Results of terrible triads in the elbow: The advantage of primary restoration of medial structure

Department of Orthopaedic Surgery, Korea University College of Medicine, Seoul 136-705, Korea.
Journal of Orthopaedic Science (Impact Factor: 0.94). 09/2010; 15(5):612-9. DOI: 10.1007/s00776-010-1515-8
Source: PubMed


The purpose of this study was to report the clinical and radiological outcomes and surgical strategy for terrible triad injury of the elbow. We hypothesized that the outcomes of this type of injury would be satisfactory if the medial structure was routinely restored at the same time as the repair of the lateral structure.
We retrospectively reviewed the results of this treatment performed in 13 elbows with terrible triads. Our surgical protocol included fixation or replacement of the radial head and repair of the ruptured lateral ulnar collateral ligament through the lateral traumatic window. In all cases, simultaneous fixation of the coronoid and repair of the common flexor muscle were performed through the medial traumatic window. In eight patients with medial collateral ligament injury, the ligament was always repaired. The follow-up period ranged from 18 to 41 months (mean, 25 months).
The flexion-extension arc of the elbow averaged 128° and forearm rotation averaged 134.6°. The mean Mayo elbow performance score was 95 points (range, 85 to 100), which corresponded to ten excellent results, and three good results. Concentric stability was restored to all cases. As postoperative complications, one patient had ulnar nerve neuropathy.
The present operative procedures restoring all damaged lateral and medial structures through the lateral and the medial windows provided satisfactory clinical and radiological outcomes and are recommended for patients with terrible triad injury.

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    • "Forthman et al.[19] reported good results in 22 terrible triad cases without MCL repair, and their findings demonstrated that the MCL has the potential to heal (or scar) in a way that restores function by avoiding varus elbow stress. On the other hand, Jeong et al.[5] repaired the MCL structure in 8 of 13 cases of terrible triad injuries without a large medial softtissue dissection, and the rate of postoperative complication was low. More importantly, biomechanical study suggests that transosseous suture repair of both the LCL and MCL helps to restore elbow stability in either the varus or valgus position, and restores active kinematics in the dependent position.[35] "
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    ABSTRACT: Background Terrible triad of the elbow can be a challenging injury to treat, with a history of well-known complications. The purpose of this study is to report the outcomes of a modification of the standard surgical protocol for the repair of terrible triad of the elbow injuries. Methods We retrospectively reviewed terrible triad of the elbow injuries treated at our hospital using a modified surgical technique. Our surgical procedure includes fixation or replacement of the radial head and repair of the ruptured lateral collateral ligament (LCL) through a lateral approach. Simultaneous fixation of the coronoid process and repair of the common flexor muscle and medial collateral ligament (MCL) injury were performed through an anteromedial incision. Mayo Elbow Performance Score (MEPS) was determined for each patient at the final clinic visit. The Broberg and Morrey classification was used for evaluating traumatic arthritis. Results There were 21 patients (21 elbows) included in the analysis, and the mean follow-up period was 32 months (range, 24 to 48 months). At the last follow-up the mean flexion-extension arc of the elbow was 126° and the mean forearm rotation was 139°. The mean MEPS was 95 points (range, 85 to 100 points), with 19 excellent results and two good results. Concentric stability was restored in all cases. Two patients had heterotopic ossification, one patient had radial head nonunion, one patient had a superficial infection, and one patient had ulnar nerve neuropathy. Conclusion Our surgical strategy for terrible triad of the elbow has the advantage of providing both bony and soft-tissue stability simultaneously, thereby allowing active early motion as well as functional recovery of the elbow.
    Injury 06/2014; 45(6). DOI:10.1016/j.injury.2013.12.012 · 2.14 Impact Factor
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    • "Recommendations for management: (1) Osteosythesis of the radial head and coronoid [40,59,66–71] (2) Repair of LCL complex [40,59,66–71] (3) Repair of the MCL if elbow instability persists after structures in 1 + 2 addressed [67] [71] [72] (a) In particular for throwing athletes [73] (4) Hinged external fixation if elbow remains unstable intraoperatively after 1,2 + 3 addressed [63] [67] [69] [72] Conclusion This article has provided an overview of the common patterns of injury encountered in elbow fracture dislocations. It can be seen from the complex relationship between the primary and secondary anatomical restraints of the elbow that disruption of these crucial structures correlates with the severity of the injury. "
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    ABSTRACT: Injuries to the elbow are commonly encountered in orthopaedic practice. They range from low energy, simple isolated fractures, to high energy complex fracture dislocations with severe ligamentous disruption. Recognising the precise pattern of injury is critical in restoring elbow function and preventing chronic instability, pain and weakness. This article discusses the important osseous and ligamentous stabilisers of the elbow joint and provides management protocols for the common patterns of complex injury encountered by the practising surgeon.
    Injury 09/2013; 24. DOI:10.1016/j.injury.2013.09.032 · 2.14 Impact Factor
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    • "We chose to repair the medial collateral ligament in our patient, as we did not want prolonged immobilization for ligament healing, and to start early range of motion exercises. There has also been recent evidence to suggest good results with acute repair of the medial collateral ligament [18]. The use of a hinged external fixator would also have been an option to allow early range of motion exercises and protect the collaterals [19]. "
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    ABSTRACT: We illustrate a rare complex dislocation of the elbow involving a posterior ulno-humeral dislocation associated with open diaphyseal fracture of the ulna, radial shaft fracture, Type 1 coronoid fracture and neuropraxia of the deep branch of the radial nerve. The isolated ulno-humeral dislocation without radio-capitellar involvement, and ulnar diaphyseal fracture, makes this "reverse Monteggia" type of injury pattern very unique. This patient was managed with an initial reduction of his ulno-humeral joint and stabilization of his radius and ulna fractures. He underwent a delayed medial collateral ligament reconstruction a few days later. His fractures went on to unite fully, his elbow joint remained stable, and he achieved good range of motion of his elbow.
    Strategies in Trauma and Limb Reconstruction 08/2011; 6(2):97-101. DOI:10.1007/s11751-011-0112-5
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