgeries. Nerve problems? Nerve injuries, such 00:36:36.239 --> 00:36:38.949 as ulnar or radial nerve, specifically the posterior 00:36:38.949 --> 00:36:41.650 interosseous branch entrapments or palsies, can 00:36:41.650 --> 00:36:44.570 occur in up to 23 .5 % of cases according to 00:36:44.570 --> 00:36:47.250 some sources. These can be due to the initial 00:36:47.250 --> 00:36:49.730 injury, swelling, scar tissue formation later 00:36:49.730 --> 00:36:52.309 on, or sometimes proximity to surgical hardware. 00:36:52.329 --> 00:36:54.469 And other issues. Non -union or malunion of the 00:36:54.469 --> 00:36:56.530 fractures, meaning they don't heal or heal in 00:36:56.530 --> 00:36:59.230 a bad position. Post -traumatic arthritis or 00:36:59.230 --> 00:37:01.349 degenerative joint disease is a long -term risk 00:37:01.349 --> 00:37:03.349 due to the initial cartilage damage sustained 00:37:03.349 --> 00:37:06.269 at the time of injury, or due to residual instability 00:37:06.269 --> 00:37:09.610 or joint incongruity. And issues related to the 00:37:09.610 --> 00:37:11.989 hardware itself, painful, prominent, or loose 00:37:11.989 --> 00:37:14.550 implants sometimes requiring removal, are also 00:37:14.550 --> 00:37:17.070 potential complications. It really underscores 00:37:17.070 --> 00:37:19.190 why this injury pattern is so challenging to 00:37:19.190 --> 00:37:21.480 manage comprehensively. Given all those potential 00:37:21.480 --> 00:37:23.659 issues, what's the realistic long -term outlook? 00:37:23.840 --> 00:37:25.840 What can someone generally expect in terms of 00:37:25.840 --> 00:37:28.679 prognosis after navigating this very difficult 00:37:28.679 --> 00:37:30.880 injury in its treatment? Historically, as the 00:37:30.880 --> 00:37:33.719 name terrible triad implied, the prognosis was 00:37:33.719 --> 00:37:37.079 often poor. High rates of chronic pain, significant 00:37:37.079 --> 00:37:39.800 stiffness, limiting function, and persistent 00:37:39.800 --> 00:37:42.159 instability leading to disability were common. 00:37:42.380 --> 00:37:45.400 But things have improved. Yes. Thankfully, with 00:37:45.400 --> 00:37:47.219 significant advancements in our understanding, 00:37:47.780 --> 00:37:50.480 better imaging, modern surgical techniques, particularly 00:37:50.480 --> 00:37:53.320 more stable fixation methods, and reliable radial 00:37:53.320 --> 00:37:55.920 head replacement options, and structured early 00:37:55.920 --> 00:37:58.760 rehabilitation protocols, the outcomes have substantially 00:37:58.760 --> 00:38:02.329 improved. Generally, Good to excellent functional 00:38:02.329 --> 00:38:05.489 results, as measured by those MEPs and DASH scores, 00:38:06.150 --> 00:38:08.869 often averaging above 75, are now achievable 00:38:08.869 --> 00:38:11.590 for many patients. So the terrible aspect is 00:38:11.590 --> 00:38:14.150 perhaps less about the inevitable outcome nowadays 00:38:14.150 --> 00:38:16.369 and more about the complexity of the injury and 00:38:16.369 --> 00:38:18.369 its management. Precisely. I think that's a fair 00:38:18.369 --> 00:38:20.849 summary. With appropriate timely and skilled 00:38:20.849 --> 00:38:23.750 care, it is often possible to achieve a good 00:38:23.750 --> 00:38:26.849 functional outcome, allowing return to most activities. 00:38:26.949 --> 00:38:29.619 What predicts a better outcome? The sources consistently 00:38:29.619 --> 00:38:32.380 highlight that key predictors of a better prognosis 00:38:32.380 --> 00:38:36.320 include accurate and timely diagnosis, often 00:38:36.320 --> 00:38:39.699 relying on that crucial CP scan, prompt surgical 00:38:39.699 --> 00:38:41.840 reduction and stable fixation or replacement 00:38:41.840 --> 00:38:44.780 that allows for early protected motion, and, 00:38:44.780 --> 00:38:47.860 very importantly, adherence to a rigorous therapist 00:38:47.860 --> 00:38:50.440 -guided postoperative rehabilitation program. 00:38:50.730 --> 00:38:53.530 But it's important to have realistic expectations. 