Treatment of the terrible triad of the elbow using a single lateral incision (extensor digitorium communis split approach)

Abstract

Objective To report the surgical techniques and results of treating the coronoid process and radial head fracture with dislocation of the elbow (terrible triad of the elbow) using a single lateral incision,the extensor digitorium communis (EDC) split approach.Methods A retrospective analysis was done of 23 patients with terrible triad of the elbow who had been treated by the authors from July 2011 to June 2013.They were 14 males and 9 females,with a mean age of 42.1 years (from 16 to 68 years).All patients were treated via a single lateral approach.The coronoid process was fixated by Kirschner wires combined with the anterior capsule suture lasso fixation.For the radial head fracture,14 cases were fixated by AO HCS and 9 cases by Acumed radial head replacement.In repair of the lateral collateral ligament complex and the common extensor tendon,6 cases used No.2 Ethibon suture through bone holes at the humeral lateral epicondyle,and the other 17 cases used suture anchors.No medial collateral ligament was repaired.Twenty patients were fixated by Stryker DJD Ⅱ hinged external fixator to protect the bone and soft tissue.Results All patients were followed up from 6 to 30 months (mean,19.0 months).The last follow-ups revealed that all patients recovered daily functions of the elbow with no need of secondary release.Their elbow flexion averaged 137.0° ± 8.8°,elbow extension-4.8° ± 15.0°,range of flexion and extension 132.2° ± 21.5°,forearm pronation 88.7° ± 6.3°,forearm supination 89.6° ± 2.1°,forearm rotation 178.3° ± 6.5°,and Mayo elbow performance score(MEPS) 97.4 ± 6.9 points.No obvious pain,instability,infection,or ulnar nerve symptoms was observed.Conclusions The elbow terrible triad with bone blocking can be treated by a simple lateral incision (the EDC split approach) to repair and fix the anterior capsule + coronoid process fracture,radial head fracture,and the lateral collateral ligament complex and the common extensor tendon.If the elbow is still unstable,it is advisable to add the hinged external fixator to protect the bone and soft tissue without repairing the medial structure by another incision,minimizing injury to the elbow,elbow stiffness and ulnar nerve lesions. Key words: Elbow joint; Fractures, bone; Dislocations; Radial head; Coronoid process