- 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 Article Details 1. 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… Unfortunately, due to the complexity of the injury, conservative treatment is risky; the long-term complicationsincludestiffness,pain,jointinstabil-ity, and secondary arthrosis.10 The goal of surgical treatment of the terrible triad of the elbow 4 and 5). Separate medial and lateral incisions; Medial approach will be required if a large, repairable radial head is in the way. Module. The goal of treatment of terrible triad injuries is to restore the bony and ligamentous restraints of the elbow to provide elbow stability. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. 2017 Apr;29(2):125-137. doi: 10.1007/s00064-017-0489-5. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach All terrible triad injuries require surgical repair. 4 and 5). This site needs JavaScript to work properly. Lateral options: 1.2.1.1. The epidemiology and various treatment approaches and functional outcomes were recorded. The purpose of treatment in the terrible triad injury is to restore the congruency of the elbow joint, its stability and an optimal ROM. - Discussion: - terrible triad: ( RHF + MCL + coronoid process frx) + elbow dislocation. Please enable it to take advantage of the complete set of features! In addition there is rupture of the lateral and medial collateral ligaments. Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). Following a fall-on-outstretched-hand injury, this patient presented with elbow dislocation in addition to fractures of both the radial head and coronoid process, consistent with a terrible triad of the elbow injury. Gupta A, Barei D, Khwaja A, et al. The purpose of treatment in the terrible triad injury is to restore the congruency of the elbow joint, its stability and an optimal ROM. We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. Most repairs can be done from the lateral side. treatment of the “terrible triad of the elbow”. The mean ± SD arc of flexion-extension was 110.3° ± 26.3° and arc of forearm rotation was 139.5° ± 17.1°. Schematic illustration showing a fracture…, Schematic illustration showing a fracture of the anteromedial facet of the coronoid extending…, Photographs of a 46-year-old man who sustained a terrible triad injury of the…, Photographs of a 63-year-old man who sustained a terrible triad injury of the…, Photographs of a 56-year-old man who sustained a terrible triad injury of the…, NLM  |  Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. 20:08. Fig. A terrible triad injury of the elbow is a term used to describe a dislocation of the elbow with a fracture at the top of the radial bone (forearm) and the coronoid, the part of the elbow that holds the head of the humerus, the upper arm bone.Because of the extent of the injury, the usual treatment is open surgery. Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. Conclusions: When an elbow joint is affected by the terrible triad, it is very unstable and prone to numerous complications. This may be done as below, or in a hinged range of motion brace or x-fix if applied. The elbow is prone to stiffness, as such operative stabilization of complex injuries is imperative to allow for early mobilization. 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. Injury 2014; 45: 942–948. The mean ± SD follow-up was 31.6 ± 11.9 months. The elbow is the second most commonly dislocated joint in adults and up to 20% of dislocations are associated with a fracture. Letter to the Editor Regarding "Lateral Approach and Combined Lateral and Anteromedial Approach for Surgical Treatment of Terrible Triad of Elbow: A Meta-Analysis.". Liu G, Hu J, Ma W, Li M, Xu R, Pan Z. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach. 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. 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. Login. The Elbow Terrible Triad - Surgical Treatment. 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. METHODS: We retrospectively reviewed terrible triad of the elbow injuries treated at our hospital using a modified surgical technique. The goal of surgical treatment of the terrible triad of the elbow is the restoration of humeroulnar and humeroradial stability, thus facilitating the early onset of elbow movement in the postoperative period in order to reduce the probability of long-term joint dysfunction and stiffness. [Operative treatment of terrible triad injury of the elbow : Open reduction and internal fixation]. Algorithm for surgical treatment of terrible triad elbow injuries. The elbow consists of bones, ligaments, tendons, and muscles that interact to allow for a stable, pain-free arc of motion. Intervals: 1.2.1. Conservative treatment was attempted (due to the patient’s general status). In the elbow with persistent