Treatment Of Terrible Triad Injuries Research Articles

Is partial excision of the radial head safe and effective in all-arthroscopic treatment of terrible triad fractures?

Our study aimed to evaluate the clinical and radiologic results of all-arthroscopic treatment of terrible triad injuries followed-up for a minimum of 5 years and investigate how arthroscopic partial excision for radial head fractures affects the results at the final follow-up. We retrospectively reviewed consecutive patients with terrible triad injuries who underwent all-arthroscopic treatment between January 2011 and June 2018. In group I, we performed conservative or arthroscopic fixation of stable radial head fractures, while in group II, arthroscopic partial excision of unstable radial head fractures involving <30%-50% of the articular surface area was performed. Clinical outcomes were measured by visual analog scale score and assessment of instability, range of motion (ROM), and Mayo Elbow Performance Score. Radiological outcomes were evaluated using x-rays, and the integrity of the repaired lateral collateral ligament complex was confirmed through magnetic resonance imaging. Thirty-two patients with an average age of 49.5±16.2 years met the inclusion criteria and were followed-up for a mean of 82.7±22.2 months. Twenty patients were assigned to group I and 12 patients to group II. Clinical outcomes showed no significant differences between the two groups at the final follow-up (P>0.05). On radiological evaluation, more heterotopic ossifications were found in the radial head excision group (group II, 66.7% versus group I, 35%, P=0.02); however, there was no significant difference in ROM between the two groups (P>0.05). In all-arthroscopic treatment of terrible triad injuries, arthroscopic partial excision of the radial head did not seem to have a significant impact on elbow joint stability. Level of evidence: III.

Characteristics of rehabilitation protocols following operative treatment of terrible triad elbow injuries and the influence of early motion: A systematic review and meta-analysis

Background As no consensus exists on the optimal postoperative rehabilitation protocol in terrible triad injuries, we sought to characterize the reported protocols and relate them to postoperative range of motion (ROM) measures and Mayo Elbow Performance Score (MEPS). Methods A systematic review was performed by searching PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles on the operative treatment of terrible triad injuries reporting postoperative rehabilitation protocols were included. Included studies were descriptively summarized. Methodologic quality was assessed using the Methodological Index for Non-randomized Studies criteria. Meta-analysis compared postoperative ROM measures and the MEPS between patients initiating passive ROM exercises at ≤7 days vs. &gt;7 days. Results Our review included 36 articles with 1123 elbows (66% male, mean age: 43 years, follow-up: 27 months). Of the studies reporting physical therapy protocols, it was most commonly initiated at 7 days postoperatively (6/36, 17%), passive ROM exercises at 7 days (3/25, 12%), and active ROM at 21 days (4/26, 15%). On meta-analysis, early passive ROM initiation was not associated with improved elbow ROM or MEPS. Discussion While rehabilitation protocols commonly advised passive ROM at one week post-operatively, meta-analysis did not support functional benefits of early passive ROM. Study design Systematic Review; Level of evidence, 4.

The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow.

To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting. This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up. Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating roomfor stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69). This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

Terrible Triad Injuries around the Elbow: It is Still a Puzzle? Prospective Study.

