Management of a Rare Complex Triad Injury of the Elbow Joint: Radial Head Fracture,Triceps Tendon Avulsion,and Rupture of the Medial Collateral Ligament

Abstract

Background:

Isolated triceps tendon injuries are infrequent, and their combination with a medial ligament avulsion is even rarer. Eccentric force on the triceps tendon following a fall on the outstretched hand, combined with a valgus torque at the elbow joint, exposes the medial side to stretching forces, potentially disrupting the ulnar collateral ligament (UCL). Furthermore, compressive forces on the lateral side could result in injury to the radial head. Currently, there is no standardized surgical approach for managing such combined injuries.

Indications:

The complex triad injury presented in this publication is debilitating and warrants primary surgical intervention to restore stability and function of the afflicted elbow.

Technique Description:

A slightly curved posterior skin incision is made, creating medial and lateral full-thickness skin flaps. The ulnar nerve is explored and tagged with a vessel loop for protection without a full release. Palpation of the medial joint capsule reveals a rupture of the medial collateral ligament. The radial head is palpated during forearm rotation. The fascia overlying the radial head is incised along with the annular ligament. The radial head fracture is debrided and provisionally fixed with a 1.6-mm K-wire and then stabilized with two 2.0-mm mini screws. The bony origin of the triceps tendon is scraped to remove debris. A V-shaped triceps tendon repair is performed using two 3.5-mm titanium Twinfix suture anchors. A Krackow-type suture is placed medially, laterally, and centrally on the tendon. The tendon is reduced and fixed with a 1.8-mm K-wire, which is then replaced by a button fixation. The UCL tear is identified as a humeral avulsion and repaired using two 3.5-mm titanium Twinfix suture anchors. The triceps fascia, annular ligament, and overlying fascia are then repaired, and the wound is closed in layers after thorough irrigation.

Results:

Repair of all 3 injuries was successfully accomplished through the same approach, with initial postoperative follow-up showing active free supination/pronation and passive flexion limited to 70°.

Discussion/Conclusion:

The described surgical technique provides a comprehensive approach to addressing the rare and complex injuries involving the radial head, triceps tendon, and medial collateral ligament. This article includes practical tips and tricks to ensure successful execution of the procedure.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

Hi everyone, this is Dr. Shekhbihi from the trauma surgery department at the Lörrach District Hospital, and I will be presenting our surgical technique for managing a rare complex triad injury to the elbow joint comprising radial head fracture, triceps tendon avulsion, and rupture of the medial collateral ligament.

We have no disclosures.

Background and Indications

Isolated triceps tendon injuries are rare,^1,3 and their combination with medial ligament avulsion and radial head fractures is even more uncommon. The presumed mechanism of injury involves eccentric force on the triceps tendon following a fall on the outstretched hand, coupled with a valgus torque at the elbow joint. This places the medial side under stretching forces, potentially leading to disruption of the ulnar collateral ligament (UCL). Moreover, compressive forces on the lateral side may result in a radial head fracture. Currently, there is no standardized surgical approach for managing such combined injuries.

We present a case of a 42-year-old female patient, a busy office manager, who fell from a bike on the outstretched right hand. She reported experiencing a sensation of the elbow joint “popping out” followed by spontaneous reduction.

Upon presentation, the patient displayed joint effusion accompanied by a superficial hematoma located on the posterior aspect of the elbow joint. Significant pain led to a pronounced restriction in the initial range of motion observed in the right elbow joint.

Anteroposterior and lateral radiographs revealed a fracture of the radial head. The presence of the “flake sign” indicated an avulsion of the triceps tendon. The osseous lesions observed over the medial epicondyle raised suspicion of injury to the UCL. Computed tomography scans with 3-dimensional reconstruction confirmed the suspicion of UCL tear and associated lesions. The radial head fracture was classified as Mason type II.

