Does Timing of Surgery Affect Treatment of the Terrible Triad of the Elbow? At 8 months of follow-up and 2 months of physiotherapy, the patient made a good recovery in regard to pain and mobility. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. COVID-19 is an emerging, rapidly evolving situation. The terrible triad of the elbow and the Essex-Lopresti are two rare injuries but their association is unique [1, 2]. This site needs JavaScript to work properly. 1A). USA.gov. Elbow Trauma Rehabilitation Protocol Includes post ORIF, or conservatively managed trauma when active ROM indicated N.B. Resection of radial head alone is contraindicated. Whereas the importance of early recognition of neurovascular compromise is well described and nearly universally recognized, the importance of timely and correct treatment in preventing delayed complications and potential instability is often less emphasized in the radiology literature. Faculté de medecine et de pharmacie de Marrakech, University Hospital Mohammed VI, Marrakech, Morocco. 2019 Dec;11(6):450-458. doi: 10.1177/1758573218809375. 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 range of motion and prevent elbow stiffness . Six months after the accident, the patient made a good recovery. [Progress on diagnosis and treatment of the terrible triad of elbow joint]. Early management is a favourable prognostic factor for final outcome. March 10, 2011 71 Comments . Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. This course of physical therapy successfully treat a undisplaced terrible triad injury in very limited selected supervised patients. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. The elbow dislocation is a frequent and an easily diagnosed pattern, at the opposite of the DRUJ dislocation, which is often missed in the emergency department if an adequate physical exam with the appropriate radiographs is not carried out [3]. Terrible triad … 2013 Apr;27(4):496-9. In some accidents, the elbow dislocates (the radius and ulna are pulled apart from the humerus) without any bones breaking; surgeons call this injury a “simple dislocation”. Clin Orthop Relat Res. 2017 Jul;120(7):595-610. doi: 10.1007/s00113-017-0373-7. Clinical assessment of the post-operative ROM (A and B). Consequently, each time a radial head fracture associated or not to an elbow dislocation is diagnosed, an ipsilateral wrist examination is mandatory to diagnose an Essex-Lopresti injury; otherwise, chronic wrist symptoms can develop, such as pain and instability [4]. Please enable it to take advantage of the complete set of features! Epub 2017 Jun 13. The Essex-Lopresti refers to an association of a radial head fracture dislocation, an interosseous membrane rupture and a DRUJ dislocation [3]. The treatment of terrible triad injuries of the elbow continues to evolve. Can we treat select terrible triad injuries nonoperatively? The unhappy triad is the name of a severe injury involving three crucial parts of your knee joint. A study [9] has shown that coronoid fractures do not need to be fixed if there is stability in the ROM after repair of lateral structures. Development of a novel real-time simulation of human skeleton/muscles. Closed reduction of the DRUJ was achieved but it was instable, a fixation with a TightRope was used (Fig. In the elbow with persistent instability after repair of these elements, application of a static external fixation, hinged external fixation, ulnohumeral joint pinning, or an internal hinge may be needed. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. [6, 7]: (i) the humeroradial joint: LCL complex must be repaired in all cases eventually with the common extensor origin, radial head fractures are either treated functionally if minimally displaced, fixed, or if comminuted, replaced by an implant. Chan K, MacDermid JC, Faber KJ, King GJ, Athwal GS. AIM OF SURGERY: Reconstruction of the most important ligamentous and osseus structures of the elbow after terrible triad injury via the radial head to the lateral collateral ligament complex (LCL) and if necessary beginning at the coronoid process. The terrible triad of the elbow is posterior or posterolateral dislocation of the ulnohumeral joint with fractures of the radial head and coronoid process. No similar case has been found in the literature review. Shoulder Elbow. of “terrible triad of the elbow”, which was first described by Hotchkiss in 19961, is a severe pattern of elbow fracture-dislocation injury that consists of posterior dis- … Stable elbow, > 100 degrees motion in all patients Abstract. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? The stability was rechecked and upgrade of the stable range of motion (ROM) was assessed, the elbow was now stable from −20° extension to complete flexion. In patients who undergo treatment after the acute injury period, the coronoid may require reconstruction using radial head autograft, iliac crest autograft, olecranon autograft, or allograft. Elbow dislocations are staged depending on the disruption of the following stabilizers: the ulnohumeral articulation, MCL, and LCL.  |  A computed tomography (CT) confirmed the stage 2 coronoid process fracture and a partial radial head fracture, the PRUJ dislocation was also demonstrated (Fig. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. Following radial head replacement or ORIF the LCL should be repaired to the lateral condyle using suture anchors or transosseous sutures (Figs. Surgical technique - Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People's Hospital. The treatment of terrible triad injuries of the elbow continues to evolve. Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? The goal of physiotherapy is to reduce pain and swelling, restore your elbow’s full range of motion, and strengthen muscles. No ligament reconstruction . With recent developments in pathology, anatomy and biomechanics of the elbow … 20:08. 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. When the radial head fracture is accompanied by an interosseous membrane lesion affecting the distal radioulnar joint (DRUJ), it is given the name Essex-Lopresti injury [4]. 2018 Jul;10(3):216-222. doi: 10.1177/1758573217713694. What you’ve sustained is called the terrible triad injury, because you’ve broken your ulnar, radial head and also dislocated your entire elbow.’ A picture of this is below, and while I kinda just shrug my shoulders at it, anyone in the medical field just looks a bit uncomfortable and says ‘ouch’ when they see it, so I guess the gap in the bone is where I broke it. 2013. The case was managed with closed reduction of the elbow dislocation and distal radioulnar joint followed by open reduction and repair of the damaged structures in the elbow and an unloading of the interosseous membrane. (iii) The stability of the elbow is assessed; if still unstable, a hinged external fixator or repair of the MCL is discussed. 2018 Jul 9;24:4745-4752. doi: 10.12659/MSM.907146. Unfallchirurg. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach J Int Med Res . Romero Pérez B, Marcos García A, Medina Henríquez JA, Muratore Moreno G. Oxford University Press is a department of the University of Oxford. Mobility of the right elbow was −20° for extension and 100° for flexion; the wrist mobility was respectively 60° and 20° of flexion and extension. Jupiter and Ring JBJS 2002 . The distal radioulnar dislocation should also be reduced by placing the forearm in maximum supination and stabilized either with a brachiopalmar splint, a percutaneous Kirschner wire, repairing the triangular ligament or the central band of the interosseous membrane [10]. By Joaquin Sanchez-Sotelo 58 Videos. Other names for it include: terrible triad; O’Donoghue’s triad Clin Orthop Relat Res. (A) X-ray of elbow profile shows the posterior elbow dislocation with a detached anterior fragment from the coronoid; (B) three-fourth X-ray of the forearm before the reduction demonstrates significant ulnar negative variance. Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. J Clin Med. The elbow was stable, and the grip strength was comparable to the contralateral side (Fig. - 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 The lateral collateral ligament (LCL) and the common extensor muscle were repaired.  |  Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Generally these should commence around day 7-10 for a terrible triad or elbow dislocation unless otherwise specified in the operating report. 4 and 5). 5 patients: dislocated for 2 to 9 months . Fractures and dislocations of the elbow. The Elbow Terrible Triad - Surgical Treatment. Free active assisted flexion, free extension to -30 deg off full extension, lying with shoulder 90 deg of abduction. 4A and B). It is a complex trauma, associating … 2018 Aug;46(8):3053-3064. doi: 10.1177/0300060518771263. In our case, the testing showed a stable elbow, so we decided not to fix the coronoid fracture furthermore that it was a small anteromedial fragment stage 2 according to the O’Driscoll classification. This may be done as below, or in a hinged range of motion brace or x-fix if applied. Copyright © 2020 Oxford University Press and JSCR Publishing Ltd. Keywords: [Selective neurotization of the median nerve in young patients with CV-CVIIcomplicated spinal cord injury]. Anteroposterior X-ray of the wrist showing the DRUJ reduction and the TightRope stabilization. 'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. Shoulder Elbow. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Zhongguo Gu Shang. - Terrible triad injury of the elbow: how to improve outcomes? Joaquin Sanchez-Sotelo. Treatment of terrible triad injuries at a mean follow-up of nine years. Login to view comments. terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation. Hotchkiss RN. Distal arm pain should not simply be dismissed as referred pain [5]. A terrible triad combines three injuries: dislocation of the elbow, fracture of the radial head, and fracture of the coronoid. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. On examination, there was a deformity of his right elbow with pain in the ipsilateral wrist; there were no skin or distal neurovascular disorders. If plain radiographs are inconclusive or there is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important [4]. The use of a hinged external protection is recommended as it allows quick articular mobilization [8]. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Clin Orthop Relat Res. Surgical management is quite standardized according to Pugh et al. Zhou C, Lin J, Xu J, Lin R, Chen K, Sun S, Kong J, Shui X. Med Sci Monit. 3D reconstruction CT scan of the elbow shows a radioulnar proximal dislocation with O’Driscoll type 2-2 anteromedial fracture. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. The “terrible triad of the elbow” is a notorious combination of elbow dislocation and fractures of the coronoid process and radial head that has historically been difficult to manage and had an unsatisfactory prognosis 36-38, almost unavoidably causing long‐standing postoperative pain, elbow instability and a range of complications. Chronic Simple Elbow Dislocation . 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. In the elbow with persistent instability after repair of these elements, application of a static external fixation, hinged external fixation, ulnohumeral joint pinning, or an internal hinge … 2). 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]. HHS Epub 2018 Nov 6. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. A sling was used for comfort for 2 weeks postoperatively with physiotherapy and ROM exercises initiated early. There was mild widening of the DRUJ with significant ulnar negative variance (Fig. We managed a surgical treatment the second day of admission. 1 Introduction Fracture dislocation of the elbow , termed terrible triad , involves three anatomic injuries: coronoid fracture, radial head fracture , and posterior elbow dislocation. According to that elbow stability status and the coronoid fracture stage, we decided a conservative treatment for the anteromedial coronoid fracture. "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. Historically, the combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture has had a consistently poor outcome; for this reason, it is called the terrible triad. Of coronoid process fixation, and the Essex-Lopresti refers to three combined lesions: elbow dislocation unless otherwise in! 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