00:38:53.789 --> 00:38:56.170 Yes, absolutely. It's also important for patients 00:38:56.170 --> 00:38:59.130 to have realistic expectations. Achieving a completely 00:38:59.130 --> 00:39:01.909 normal elbow with full symmetrical range of motion 00:39:01.909 --> 00:39:04.309 compared to the uninjured side is actually quite 00:39:04.309 --> 00:39:06.710 rare, even with optimal treatment. What sort 00:39:06.710 --> 00:39:09.309 of range is typical? Sources consistently cite 00:39:09.309 --> 00:39:11.690 average functional arcs of motion after surgery, 00:39:12.190 --> 00:39:15.309 typically around 110 to 115 degrees of combined 00:39:15.309 --> 00:39:17.769 flexion and extension. Often there's some degree 00:39:17.769 --> 00:39:20.010 of flexion contracture, a loss of full extension, 00:39:20.070 --> 00:39:22.869 maybe 10, 15, even 20 degrees, that persists. 00:39:23.250 --> 00:39:25.030 While not fully normal, this range of motion 00:39:25.030 --> 00:39:27.110 is usually sufficient for most activities of 00:39:27.110 --> 00:39:29.420 daily living. So it sounds like aiming for a 00:39:29.420 --> 00:39:32.000 highly functional elbow rather than a perfectly 00:39:32.000 --> 00:39:34.719 normal one is the realistic goal. That's often 00:39:34.719 --> 00:39:37.599 the case, yes. Maximizing function within the 00:39:37.599 --> 00:39:39.500 limits imposed by the injury. The source has 00:39:39.500 --> 00:39:42.219 also suggested that where you receive care might 00:39:42.219 --> 00:39:45.199 matter, the experience level. Yes, that was noted. 00:39:45.440 --> 00:39:48.360 Some sources, including the one from Mayo Clinic, 00:39:48.760 --> 00:39:50.860 have reported better outcomes in these highly 00:39:50.860 --> 00:39:54.199 complex cases when managed at higher volume centers 00:39:54.199 --> 00:39:57.860 by surgeons who have significant experience specifically 00:39:57.860 --> 00:40:00.440 in complex elbow trauma and reconstruction. It 00:40:00.440 --> 00:40:03.019 makes sense. The technical demands of these surgeries, 00:40:03.820 --> 00:40:07.420 the nuances of fixation, implant choice, ligament 00:40:07.420 --> 00:40:10.659 repair, and the careful orchestration of postoperative 00:40:10.659 --> 00:40:13.820 management likely benefit from that focused experience. 00:40:14.059 --> 00:40:17.019 That was a truly deep dive into a remarkably 00:40:17.019 --> 00:40:19.679 challenging injury. Let's try and consolidate 00:40:19.679 --> 00:40:22.000 some key facts with our lightning round. Quick 00:40:22.000 --> 00:40:24.179 questions, sharp answers based purely on the 00:40:24.179 --> 00:40:26.519 sources we've explored today. Ready? Ready when 00:40:26.519 --> 00:40:30.039 you are. Okay. What are the three essential structural 00:40:30.039 --> 00:40:32.639 components defining a terrible triad injury? 00:40:32.940 --> 00:40:35.880 That's the posterior elbow dislocation, the radial 00:40:35.880 --> 00:40:38.400 head or neck fracture, and the coronoid process 00:40:38.400 --> 00:40:41.150 fracture. Which classification system for cornoid 00:40:41.150 --> 00:40:43.289 fractures is generally considered most useful 00:40:43.289 --> 00:40:46.030 for guiding surgical planning, and why? That 00:40:46.030 --> 00:40:48.150 would be the odriscal classification, because 00:40:48.150 --> 00:40:50.969 it's based on the anatomical location, the tip, 00:40:51.210 --> 00:40:54.510 antiremedial facet, or base, which directly dictates 00:40:54.510 --> 00:40:56.730 the surgical approach and the fixation strategy 00:40:56.730 --> 00:41:00.190 needed. For a severely comminuted, irreparable 00:41:00.190 --> 00:41:03.130 radial head fracture in a terrible triad, what 00:41:03.130 --> 00:41:05.920 is the usual surgical treatment? Radial head 00:41:05.920 --> 00:41:08.780 arthroplasty, so replacement of the radial head 00:41:08.780 --> 00:41:11.260 with an implant. What forearm position is often 00:41:11.260 --> 00:41:14.559 recommended during LCL repair if the MCL is intact 00:41:14.559 --> 00:41:17.079 and what's the reasoning? Pronation is often 00:41:17.079 --> 00:41:19.639 recommended because pronation tensions the LCL 00:41:19.639 --> 00:41:22.400 and helps to reduce that tendency towards poster 00:41:22.400 --> 00:41:24.739 lateral rotation. What is the most common major 00:41:24.739 --> 00:41:27.079 complication encountered after surgical fixation 00:41:27.079 --> 00:41:30.090 of a terrible triad injury? Stiffness. or loss 00:41:30.090 --> 00:41:32.909 of motion, often due to scar tissue, capsular 00:41:32.909 --> 00:41:35.289 contracture, or sometimes heterotopic ossification. 