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Abstract Objective To evaluate the functional results of patients submitted to a surgical approach for the treatment of the terrible triad of the elbow, analyzing the treatment methods used and associated epidemiological variables. Methods Patients who underwent surgical treatment for the terrible triad of the elbow from February 2018 to June 2020 at our service were evaluated. The identified sample consisted of 17 patients, but of these, only 13 completed all stages of the study and, therefore, were considered as the universe to be considered. Epidemiological information of interest was collected: age, sex, hand of dominance, affected side, characteristics and classification of injuries, trauma mechanism, time to surgery, type of procedure performed and range of motion. The Mason classification was used for radial head fractures and the Regan and Morrey classification for the coronoid process. In order to perform a functional analysis, the DASH and BRUCE questionnaires were applied. Results About 77% of the patients were male, 92% of the fracture mechanisms were due to high-energy trauma. Contrary to this, the predominance of the non-dominant side was observed as the most affected. Evaluating the results according to the time to start the treatment, the patients operated within 14 days had statistically better functional results. Conclusion Surgical treatment of TTIE generates acceptable functional results in most cases. The success of the treatment is related to the time interval between the trauma and the first surgery, in addition to the severity of the injuries.
Resumo Objetivo Avaliar os resultados funcionais dos pacientes submetidos a abordagem cirúrgica para o tratamento da tríade terrível do cotovelo, analisando os métodos de tratamento utilizados e variáveis epidemiológicas associadas. Métodos Foram avaliados pacientes submetidos aotratamento cirúrgico de tríade terrível do cotovelo de fevereiro de 2018 a junho de 2020 em nosso serviço. A amostra identificada foi de 17 pacientes, mas destes apenas 13 concluíram todas as etapas das pesquisas e por isso foram considerados como o universo a ser levado em consideração. Coletou-se informações epidemiológicas de interesse: idade, sexo, dominância, lado acometido, características e classificações das lesões, mecanismo do trauma, tempo para cirurgia, tipo de procedimento realizado e o arco de movimento. Foi utilizada a classificação de Mason para a fratura de cabeça do rádio e a de Regan e Morrey, para o processo coronoide. A fim de realizar uma análise funcional, aplicou-se os questionários de DASH e BRUCE. Resultados Cerca de 77% dos pacientes foram do sexo masculino, 92% dos mecanismos de fratura foram por trauma de alta energia. Contrariamente a esta, observou-se a predominância do lado não dominante como o mais afetado. Avaliando os resultados de acordo com o tempo para início do tratamento, os pacientes operados em até 14 dias obtiveram resultados funcionais estatisticamente melhores. Conclusão O tratamento cirúrgico da TTC gera resultados funcionais aceitáveis na maioria dos casos. O sucesso do tratamento está relacionado ao intervalo de tempo entre o trauma e a primeira cirurgia, além de se relacionar com a gravidade das lesões.
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Humans , Male , Female , Ulna/injuries , Elbow Joint , Elbow Injuries , Radial Head and Neck FracturesABSTRACT
Objective:To analyze the types of ulnar coronoid process fractures in terrible triad injury (TTI) using three coronoid fracture classification systems and to explore the characteristics of coronoid process fractures and compare the reliability of different coronoid process fractures classification systems in TTI.Methods:A retrospective case series study was used to analyze the CT data of 43 patients with typical TTI admitted to First Affiliated Hospital of Fujian Medical University from January 2013 to October 2020. There were 26 males and 17 females, aged from 18 to 88 years [(41.8±15.6)years]. An independent three-dimensional model of the proximal ulna was established using the CT three-dimensional reconstruction technology. The characteristics of the coronoid process fractures were observed. The Regan-Morrey classification, O'Driscoll classification and Adams classification were used to classify the ulnar coronoid process fractures. The reliability of the three classification systems of coronoid fractures was analyzed.Results:The fracture line of the coronoid process was mostly located anterolaterally. Among all patients with ulnar coronoid fractures, there were 17 patients (40%) with type I, 19 (44%) with type II and 7(16%) with type III according to Regan-Morrey classification; there were 34 patients (79%) with type I, 2(5%) with type II and 7(16%) with type III according to O'Driscoll classification; there were 12 patients (28%) with type I, 3(7%) with type II, 7(16%) with type III, 18(42%) with type IV AL and 2(5%) with type IV AM according to Adams classification. Through reliability analysis, the Kappa coefficients of the inter-observer and intra-observer 1, 2, 3 of Regan-Morrey classification were 0.752, 0.813, 0.772 and 0.703, respectively; the Kappa coefficients of the inter-observer and intra-observer 1, 2, 3 of O'Driscoll classification were 0.797, 0.774, 0.837 and 0.775, respectively; the Kappa coefficients of the inter-observer and intra-observer 1, 2, 3 of Adams classification were 0.805, 0.835, 0.837 and 0.875, respectively.Conclusions:Most of the coronoid process fractures locate anterolaterally in TTI. Compared with Regan-Morrey classification and O'Driscoll classification, the reliability of Adams classification is best. Adams classification further subdivides the anterolateral fractures of the coronoid process, which may be more suitable in evaluating the classification of ulnar coronoid process fractures in TTI.