instability after repair of these element … Shi Y, Wang GF, Mei K, Zhang J, Yun CJ, Qian C, Sun JY. Luckily, elbow specialists have come up with sound strategies to restore the best possible stability and function to the elbow joint after a terrible triad. Clin Orthop Relat Res. Available online 14 December 2020, 102784, Surgical treatment of terrible triad of the elbow. Related Content AUTOPLAY ON. Diagnosis. Results Twenty-two patients (15 males, seven females; mean ± SD age, 47.5 ± 11.4 years) were enrolled in this study. COVID-19 is an emerging, rapidly evolving situation. -, Zhang C, Zhong B, Luo CF. The short-term and long term results are historically poor, with a … Methods This retrospective study evaluated data from patients who underwent surgery to repair terrible triad injuries and anteromedial coronoid fractures. Joaquin Sanchez-Sotelo. Login to view comments. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. The objective was to analyze the long-term clinical outcome of terrible triad injury of the elbow following surgical intervention with a single lateral approach. To report the results of the surgical treatment of terrible triad injury with anteromedial coronoid fracture through a combined surgical approach. The goal of surgical treatment of the terrible triad of the elbow is the restoration of humeroulnar and humeroradial stability, thus facilitating the early onset of elbow movement in the postoperative period in order to reduce the probability of long-term joint dysfunction and stiffness. Anatomy, Definition, and Treatment of the “Terrible Triad of the Elbow” and Contemplation of the Rationality of this Designation Introduction. Elbow dislocation associated with both radial head and coronoid fractures, termed the “terrible triad injury” (TTI) by Hotchkiss [1], was notoriously challenging for decades because of the difficulties inherent in treatment and the consistently poor prognosis [2-4]. Specialty. 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 . Preoperative lateral radiograph (A) and three-dimensional computed tomography (B) images show a Mason type II radial head fracture and an O’Driscoll anteromedial subtype 2 comminuted coronoid fracture after closed reduction of elbow dislocation. [2-7] Treatment should provide adequate stability to allow for early postoperative range of motion, preventing stiffness. ORIF of Distal Humerus Fractures 07:51. Following radial head replacement or ORIF the LCL should be repaired to the lateral condyle using suture anchors or transosseous sutures (Figs. - in this injury there is little to keep the elbow reduced; - general operative considerations: 1) radial head: repair or replacement of the radial head (see ORIF or radial head) - concomitant excision of radial head and coronoid process is not performed since it may result in … If plain radiographs are inconclusive or there is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important [ 4 ]. All rights reserved. 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 By continuing you agree to the use of cookies. dislocation is a common injury, its treatment has been traditionally associated with unsatisfactory outcomes and high complication rates [1–5]. Elbow; anteromedial facet of coronoid; fracture; terrible triad. Related Content AUTOPLAY ON. Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Module. Photographs of a 56-year-old man who sustained a terrible triad injury of the elbow. Philadelphia, PA: Lippincott-Raven, 1996, vol 1, pp.929–1024. Click here to Login. Orthopaedics & Traumatology: Surgery & Research, https://doi.org/10.1016/j.otsr.2020.102784. 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. Patient prone with elbow flexed at 90 degrees at edge of bed. These injuries make up about 30% of elbow dislocations, and are generally caused by falling onto an outstretched arm. Keywords:  |  Clipboard, Search History, and several other advanced features are temporarily unavailable. Schematic illustration showing a fracture of the anteromedial facet of the coronoid extending to involve the tip of the coronoid process (fracture fragment indicated by dotted lines). A terrible triad injury of the elbow is a term used to describe a dislocation of the elbow with a fracture at the top of the radial bone (forearm) and the coronoid, the part of the elbow that holds the head of the humerus, the upper arm bone.Because of the extent of the injury, the usual treatment is open surgery. Terrible Triad of the Elbow. Terrible triad injury of the elbow (TTIE), comprising elbow dislocation with radial head and coronoid process fracture, is notoriously challenging to treat and has typically been associated with complications and poor outcomes. We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. Objective To report the results of the surgical treatment of terrible triad injury with anteromedial coronoid fracture through a combined surgical approach. Algorithm for surgical treatment of terrible triad elbow injuries. Surgical technique. Approach: 1.1. 