The "terrible triad" injury of the elbow, consisting of fractures of the coronoid process and radial head along with posterolateral elbow dislocation and refractory instability, has historically led to poor functional outcomes. Traditional treatment focused on bony injuries, but it is now recognized that soft-tissue injuries must also be addressed. Surgical management aims to restore bony and soft-tissue stabilizers, including fixation of the coronoid process and radial head, repair of ligament complexes, and reduction of elbow dislocation. Studies emphasize the importance of early reduction and tailored treatment. This study discusses means and methods of treating this complex injury, highlighting the significance of addressing both bony and soft-tissue injuries for better functional outcomes. This is a prospective study conducted at a single center and involved 27 consecutive patients diagnosed with terrible triad injuries around the elbow. The objective was to evaluate functional outcomes and complications associated with surgical treatment of terrible triad injuries around the elbow. From July 2017 to October 2018, 27 patients with terrible triad injuries around the elbow were operated on and evaluated for a minimum of 1 year in terms of functional results using the mean elbow performance score (MEPS) and VAS score. The surgical protocol included coronoid fixation or repair of the anterior capsule, radial head fixation or arthroplasty, and repair of the lateral collateral ligament (LCL) in a sequential manner. The medial collateral ligament was repaired if the elbow remained unstable.On follow-up, mean MEPS scores improved significantly. The final mean range of motion of the operated upper limb was as follows: 28.5° of extension deficit (standard deviation [SD] 9.07, range, 10°-40°), 117.5° of flexion (SD 13.18, range, 90°-130°), 70.9° of supination (SD 10.19, range, 40°-85°), and 65.5° of pronation (SD 9.54, range, 40°-80°) at the end of 1 year. A total of 12 patients had complications. Out of the 12 patients, three had elbow arthritis, two had heterotopic ossification, three had radial nerve neuropraxia, two patients had elbow stiffness, and two patients suffered from ulnar nerve neuropathy. Surgical intervention in terrible triad injuries around the elbow in the form of coronoid fixation, radial head fixation, or arthroplasty and soft-tissue repair around the elbow gives satisfactory results at the end of 1 year. Addressing each and every component of fracture in a sequential and step-wise manner is associated with good functional outcomes at the end of 1 year.

Coronoid tip fractures in terrible triad injuries can be safely treated without fixation.

The optimal treatment of terrible triad injuries of the elbow (TTI) remains topic of ongoing discussion. The aim of this study was to determine whether different treatment strategies for coronoid tip fractures in terrible triad injuries influences the clinical and radiological results in a mid-term follow-up. A total of 62 patients with surgical treatment of a TTI including a coronoid tip fracture (37 women, 25 men; mean age, 51years) were available for follow-up assessment after an average of 4.2years (range 24-110months). Thirteen patients had O'Driscoll 1.1 and 49 O'Driscoll 1.2 coronoid fractures, of which 26 were treated with and 36 without fixation. Range of motion, the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score as well as grip strength were evaluated. Radiographs were analyzed for all participants. No significant benefit in outcome variables could be detected between patients, whose coronoid had been fixed, compared to patients without fixation of the coronoid. In the coronoid fixation group, patients had mean outcome scores of 81.5 ± SD 19.1 (range 35-100) for MEPS, 31.0 ± SD 12.5 (range 11-48) for OES and 27.7 ± SD 23 (range 0-61) for DASH score, while in the no-fixation group, mean MEPS was 90.8 ± SD 16.5 (range 40-100), mean OES was 39.0 ± SD 10.4 (range 16-48) and mean DASH score was 14.5 ± SD 19.9 (range 0-48). Mean range of motion was 116° ± SD 21° (range 85-140°) versus 124° ± SD 24° (range 80-150°) in extension-flexion and 158° ± SD 23° (range 70-180°) versus 165° ± SD 12° (range 85-180°) in pronation-supination. Overall complication rate was 43.5% and revision rate was 24.2%, with no significant differences between both groups. Suboptimal results were more frequently seen in patients who had degenerative or heterotopic changes on their latest radiograph. Sufficient elbow stability and good outcomes can be achieved in most patients with TTI and coronoid tip fractures. Although some bias in treatment allocation and group heterogeneity cannot be completely omitted, our analysis detected no significant benefit in outcome when the coronoid tip fracture has been fixed compared to patients with non-fixed coronoid tip. Therefore, we would suggest a no-fixation approach for coronoid tip fractures as primary treatment in TTI of the elbow. Level III, retrospective comparative study.

Internal Joint Stabilizer: A Safe Treatment for Traumatic Elbow Instability.

