20:08. Elbow; anteromedial facet of coronoid; fracture; terrible triad. Three patients required secondary surgeries. The goals of surgery include (1) reestablishing the support provided by the radial head, (2) performing a dedicated, secure ligament repair, and (3) fixing the coronoid fracture (if the fractured coronoid piece is small, it may not require fixation). Treatment strategy of terrible triad of the elbow: experience in Shanghai 6th People's Hospital. Anatomy, Definition, and Treatment of the “Terrible Triad of the Elbow” and Contemplation of the Rationality of this Designation Introduction. Philadelphia, PA: Lippincott-Raven, 1996, vol 1, pp.929–1024. An understanding of the specific anatomy of these structures is paramount to the successful treatment of terrible triad injuries. Specialty. Article Details 1. Our surgical procedure includes fixation or replacement of the radial head and repair of the ruptured Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach 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 Following radial head replacement or ORIF the LCL should be repaired to the lateral condyle using suture anchors or transosseous sutures (Figs. 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. PURPOSE: To review epidemiological characteristics and treatment outcomes of the terrible triad of the elbow. Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). 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. The goal of treatment of terrible triad injuries is to restore the bony and ligamentous restraints of the elbow to provide elbow stability. The mean ± SD follow-up was 31.6 ± 11.9 months. -, Egol KA, Immerman I, Paksima N, et al. HHS 1.1.2. Treatment strategy of terrible triad of the elbow: experience in Shanghai 6th People's Hospital. Following radial head replacement or ORIF the LCL should be repaired to the lateral condyle using suture anchors or transosseous sutures (Figs. Conservative treatment was attempted (due to the patient’s general status). Photographs of a 56-year-old man who sustained a terrible triad injury of the elbow. Authors of section Editors. By Joaquin Sanchez-Sotelo 58 Videos. 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. By Joaquin Sanchez-Sotelo 58 Videos. 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. Most repairs can be done from the lateral side. 20.1 (a–f) Complex elbow instability (terrible triad). Diagnosis. Meena MK, Singh K, Meena S, Kumbhare C, Chouhan D. Bull Emerg Trauma. (1) Terrible triad injury of the elbow is a complex injury that is classically defined as elbow dislocation along with fractures of the coronoid process of the ulna and the radial head. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. Lateral options: 1.2.1.1. Fractures and dislocations of the elbow In Rockwood CA, editor; Jr, Green DP, Bucholz RW, Heckman JD, editors. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. In addition there is rupture of the lateral and medial collateral ligaments. 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 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 … 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… The elbow consists of bones, ligaments, tendons, and muscles that interact to allow for a stable, pain-free arc of motion. Lateral options: 1.2.1.1. During the last 20 years, pathologic, biomechanical and clinical knowledge has greatly progressed. 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. Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. The aims of the present paper were to summarize the anatomic and pathophysiological bases, highlight the crucial importance of the humeroradial column and lateral collateral ligament, and to determine the importance of the coronoid process. 1.1.2. Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Orthopaedics & Traumatology: Surgery & Research, https://doi.org/10.1016/j.otsr.2020.102784. The “terrible triad injury” of the elbow is the combination of an elbow dislocation, a radial head fracture and a coronoid process fracture. We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. Separate medial and lateral incisions; Medial approach will be required if a large, repairable radial head is in the way. COVID-19 is an emerging, rapidly evolving situation. Finally, we propose a simple algorithm to guide repair. Separate medial and lateral incisions; Medial approach will be required if a large, repairable radial head is in the way. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. 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 All rights reserved.  |  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 . 4 and 5). Login to view comments. 2020 Jul;8(3):207-208. doi: 10.30476/BEAT.2020.86013. Prevention of these severe complications requires initial understanding of the lesion mechanism and precise analysis of all lesions. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. 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. Approach: 1.1. 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. NIH 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. Response to the Letter to Editor Regarding "Lateral Approach and Combined Lateral and Anteromedial Approach for Surgical Treatment of Terrible Triad of Elbow: A Meta-Analysis". Surgery is the treatment of choice as closed reduction is usually insufficient, as seen in this case. [2-7] Treatment should provide adequate stability to allow for early postoperative range of motion, preventing stiffness. 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. 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. Postoperative lateral (C) and AP (D) radiographs show a Kirschner wire shifting from the radial head at the 1-year follow-up, and this patient underwent a second surgery to remove the Kirschner wire. 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. 2020 Jul;8(3):209. doi: 10.30476/BEAT.2020.86026. Please enable it to take advantage of the complete set of features! An ACL surgery is common and the meniscus can be treated during the surgery as well. This site needs JavaScript to work properly. 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. Select Management. The Elbow Terrible Triad - Surgical Treatment. Available online 14 December 2020, 102784, Surgical treatment of terrible triad of the elbow. Login to view comments. The Elbow Terrible Triad - Surgical Treatment. The anteromedial coronoid fracture was repaired with a suture anchor through an anteromedial approach. Select Management. Injury 2014; 45: 942–948. Extensors are elevated off th… ORIF of Distal Humerus Fractures 07:51. Introduction. Keywords: Surgeons performed fixation of the radial head fracture and repair of the lateral collateral ligament through a lateral approach and fixation of the coronoid fracture through an anteromedial approach. Algorithm for surgical treatment of terrible triad elbow injuries. Login. An ACL surgery is common and the meniscus can be treated during the surgery as well. We help you select the appropriate treatment of Terrible triad located in our module on Proximal forearm. The terrible triad is an uncommon injury, which includes an elbow posterior dislocation with fractures of the radial head and coronoid process of the ulna. We use cookies to help provide and enhance our service and tailor content and ads. 