00:41:35.610 --> 00:41:37.769 And what specific type of imaging is considered 00:41:37.769 --> 00:41:40.429 essential beyond plain x -rays for effective 00:41:40.429 --> 00:41:42.969 surgical planning? Computed tomography, the CT 00:41:42.969 --> 00:41:46.309 scan, especially valuable with 3D reconstruction 00:41:46.309 --> 00:41:48.849 views. Excellent. Those cover the core factual 00:41:48.849 --> 00:41:51.789 anchors from our comprehensive sources. To try 00:41:51.789 --> 00:41:54.590 and summarize this very complex topic into practical 00:41:54.590 --> 00:41:57.230 takeaways for you, our listener, here are five 00:41:57.230 --> 00:41:59.429 key points from this deep dive into terrible 00:41:59.429 --> 00:42:03.210 triad entries. First. Always maintain a high 00:42:03.210 --> 00:42:05.730 index of suspicion for a terrible triad following 00:42:05.730 --> 00:42:09.110 any elbow dislocation. It's a specific and severe 00:42:09.110 --> 00:42:11.309 pattern. Don't underestimate it. Crucial first 00:42:11.309 --> 00:42:13.670 step. Second, detailed imaging, particularly 00:42:13.670 --> 00:42:17.849 a CT scan, often with 3D reconstruction, is vital 00:42:17.849 --> 00:42:20.789 for accurately characterizing the complex bony 00:42:20.789 --> 00:42:23.210 injuries and planning the appropriate surgical 00:42:23.210 --> 00:42:25.070 intervention. Can't plan without the full picture. 00:42:25.250 --> 00:42:27.960 Third. Surgical treatment is necessary in nearly 00:42:27.960 --> 00:42:31.019 all cases. The main goal is to restore stability, 00:42:31.139 --> 00:42:33.619 fixing both bone and ligaments reliably enough 00:42:33.619 --> 00:42:35.920 to allow immediate, protected early range of 00:42:35.920 --> 00:42:38.420 motion. Stability for motion is key. Fourth, 00:42:38.719 --> 00:42:40.940 timely surgical management, ideally within about 00:42:40.940 --> 00:42:43.519 14 days of the injury, combined with a rigorous 00:42:43.519 --> 00:42:46.000 early post -operative rehabilitation program 00:42:46.000 --> 00:42:48.380 focused on controlled motion, are absolutely 00:42:48.380 --> 00:42:51.039 critical for optimizing recovery and minimizing 00:42:51.039 --> 00:42:53.460 that dreaded complication of stiffness. Timing 00:42:53.460 --> 00:42:56.630 and rehab are paramount. And fifth, given the 00:42:56.630 --> 00:42:58.530 intricate nature of these injuries and their 00:42:58.530 --> 00:43:01.530 demanding management, seeking care from orthopedic 00:43:01.530 --> 00:43:04.349 surgeons or centers with specific experience 00:43:04.349 --> 00:43:07.969 in complex elbow trauma can significantly influence 00:43:07.969 --> 00:43:10.650 the potential outcomes. Experience likely matters 00:43:10.650 --> 00:43:13.070 here. That brings us towards the close of this 00:43:13.070 --> 00:43:16.449 deep dive into the terrible triad. If you found 00:43:16.449 --> 00:43:18.829 this discussion valuable and insightful, please 00:43:18.829 --> 00:43:21.050 do consider rating and sharing the show on LinkedIn 00:43:21.050 --> 00:43:24.429 or X. And thank you immensely for guiding us 00:43:24.429 --> 00:43:27.050 through this really challenging orthopedic topic 00:43:27.050 --> 00:43:30.110 with such clarity and detail. It was my pleasure. 00:43:30.369 --> 00:43:32.329 A fascinating and important injury to discuss. 00:43:32.590 --> 00:43:34.849 As we conclude, here's a final thought for you 00:43:34.849 --> 00:43:36.949 to reflect on, drawing directly from the sources 00:43:36.949 --> 00:43:39.869 we've explored. Despite considerable advances 00:43:39.869 --> 00:43:42.590 in our understanding and techniques, the management 00:43:42.590 --> 00:43:45.190 of terrible triad injuries remains a profound 00:43:45.190 --> 00:43:47.929 balancing act. It truly does. It's a continuous 00:43:47.929 --> 00:43:50.750 effort by the surgical and therapy teams to achieve 00:43:50.750 --> 00:43:53.510 just enough stability to prevent re -dislocation 00:43:53.510 --> 00:43:56.449 and allow healing, while simultaneously allowing 00:43:56.449 --> 00:43:58.809 enough early motion to regain functional use 00:43:58.809 --> 00:44:01.530 and fight off stiffness. The patient's entire 00:44:01.530 --> 00:44:04.210 journey involves navigating this fine line, where 00:44:04.210 --> 00:44:06.829 the ultimate outcome really hinges on the success 00:44:06.829 --> 00:44:09.309 of both the initial surgical reconstruction and 00:44:09.309 --> 00:44:11.909 their dedicated long -term rehabilitation. A 00:44:11.909 --> 00:44:14.530 partnership between surgeon, therapist, and patient. 00:44:14.769 --> 00:44:16.670 Until next time, keep diving deep.