OKOJ

OKOJ, Volume 6, No. 9


Current Concepts in Management of the Terrible Triad Elbow Injury

Posterior dislocation of the elbow with associated fractures of the coronoid process and radial head has been termed the"terrible triad"because of the many challenges encountered in its management. There has been little discussion of these injuries in the literature, particularly with regard to patterns of injury, decisions regarding treatment, surgical tactics, and outcomes. However, with recent advances in our understanding of elbow biomechanics, improved imaging, and better implant and prosthesis designs, a systematic approach to treatment of the terrible triad injury can now be employed. This includes fixation or replacement of the radial head, fixation of the coronoid fragment, repair of the lateral collateral ligament complex, and repair of the medial collateral ligament and/or application of a hinged external fixator for patients with residual instability.

    • Keywords:
    • radial head fracture

    • coronoid fracture

    • complex elbow dislocation

    • fracture-dislocation of the elbow

    • elbow instability

    • Subspecialty:
    • Shoulder and Elbow

Medial Instability of the Ankle

Patients with medial instability of the ankle report a feeling of giving way, especially medially, when walking on uneven ground, downhill, or down stairs; pain at the anteromedial aspect of the ankle; and sometimes pain in the lateral ankle, especially during dorsiflexion of the foot. A history of chronic instability manifested by recurrent injuries with pain, tenderness, and occasionally bruising over the medial and lateral ligaments indicates combined medial and lateral instability that is believed to result in rotational instability of the talus in the ankle mortise. Acute injuries to the medial ankle ligaments (deltoid ligament complex) occur much less frequently than do injuries to the lateral ligaments. Typically, the foot was on the ground when an eversion force caused a valgus stress to the ankle, or an internal rotation force caused a pronation stress to the hindfoot. The injury can also occur in association with a lateral ankle fracture. Conservative treatment, including shoe modifications and orthotics with medial arch support, physiotherapy to strengthen the tibialis posterior muscle, and proprioceptive training, is advised as a first measure. If the symptoms of giving way and medial ankle instability persist, surgical treatment should be considered. Options for surgery include medial ligament repair for acute injuries, lateral ligament reconstruction for rotational instability, and calcaneal lengthening osteotomy for preexisting valgus/pronation deformity.

    • Keywords:
    • deltoid ligament injury

    • medial ankle instability

    • chronic ankle sprain

    • chronic ankle instability

    • chronic medial ligament instability

    • rotational ankle instability

    • Subspecialty:
    • Foot and Ankle

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