To report early results of the "Internal Joint Stabilizer of the Elbow" (IJS-E) in the treatment of terrible triad injuries and other unstable traumatic elbow dislocations. Retrospective cohort study. Level 1 trauma center. Seventeen patients with traumatic elbow instability treated with IJS-E over a 2-year period; 7 of whom sustained terrible triad-type injuries. Open reduction internal fixation with the "IJS-E". Elbow stability and arc of motion were assessed radiographically and clinically. Disabilities of the Arm, Shoulder and Hand scores were collected by telephone. All elbows were radiographically stable at the time of IJS-E removal. Mean time of follow-up was 9 months from index operation (range, 2.5-24 months). Mean elbow arc of motion was restored to flexion-extension 92 degrees (range, 5-125; SD, 31 degrees) and forearm pronation-supination 139 degrees (range, 0-180; SD, 48 degrees). Mean Disabilities of the Arm, Shoulder and Hand score was 22.2 (range, 7.5-45.7; SD, 13.3) for patients at least 1 month from surgery on the ipsilateral extremity. Five patients (30%) developed complications, and -2 (12%) required revision for implant failure. The IJS-E offered reliable treatment of traumatic elbow instability, particularly terrible triad-type injuries. It permited early range of motion and was effective in restoring elbow stability. We believe that the use of this relatively novel system should be further explored. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Single Modified Posterior Approach through the Space of the Proximal Radioulnar Joint for Terrible Triad Injury: A Comparative Study.

ObjectiveIn order to reduce surgical scars and the risk of neurovascular injury for the treatment of terrible triad injuries of the elbow (TTI), minimally invasive and better therapeutic effect approaches are being explored to replace the conventional combined lateral and medial approach (CLMA). This study was performed to compare the clinical effect and security of the modified posterior approach (MPA) through the space of the proximal radioulnar joint vs the CLMA for treatment of TTI.MethodsThis study retrospectively analyzed 76 patients treated for TTI from January 2009 to December 2020 (MPA: n = 44; CLMA: n = 32). Treatment involved plate and screw fixation or Steinmann pin fixation for the radial head and ulnar coronoid process fractures. Surgeons only sutured the lateral ligament because the medial collateral ligament was usually integrated in the TTI. The continuous variables were compared by the independent Student t‐test and the categorical variables by the χ2‐test or Fisher's exact test.ResultsBoth groups of patients attained a satisfactory MEPS after the operation. The MEPS (MPA: 96.82 ± 6.04 vs CLMA: 96.56 ± 5.51) was not significantly different between the two groups (p > 0.05). However, the MPA resulted in better elbow flexion and extension (MPA: 123.98 ± 10.09 vs CLMA: 117.66 ± 8.29), better forearm rotation function (MPA: 173.41 ± 6.81 vs CLMA: 120.00 ± 12.18), and less intraoperative hemoglobin (MPA: 9.34 ± 5.64 vs CLMA: 16.5 ± 8.75) and red cell volume loss (MPA: 3.09 ± 2.20 vs CLMA: 6.70 ± 2.97) (All p < 0.05). Although the CLMA had a shorter surgery time (MPA: 171.73 ± 80.68 vs CLMA: 130.16 ± 71.50) (p < 0.05), it had a higher risk of neurologic damage (MPA: 0 vs CLMA: 4) (p < 0.05). Four patients developed forearm or hand numbness after the CLMA, but no patients developed numbness after the MPA. All 76 patients were followed up for 15 months postoperatively.ConclusionThe MPA through the space of the proximal radioulnar joint has more prominent advantages than the CLMA for TTI, including single scar, clear exposure, good fixation, lower risk of neurovascular injury, and better elbow joint motion. It is a safe and effective surgical approach that is worthy of clinical promotion.

Radial head arthroplasty vs. open reduction and internal fixation for the treatment of terrible triad injury of the elbow: A systematic review and meta-analysis update.

