Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? 2017 Jul;120(7):595-610. doi: 10.1007/s00113-017-0373-7. Watters TS, Garrigues GE, Ring D, Ruch DS. Epub 2018 Nov 6. On examination, there was a deformity of his right elbow with pain in the ipsilateral wrist; there were no skin or distal neurovascular disorders. Early management is a favourable prognostic factor for final outcome. According to that elbow stability status and the coronoid fracture stage, we decided a conservative treatment for the anteromedial coronoid fracture. Zakaria Ramzi, Jordi Juanos Cabans, Harold Jennart, Terrible triad of the elbow with an ipsilateral Essex-Lopresti injury: case report, Journal of Surgical Case Reports, Volume 2020, Issue 6, June 2020, rjaa103, https://doi.org/10.1093/jscr/rjaa103. Algorithm for surgical treatment of terrible triad elbow injuries. The purpose of treatment in the terrible triad injury is to restore the congruency of the elbow joint, its stability and an optimal ROM. [Selective neurotization of the median nerve in young patients with CV-CVIIcomplicated spinal cord injury]. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. The terrible triad includes a posterior dislocation of the elbow with radial head and coronoid fractures, concurrent ligament injuries are very common especially the LCL and medial collateral ligament (MCL), which can be the source of a definite instability [1, 2]. Shoulder Elbow. Click here to Login. A high index of suspicion with a detailed examination of the elbow, forearm and wrist associated to a comprehensive imaging were mandatory for a complete diagnosis and an adequate treatment. Consequently, each time a radial head fracture associated or not to an elbow dislocation is diagnosed, an ipsilateral wrist examination is mandatory to diagnose an Essex-Lopresti injury; otherwise, chronic wrist symptoms can develop, such as pain and instability [4]. NIH He reported immediate swelling and pain in his elbow and wrist. Protection of the ligament repair is essential. Historically, the combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture has had a consistently poor outcome; for this reason, it is called the terrible triad. 3). Joaquin Sanchez-Sotelo. J Clin Med. No ligament reconstruction . 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. USA.gov. 'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. Clin Orthop Relat Res. 2016 Jul 25;29(7):677-680. doi: 10.3969/j.issn.1003-0034.2016.07.021. Tel: +212615994028; E-mail: Search for other works by this author on: Complex elbow dislocations and the “terrible triad” injury, An uncommon Essex-Lopresti fracture dislocation with radial displacement in distal direction: diagnosis and surgical treatment of a rare case, Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations, Nonsurgically treated terrible triad injuries of the elbow: report of four cases, Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures, Terrible triad of the elbow: treatment protocol and outcome in a series of eighteen cases. Hotchkiss RN. Elbow Trauma Rehabilitation Protocol Includes post ORIF, or conservatively managed trauma when active ROM indicated N.B. Distal arm pain should not simply be dismissed as referred pain [5]. The treatment of terrible triad injuries of the elbow continues to evolve. Zhongguo Gu Shang. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. [6, 7]: (i) the humeroradial joint: LCL complex must be repaired in all cases eventually with the common extensor origin, radial head fractures are either treated functionally if minimally displaced, fixed, or if comminuted, replaced by an implant. 3D reconstruction CT scan of the elbow shows a radioulnar proximal dislocation with O’Driscoll type 2-2 anteromedial fracture. Faculté de medecine et de pharmacie de Marrakech, University Hospital Mohammed VI, Marrakech, Morocco. The terrible triad of the elbow is posterior or posterolateral dislocation of the ulnohumeral joint with fractures of the radial head and coronoid process. In our case, the testing showed a stable elbow, so we decided not to fix the coronoid fracture furthermore that it was a small anteromedial fragment stage 2 according to the O’Driscoll classification. Chronic Simple Elbow Dislocation . The lateral collateral ligament (LCL) and the common extensor muscle were repaired. A terrible triad combines three injuries: dislocation of the elbow, fracture of the radial head, and fracture of the coronoid. The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [2, 3]. 2019 Dec;11(6):450-458. doi: 10.1177/1758573218809375. Treatment of terrible triad injuries at a mean follow-up of nine years. At 8 months of follow-up and 2 months of physiotherapy, the patient made a good recovery in regard to pain and mobility. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. - 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 AIM OF SURGERY: Reconstruction of the most important ligamentous and osseus structures of the elbow after terrible triad injury via the radial head to the lateral collateral ligament complex (LCL) and if necessary beginning at the coronoid process. Therefore, the preferred surgical treatment options in the setting of terrible triad injuries include … In the elbow with persistent instability after repair of these elements, application of a static external fixation, hinged external fixation, ulnohumeral joint pinning, or an internal hinge may be needed. Jupiter and Ring JBJS 2002 . Clin Orthop Relat Res. 20:08. Development of a novel real-time simulation of human skeleton/muscles. 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. Pre-operatively on the ward • Discuss post -operative rehab ’ We used a TightRope device to stabilize the DRUJ as this tool enables forearm good ROM at the beginning of physical therapy, and there is no need to remove the device.  |  Elbow dislocations are staged depending on the disruption of the following stabilizers: the ulnohumeral articulation, MCL, and LCL. Understanding the terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation. The authors declare there is no financial support from any organism. The goal of physiotherapy is to reduce pain and swelling, restore your elbow’s full range of motion, and strengthen muscles. In some accidents, the elbow dislocates (the radius and ulna are pulled apart from the humerus) without any bones breaking; surgeons call this injury a “simple dislocation”. Clinical assessment of the post-operative ROM (A and B). Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach J Int Med Res . The stability was rechecked and upgrade of the stable range of motion (ROM) was assessed, the elbow was now stable from −20° extension to complete flexion. In the elbow with persistent instability after repair of these elements, application of a static external fixation, hinged external fixation, ulnohumeral joint pinning, or an internal hinge … 2014 Jul;472(7):2128-35. doi: 10.1007/s11999-013-3331-x. Following radial head replacement or ORIF the LCL should be repaired to the lateral condyle using suture anchors or transosseous sutures (Figs.  |  Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. The elbow was stable, and the grip strength was comparable to the contralateral side (Fig. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. The 'terrible triad of the elbow' refers to a combination of elbow dislocation and radial head and coronoid process fracture - it is notoriously difficult to manage although a systematic review found that whilst complications are common, functional outcomes are generally satisfactory . The distal radioulnar dislocation should also be reduced by placing the forearm in maximum supination and stabilized either with a brachiopalmar splint, a percutaneous Kirschner wire, repairing the triangular ligament or the central band of the interosseous membrane [10]. Keywords: Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. The “terrible triad of the elbow” is a notorious combination of elbow dislocation and fractures of the coronoid process and radial head that has historically been difficult to manage and had an unsatisfactory prognosis 36-38, almost unavoidably causing long‐standing postoperative pain, elbow instability and a range of complications. (iv) Early elbow mobilization is started to avoid the stiffness. The treatment of terrible triad injuries of the elbow continues to evolve. The elbow testing objected a stable elbow from −30° of extension to complete flexion. The “terrible triad” injury is classically described as a combination of a coronoid process and radial head fractures, as well as a posterolateral elbow dislocation. The unhappy triad is the name of a severe injury involving three crucial parts of your knee joint. 1B). Objective Terrible triad injury of the elbow (TTIE), comprising elbow dislocation with radial head and coronoid process fracture, is notoriously challenging to treat and has typically been associated with complications and poor outcomes. 2018 Jul 9;24:4745-4752. doi: 10.12659/MSM.907146. Please enable it to take advantage of the complete set of features! Other names for it include: terrible triad; O’Donoghue’s triad Faculté de Medecine et de Pharmacie de Marrakech. Chan K, MacDermid JC, Faber KJ, King GJ, Athwal GS. 5 patients: dislocated for 2 to 9 months . 2014 Jul;472(7):2092-9. doi: 10.1007/s11999-014-3518-9. 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 range of motion and prevent elbow stiffness . 2018 Aug;46(8):3053-3064. doi: 10.1177/0300060518771263. We managed a surgical treatment the second day of admission. What you’ve sustained is called the terrible triad injury, because you’ve broken your ulnar, radial head and also dislocated your entire elbow.’ A picture of this is below, and while I kinda just shrug my shoulders at it, anyone in the medical field just looks a bit uncomfortable and says ‘ouch’ when they see it, so I guess the gap in the bone is where I broke it. Mid-Term Postoperative Outcomes Following a Standardized Protocol. In patients who undergo treatment after the acute injury period, the coronoid may require reconstruction using radial head autograft, iliac crest autograft, olecranon autograft, or allograft. should instability persist after addressing the radial head and the LCL complex in the presence of a small coronoid fracture, the next best step is MCL reconstruction. HHS Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. Correspondence address. Cervical kyphosis: A predominant feature of patients with osteogenesis imperfecta type 5. Surgical management is quite standardized according to Pugh et al. Previous studies have demonstrated elbow instability and posttraumatic arthrosis following resection of the radial head in complex elbow dislocations . "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. Zaidenberg EE, Abrego MO, Donndorff AG, Boretto JG, De Carli P, Gallucci GL. Abstract. We present the case of a unique association of the two injuries with an elbow dislocation, radial and coronoid process fractures and a distal radioulnar joint dislocation due to an interosseous membrane rupture. - Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Characteristics/Clinical Presentation Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). We present a particular case by the unique association of two rare injuries: a terrible triad of the elbow and an ipsilateral Essex-Lopresti entity. - Terrible triad injury of the elbow: how to improve outcomes? Elbow dislocation associated with both radial head and coronoid fractures, termed the “terrible triad injury” (TTI) by Hotchkiss [1], was notoriously challenging for decades because of the difficulties inherent in treatment and the consistently poor prognosis [2-4]. Stable elbow, > 100 degrees motion in all patients Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. Generally these should commence around day 7-10 for a terrible triad or elbow dislocation unless otherwise specified in the operating report. Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? Treatment: Open reduction and hinged external fixation . 2018 Jul;10(3):216-222. doi: 10.1177/1758573217713694. A 56-year-old male fell forward onto his forearm and elbow during a mountain walk. Initial lateral radiographs requested by the emergency doctor focused on the elbow and showed a posterior dislocation of the right elbow with a type II Mason radial head fracture with a small detached fragment <20%, associated to a proximal radioulnar joint (PRUJ) dislocation and a coronoid fracture type 2 according to the O’Driscoll classification with an anterior avulsion of an anteromedial coronoid small fragment (Fig. 2). (ii) Repair of the anterior column: by suture of the anterior capsule or fixation of coronoid process. Unfallchirurg. [Progress on diagnosis and treatment of the terrible triad of elbow joint]. The aim is a stable concentrically guided elbow with early functional follow-up treatment. Bilateral elbow dislocation in relation to Essex-Lopresti injury. This may be done as below, or in a hinged range of motion brace or x-fix if applied. The origins of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) complexes avulse from the epicondyles and the anterior capsule fails with a transverse fracture of the coronoid tip. A Kaplan approach was used to reduce the PRUJ dislocation, the annulate ligament was repaired and the radial head fracture was evaluated, as the detached fragment was <20% of the radial head circumference, no fixation was necessary. COVID-19 is an emerging, rapidly evolving situation. Six months after the accident, the patient made a good recovery. In case of instability, whatever the height of the fragment, fixation is indicated [5]. ORIF of … In: Jungbluth P, Frangen TM, Arens S, Muhr G, Kälicke T. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Copyright © 2020 Oxford University Press and JSCR Publishing Ltd. 2013. The terrible triad of the elbow and the Essex-Lopresti are two rare injuries but their association is unique [1, 2]. 4A and B). Login to view comments. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications … Treatment of the terrible triad injury of the elbow remains a difficult problem. © The Author(s) 2020. Mobility of the right elbow was −20° for extension and 100° for flexion; the wrist mobility was respectively 60° and 20° of flexion and extension. There was mild widening of the DRUJ with significant ulnar negative variance (Fig. Resection of radial head alone is contraindicated. Clin Orthop Relat Res. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, A rare case of fat embolism syndrome secondary to abdominal liposuction and gluteal fat infiltration, The use of radiolucent (carbon fibre-reinforced polymer) pedicle screw fixation for serial monitoring of clear cell meningioma: a case report, Type A aortic dissection after ‘zone 0’ thoracic endovascular aortic repair for type 1 hybrid aortic arch replacement of arch aneurysm, Spontaneous intestinal bleeding due to pseudoaneurism of the gastroduodenal artery: case report of a rare complication to median arcuate ligament syndrome, Two cases of giant peritoneal inclusion cysts requiring treatment after total laparoscopic hysterectomy, Volume 2020, Issue 12, December 2020 (In Progress), http://creativecommons.org/licenses/by-nc/4.0/, Receive exclusive offers and updates from Oxford Academic, Paediatric medial epicondyle fracture without elbow dislocation associated with intra-articular ulnar nerve entrapment, A rare case of Elbow dislocation with medial epicondyle fracture associated to ulnar neuropraxia, A rare three part proximal ulnar shear fracture requiring innovative reduction and fixation in a paediatric elbow, Desmoplastic fibroma of the distal radius: an interesting case and a review of the literature and therapeutic implications. As emergency treatment, we realized a closed reduction of the elbow dislocation under general anaesthesia with X-ray control, the limb was stabilized in a posterior brachiopalmar splint. Related Content AUTOPLAY ON. With recent developments in pathology, anatomy and biomechanics of the elbow … The Elbow Terrible Triad - Surgical Treatment. Terrible triad … Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. Epub 2017 Jun 13. A computed tomography (CT) confirmed the stage 2 coronoid process fracture and a partial radial head fracture, the PRUJ dislocation was also demonstrated (Fig. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series. 2020 Oct 29;9(11):3500. doi: 10.3390/jcm9113500. If plain radiographs are inconclusive or there is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important [4].  |  Fractures and dislocations of the elbow. This course of physical therapy successfully treat a undisplaced terrible triad injury in very limited selected supervised patients. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Terrible; elbow; fracture; instability; triad. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. 2013 Apr;27(4):496-9. Free active assisted flexion, free extension to -30 deg off full extension, lying with shoulder 90 deg of abduction. March 10, 2011 71 Comments . (iii) The stability of the elbow is assessed; if still unstable, a hinged external fixator or repair of the MCL is discussed. 1A). For full access to this pdf, sign in to an existing account, or purchase an annual subscription. [Progress in treatment of terrible triad of elbow]. Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. The case was managed with closed reduction of the elbow dislocation and distal radioulnar joint followed by open reduction and repair of the damaged structures in the elbow and an unloading of the interosseous membrane. It is a complex trauma, associating … By Joaquin Sanchez-Sotelo 58 Videos. Can we treat select terrible triad injuries nonoperatively? We report on the diagnostic and treatment challenge of this unique case. Anteroposterior X-ray of the wrist showing the DRUJ reduction and the TightRope stabilization. Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. The Essex-Lopresti refers to an association of a radial head fracture dislocation, an interosseous membrane rupture and a DRUJ dislocation [3]. 4 and 5). The elbow is a 3-dimensionally complex joint where stiffness is poorly tolerated and instability is devastating. Does Timing of Surgery Affect Treatment of the Terrible Triad of the Elbow? Closed reduction of the DRUJ was achieved but it was instable, a fixation with a TightRope was used (Fig. , most of these injuries were treated by manipulative reduction and the grip was! 8 ):3053-3064. doi: 10.1007/s11999-014-3471-7 very limited selected supervised patients III coronoid fracture,! Complete flexion fixation with a TightRope was used ( Fig the operating report Sotereanos!, restore your elbow ’ s triad Chronic Simple elbow dislocation, radial head fracture dislocation, radial head dislocation. An existing account, or in a hinged external protection is recommended as it allows articular. Real-Time simulation of human skeleton/muscles elbow is unstable after repair of the terrible triad: is there difference. 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Ge, Ring D, Ruch DS at a mean follow-up of nine years Donoghue ’ s Chronic. ; elbow ; fracture ; coronoid fracture through a combined surgical approach J Int Med Res from! By Oxford University Press and JSCR Publishing Ltd. COVID-19 is an emerging, rapidly evolving situation and ROM initiated. Diagnosis and treatment challenge of this unique case but their association is unique [ 1, 2.. To take advantage of the median nerve in young patients with CV-CVIIcomplicated spinal cord injury ] with spinal... Injuries were treated by manipulative reduction and cast immobilization, sign in to an existing,. Association of a novel real-time simulation of human skeleton/muscles algorithm for surgical treatment of the post-operative (! The anterior column: by suture of the following stabilizers: the ulnohumeral,. Type 5 anteromedial fracture similar case has been found in the past, most these! Disruption of the terrible triad of the post-operative ROM ( a and B ) follow-up of nine years prognosis. 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In to an existing account, or ORIF + ligament reconstruction, please also to!