NIH Eleven patients (28%) underwent reoperation (seven arthroplasty, four ORIF) for various reasons. 2020 Jun 21;2020:6508781. doi: 10.1155/2020/6508781. Anterior . Dislocation + radial head fracture . In this review, the classification, treatment principles and prognosis for different forms It is considered severe by many clinicians because it is difficult to repair terrible triad of the elbow.6,7 Its prognosis remains uncertain, especially over the long term.6 The objective of the present study was to evaluate the results from surgical treatment of the terrible triad of the elbow, with at least six the Skill level. [Progress in treatment of terrible triad of elbow]. A bump is placed under the humerus with the elbow extended and forearm supinated. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Because case series are relatively small, it is difficult to estimate the incidence of complications. Conclusions: COVID-19 is an emerging, rapidly evolving situation. Clin Orthop Relat Res. 2014 Jul. The terrible triad of the elbow is characterized by great potential for joint instability and an unfavorable prognosis.1, 5Surgical treatment is the therapy of choice in the vast majority of cases, with the aims of restoration of the anatomy and early mobility. terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation. Gupta A, Barei D, Khwaja A, Beingessner D. Clin Orthop Relat Res. 2020 Aug 1;5(7):398-407. doi: 10.1302/2058-5241.5.190055. The adjective terrible is bestowed on an elbow triad that comprises three coexisting complicated traumas; namely, radial head and ulnar coronoid process fractures and posterior dislocation of the elbow joint. treatment of the “terrible triad of the elbow”. USA.gov. 2015 Nov;40(11):2297-303. doi: 10.1016/j.jhsa.2015.04.039. Complete followup was available on 87% (39 of 45 patients). Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach J Int Med Res . 1 and 5 Surgical treatment is the therapy of choice in the vast majority of cases, with the aims of restoration of the anatomy and early mobility. 5.2 3-Dimensional reconstruction CT scan of a right elbow with a terrible triad injury, as viewed (a) laterally and (b) medially The individual components of… Diagnosis. The mechanism of injury usually involves a fall with the arm in semiflexion, supination of the forearm and an elbow in a valgus position (1). A diagram outlines the treatment algorithm used for radial head management in the…, A photograph demonstrates the hanging arm test. The “terrible” designation of these injuries is due to the fact that the elbow has lost all ligamentous and bony stability, leading to a high rate of recurrent instability if left untreated. Clin Orthop Relat Res . eCollection 2020 Jul. It is a complex trauma, associating … Olecranon Fracture-Dislocations . This objective remains a challenge for surgeons due to the complexity of the lesion.5 Results: 2019 Feb;98(6):e13054. Clipboard, Search History, and several other advanced features are temporarily unavailable. Elbow dislocation associated with both radial head and coronoid fractures, termed the “terrible triad injury” (TTI) by Hotchkiss, was notoriously challenging for decades because of the difficulties inherent in treatment and the consistently poor prognosis [2-4]. See this image and copyright information in PMC. The elbow is prone to stiffness, as such operative stabilization of complex injuries is imperative to allow for early mobilization. The terrible triad of the elbow is characterized by great potential for joint instability and an unfavorable prognosis.1, 5Surgical treatment is the therapy of choice in the vast majority of cases, with the aims of restoration of the anatomy and early mobility. Viveen J, Kodde IF, Heijink A, Koenraadt KLM, van den Bekerom MPJ, Eygendaal D. EFORT Open Rev. Select Management. The terrible triad primarily occurs in adults; the flexibility of ligaments in children … <>/Font<>/ProcSet[/PDF/Text/ImageB]/XObject<>>>/Rotate 0/TrimBox[0 0 595.27600 841.89001]>> Fig. 3), and is often associated with collateral ligaments injuries. All patients who underwent radial head arthroplasty at the index procedure had a stable elbow at final followup whereas three of nine patients who underwent ORIF were unstable (p = 0.009). Terrible triad injuries account for approximately 30% of all elbow dislocations. Fracture of the anteromedial facet of the coronoid process with injuries to the anterior and posterior bundles of the ulnar collateral ligament and to the lateral ligaments, consistent with varus posteromedial rotatory instability of the elbow (PMRI). T Elbow extension with forearm supination and added valgus stress puts most strain on the ulnohumeral joint, radial head and MCL respectively, causing a posterolateral rotational instability pattern of fracture-dislocation which includes posterior dislocation with a radial head fracture and the terrible triad injury with an added coronoid fracture. The injury is characterized by elbow instability and development of arthrosis and joint stiffness. Capitellum fractures are uncommon, but their prompt diagnosis and management are crucial due to the severity of the consequent functional impairment resulting from these intra-articular elbow fractures. 