Terrible triad injury of the elbow (TTIE) is a severe high-energy injury to the elbow, mainly including elbow dislocation, coronoid fracture and radial head fracture. It is difficult to maintain the stability of the elbow joint using traditional conservative treatment, and there is a high risk of redislocation and various complications. Therefore, surgical treatment is currently advocated, mainly for repairing damaged ligaments and reconstructing bony structures, but there is still controversy about the treatment plan for the radial head. The current meta-analysis was conducted to compare the differences in efficacy of radial head arthroplasty (RHA) and open reduction internal fixation (ORIF) in the treatment of TTIE. Published literature related to the treatment (either ORIF or RHA) of TTIE was searched for in Embase, PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ProQuest Dissertations and Theses, Cochrane Library and Chinese Biomedical Literature Database. According to the search strategy, a total of 1,928 related publications were retrieved. The patient must have been diagnosed with TTIE and required surgery on the radial head. The interventions were RHA and ORIF. Non-case-control studies, case reports, review articles, letters, duplicate reports and literature without sufficient relevant data were excluded. The quality of the literature was evaluated according to the Cochrane systematic review methodology and the Jadad scale. After data extraction, meta-analysis was performed using ReviewManager 5.4 software (Cochrane). A total of 15 studies involving 455 patients (189 who underwent RHA and 266 who underwent ORIF) were included. Range of motion (ROM) of the forearm (pronation-supination arc) after surgery in the RHA group [95% CI (0.28, 9.59); P=0.04] was found to be significantly superior to the ORIF group, with a lower incidence of complications [95% CI (0.22, 0.84); P=0.01]. However, there was no statistically significant difference for the Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand Score nor for ROM of the elbow (flexion-extension arc). Overall, compared with the ORIF group, the RHA group had better forearm rotational ROM and fewer complications after surgery. Therefore, RHA was found to be superior to ORIF in the treatment of TTIE.

Is Repair of a Small Coronoid Fracture Required in the Surgical Treatment of Terrible Triad Injury of the Elbow?

Background: Multiple treatment protocols have been described in literature for the treatment of terrible triad injury (TTI) of the elbow. We believe that repair of the medial collateral ligament (MCL) should be performed in preference to repair of a small coronoid fracture if the elbow is unstable after fixation/replacement of the radial head and repair of the lateral collateral ligament (LCL). The aim of this study is to report the outcomes of surgical treatment of patients with TTI associated with a small coronoid fracture in whom the coronoid fracture was not addressed. Methods: This study is a retrospective case series of 12 consecutive patients who underwent surgery for acute TTI with a small coronoid fracture (9 Regan-Morrey type I and 3 Regan-Morrey type II). Ten patients had complete MCL injuries. All patients underwent repair of the torn LCL and MCL and treatment of the radial head. The coronoid fracture was not surgically treated. At the final follow-up, the range of motion, degree of flexion contracture, Mayo elbow performance score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) were measured. Results: The mean follow-up period was 13.5 months. At the final follow-up, the mean arc of elbow flexion was 132° and the mean flexion contracture was 10°. The mean arc of forearm rotation was 148°. None of the patients demonstrated elbow instability. The mean MEPS was 92.5 points with seven having excellent results and five having good results. The average DASH score was 11.2 points. Conclusions: Our results showed that good elbow stability, arc of motion and clinical outcomes could be achieved without repair of small coronoid fractures in the treatment of TTI. The repair of MCL injuries should be given priority over the fixation of small coronoid fractures to regain elbow stability. Level of Evidence: Level IV (Therapeutic).

Arthroscopically Assisted Fixation of Terrible Triad Variant Injuries of the Elbow With Small-Bore Needle Arthroscopy

The range of diagnostic and therapeutic applications of needle arthroscopy (NA) continue to expand due to advances in image quality and resolution. Minimally invasive techniques can be augmented by the smaller camera size and reduced fluid use made possible by NA. Small-bore arthroscopy presents opportunities for use in smaller joints, such as the elbow, where applications of standard arthroscopic equipment may be limited by small anatomic spaces and fluid extravasation. In this Technical Note, we present our technique for NA-assisted treatment of terrible triad injuries, specifically in the setting of an intact radial head. The technique describes a stepwise approach to arthroscopically aided fixation of the coronoid process, followed by open reconstruction of the lateral collateral ligament complex.

What Factors Are Associated with Reoperation After Operative Treatment of Terrible Triad Injuries?

