Terrible triad injury of the elbow: how to improve outcomes?

Orthopaedics-Traumatology Department, Toulouse-Purpan university hospital, place du Dr-Baylac, 31059 Toulouse, France.
Orthopaedics & Traumatology Surgery & Research (Impact Factor: 1.06). 04/2010; 96(2):147-54. DOI: 10.1016/j.rcot.2010.02.008
Source: PubMed

ABSTRACT Dislocation of the elbow joint combined with fractures of the radial head and ulnar coronoid process is referred to as Terrible Triad Injury (TTI). The purpose of this study is to report our experience in the management of this specific injury and to validate the therapeutic choices of our treatment.
Between 1996 and 2006, 23 TTI in 22 patients were treated in our department. Fifteen males and seven females of mean age 46 years were included in this series.Internal fixation of the radial head was performed in 13 cases and arthroplasty in four. Fractures of the coronoid process were managed by surgical fixation in 10 cases. All torn ligaments were reconstructed which include 19 lateral and six medial ligament reconstructions.
Thirteen patients (14 elbows) were reviewed at a mean follow-up of 63 months, four patients at a mean follow-up of 11 month (range, 6 to 18 months), and five patients were lost to follow-up. All patients had stable elbow joint and in 90% of the cases, patients reported mild or no elbow pain. The arc of extension-flexion ranged from 18 to 127 grades, while the average arc of pronation-supination was 134 grades. The mean Mayo Elbow Performance Score was 87. Only one patient suffered from osteoarthritis 8 years after trauma and all elbows were centred on X-rays. Negative prognosis factor was associated with Mason type 3 radial head fractures.
The principle of the surgical management is based on two main objectives: restoration of bony stabilizing structures (radial head and coronoid process) and lateral collateral ligament reconstruction. A medial surgical approach is recommended in the case of persistent posterolateral instability following lateral collateral ligament reconstruction or when fixation of a large coronoid process fragment is indicated. The use of an external fixator is only advocated in case of persistent instability following the reconstruction of bony and ligamentous structures.
Level IV: Retrospective study.

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    ABSTRACT: Objetivo avaliar o resultado do tratamento cirúrgico da tríade terrível do cotovelo (fratura da cabeça do rádio e do processo coronoide e luxação do cotovelo) e suas complicações. Métodos entre agosto de 2002 e agosto de 2010 foram tratados 15 cotovelos (15 pacientes) com tríade terrível pelo Grupo de Ombro e Cotovelo do Departamento de Ortopedia e Traumatologia da Faculdade de Ciências Médicas da Santa Casa de São Paulo. Nove (60%) eram do sexo masculino e seis (40%) do feminino; a idade variou de 21 a 66, com média de 41. Com a exceção de um caso, que foi submetido a cirurgia artroscópica, todos foram submetidos a cirurgia aberta. A fratura do processo coronoide foi fixada em 10 pacientes (66,7%). A fratura da cabeça do rádio foi submetida a osteossíntese interna em 11 casos (73,3%); em três (20%), a cabeça do rádio foi ressecada; em um caso, somente o fragmento da fratura foi ressecado. Os ligamentos colaterais, com exceção de um caso, foram reparados sempre que se encontrassem lesados; foram encontradas 10 (66,7%) lesões do colateral medial e 15 (100%) do lateral. O seguimento no período pós‐operatório foi, em média, de 62 meses, com mínimo de 12. A avaliação pós‐operatória foi feita por meio do escore de Bruce. Resultados mais de 80% dos pacientes recuperaram os arcos de movimentos funcionais e, de acordo com o escore de Bruce, apenas 26% obtiveram resultados considerados satisfatórios. Conclusão apesar dos resultados insatisfatórios, os arcos funcionais de movimento e a função do cotovelo podem ser restaurados.
    Revista Brasileira de Ortopedia (English Edition). 01/2014; 49(3):271–278.
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    ABSTRACT: The treatment of terrible triad injury with a poor outcome after intervention has not been successful thus far. The purpose of this study was to evaluate the efficacy of arthrolysis and reconstruction in the treatment of terrible triad injury with a poor outcome after surgical as well as conservative intervention. Twelve patients (12 elbows) with the diagnosis of terrible triad injury were respectively reviewed. All the 12 patients had elbow dysfunction after conservative and surgical treatment of the terrible triad injury. Preoperatively, the flexion arc and forearm rotation were 36.7° ± 28.5° and 51.3° ± 43.4°, respectively, and the Mayo Elbow Performance Score was 56.3 points. The mean interval between the primary injury and our surgical treatment was 6.6 months. Our surgical intervention included elbow arthrolysis, ulnar nerve transposition, radial head replacement, coronoid process and ligament repair, and hinged external fixation. Patients were encouraged to participate in rehabilitation training 24 h after surgery. The mean follow-up duration was 20.1 months; the flexion arc and forearm rotation were 122° ± 18° and 140° ± 20°, respectively, and the mean Mayo Elbow Performance Score was 94.6 points (9 excellent, 3 good). Concentric stability was restored in all elbows. Complications included superficial pin tract infection (1), heterotopic ossification (3), and ulnar nerve palsy (1); the ulnar nerve symptoms had improved at the last follow-up. The combination of open arthrolysis and reconstruction performed at a mean interval of 6-month posttrauma can restore functional mobility in cases of terrible triad injury with a poor outcome after surgical as well as conservative intervention. Thus, it may be an effective alternative for the treatment of the poor outcome terrible triad injury. We recommend early functional rehabilitation with adherence to the guidelines for hinged external fixation.
    Archives of Orthopaedic and Trauma Surgery 01/2014; · 1.36 Impact Factor
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    ABSTRACT: Objective to evaluate the results from surgical treatment of the terrible triad of the elbow (fracture of the radial head, fracture of the coronoid process and elbow dislocation) and its complications. Methods between August 2002 and August 2010, 15 patients (15 elbows) with the terrible triad were treated by the Shoulder and Elbow Group of the Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa de São Paulo. Nine (60%) were male and six (40%) were female; their ages ranged from 21 to 66 years, with a mean of 41 years. With the exception of one case that underwent arthroscopic surgery, all the patients underwent open surgery. The fracture of the coronoid process was fixed in 10 patients (66.7%). The fracture of the radial head was treated by means of internal osteosynthesis in 11 cases (73.3%); in three cases (20%), the radial head was resected; and in one case, only the fragment of the fracture was resected. The collateral ligaments, except for one case, were repaired whenever they were found to be injured; ten cases (66.7%) of medial collateral injury and 15 (100%) of lateral collateral injury were found. The mean length of the postoperative follow‐up was 62 months, with a minimum of 12 months. The postoperative evaluation was done by means of the Bruce score. Results more than 80% of the patients recovered their functional ranges of motion but, according to the Bruce score, only 26% of the patients achieved results that were considered satisfactory. Conclusion despite the unsatisfactory results, the functional ranges of motion and elbow function could be restored.
    Revista Brasileira de Ortopedia 01/2014; 49(3):271–278.

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