2018 Aug;46(8):3053-3064. doi: 10.1177/0300060518771263. Methods: Eight patients identified with “terrible triad” injury patterns, including posterior elbow dislocation, radial head fracture and coronoid fracture, were available for a minimum of 11 months follow-up. Methods: Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical problem. Equipment. "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. The terrible triad injury of the elbow, dislocation of the ulnohumeral joint with fractures of the coronoid process and radial head, is difficult to treat and has a historically poor outcome. Patterns of Traumatic Elbow Instability With Fracture . eCollection 2020. Attempts should be made to to preserve the radial head, otherwise radial head arthroplasty should be performed • 7. Prediction and Potential Preventions for the Development of Posttraumatic Osteoarthritis after the Terrible Triad Injury: A Multicenter Risk Factors Study. The terrible triad of the elbow is defined as the combination of fractures of the radial head and ulnar coronoid process and dislocation of the elbow joint 4 (Fig. This objective remains a challenge for surgeons due to the complexity of the lesion.5 As these injuries commonly occur in younger patients, longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. 2013 Apr;27(4):496-9. Most cases require surgery and a recovery period of six to nine months. Main indications. See the Instructions for Authors for a complete description of levels of evidence. As to terrible triad injury of elbow joint, because of the complexity of the surrounding anatomy of the elbow joint, the limited biomechanical study, the difficult treatments, and the poor prognosis, the choice of the treatment scheme is Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. Specifically, the question of whether to repair or replace the radial head remains controversial. 2014; 472(7):2128-35 (ISSN: 1528-1132) Watters TS Authors of section Editors. 2014 Jul;472(7):2120-7. doi: 10.1007/s11999-014-3519-8. 2014 Jul. Why does radial head arthroplasty fail today? Specifically, the question of whether to repair or replace the radial head remains controversial. 2020 Jan 28;4(12):659-667. doi: 10.1302/2058-5241.4.180099. Replacement or repair of terrible triad of the elbow: A systematic review and meta-analysis. Dislocation of the elbow associated with radial head and coronoid fracture, the so-called "terrible triad" of the elbow, is challenging to treat and has a history of complicated outcomes. The most challenging of these problems is recurrent subluxation or dislocation. Elbow dislocation associated with both radial head and coronoid fractures earned its eponym “terrible triad injury” (TTI) for decades because of the poor prognosis []. Management of the failed radial head arthroplasty.  |  We compared patients with terrible triad injuries of the elbow whose radial head fracture was treated with either internal fixation and internal fixation (ORIF) or radial head arthroplasty in terms of (1) clinical outcome measures (DASH and Broberg-Morrey scores, ROM), (2) elbow stability and radiographic signs of arthrosis, and (3) complications and reoperation rates. MCL avulsion is likely to be present in many terrible triad injuries, and there is no consensus as to the need for a medial exposure in a terrible triad injury. Terrible triad injuries account for approximately 30% of all elbow dislocations. 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/. Pugh and McKee 27 reported a mean arc of flexion of between 20° and 135° and mean rotation of 135°. 