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.