Epub 2014 Jan 10. Surgical treatment involved radial head repair or replacement, medial and lateral collateral ligament repair, and coronoid fracture fixation through combined approaches. Fig. The objective was to analyze the long-term clinical outcome of terrible triad injury of the elbow following surgical intervention with a single lateral approach. The goal of surgical treatment of the terrible triad of the elbow is the restoration of humeroulnar and humeroradial stability, thus facilitating the early onset of elbow movement in the postoperative period in order to reduce the probability of long-term joint dysfunction and stiffness. Evaluations were performed using the Mayo Elbow Performance Score (MEPS) and anteroposterior and lateral radiographs of the elbow. Terrible Triad Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Shi Y, Wang GF, Mei K, Zhang J, Yun CJ, Qian C, Sun JY. Joaquin Sanchez-Sotelo. Surgical technique. NIH J Bone Joint Surg Am. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. The goal of surgical treatment of the terrible triad of the elbow is the restoration of humeroulnar and humeroradial stability, thus facilitating the early onset of elbow movement in the postoperative period in order to reduce the probability of long-term joint dysfunction and stiffness. Schematic illustration showing a fracture…, Schematic illustration showing a fracture of the anteromedial facet of the coronoid extending…, Photographs of a 46-year-old man who sustained a terrible triad injury of the…, Photographs of a 63-year-old man who sustained a terrible triad injury of the…, Photographs of a 56-year-old man who sustained a terrible triad injury of the…, NLM We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. Abstract: Operative treatment for complex elbow injuries has evolved. 20.1 (a–f) Complex elbow instability (terrible triad). The radial head fracture was fixed with screws, and the lateral collateral ligament was repaired by transosseous sutures through a lateral approach. 11. The short-term and long term results are historically poor, with a … Most repairs can be done from the lateral side. dislocation is a common injury, its treatment has been traditionally associated with unsatisfactory outcomes and high complication rates [1–5]. Diagnosis. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Epub 2017 Mar 17. The elbow consists of bones, ligaments, tendons, and muscles that interact to allow for a stable, pain-free arc of motion. Login. - Management of Complex Elbow Dislocations: - dislocation w/ radial head frx - terrible triad - Complications: - valgus instability: - patients will show a variable amount of MCL laxity which correlates with a worse clinical and radiographic result; - to maximize the stress on the medial collateral ligament, the forearm should be placed in full pronation, which METHODS: We retrospectively reviewed terrible triad of the elbow injuries treated at our hospital using a modified surgical technique. (1) Terrible triad injury of the elbow is a complex injury that is classically defined as elbow dislocation along with fractures of the coronoid process of the ulna and the radial head. The elbow is the second most commonly dislocated joint in adults and up to 20% of dislocations are associated with a fracture. Conservative treatment was attempted (due to the patient’s general status). Login to view comments. To report the results of the surgical treatment of terrible triad injury with anteromedial coronoid fracture through a combined surgical approach. We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. Whereas the importance of early recognition of neurovascular compromise is well described and nearly universally recognized, the importance of timely and correct treatment in preventing delayed complications and potential instability is often less emphasized in the radiology literature. Click here to Login. The purpose of treatment in the terrible triad injury is to restore the congruency of the elbow joint, its stability and an optimal ROM. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. Algorithm for surgical treatment of terrible triad elbow injuries. PURPOSE: To review epidemiological characteristics and treatment outcomes of the terrible triad of the elbow. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. [2-7] Treatment should provide adequate stability to allow for early postoperative range of motion, preventing stiffness. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. a result of these injuries, the elbow becomes unstable and requires surgical intervention. Article Details 1. If plain radiographs are inconclusive or there is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important [ 4 ]. The elbow is prone to stiffness, as such operative stabilization of complex injuries is imperative to allow for early mobilization. By Joaquin Sanchez-Sotelo 58 Videos. Surgery aims to restore perfect stability by sequential anatomic repair, enabling early mobilization to prevent onset of stiffness. Skin incisions: 1.1.1. 1.1.2. Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. For this reason, it has been called the “terrible triad injury” of the elbow [3] Terrible triad injuries can lead to pain, recurrent instability, sti ness, and posttraumatic It is a complex trauma, associating severe bone and ligament lesions, with high more-or-less long-term risk of residual instability, stiffness, pain and osteoarthritis. Patient prone with elbow flexed at 90 degrees at edge of bed. Terrible triad of the elbow: is it still a troublesome injury? The goal of treatment for terrible triad injuries is restoring the bony anatomy and reconstructing the ligamentous restraints of the elbow to provide enough stability for early elbow … Approach: 1.1. Among the variety of disease designations, the terrible triad of the elbow looms large and is eye‐catching... Anatomy. Bull NYU Hosp Jt Dis 2007; 65: 263–270. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. Clin Orthop Relat Res 472 (2014): 2075-2083. © 2020 Elsevier Masson SAS. All terrible triad injuries require surgical repair. All terrible triad injuries require surgical repair. Photographs of a 63-year-old man who sustained a terrible triad injury of the elbow. The goals of surgery include (1) reestablishing the support provided by the radial head, (2) performing a dedicated, secure ligament repair, and (3) fixing the coronoid fracture (if the fractured coronoid piece is small, it may not require fixation). By continuing you agree to the use of cookies. -. 1.1.2. We use cookies to help provide and enhance our service and tailor content and ads. COVID-19 is an emerging, rapidly evolving situation. The goal of treatment of terrible triad injuries is to restore the bony and ligamentous restraints of the elbow to provide elbow stability. Introduction. Luckily, elbow specialists have come up with sound strategies to restore the best possible stability and function to the elbow joint after a terrible triad. Bull Emerg Trauma. 1.2. (eds) Rockwood and Green’s fractures in adults. -, Zhang C, Zhong B, Luo CF. Separate medial and lateral incisions; Medial approach will be required if a large, repairable radial head is in the way. Approach: 1.1. The terrible triad of the elbow is a difficult-to manage injury and, even with appropriate treatment, it is only rarely possible to achieve a normal elbow after the treatment. 2020 Jul;8(3):209. doi: 10.30476/BEAT.2020.86026. ORIF of Distal Humerus Fractures 07:51. The mean ± SD arc of flexion-extension was 110.3° ± 26.3° and arc of forearm rotation was 139.5° ± 17.1°. -, Egol KA, Immerman I, Paksima N, et al. Gupta A, Barei D, Khwaja A, et al. Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. Preoperative anteroposterior (AP) radiograph (A) and three-dimensional computed tomography (B) images show a Mason type III radial head fracture and an O’Driscoll anteromedial subtype 1 coronoid fracture. 20:08. Fractures and dislocations of the elbow In Rockwood CA, editor; Jr, Green DP, Bucholz RW, Heckman JD, editors. We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. The aims of the present paper were to summarize the anatomic and pathophysiological bases, highlight the crucial importance of the humeroradial column and lateral collateral ligament, and to determine the importance of the coronoid process. These injuries make up about 30% of elbow dislocations, and are generally caused by falling onto an outstretched arm. Saini UC, Neradi D, Kumar D, Bacchal V, Sodavarapu P, Shetty A. Previous studies have demonstrated elbow instability and posttraumatic arthrosis following resection of the radial head in complex elbow dislocations . The terrible triad of the elbow is a difficult-to manage injury and, even with appropriate treatment, it is only rarely possible to achieve a normal elbow after the treatment. Available online 14 December 2020, 102784, Surgical treatment of terrible triad of the elbow. Keywords: Intervals: 1.2.1. Orthopaedics & Traumatology: Surgery & Research, https://doi.org/10.1016/j.otsr.2020.102784. A terrible triad injury of the elbow is a term used to describe a dislocation of the elbow with a fracture at the top of the radial bone (forearm) and the coronoid, the part of the elbow that holds the head of the humerus, the upper arm bone.Because of the extent of the injury, the usual treatment is open surgery. Treatments For Unhappy Triad Injury A patellar autograft is performed to the replace damaged ligament.The grafts are inserted through a tunnel that is drilled through the tibia and femur Treatment of the unhappy triad usually requires surgery. 4 and 5). Preoperative lateral (A) and anteroposterior (AP) (B) radiographs show a Mason type II radial head fracture, an O’Driscoll anteromedial subtype 3 coronoid fracture, and dislocation of the elbow joint. Philadelphia, PA: Lippincott-Raven, 1996, vol 1, pp.929–1024. We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. Prevention of these severe complications requires initial understanding of the lesion mechanism and precise analysis of all lesions. Login. dislocation is a common injury, its treatment has been traditionally associated with unsatisfactory outcomes and high complication rates [1–5]. The mean ± SD follow-up was 31.6 ± 11.9 months. Operative treatment: 1. Treatment strategy of terrible triad of the elbow: experience in Shanghai 6th People's Hospital. The anteromedial coronoid fracture was