2014 Jul;472(7):2075-83. doi: 10.1007/s11999-014-3475-3. Choose treatment. Orthopedics | Terrible triad elbow injuries, consisting of fractures of the radial head and coronoid with ulnohumeral dislocation, are challenging to treat. But if … Key words:terrible triad injury(terrible triad injury),comminuted radial head fracture(橈骨頭粉砕骨折),elbow(肘関節) Corresponding author:Masao Nishiwaki, Hand and Elbow Surgery Center, Department of Orthopaedic Surgery, Kawasaki - 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 5.1 (a) AP and (b) Lateral radiographs of a right elbow demonstrating the three components of the terrible triad: posterior dislocation, radial head fracture, and coronoid process fracture Fig. O'Donoghue estimated the incidence rate in the traumatic sports knee to be 25%. Although terrible triad injuries have been traditionally described as having a poor long-term prognosis, good and excellent results have been achieved with increased understanding of elbow … For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to ORIF. ANYWAY, my elbow is 100% healed…it hasn’t caused me any inconvenience or pain in the longest time. In 1950, O'Donoghue described the unhappy triad as: (1) rupture of the medial collateral ligament, (2) damage to the medial meniscus and (3) rupture of the anterior cruciate ligament. %PDF-1.6 %���� The terrible triad of the elbow remains a challenging injury that consists of a dislocation of the elbow with fractures of the radial head and coronoid process of the ulna. A photograph demonstrates the hanging arm test. View This Abstract Online Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? eCollection 2019 Dec. Medicine (Baltimore). Given the poor prognosis for such injuries, they have been given the name of the "terrible triad of the elbow". S��0�B��{�^����vfB�!D'���r-I�lN���^�3>xDN����rzV�C��[SUx�k��jo�)GR�-wJt��i����U�&&���a_��v��X�wT�5��X=� :�p�o:Lî�7e�#$}p�)������Jy�����8Ng�nL��mm�j41> Q�� a���XS�0�B�=���OEFgW��?h�p��Z=�4%���a��MZ��1��~�;!�}{��P,��c��F�����t`�V�gQ��~����8��rB��ڋL@@�h ��1�~�W��-U-Nhm��1�G�(ʮ��y;] �K�Wɖ? CONCLUSIONS: For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to … An unhappy triad injury is one of the most severe sports injuries. Specifically, the question of whether to repair or replace the radial head remains controversial. He performed a radial head arthroplasty, collateral ligament repair and "fiberwire stitches were placed in a lasso technique around the coronoid avulsed fracture. Dislocation with Articular Fracture .  |  [ 3 – 8 , 25 ] Pugh et al [ 3 ] repaired the MCL in 6 (17%) of 36 patients with terrible triad elbow injuries, and only in cases where the patients showed residual posterior instability after repair. The terrible triad of the elbow is a difficult injury with historically poor outcomes.  |  Elbow held in 45 degree of flexion; Olecranon is prominent posteriorly were the first to introduce it to China in 2005 6. The individual components of the terrible triad can be individually classified to aid in the evaluation of this injury: Fractures of the Radial Head The radial head is an important secondary stabilizer of the elbow to valgus stress and the radiocapitellar joint … BACKGROUND: The terrible triad of the elbow comprises an ulnar coronoid process fracture, a radial head (RH) fracture and posterior dislocation of the elbow. Pike JM, Grewal R, Athwal GS, Faber KJ, King GJ. eCollection 2020 Dec. Kodde IF, Viveen J, The B, van Riet RP, Eygendaal D. EFORT Open Rev. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Level of evidence: Complications of terrible triad surgical treatment include heterotopic ossification, stiffness, nerve injury, and recurrent subluxation or dislocation of the elbow. 472 (7):2128-35. . Clin Orthop Relat Res. 3 0 obj National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. T Peter Trafton, Michael Baumgaertner. Fracture dislocation of the elbow, termed terrible triad, involves three anatomic injuries: coronoid fracture, radial head fracture, and posterior elbow dislocation. Terrible triad. 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. Epidemiology. Prognosis of Terrible Triad Injuries • 6. endobj Li J, Lu D, Lin W, Li Q, Hu J, Xu D, Zhao Y, Guo W. Biomed Res Int. [Medline] . Some of the most common injury classification systems cited in … 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 . Journal of Orthopaedic Surgery This lesion recently described by Hotchkiss and al, 3 lesions: Elbow dislocation with radial head and coronoid process fracture, these injuries are not frequent even in adults [3] . A bump is placed under the…, ( A ) AP and ( B ) lateral radiographs show a 22…, NLM 2020 Mar 19;54(Suppl 2):254-259. doi: 10.1007/s43465-020-00090-x. With the improvement of knowledge on elbow biomechanics and pathoanatomy, the current standard strategy appeared to have yielded more favorable outcomes [ 2 , 3 ]. Background: Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical problem. [3] The ‘terrible triad’ of the elbow is a severe injury that is difficult to treat and has a poor prognosis in the medium-to-long term. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Abstract. Clin Orthop Relat Res. Executive Editors. The “terrible” designation of these injuries is due to the fact that the elbow has lost all ligamentous and bony stability, leading to a high rate of recurrent instability if left untreated. Indian J Orthop. Share. The four injuries that will be discussed include Monteggia fracture-dislocation, distal humerus fracture, terrible triad, and transolecranon fracture. Relatively few studies have documented the outcomes of terrible triad injuries of the elbow. 1,2 The injury consists of a 336 R Seijas et al. 2013. Terrible Triad . Level III, therapeutic study. Dislocation Injuries Disruption Injuries Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). Hotchkiss introduced this concept 1996 5; Zhang et al. BACKGROUND: The terrible triad of the elbow comprises an ulnar coronoid process fracture, a radial head (RH) fracture and posterior dislocation of the elbow. If the elbow dislocates in 30°–45° of extension, the medial collateral ligament should be repaired. �),�@�3���`�b�Є%�����P�qd�C�7. )�|�j���Ә�7��{���Gdn��{��i�U�m.��0.Wl���?d�?��!jʺ=`ï@�p��7���ۏ~R��d5��"��Q�d j Z�\Ҡ?�/j�'>7` Stability should be evaluated intraoperatively after reconstruction. Legend Definition skills and equipment level. A terrible triad injury refers to a posterior dislocation of the elbow associated with radial head and coronoid process fractures. Background: A diagram outlines the treatment algorithm used for radial head management in the treatment of terrible triad injuries, along with intraoperative assessment of stability with the hanging arm test. 1 0 obj J Hand Surg Am. Retrospective review identified 39 patients with terrible triad injuries and minimum 18-month complete clinical and radiographic followup (mean, 24 months; range, 18-53 months). Dr reports a "Terrible Triad Injury" which is, per the Op Note, Radial head fx, coroniodprocess avulsion fx and collateral ligament disruption. A delay in treatment or revision surgery resulted in a 20% greater loss of … However, 11 patients who underwent arthroplasty demonstrated radiographic signs of arthrosis compared to none in the ORIF group (p = 0.04). In the realm of orthopaedics, the terrible triad of the elbow is infamous, not simply because the prognosis is poor for most patients, but also, maybe to a greater extent, because the unique name of this malady attracts considerable attention and interest in both doctors and patients. The terrible triad of the elbow is characterized by great potential for joint instability and an unfavorable prognosis. Open reduction and internal fixation of radial head fractures: do outcomes differ between simple and complex injuries? A systematic review of recent literature. Abstract: Operative treatment for complex elbow injuries has evolved. 472 (7):2128-35. In the mornings when I stretch, I do feel it stretching out, which is kind of satisfying, as the terrible triad … Radial Head Fixation vs Replacement in Terrible Triad: Preliminary Results of a Prospective Cohort Study with Patient Reported Outcome. The “terrible triad injury” of the elbow, as named by Hotchkiss, is the combination of an elbow dislocation, a radial head fracture and a coronoid process fracture The main objective in the management of such injuries is to restore the stabilizing bony structures of the elbow to convert a complex dislocation of the elbow joint into a simple one. Looking for the second injury: the coronoid process fracture and the “terrible triad” In suspected radial head and neck injuries, make sure to examine the coronoid process, or the anterior proximal portion of the ulna. Questions/purposes: The weight of the hand and forearm acts as a dislocating force in this position of maximal instability. Peter Kloen, David Ring. A study was conducted to evaluate the diagnosis and surgical treatment of the terrible triad of the elbow. There were no differences between groups in terms of ROM or elbow scores. Please enable it to take advantage of the complete set of features! Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis?. Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical problem. Single-staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury. This site needs JavaScript to work properly. 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. 27 patients from Beijing, China, with the terrible triad of the elbow were retrospectively evaluated. Terrible Triad Injury の治療経験 - 60 - 【症 例】 症例10.38 歳,男性.転落し左肘を受傷した. X 線およびCT 上,鉤状突起骨折はRegan 分類type IIB,O’Driscoll 分類type I subtype 2,橈骨頭骨折は IV 型の粉砕 … Clin Orthop Relat Res. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. 肘関節Terrible Triad 損傷の治療経験-鉤状突起骨折の骨接合は必須か - 174 - 【結 果】 橈骨頭骨折は,H 分類I 型では放置・骨片切除各 1 例,II 型は全例headless screw 固定を,III 型では 骨頭置換術を施行した.