1A). - Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. A sling was used for comfort for 2 weeks postoperatively with physiotherapy and ROM exercises initiated early. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Protection of the ligament repair is essential. The Essex-Lopresti refers to an association of a radial head fracture dislocation, an interosseous membrane rupture and a DRUJ dislocation [3]. 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 … 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation. 20:08. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Shoulder Elbow. This may be done as below, or in a hinged range of motion brace or x-fix if applied. Tel: +212615994028; E-mail: Search for other works by this author on: Complex elbow dislocations and the “terrible triad” injury, An uncommon Essex-Lopresti fracture dislocation with radial displacement in distal direction: diagnosis and surgical treatment of a rare case, Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations, Nonsurgically treated terrible triad injuries of the elbow: report of four cases, Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures, Terrible triad of the elbow: treatment protocol and outcome in a series of eighteen cases.  |  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. Joaquin Sanchez-Sotelo. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, A rare case of fat embolism syndrome secondary to abdominal liposuction and gluteal fat infiltration, The use of radiolucent (carbon fibre-reinforced polymer) pedicle screw fixation for serial monitoring of clear cell meningioma: a case report, Type A aortic dissection after ‘zone 0’ thoracic endovascular aortic repair for type 1 hybrid aortic arch replacement of arch aneurysm, Spontaneous intestinal bleeding due to pseudoaneurism of the gastroduodenal artery: case report of a rare complication to median arcuate ligament syndrome, Two cases of giant peritoneal inclusion cysts requiring treatment after total laparoscopic hysterectomy, Volume 2020, Issue 12, December 2020 (In Progress), http://creativecommons.org/licenses/by-nc/4.0/, Receive exclusive offers and updates from Oxford Academic, Paediatric medial epicondyle fracture without elbow dislocation associated with intra-articular ulnar nerve entrapment, A rare case of Elbow dislocation with medial epicondyle fracture associated to ulnar neuropraxia, A rare three part proximal ulnar shear fracture requiring innovative reduction and fixation in a paediatric elbow, Desmoplastic fibroma of the distal radius: an interesting case and a review of the literature and therapeutic implications. As emergency treatment, we realized a closed reduction of the elbow dislocation under general anaesthesia with X-ray control, the limb was stabilized in a posterior brachiopalmar splint. Anteroposterior X-ray of the wrist showing the DRUJ reduction and the TightRope stabilization. Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. ORIF of … The Elbow Terrible Triad - Surgical Treatment. The unhappy triad is the name of a severe injury involving three crucial parts of your knee joint. 2013 Apr;27(4):496-9. 2018 Jul;10(3):216-222. doi: 10.1177/1758573217713694. A computed tomography (CT) confirmed the stage 2 coronoid process fracture and a partial radial head fracture, the PRUJ dislocation was also demonstrated (Fig. 2016 Jul 25;29(7):677-680. doi: 10.3969/j.issn.1003-0034.2016.07.021. A high index of suspicion with a detailed examination of the elbow, forearm and wrist associated to a comprehensive imaging were mandatory for a complete diagnosis and an adequate treatment. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. Clin Orthop Relat Res. 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]. 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. Login to view comments. Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. A terrible triad combines three injuries: dislocation of the elbow, fracture of the radial head, and fracture of the coronoid. Treatment of terrible triad injuries at a mean follow-up of nine years. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. In case of instability, whatever the height of the fragment, fixation is indicated [5]. 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. Does Timing of Surgery Affect Treatment of the Terrible Triad of the Elbow? A Kaplan approach was used to reduce the PRUJ dislocation, the annulate ligament was repaired and the radial head fracture was evaluated, as the detached fragment was <20% of the radial head circumference, no fixation was necessary. Chronic Simple Elbow Dislocation . USA.gov. 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. Copyright © 2020 Oxford University Press and JSCR Publishing Ltd. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. 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. The goal of physiotherapy is to reduce pain and swelling, restore your elbow’s full range of motion, and strengthen muscles. 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. Cervical kyphosis: A predominant feature of patients with osteogenesis imperfecta type 5. 4A and B). For full access to this pdf, sign in to an existing account, or purchase an annual subscription. 4 and 5). 'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. Zhou C, Lin J, Xu J, Lin R, Chen K, Sun S, Kong J, Shui X. Med Sci Monit. Understanding the Clin Orthop Relat Res. On examination, there was a deformity of his right elbow with pain in the ipsilateral wrist; there were no skin or distal neurovascular disorders. The aim is a stable concentrically guided elbow with early functional follow-up treatment. Mid-Term Postoperative Outcomes Following a Standardized Protocol. For terrible triads, or ORIF + ligament reconstruction, please also refer to ligament repair protocols. Treatment of the terrible triad injury of the elbow remains a difficult problem. Therefore, the preferred surgical treatment options in the setting of terrible triad injuries include … 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. Pre-operatively on the ward • Discuss post -operative rehab ’ 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]. Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. [Progress in treatment of terrible triad of elbow]. By Joaquin Sanchez-Sotelo 58 Videos. 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 ]. We present the case of a unique association of the two injuries with an elbow dislocation, radial and coronoid process fractures and a distal radioulnar joint dislocation due to an interosseous membrane rupture. 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. 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 . Treatment: Open reduction and hinged external fixation . [Selective neurotization of the median nerve in young patients with CV-CVIIcomplicated spinal cord injury]. The use of a hinged external protection is recommended as it allows quick articular mobilization [8]. Please enable it to take advantage of the complete set of features! Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 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. Characteristics/Clinical Presentation 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]. Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? Clipboard, Search History, and several other advanced features are temporarily unavailable. Terrible; elbow; fracture; instability; triad. The “terrible triad” injury is classically described as a combination of a coronoid process and radial head fractures, as well as a posterolateral elbow dislocation. 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- … Previous studies have demonstrated elbow instability and posttraumatic arthrosis following resection of the radial head in complex elbow dislocations . Keywords: No ligament reconstruction . The treatment of terrible triad injuries of the elbow continues to evolve. Zaidenberg EE, Abrego MO, Donndorff AG, Boretto JG, De Carli P, Gallucci GL. The terrible triad of the elbow and the Essex-Lopresti are two rare injuries but their association is unique [1, 2]. Six months after the accident, the patient made a good recovery. Resection of radial head alone is contraindicated. The lateral collateral ligament (LCL) and the common extensor muscle were repaired. Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. (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. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications … We managed a surgical treatment the second day of admission. The DRUJ and PRUJ dislocations were suggestive of a complete disruption of the interosseous membrane. [Progress on diagnosis and treatment of the terrible triad of elbow joint]. [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. 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. 1B). Clinical assessment of the post-operative ROM (A and B). The treatment of terrible triad injuries of the elbow continues to evolve. With recent developments in pathology, anatomy and biomechanics of the elbow … March 10, 2011 71 Comments . Copyright © 2015 American Society for Surgery of the Hand. A 56-year-old male fell forward onto his forearm and elbow during a mountain walk. 3). We report on the diagnostic and treatment challenge of this unique case. Hotchkiss RN. The elbow is a 3-dimensionally complex joint where stiffness is poorly tolerated and instability is devastating. 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 . Correspondence address. The terrible triad includes a posterior dislocation of the elbow with radial head and coronoid fractures, concurrent ligament injuries are very common especially the LCL and medial collateral ligament (MCL), which can be the source of a definite instability [1, 2]. Can we treat select terrible triad injuries nonoperatively? We present a particular case by the unique association of two rare injuries: a terrible triad of the elbow and an ipsilateral Essex-Lopresti entity. 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/. 3D reconstruction CT scan of the elbow shows a radioulnar proximal dislocation with O’Driscoll type 2-2 anteromedial fracture. Fractures and dislocations of the elbow. 2018 Aug;46(8):3053-3064. doi: 10.1177/0300060518771263. (iv) Early elbow mobilization is started to avoid the stiffness. The elbow testing objected a stable elbow from −30° of extension to complete flexion. The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [ 2, 3 ]. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. 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. He reported immediate swelling and pain in his elbow and wrist. 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. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach J Int Med Res . 2020 Oct 29;9(11):3500. doi: 10.3390/jcm9113500. 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]. Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. Epub 2017 Jun 13. 2013. The origins of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) complexes avulse from the epicondyles and the anterior capsule fails with a transverse fracture of the coronoid tip. This course of physical therapy successfully treat a undisplaced terrible triad injury in very limited selected supervised patients. 2019 Dec;11(6):450-458. doi: 10.1177/1758573218809375. The purpose of treatment in the terrible triad injury is to restore the congruency of the elbow joint, its stability and an optimal ROM. - 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 J Clin Med. This site needs JavaScript to work properly. Generally these should commence around day 7-10 for a terrible triad or elbow dislocation unless otherwise specified in the operating report. The authors declare there is no financial support from any organism. 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”. (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. 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. If plain radiographs are inconclusive or there is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important [4]. COVID-19 is an emerging, rapidly evolving situation. Jupiter and Ring JBJS 2002 . Surgical technique - Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People's Hospital. Stable elbow, > 100 degrees motion in all patients Click here to Login. Zhongguo Gu Shang. 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. The terrible triad of the elbow is posterior or posterolateral dislocation of the ulnohumeral joint with fractures of the radial head and coronoid process. 2017 Jul;120(7):595-610. doi: 10.1007/s00113-017-0373-7. Terrible triad … Epub 2018 Nov 6. An elbow dislocation associated with a displaced fracture of the radial head and coronoid process almost always renders the elbow unstable, making surgical fixation necessary. Algorithm for surgical treatment of terrible triad elbow injuries. Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series. Bilateral elbow dislocation in relation to Essex-Lopresti injury. The elbow was stable, and the grip strength was comparable to the contralateral side (Fig. 2). 5 patients: dislocated for 2 to 9 months . Distal arm pain should not simply be dismissed as referred pain [5]. Elbow Trauma Rehabilitation Protocol Includes post ORIF, or conservatively managed trauma when active ROM indicated N.B. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2014 Jul;472(7):2092-9. doi: 10.1007/s11999-014-3518-9. 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. Onto his forearm and elbow during a mountain walk was stable, and repair of the elbow with functional!: 10.1007/s11999-013-3331-x KA, Weiser RW, Sotereanos DG remains a difficult problem:2092-9. doi 10.1177/1758573218809375. Aim is a favourable prognostic factor for final outcome the anteromedial coronoid fracture dislocation [ 3 ] postoperatively physiotherapy... 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