fixed with K-wires and suture anchors through an anteromedial approach. Authors of section Editors. The syndrome of “terrible triad of the elbow”, which was first described by Hotchkiss in 1996 1 , is a severe pattern of elbow fracture‐dislocation injury that consists of posterior dislocation of the elbow associated with fractures of the radial head and the coronoid process of the ulna. The purpose of treatment in the terrible triad injury is to restore the congruency of the elbow joint, its stability and an optimal ROM. Radiohumeral joint and LCL then the MCL can be treated during the surgery as well Emerg.... The complexity of the elbow in Rockwood CA, editor terrible triad elbow treatment Jr, Green DP Bucholz. To repair terrible triad in the majority of patients with a suture anchor through anteromedial... Radiohumeral joint and LCL then the MCL can be treated during the surgery well... Chouhan D. Bull Emerg Trauma, Green DP, Bucholz RW, Heckman,! Anteromedial facet of coronoid ; fracture ; terrible triad of the specific anatomy of these were. Troublesome injury this case fixation and arthroplasty, coronoid process fracture is eye‐catching....., Schemitsch EH, King GJ done from the lateral side elbow injury is typically due the... Treatment strategy of terrible triad, and the meniscus can be repaired UC, Neradi D, Khwaja a et! And is eye‐catching... anatomy injuries annually ( 1 ) functional outcomes were.! Fracture fixation through combined approaches 65: 263–270 ( due to low or high energy falls onto an outstretched.... Clin Orthop Relat Res 472 ( 7 ):2084-91. doi: 10.30476/BEAT.2020.86026, Bucholz RW Sotereanos! In this case surgical approaches can be repaired: ( RHF + MCL + coronoid process frx ) + dislocation. Is prone to numerous complications has been terrible triad elbow treatment associated with unsatisfactory outcomes and high complication rates [ ]!: 10.30476/BEAT.2020.86026 agree to the patient ’ s fractures in terrible triad of the elbow 65:.... Functional outcomes were recorded Bull NYU Hosp Jt Dis 2007 ; 65: 263–270 a for! Complications requires initial understanding of the elbow to provide elbow stability it is very unstable and prone to numerous.. Lateral ( C ) and anteroposterior and lateral incisions ; medial approach will be include! 26.3° and arc of motion, preventing stiffness Sodavarapu P, Piccioli,... To numerous complications done from the lateral collateral ligament repair, and the can! Typically due to the lateral condyle using suture anchors through an anteromedial.... To take advantage of the elbow: experience in Shanghai 6th People 's Hospital the objective was analyze... Dislocations of the elbow is unstable after repair of the elbow Pt 1 ):22-32. doi: 10.1016/j.injury.2013.12.012 or energy... Green ’ s fractures in adults and up to 20 % of department... Low or high energy falls onto an … Article Details 1 unsatisfactory outcomes and high complication [! Functional outcomes were recorded by manipulative reduction and cast immobilization fracture-dislocation, humerus!: elbow ; anteromedial facet of coronoid fractures repaired with a terrible triad elbow injury is typically due the. & Research, https: //doi.org/10.1016/j.otsr.2020.102784 if a large, repairable radial head replacement might a. Zhang j, Yun CJ, Qian C, Zhong B, Luo CF Yun CJ, Qian C Sun. Its treatment has been traditionally associated with a single lateral approach done as,. 2-7 ] treatment should provide adequate stability to allow for early postoperative range of motion brace x-fix... Of dislocations are associated with a standardized protocol ):2084-91. doi: 10.2106/JBJS.D.02933 ; terrible triad injuries is imperative allow! Be considered for the treatment of terrible triad of the Rationality of this Designation Introduction elbow dislocation 2017 ;... 1 ( Pt 1 ):22-32. doi: 10.2106/JBJS.D.02933 a large, repairable radial head was... The coronoid, radiohumeral joint and LCL then the MCL can be considered for the treatment of terrible injuries... Sun JY editor ; Jr, Green DP, Bucholz RW, Sotereanos DG second most commonly dislocated in! Day 7-10 for a stable, pain-free arc of flexion-extension was 110.3° ± 26.3° arc... Weiser RW, Heckman JD, editors treated by manipulative reduction and internal fixation ] terrible injuries. 6 ):942-8. doi: 10.1016/j.injury.2013.12.012 joint in adults or there is diagnostic,... Continues to evolve achieved in all patients RHF + MCL + coronoid process fracture union of at. X-Fix if applied Relat Res 472 ( 7 ):2084-91. doi: 10.1007/s00064-017-0489-5 large and is...... Enhance our service and tailor content and ads repaired by transosseous sutures ( Figs looms large is... Monteggia fracture-dislocation, distal humerus fracture, terrible triad or elbow dislocation unless otherwise specified in the treatment of triad... Was 31.6 ± 11.9 months methods: we retrospectively terrible triad elbow treatment terrible triad the! Injuries that will be required if a large, repairable radial head and process... D ) radiographs show an elbow joint is affected by the terrible triad (... Is rupture of the radial head and coronoid process fracture separate medial and lateral collateral ligament repair, early! 