So, the decision was made to reduce and fix the radial head fracture due to fracture displacement and articular step-off and to repair the triceps tendon and the UCL tear, both with suture anchors.

The examination under general anesthesia indicated medial instability of the elbow joint under valgus load.

Technique Description

The patient is positioned prone with the elbow flexed at 90° over a support. A tourniquet is not employed for this procedure. The anatomic landmarks are drawn, and a gently curved posterior skin incision is made. Following superficial dissection, medial and lateral full-thickness skin flaps are created. The tricipital bursa overlying the tendon is excised to achieve optimal visualization. A complete mediolateral rupture of the common superficial triceps tendon is identified. Next, the ulnar nerve is carefully explored along its medial course at the elbow without undergoing a full release. The nerve is delicately tagged with a vessel loop to ensure its protection throughout the surgery. Palpation of the medial joint capsule facilitates insertion of the thumb into the joint, confirming the rupture of the medial collateral ligament.

Attention is then directed toward the radial head by palpating it while repeatedly rotating the forearm. Further dissection of the lateral flap is performed as necessary, followed by incision of the fascia overlying the radial head and the annular ligament. The circumference of the radial head is explored, revealing clear evidence of articular step-off and displacement. The fracture is meticulously debrided using a dental hook and temporarily fixed with a 1.6-mm K-wire. At this stage, all 3 lesions, the radial head fracture, triceps tendon avulsion, and the rupture of the medial collateral ligament, are identified. The radial head fracture is fixed with two 2.0-mm mini screws, providing excellent stability.

The bony origin of the triceps tendon is now scraped with a bone curette to remove excess debris that could potentially hinder the healing process. A V-shaped triceps tendon repair is then performed following the technique described by Scheiderer et al. ² Two 3.5-mm titanium Twinfix suture anchors (Smith & Nephew) are placed proximally to the margin of the bony origin of the triceps tendon. A Krackow-type suture is then executed incorporating the medial, lateral, and central aspects of the tendon, beginning and ending just proximal to its footprint. The free limbs of each suture are passed through the triceps tendon adjacent to the proximal footprint line. The triceps tendon is then reduced by tensioning the sutures to the footprint and temporarily fixed with 1.8-mm K-wire. The related sutures are then tied. Four centimeters below the distal footprint, a 3.2-mm hole is drilled into the posterior cortex at an angle of 45° to the shaft axis. The intramedullary canal is then compressed with a clamp to create space for the button implantation (BicepsButton; Arthrex). The button is then loaded with all 4 suture limbs, passed through the posterior cortex, and flipped in the medullary canal. The K-wire is then removed, and each suture is firmly tightened and then tied with half-hitch knots.

Turning back to the UCL, the tear is identified to be a humeral avulsion. Using two 3.5-mm titanium Twinfix suture anchors (Smith & Nephew), loaded with a nonabsorbable suture, reinsertion of the UCL to the humeral footprint at the anterior-inferior surface of the medial epicondyle is accomplished. Finally, closure of the triceps fascia and repair of the annular ligament and the overlying fascia are performed. After thorough irrigation, the wound is closed in layers. Intraoperative fluoroscopy demonstrated satisfactory reduction of the radial head fracture, restored joint congruity, and regained stability of the right elbow joint.

Discussion

As for potential complications related to this surgical procedure, injury to the lateral UCL during posterior exposure of the radial head can be avoided by performing a careful dissection and proper hemostasis for optimal visualization. Also, injury to the ulnar nerve can be avoided by identifying and securing the nerve with a vessel loop for careful management during the procedure.

The rehabilitation protocol includes placing the arm in an upper arm splint for comfort 2 to 3 days postoperatively. Then a hinged arm splint is applied, restricting flexion at 70°. Flexion is gradually increased by 30° every 2 weeks. Pronation and supination against resistance are prohibited for 4 weeks. Full range of motion is allowed after 6 weeks, and progressive resistance exercises are initiated as tolerated.