Terrible triad injuries of the elbow, consisting of posterior ulnohumeral joint dislocation with associated fractures of the radial head and coronoid process, are challenging injuries due to the difficulty in restoring stability to the joint surgically while also attempting to allow early ROM to prevent stiffness. Furthermore, complications are both debilitating and relatively common, frequently requiring reoperation. (1) What patient-, injury-, or surgery-related factors are associated with reoperation after surgical treatment of terrible triad injuries of the elbow? (2) What are the most common causes of reoperation after these injuries? Between January 2000 and June 2017, we identified 114 patients who had surgery for terrible triad injuries at two tertiary-care referral centers. Of those, 40% (46 of 114) were lost to follow-up before 1 year, and an additional 5% (6 of 114) were excluded because they underwent the index surgery at an outside institution (n = 4) or underwent closed reduction with or without percutaneous pinning (n = 2). That left 62 patients for analysis in this retrospective study with a minimum of 1-year follow-up (median 22 months; range 12 to 65) or who met the endpoint of reoperation before 1 year. During the study period, indications for surgical treatment of terrible triad injuries of the elbow included joint incongruity or instability precluding early ROM. In our study cohort, 45% (28 of 62) underwent reoperation. Indications for reoperation after surgical treatment included stiffness that interfered with activities of daily life, symptomatic prominent hardware, ulnar neuropathy, instability of the elbow joint at rest or with range of motion, and infection. Patient-related (such as age, sex, race), injury-related (for example, ipsilateral extremity fracture, open fracture), and surgery-related factors (for instance, time to surgery, radial head treatment) as well as outcomes were collected by the treating surgeon at the time of follow-up and ascertained using chart review. The primary outcome measure was reoperation after surgical treatment of a terrible triad injury of the elbow. Bivariate analysis was used to assess whether explanatory variables were associated with reoperation after surgical treatment of terrible triad injuries of the elbow. Of the patient-, injury-, and surgery-related factors that were analyzed, only radial head treatment was associated with an increased reoperation risk (p = 0.03). No other variable met criteria for inclusion in our multivariable logistic regression model (p < 0.10), and therefore, a multivariable logistic regression model was not performed. The most common indication for reoperation was stiffness (21% [13 of 62 patients]), followed by symptomatic hardware (18% [11 of 62 patients]), nerve symptoms (ulnar neuropathy 16% [10 of 62 patients] and incisional neuroma 2% [1 of 62 patients]), instability (6% [4 of 62 patients]), and wound problems (infection 2% [1 of 62 patients]). The reoperation risk after surgical treatment of terrible triad injuries of the elbow is high. No patient- or injury-related factors were associated with the reoperation risk. Based on our finding, we recommend fixation of radial head fractures in these injuries when feasible and compatible with early postoperative motion, and we suggest the use of radial head excision or arthroplasty as a secondary options. Level III, therapeutic study.

橈骨頭粉砕骨折を伴った肘関節terrible triad injuryの治療

橈骨頭粉砕骨折を伴った肘関節terrible triad injuryの治療

Treatment of terrible triad injuries at a mean follow-up of nine years.

To evaluate the sustainability of the early clinical and radiological outcomes of terrible triad injuries at long-term follow-up. Twelve consecutive patients who underwent fixation of terrible triad injuries with minimum of seven years of follow-up. Functional and radiological outcomes at one year and final follow-up were compared. We assessed Mayo Elbow Performance Score, Quick-Disability of the Arm Shoulder and Hand, and modified-American Shoulder and Elbow Surgeons Scores. Radiological evaluation included Broberg and Morrey classification and Hastings classification for heterotopic ossification. The mean age of patients was 55 years, with a median follow-up of 9.3 years. At final evaluation, mean flexion, extension, supination, and pronation were 145°, 6°, 82°, and 80°, respectively; mean Mayo Elbow Performance Score, modified-American Shoulder and Elbow Surgeons Scores, and Quick-Disability of the Arm Shoulder and Hand scores were, respectively, 97, 92, and 4.9 points. There was no statistical difference between early and final follow-up range of motion, Mayo Elbow Performance Score, and Quick-Disability of the Arm Shoulder and Hand. However, radiological changes were observed in 66% of the patients at final follow-up. Two patients underwent reoperation, with final satisfactory results. Our results suggested that using a standardized protocol, satisfactory clinical outcomes at early follow-up could be maintained over time. However, early complications and osteoarthritic changes at long-term follow-up can be expected. Therapeutic IV Cases series.

Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach.

SummaryObjectiveTo report the results of the surgical treatment of terrible triad injury with anteromedial coronoid fracture through a combined surgical approach.MethodsThis retrospective study evaluated data from patients who underwent surgery to repair terrible triad injuries and anteromedial coronoid fractures. Surgical treatment involved radial head repair or replacement, medial and lateral collateral ligament repair, and coronoid fracture fixation through combined approaches. Evaluations were performed using the Mayo Elbow Performance Score (MEPS) and anteroposterior and lateral radiographs of the elbow.ResultsTwenty-two patients (15 males, seven females; mean ± SD age, 47.5 ± 11.4 years) were enrolled in this study. Fracture union and concentric reduction of both the ulnotrochlear and radiocapitellar articulations were achieved in all patients. The mean ± SD follow-up was 31.6 ± 11.9 months. The mean ± SD arc of flexion–extension was 110.3° ± 26.3° and arc of forearm rotation was 139.5° ± 17.1°. The mean ± SD MEPS was 88.1 ± 12.2 points, with results classified as excellent in eight elbows, good in ten, and fair in four. Six patients had radiographic signs of post-traumatic arthritis. Three patients required secondary surgeries.ConclusionCombined surgical approaches can be considered for the treatment of terrible triad injuries in association with anteromedial coronoid fractures.

Progress on the treatment of terrible triad injury of elbow joint

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 still controversial. This article summarizes the anatomy, injury mechanism, surgical treatment and prognosis of elbow joint by retrieving a large number of references. Currently, there are various surgical treatments for triad injury of elbow joint, but due to individual differences, the clinical efficacy is mostly uncertain. In the treatment of triad injury of elbow joint, most orthopedics doctors still choose the lateral surgical approach to fix the coronary fracture, repair or replace the radial head, routinely repair the lateral collateral ligament, and not recommend to repair the medial collateral ligament, so it still remains to be discussed.

Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol: Retrospective analysis of a prospective cohort.

The aim of the present study was to investigate the efficacy of the surgical treatment of terrible triad injuries of the elbow using a modified standard surgical approach, and treatment determined by the mode and mechanism of injury, and intraoperative findings.The study was a retrospective analysis of a prospective cohort of patients presenting with terrible triad injuries of the elbow, who underwent surgical treatment between July 2009 and January 2014. All patients were treated surgically according to a modified Pugh standard protocol. Elbow functional status and range of movements were evaluated at 3 months, 6 months, 1 year, and 2 years or more after surgery. Radiographic signs of post-traumatic arthritis were rated according to the Broberg and Morrey system.Our series included a final cohort of 29 males and 13 females with a mean age of 48.23 ± 10.95 years at the time of injury. The mean follow-up period was 30.47 ± 7.65 months. The mean flexion-extension arc was 107° ± 22°, and the average forearm rotation arc was 145° ± 14°. The mean Mayo Elbow Performance Score was 88 ± 10 points (range 55 to 100 points), with excellent results in 24 elbows, good results in 16, and poor results in 2. Functional results of the elbow improved significantly from 3 months postoperatively (P < .05), but tended to plateau from 1 year after surgery. Thirteen patients had radiographic signs of arthrosis (9 grade 1, 4 grade 2). Postoperative complications were local infection around the incision (n = 1), transient postoperative median nerve paralysis (n = 1), and postoperative posterior interosseous nerve paralysis (n = 1). Four patients required further surgery. Five patients had evidence of heterotopic ossification.Overall, we show that slight modifications to Pugh standard protocol for the surgical treatment of terrible triad injuries can lead to good to excellent results, although there were a good number of complications. The ideal surgical approach and treatment should be based on the mode and mechanism of injury, and intraoperative findings, and modifying the standard surgical treatment approach for terrible triad elbow injuries may be beneficial.