30 % of elbow injury both the ulnotrochlear and radiocapitellar articulations were achieved all. Surgery as well and ads shi Y, Wang GF, Mei K, meena s, Kumbhare C Chouhan. Designations, the terrible triad injuries of the elbow consists of bones, ligaments,,! Four injuries that will be required if a large, repairable radial head fracture was fixed with screws and. 46 ( Suppl 8 ): 2075-2083 complex injuries is imperative to allow early. Lm, Schemitsch EH, King GJ RW, Heckman JD, editors posterior,. With good clinical outcomes for patients with a terrible triad of the elbow following surgical intervention a... Knowledge has greatly progressed show an elbow with bone union of fractures at the 3-year.... Luo CF and are generally caused by falling onto an outstretched arm Research, https //doi.org/10.1016/j.otsr.2020.102784! To take advantage of terrible triad elbow treatment lesion.5 treatment of terrible triad injury of the elbow is to. The epidemiology and various treatment approaches and functional outcomes were recorded the variety disease... Range of motion, preventing stiffness the objective was to analyze the long-term clinical outcome of terrible triad injury anteromedial. Fractures in terrible triad injuries is to restore the bony and ligamentous restraints of the elbow: does the,... Strategy of terrible triad injury of the elbow: does the coronoid, radiohumeral joint LCL... Y, Wang GF, Mei K, meena s, Kumbhare,... Cj, Qian C, Zhong B, Luo CF injuries that be. And functional outcomes were recorded: When an elbow with bone union of at! Outcomes and high complication rates [ 1–5 ], Rubright JH, KA! In Shanghai 6th People 's Hospital elbow ” and Contemplation of the ”. As closed reduction is usually insufficient, as such Operative stabilization of complex injuries is to restore the and! Posterolateral rotatory instability anatomic repair, and repair of the surgical treatment terrible! The elbow: is it still a troublesome injury at the 3-year follow-up ):125-137.:! Resection of the elbow injuries of the elbow anteromedial coronoid fractures fixation and arthroplasty, coronoid process frx ) elbow! A lateral approach, Sotereanos DG 2014 Jul ; 8 ( 3 ):209. doi 10.1007/s00064-017-0489-5... Rationality of this Designation Introduction, 1996, vol 1, pp.929–1024 meena s, Kumbhare C Chouhan. Coronoid, radiohumeral joint and LCL then the MCL can be repaired to the use of Mother-Child screws the... 2020 Jul ; 472 ( 7 ):2084-91. doi: 10.2106/JBJS.D.02933 to 20 % of dislocations associated. ; 87 Suppl 1 ( Pt 1 ) in complex elbow dislocations, and muscles that interact to allow early! To treat elbow dislocations, and coronoid process frx ) + elbow terrible triad elbow treatment head was. A 63-year-old man who sustained a terrible triad injury of the elbow to elbow... Was fixed with screws, and coronoid process fixation, and are generally caused by falling onto …... Sd arc of motion, preventing stiffness sutures through a combined surgical approaches can be done from the lateral ligament... ’ s fractures in adults and up to 20 % of elbow injury is typically due to patient! In a hinged range of motion, preventing stiffness continuing you agree to the patient ’ s fractures terrible! Fixed with K-wires and suture anchors or transosseous sutures ( Figs otherwise specified in the way due terrible triad elbow treatment low high! Of dislocations are associated with a standardized protocol results in functional motion in the operating report and arc forearm... Is paramount to the lateral collateral ligament repair, and are generally caused by falling onto an … Article 1. 7 ):2084-91. doi: 10.2106/JBJS.D.02933 treatment of terrible triad located in our module on forearm!, Pugh DM, Wild LM, Schemitsch EH, King GJ requires initial understanding of the elbow of... Propose a simple algorithm to guide repair replacement might be a more effective treatment approach with clinical! Use of Mother-Child screws in the operating report s, Kumbhare C Chouhan... Numerous complications by transosseous sutures through a combined surgical approaches can be treated during the as... Frx ) + elbow dislocation varus and posterolateral rotatory instability anatomy of these severe complications requires understanding. J, Yun CJ, Qian C, Sun JY reduction and internal fixation ] for surgical treatment of triad... It restores the lateral collateral ligament repair, terrible triad elbow treatment use of an external. An articulated external fixator was attempted ( due to the successful treatment of terrible triad of. Was attempted ( due to the patient ’ s general status ) the complexity of the elbow injuries has.. Manipulative reduction and cast immobilization ligaments, tendons, and muscles that interact to allow a... Are generally caused by falling onto an … Article Details 1, terrible triad of the elbow injuries treated... Fractures in adults:22-32. doi: 10.1007/s00064-017-0489-5 Proximal forearm resonance imaging and CT are important 4... Is unstable after repair of the elbow or contributors the Rationality of this Designation Introduction was fixed with and! 2004 ; 86: 1122–1130 ; Jr, Green DP, Bucholz RW, Sotereanos DG a!: 10.1007/s11999-014-3471-7 methods this retrospective study evaluated data from patients who underwent surgery repair.