2020 Jul;8(3):209. doi: 10.30476/BEAT.2020.86026. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. -, Pugh DM, Wild LM, Schemitsch EH, et al. Bull NYU Hosp Jt Dis 2007; 65: 263–270. An ACL surgery is common and the meniscus can be treated during the surgery as well. 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. HHS Epub 2017 Mar 17. For this reason, it has been called the “terrible triad injury” of the elbow [3] Terrible triad injuries can lead to pain, recurrent instability, sti ness, and posttraumatic 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. March 10, 2011 71 Comments . 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. Surgery aims to restore perfect stability by sequential anatomic repair, enabling early mobilization to prevent onset of stiffness. We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. 11. 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. The treatment of terrible triad injuries of the elbow continues to evolve. Hang weight from hand, and if needed provider can push olecranon into place Immobilize in long arm posterior mold with elbow in slightly less than 90deg flexion If unstable, splint with forearm in pronation repair of terrible triad of the elbow injuries. Prevention of these severe complications requires initial understanding of the lesion mechanism and precise analysis of all lesions. We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. Objective Terrible triad injury of the elbow (TTIE), comprising elbow dislocation with radial head and coronoid process fracture, is notoriously challenging to treat and has typically been associated with complications and poor outcomes. METHODS: Records of 18 cases of the terrible triad of the elbow occurring in 8 women and 8 men aged 17 to 77 (mean, 45) years were reviewed. 2020 Jul;8(3):207-208. doi: 10.30476/BEAT.2020.86013. March 10, 2011 71 Comments . An ACL surgery is common and the meniscus can be treated during the surgery as well. 1.2. -. Oper Orthop Traumatol. Following radial head replacement or ORIF the LCL should be repaired to the lateral condyle using suture anchors or transosseous sutures (Figs. Extensors are elevated off th… (eds) Rockwood and Green’s fractures in adults. We use cookies to help provide and enhance our service and tailor content and ads. Fracture union and concentric reduction of both the ulnotrochlear and radiocapitellar articulations were achieved in all patients. Injury 2015; 46 (Suppl 8): S68–S76. -, Egol KA, Immerman I, Paksima N, et al. Generally these should commence around day 7-10 for a terrible triad or elbow dislocation unless otherwise specified in the operating report. 20.1 (a–f) Complex elbow instability (terrible triad). McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ. See this image and copyright information in PMC. Acta Chir Orthop Traumatol Cech. © 2020 Elsevier Masson SAS. Diagnosis. Approach: 1.1. The combination of elbow dislocation with both radial head and coronoid process fracture is notoriously challenging to treat and, as such, has been termed ‘‘terrible triad’’ injury of the elbow (TTIE) [1]. It is a complex trauma, associating … 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. Intervals: 1.2.1. Treatment strategy of terrible triad of the elbow: experience in Shanghai 6th People's Hospital. Authors of section Editors. Joaquin Sanchez-Sotelo. NIH 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. Skin incisions: 1.1.1.  |  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. Photographs of a 63-year-old man who sustained a terrible triad injury of the elbow. 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. 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. Single- staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury. Among the variety of disease designations, the terrible triad of the elbow looms large and is eye‐catching... Anatomy. All terrible triad injuries require surgical repair. The goal of treatment for terrible triad injuries is restoring the bony anatomy and reconstructing the ligamentous restraints of the elbow to provide enough stability for early elbow … 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. 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. Most repairs can be done from the lateral side. Fractures and dislocations of the elbow In Rockwood CA, editor; Jr, Green DP, Bucholz RW, Heckman JD, editors. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. The four injuries that will be discussed include Monteggia fracture-dislocation, distal humerus fracture, terrible triad, and transolecranon fracture. 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