1. Terrible triad
Case for small group discussion: Upper extremity fractures—decision making and methods of stabilization
AO Trauma Advanced Principles Course

2. 42-year-old man, fell off his mountain bike
Isolated trauma
Nondominant arm
Neurovascular structures intact
Discussion points:
What is the injury? Identify all components. If you cannot, what imaging will you order?
What type of treatment should this fracture receive?
What type of reduction is needed: open or closed reduction?
If closed reduction is chosen should it be done in the emergency room?
Is any other information needed: CT scan?

3. Redislocated after reduction.
Point out that increased flexion can lead to greater stability, but too much flexion can impede blood flow.
Discussion points:
Discuss importance of emergent surgical reduction
What is the surgical approach?
Discuss reduction techniques?

4. Discussion points:
Discuss diagnosis after CT scan. Can you now identify all components of the injury?
Does it change your initial plan?
With a CT scan what is the surgical approach needed?
How should this fracture be treated: ORIF vs radial head arthroplasty?
How should the coronoid be managed?
Discuss management of soft tissues, and the LCL and MCL

5. Discussion points:
Discuss what has been achieved
What are the rehabilitation protocols?

6. Summary
Dislocation with fractures of the coronoid and terrible triad can be very unstable
Repair of the coronoid, restoration of radiocapitellar contact, and reattachment of the origin of the LCL to the lateral epicondyle usually restores stability
MCL repair is not usually necessary
Moderator should ask participants to summarize what else they have learned from this case.