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: 1.26). 04/2010; 96(2):147-54. DOI: 10.1016/j.otsr.2009.11.009
Source: PubMed


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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    • "Certain small size epiphyseal fractures of the radial head correspond to lesions in relation to dislocation. The assessment of the fracture at the level of the coronoid process is very important for the diagnosis because its integrity helps guarantee the overall stability of the elbow joint [23] [24] [25] [26]. If the ulnar fracture is at the base of the coronoid process or even distal to it, the stability of the elbow will be compromised. "
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    ABSTRACT: The aim of this study was to report the epidemiological characteristics and the experience of 5 departments of trauma, in France, in the management of fractures of the proximal ulna.
    Injury 01/2015; 46:S18-S23. DOI:10.1016/S0020-1383(15)70006-9 · 2.14 Impact Factor
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    • "Esse resultado é diferente do de outras séries. 2,5 No estudo de Chemama et al., 5 em 2010, os valores do escore de Mayo foram melhores para os pacientes submetidos à fixação quando comparados com os pacientes que não fixaram o coronoide, porém o autor não fez uma análise estatística de seus resultados. As fraturas do processo coronoide dos tipos II e III têm recomendação para o tratamento cirúrgico. "
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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 05/2014; 49(3):271–278. DOI:10.1016/j.rbo.2014.01.011
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    • "This result is different from that of other series. 2,5 In the study by Chemama et al., 5 in 2010, the Mayo scores were better among the patients who underwent fixation than among those who did not undergo coronoid fixation, although these authors did not perform any statistical analysis on their results. Surgical treatment is recommended for type II and III fractures of the coronoid process. "
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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.
    05/2014; 49(3):271–278. DOI:10.1016/j.rboe.2014.03.006
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