The epidemiology and various treatment approaches and functional outcomes were recorded. Most repairs can be done from the lateral side. 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 . Keywords: The mean range of flexion-extension of 113° and the mean contracture in flexion of 24° showed us that limitations on the range of motion are common findings in treating this injury. Our review had indicated that patients with terrible triad injuries undergo arthroplasty replacement have better clinical outcomes and fewer post-surgery complications than those received the repair surgery. In addition there is rupture of the lateral and medial collateral ligaments. 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. Specialty. Generally these should commence around day 7-10 for a terrible triad or elbow dislocation unless otherwise specified in the operating report. This objective remains a challenge for surgeons due to the complexity of the lesion.5 Clin Orthop Relat Res 472 (2014): 2075-2083. Letter to the Editor Regarding "Lateral Approach and Combined Lateral and Anteromedial Approach for Surgical Treatment of Terrible Triad of Elbow: A Meta-Analysis.". COVID-19 is an emerging, rapidly evolving situation. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. 2005 Mar;87 Suppl 1(Pt 1):22-32. doi: 10.2106/JBJS.D.02933. Separate medial and lateral incisions; Medial approach will be required if a large, repairable radial head is in the way. The elbow consists of bones, ligaments, tendons, and muscles that interact to allow for a stable, pain-free arc of motion. Login to view comments. Skin incisions: 1.1.1. Posterior skin incision; If a medial exposure is contemplated, this incision will allow access to the medial and lateral elbow through one incision by raising flaps. Evaluations were performed using the Mayo Elbow Performance Score (MEPS) and anteroposterior and lateral radiographs of the elbow. The anteromedial coronoid fracture was repaired with a suture anchor through an anteromedial approach.  |  The elbow is the second most commonly dislocated joint in adults and up to 20% of dislocations are associated with a fracture. Click here to Login. -, Zhang C, Zhong B, Luo CF. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. Joaquin Sanchez-Sotelo. Shi Y, Wang GF, Mei K, Zhang J, Yun CJ, Qian C, Sun JY. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. Six patients had radiographic signs of post-traumatic arthritis. Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Finally, we propose a simple algorithm to guide repair. Diagnosis. All terrible triad injuries require surgical repair. 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. 11. Login. Surgery aims to restore perfect stability by sequential anatomic repair, enabling early mobilization to prevent onset of stiffness. This type of elbow injury is typically due to low or high energy falls onto an … 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. 20.1 (a–f) Complex elbow instability (terrible triad). ORIF of Distal Humerus Fractures 07:51. Login. 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/. This may be done as below, or in a hinged range of motion brace or x-fix if applied. Clin Orthop Relat Res. By continuing you agree to the use of cookies. The radial head fracture was fixed with a plate and screws, and the lateral collateral ligament was repaired by a suture anchor through a lateral approach. Therefore, the preferred surgical treatment options in the setting of terrible triad injuries include open reduction and internal fixation (ORIF) or radial head arthroplasty . 4th ed. With operative treatment, the surgeon should attempt to perform internal fixation of the coronoid fracture, to regain normal radiocapitellar contact (either by preserving the radial head with open reduction and internal Instability recurred after hyperflexed and well-fitted cast Surgery can consist in open reduction and internal fixation of the fractures, external fixation, exploration, and repair of the medial collateral ligament and/or lateral ulnar collateral ligament. - 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 J Bone Joint Surg Am 2004; 86: 1122–1130. Diagnosis. It is a complex trauma, associating … Injury. Please enable it to take advantage of the complete set of features! 4 and 5). Postoperative lateral (C) and AP (D) radiographs show concentric reduction of both the ulnotrochlear and radiocapitellar articulations, with no evidence of elbow instability at the 2-year follow-up. Fig. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. Use of Mother-Child Screws in the Treatment of Coronoid Fractures in Terrible Triad Injury of the Elbow. Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. USA.gov. Epub 2017 Mar 17. [Operative treatment of terrible triad injury of the elbow : Open reduction and internal fixation]. Conclusions: Our review had indicated that patients with terrible triad injuries undergo arthroplasty replacement have better clinical outcomes and fewer post-surgery complications than those received the repair surgery. 20:08. We treated twenty-five patients with terrible triad injury of the elbow from July 1, 2017, to June 30, 2020, and performed post hoc analysis. Authors of section Editors. Elbow; anteromedial facet of coronoid; fracture; terrible triad. dislocation is a common injury, its treatment has been traditionally associated with unsatisfactory outcomes and high complication rates [1–5]. By Joaquin Sanchez-Sotelo 58 Videos. Because the radial head is an important secondary stabilizer, excision in the setting of complex elbow instability is … Anatomy, Definition, and Treatment of the “Terrible Triad of the Elbow” and Contemplation of the Rationality of this Designation Introduction. 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. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Operative treatment: 1. 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. -, Egol KA, Immerman I, Paksima N, et al. Following radial head replacement or ORIF the LCL should be repaired to the lateral condyle using suture anchors or transosseous sutures (Figs. This site needs JavaScript to work properly. If after anatomical restoration of stability elements, the elbow remains unstable, options include repair of the medial collateral ligament or stabilization assumed by hinged external fixator. Fracture union and concentric reduction of both the ulnotrochlear and radiocapitellar articulations were achieved in all patients. March 10, 2011 71 Comments . Orthopaedics & Traumatology: Surgery & Research, https://doi.org/10.1016/j.otsr.2020.102784. 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. Hotchkiss RN . Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. 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. 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