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. March 10, 2011 71 Comments . 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. Use of Mother-Child Screws in the Treatment of Coronoid Fractures in Terrible Triad Injury of the Elbow. Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. Skin incisions: 1.1.1. Injury. March 10, 2011 71 Comments . Gupta A, Barei D, Khwaja A, et al. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. Injury 2015; 46 (Suppl 8): S68–S76. Click here to Login. Authors of section Editors. Postoperative lateral (C) and anteroposterior (D) radiographs show an elbow with bone union of fractures at the 3-year follow-up. 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. These injuries make up about 30% of elbow dislocations, and are generally caused by falling onto an outstretched arm. 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 purpose of treatment in the terrible triad injury is to restore the congruency of the elbow joint, its stability and an optimal ROM. 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]. J … 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/. Related Content AUTOPLAY ON. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. If plain radiographs are inconclusive or there is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important [ 4 ]. Letter to the Editor Regarding "Lateral Approach and Combined Lateral and Anteromedial Approach for Surgical Treatment of Terrible Triad of Elbow: A Meta-Analysis.". Intervals: 1.2.1. 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. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. All terrible triad injuries require surgical repair. 2005 Mar;87 Suppl 1(Pt 1):22-32. doi: 10.2106/JBJS.D.02933. terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. treatment of the “terrible triad of the elbow”. Among the variety of disease designations, the terrible triad of the elbow looms large and is eye‐catching... Anatomy. 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. Bull Emerg Trauma. 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 Joaquin Sanchez-Sotelo. Intervals: 1.2.1. Epub 2017 Mar 17. The goal of treatment of terrible triad injuries is to restore the bony and ligamentous restraints of the elbow to provide elbow stability. Hotchkiss RN . Terrible Triad of the Elbow. Six patients had radiographic signs of post-traumatic arthritis. In the elbow with persistent instability after repair of these element … -, Zhang C, Zhong B, Luo CF. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Single- staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury. Giannicola G, Calella P, Piccioli A, et al. 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]. The anteromedial coronoid fracture was fixed with K-wires and suture anchors through an anteromedial approach. © 2020 Elsevier Masson SAS. 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. Module. Oper Orthop Traumatol. It is a complex trauma, associating severe bone and ligament lesions, with high more-or-less long-term risk of residual instability, stiffness, pain and osteoarthritis. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. 11.  |  2017 Apr;29(2):125-137. doi: 10.1007/s00064-017-0489-5. Operative treatment: 1. 11 Click here to Login. Therefore, the preferred surgical treatment options in the setting of terrible triad injuries include open reduction and internal fixation (ORIF) or radial head arthroplasty . 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. Methods This retrospective study evaluated data from patients who underwent surgery to repair terrible triad injuries and anteromedial coronoid fractures. 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. Some aspects of treatment are controversial: systematic medial collateral ligament repair, or use of an articulated external fixator. Preoperative anteroposterior (AP) radiograph (A) and three-dimensional computed tomography (B) images show a Mason type III radial head fracture and an O’Driscoll anteromedial subtype 1 coronoid fracture. The elbow is the second most commonly dislocated joint in adults and up to 20% of dislocations are associated with a fracture. Extensors are elevated off th… [2-7] Treatment should provide adequate stability to allow for early postoperative range of motion, preventing stiffness. - Discussion: - terrible triad: ( RHF + MCL + coronoid process frx) + elbow dislocation. The mean ± SD arc of flexion-extension was 110.3° ± 26.3° and arc of forearm rotation was 139.5° ± 17.1°. Evaluations were performed using the Mayo Elbow Performance Score (MEPS) and anteroposterior and lateral radiographs of the elbow. 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. METHODS: We retrospectively reviewed terrible triad of the elbow injuries treated at our hospital using a modified surgical technique. -. Diagnosis. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. 4th ed. Generally these should commence around day 7-10 for a terrible triad or elbow dislocation unless otherwise specified in the operating report. Clipboard, Search History, and several other advanced features are temporarily unavailable.  |  Conclusion Combined surgical approaches can be considered for the treatment of terrible triad injuries in association with anteromedial coronoid fractures. The four injuries that will be discussed include Monteggia fracture-dislocation, distal humerus fracture, terrible triad, and transolecranon fracture. 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). -, Pugh DM, Wild LM, Schemitsch EH, et al. 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. 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 Bull NYU Hosp Jt Dis 2007; 65: 263–270. General status ) Details 1 ligaments, tendons, and repair of “... 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In addition there is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important 4. Treatment strategy of terrible triad located in our module on Proximal forearm or x-fix if applied we help select. Is imperative to allow for early postoperative range of motion outstretched arm posttraumatic arthrosis following of... Imaging and CT are important [ 4 ] complication rates [ 1–5 ] elbow with bone union of at... Restores the lateral collateral ligament repair, enabling early mobilization 20 % of elbow injury is typically due the. It still a troublesome injury articulated external fixator dislocation unless otherwise specified in the way can...