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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Available from: Pierre Mansat
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    • "The aim of TTI treatment is to restore the primary and secondary stabilizers of the elbow so as to obtain a stable joint and allow early rehabilitation; therefore, anatomical and stable osteosynthesis of coronoid process, together with the repair or replacement of radial fractures followed by ligament reconstruction, currently represents the main goals of surgery [21-26]. Although this standardized treatment appears to have yielded more favorable and reproducible clinical outcomes in recent studies [9] [11] [12] [17] [19] [20] [26] [27] [28] [29], a high rate of complications and re-interventions has been documented in the literature [6,8- 11,15,19,20,29,30]. In a recent systematic review [31], Chen observed that all but one of the 16 studies examined were retrospective, and concluded that " evidence from additional prospective studies would be welcome " to understand which refinements in surgical and post-operative management are needed to reduce complications . "
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    ABSTRACT: Background: Terrible triad injury (TTI), one of the main patterns of complex elbow instability, is difficult to treat and yields conflicting surgical results. We analyzed prospectively a series of patient affected by TTI and treated according to the current diagnostic and surgical protocols to investigate whether their application allow to obtain more predictable outcomes. Material and methods: We analyzed 26 patients with a mean age of 52 years. Preoperative X-rays and CT were performed; all patients were operated by the same elbow surgeon and underwent the same surgical and rehabilitation treatment. Final functional outcome was assessed by the Mayo Elbow Performance Score (MEPS), Quick-Disability of the Arm Shoulder and Hand-score (Q-DASH) and the modified-American Shoulder and Elbow Surgeons score (m-Ases). A radiographic evaluation was also performed. Results: Mean follow-up was 31 months. At final evaluation, mean flexion, extension, supination and pronation were 137°, 10°, 77° and 79°, respectively; mean MEPS, m-ASES and Q-DASH scores were respectively 96, 91 and 8 points. Complications observed after first surgery were: elbow stiffness in 5 cases, mild posterolateral instability in 3 cases, chronic subluxation in 1 case. Radiographic evaluation showed secondary arthritis in 9 cases, symptomatic HO in 3 cases and late hardware displacement in 2 cases. Six out of 26 patient underwent reoperation with final satisfactory results. Conclusion: The current diagnostic and therapeutic protocols allow obtaining satisfactory clinical outcomes in majority of cases but a high number of major and minor unpredictable complications persist yet. In this series, low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery. On the other hand, the strict application of current algorithms by an expert elbow surgeon appears to improve clinical results by reducing the influence of other avoidable negative prognostic factors well known in current literature, such as the incomplete recognition of injuries, delayed treatment, inadequate treatment of bony and ligamentous injuries, prolonged immobilization and, last but not least, the surgeon's inexperience. Level of evidence: Level IV, Case series, Treatment study.
    Preview · Article · Dec 2015 · Injury
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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.
    Full-text · Article · Jan 2015 · Injury
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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.
    Full-text · Article · May 2014 · Revista Brasileira de Ortopedia
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