Treatment of Terrible Triad Injury in our Hospital

Treatment of Terrible Triad Injury in our Hospital

Complex Elbow Dislocations and the "Terrible Triad" Injury.

Background:The elbow is the second most commonly dislocated joint in adults and up to 20% of dislocations are associated with a fracture. These injuries can be categorised into groups according to their mechanism and the structures injured.Methods:This review includes a literature search of the current evidence and personal experiences of the authors in managing these injuries.Results:All injuries are initially managed with closed reduction of the ulno-humeral joint and splinting before clinical examination and radiological evaluation. Dislocations with radial head fractures should be treated by restoring stability, with treatment choice depending on the type and size of radial head fracture. Terrible triad injuries necessitate operative treatment in almost all cases. Traditionally the LCL, MCL, coronoid and radial head were reconstructed, but there is recent evidence to support repairing of the coronoid and MCL only if the elbow is unstable after reconstruction of lateral structures. Surgical treatment of terrible triad injuries carries a high risk of complications with an average reoperation rate of 22%. Varus posteromedial rotational instability fracture-dislocations have only recently been described as having the potential to cause severe long-term problems. Cadaveric studies have reinforced the need to obtain post-reduction CT scans as the size of the coronoid fragment influences the long-term stability of the elbow. Anterior dislocation with olecranon fracture has the same treatment aims as other complex dislocations with the added need to restore the extensor mechanism.Conclusion:Complex elbow dislocations are injuries with significant risk of long-term disability. There are several case-series in the literature but few studies with sufficient patient numbers to provide evidence over level IV.

Results of treatment of terrible triad injury of the elbow

Background/aim A complex elbow dislocation with associated radial head and coronoid process fractures was named the terrible triad by Hotchkiss because of historically poor outcomes. This study aimed at assessing the results and functional outcome of treatment of terrible triad injuries of the elbow. Patients and methods Between 2010 and early 2013, 11 patients suffering from terrible triad injuries of the elbow were treated at Assiut University Hospitals; eight were male individuals and three were female individuals with the mean age of 43 years (range: 26–70 years). The right elbow was injured in five, and the left was injured in six patients. The radial head was replaced by a prosthesis in five and treated by internal fixation in five patients, whereas conservative treatment was decided only in one patient; the coronoid process was fixed by screws in four, whereas four were treated by suturing of the anterior capsule and were treated conservatively. Results The mean follow-up was 13.3 months (range: 6–30 months) According to the Mayo Elbow Performance Score, three patients had excellent outcome, seven had good outcome, whereas only one had fair outcome. Conclusion Prompt surgical attention with a systematic approach to restore anatomy and provide sufficient stability to allow early motion are the key factors for a successful outcome.

Risk of Subluxation or Dislocation After Operative Treatment of Terrible Triad Injuries.

The management of terrible triad injuries has evolved over the last 2 decades to include routine radial head fixation or replacement, reattachment of the lateral collateral ligament, with or without coronoid fixation. Our objective was to determine the likelihood of and factors associated with subluxation or dislocation after operative treatment of terrible triad injuries among a large group of surgeons using current techniques. Retrospective cohort study. Two level I trauma centers. A total of 107 patients with operatively treated terrible triad injuries from January 2000 to June 2015. Review of patient- and surgery-related factors during the first postoperative month. Radiographic subluxation of the ulnohumeral joint. One hundred of the 107 patients (93%) treated with open fixation of terrible triad injuries had no radiographic subluxation or redislocation. Two patients (2%) had slight transient radiographic subluxation ("drop sign") that corrected with active exercises within weeks of surgery. Five patients (5%) had persistent radiographic subluxation, 3 treated with a second surgery (3%). When treated within 2 weeks of injury, recurrent subluxation or dislocation after operative fixation of terrible triad injuries was rare (1%), provided that the radial head was replaced and the lateral collateral ligament reattached. Radiographic subluxation is very uncommon with current operative management of terrible triad injuries of the elbow within 2 weeks. Patients treated more than 2 weeks after injury might benefit from ancillary fixation to limit subluxation (ie, cross pinning, external fixation, or internal joint stabilizer). Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.