Results of terrible triads in the elbow: the advantage of primary restoration of medial structure.
ABSTRACT 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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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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ABSTRACT: 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. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications following surgical management of TTIE. Medline, EMBASE, Cochrane Library, and Google Scholar were searched to identify relevant studies, which were included if they were retrospective or prospective in design, involved participants who had TTIE, and were published in English. Outcomes of interest were functional outcomes and complications. Sixteen studies, involving 312 patients, were included in the systematic review. Mean follow up after surgery was typically 25 to 30 months. Mean Mayo elbow performance scores ranged from 78 to 95. Mean Broberg-Morrey scores ranged from 76 to 90. Mean DASH scores ranged from 9 to 31. The proportion of patients who required reoperation due to complications ranged from 0 to 54.5% (overall = 70/312 [22.4%]). Most of these complications were related to hardware fixation problems, joint stiffness, joint instability, and ulnar neuropathy. The most common complications that did not require reoperation were heterotopic ossification (39/312 [12.5%] patients) and arthrosis (35/312 [11.2%] patients). The results of this systematic review indicate that functional outcomes after surgery for TTIE are generally satisfactory and that complications are common. Further research is warranted to determine which surgical techniques optimize functional outcomes and reduce the risk of complications.PLoS ONE 05/2014; 9(5):e97476. DOI:10.1371/journal.pone.0097476 · 3.53 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 05/2014; 49(3):271–278. DOI:10.1016/j.rbo.2014.01.011