Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? Mid-Term Postoperative Outcomes Following a Standardized Protocol.

Beom-Soo Kim,Seok-Ho Byun,Du-Han Kim,Chul-Hyun Cho

doi:10.3390/jcm9113500

Abstract

The purpose of this study was to investigate mid-term outcomes and complications after operative treatment according to a standardized protocol for terrible triad injuries. Twenty-four patients that were treated by a single surgeon with a standardized surgical protocol were retrospectively reviewed. After the complete reconstruction of radial head and/or lateral collateral ligament (LCL) complex through a lateral approach, coronoid process, and/or medial collateral ligament (MCL) complex through a medial approach were fixed if the elbow is unstable. For coronoid fractures, only type III were fixed in four cases (16.7%). Twenty-two LCL (91.7%) and five MCL (20.8%) complexes were repaired. At the final follow-up, the mean MEPS and Quick-DASH score were 91.5 and 17.3, respectively. There was no recurrent instability after operation in all cases. This study revealed that operative treatment that was based on our standardized protocol for terrible triad injuries yielded satisfactory mid-term clinical and radiographic outcomes without any recurrent instability. These results suggest that Type I and II coronoid fractures in terrible triad injuries do not need to be fixed if the radial head and ligamentous complex are completely reconstructed.

Highlights

The combination of radial head and coronoid process fractures with posterior elbow dislocation is a common injury, its treatment has been traditionally associated with unsatisfactory outcomes and high complication rates [1,2,3,4,5]
Most of the studies recommended the reconstruction of both radial head and coronoid process fractures in terrible triad injuries [7,8,9,12,14], recent cadaveric and clinical studies have reported that type I or II coronoid process fractures according to Regan–Morrey classification [18] can be stable if the radial head and ligamentous complexes are completely restored [6,19]
These results suggest that Type I and II coronoid fractures in terrible triad injuries do not require fixation if the radial head and ligamentous complex are completely reconstructed

Summary

Introduction

The combination of radial head and coronoid process fractures with posterior elbow dislocation is a common injury, its treatment has been traditionally associated with unsatisfactory outcomes and high complication rates [1,2,3,4,5]. For this reason, it has been called the “terrible triad injury” of the elbow [3] Terrible triad injuries can lead to pain, recurrent instability, stiffness, and posttraumatic arthritis if not properly treated [6]. Papatheodorou et al [6] reported on a series of 14 terrible triad injuries that were treated without fixation for type I or II coronoid fractures and achieved excellent results without any residual instability

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