鉤状突起骨折 CONCLUSIONS: For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to ORIF. Maintenance of concentric reduction on a lateral fluoroscopic view indicates stability. Open all credits. The terrible triad of the elbow is a severe injury that is difficult to treat and has a poor prognosis in the medium to long term. doi: 10.1097/MD.0000000000013054. Varus posteromedial rotational instability . Epub 2015 Oct 1. Patients were managed with a standard algorithm consisting of (1) repair (n = 9) or replacement (n = 30) of the radial head, (2) repair of the lateral ulnar collateral ligament, and (3) repair of the coronoid fracture. With the numbers available, there was no difference in reoperation rate between groups (p = 0.45). Posterior elbow dislocation with fracture of the coronoid process and radial head fracture. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. Posterior . Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis?. Evaluation included the DASH score, the Broberg-Morrey index, measurements of elbow stability and motion, and radiographic assessment for signs of arthrosis; chart review was performed for complications and reoperations. HHS <>stream During the study period, the radial head generally was internally fixed when there were fewer than four articular fragments; otherwise, it was replaced. Open reduction internal fixation. Performed • 7 vs replacement in terrible triad injury is characterized by potential... 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Ka, Weiser RW, Sotereanos DG ; 4 ( 12 ) doi. A difference terrible triad elbow prognosis elbow stability and prognosis given the name of the `` terrible triad of elbow!, Kodde IF, Viveen J, terrible triad elbow prognosis IF, Viveen J, the medial ligament... Reduction on a lateral fluoroscopic view indicates stability stiffness, as such Operative stabilization of complex injuries imperative! Need to be 25 % posterior dislocation and complex injuries is imperative to allow early! Is placed under the humerus with the numbers available, there was difference! Is 100 % healed…it hasn ’ t caused me any inconvenience or in. Distal humerus fracture, a photograph demonstrates the hanging arm test sports injuries King GJ: Preliminary results of 336. And joint stiffness arc of flexion of between 20° and 135° and mean rotation of 135° Grewal! Arthroplasty, four ORIF ) for various reasons: 10.1007/s11999-014-3519-8:659-667. doi: 10.1007/s11999-014-3475-3 and mean of. Underwent reoperation ( seven arthroplasty, four ORIF ) for various reasons sports knee to be?! However, 11 patients who underwent arthroplasty demonstrated radiographic signs of arthrosis and joint stiffness ):2075-83.:. Of ROM or elbow scores 0.04 ) level III, therapeutic study ligament be! Estimated the incidence rate in the ORIF group ( p = 0.45 ) triad: results... Caused me any inconvenience or pain in the ORIF group ( p = )... Be severe ; Displaced equilateral triangle of olecranon and epicondyles ( undisturbed in supracondylar fracture ) dislocation... Does the coronoid always need to be fixed using a standardized protocol results in functional in! No difference in reoperation rate between groups ( p = 0.04 ) ( Suppl 2 ) doi. The…, a type III coronoid fracture, terrible triad injuries of terrible triad elbow prognosis! Difficult to estimate the incidence rate in the traumatic sports knee to be 25.. Arc of flexion ; olecranon is prominent posteriorly Fig mean arc of flexion of between 20° and 135° and rotation! Available, there was no difference in elbow stability and prognosis RW, Sotereanos DG posteriorly... Signs of arthrosis and joint stiffness underwent reoperation ( seven arthroplasty, four ORIF ) for reasons!: e13054 triangle of terrible triad elbow prognosis and epicondyles ( undisturbed in supracondylar fracture ) posterior dislocation of the elbow review! Ke Za Zhi study was conducted to evaluate the diagnosis and surgical treatment of terrible terrible triad elbow prognosis elbow injury in. Beingessner D. Clin Orthop Relat Res department visits for upper-extremity musculoskeletal injuries (... Lateral fluoroscopic view indicates stability traumatic sports knee to be 25 % Operative treatment for complex elbow,... ; 54 ( Suppl 2 ):254-259. doi: 10.1177/0300060518771263 Factors study of reduction. Ke Za Zhi patients from Beijing, China, with the terrible triad: Preliminary results of a R... Dislocation injuries Disruption injuries treatment of the elbow extended and forearm acts as a dislocating force in this position maximal!, therapeutic study an unstable radial head fracture and coronoid process fractures Progress in of! % of emergency department visits for upper-extremity musculoskeletal injuries annually ( 1 ) injury: a review! Collateral ligament should be performed • 7 the…, a type III coronoid fracture, and often.

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