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Objective To investigate the effect of medial collateral ligament (MCL) repair and coronoid process fracture fixation on stability of the Terrible Triad of the elbow. Methods CT and MRI scan images of elbow joints from one healthy 28-year-old male volunteer were used to establish three elbow models. Model A: normal model. Model B: repair of coronoid process fractures, without MCL repair. Model C: repair of MCL, without repair of ulnar coronoid processes. Longitudinal loads were applied on the three models to analyze the displacement and stress distributions of the elbow joint under different working conditions and compare the stability of the elbow joint. Results The displacement and stress distributions of the three models were similar. The maximum displacement and maximum stress of the articular surface were located at the ulna pulley notch, while the minimum displacement was located at the coronoid process and its medial side. The minimum stress was located at the lower lateral side of the coronoid process. There were no statistical differences in the maximum displacement and stress among the three models (P>0.05). Conclusions When the lateral column is stable, the effect of repairing the MCL and fixing the fracture block of ulnar coronoid process is similar.
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BACKGROUND: The diagnosis and treatment of the terrible triad of the elbow have achieved a breakthrough. OBJECTIVE: To introduce the definition, basic anatomy, stable structure, injury mechanism and classification of terrible triad of the elbow, and to discuss the treatment plan deeply. METHODS: The first author searched PubMed, CNKI and Wanfang databases for the articles published before September 2019. The keywords were “terrible triad of the elbow, elbow joint, fracture dislocation” in English and Chinese, respectively. A large number of articles concerning the terrible triad of the elbow in recent years were reviewed, and the treatment strategy was summarized. RESULTS AND CONCLUSION: For the terrible triad of the elbow, the operator must carefully check the patient before operation, carefully analyze the imaging examination results and three-dimensional printed model, and accurately judge the bone structure of the elbow and degree of ligament injury. During the operation, the stability of the radial head, the fracture of the coronoid process and the injury of the lateral ligament complex are usually reconstructed through a single lateral approach or a combination of internal and external approaches. Then, the stability of elbow joint is tested to determine whether it is necessary to repair the medial ligament complex or use the hinged external fixator to restore the stability of elbow joint. Early active rehabilitation is needed. The above systematic treatment can reduce postoperative complications, accelerate fracture healing, and improve elbow joint function and patients’ quality of life.
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PURPOSE@#To assess the clinical and radiographic outcomes of coronoid process fractures surgically managed with buttress plate fixation via a medial approach.@*METHODS@#A retrospective review of all coronoid fractures surgically fixed in our institution using a buttress plate technique via a medial approach between June 2012 and April 2015 by the senior author was performed. These fractures were all sizeable fractures contributing to persistent elbow instability in terrible triad or varus posteromedial rotatory instability injury patterns. A prospective telephone questionnaire was conducted to assess patient outcomes using the disabilities of the arm, shoulder and hand (DASH) score and Mayo hlbow performance score (MEPS).@*RESULTS@#Twelve patients were included in the study, comprising 10 males and 2 females with an average age of 39 years (range, 19-72 years). Mean follow-up was 16 months (range, 4-18 months). The average time to radiographic union was 4 months (range, 3-7 months). Range of motion measurements at final follow-up were obtained in 11 out of 12 patients, with one patient defaulting follow-up. All 11 patients displayed a functional elbow range of motion of at least 30°-130°, with an average arc of motion of 130° (range, 110° -140°), mean elbow flexion of 134° (range, 110° -140°) and mean flexion contracture of 3° (range, 0° -20°). The mean DASH score was 16 (range, 2.5-43.8) and the mean MEPS was 75 (range, 65-100). Complications observed included one patient with a superficial wound infection which resolved with a course of oral antibiotics and one patient with radiographic evidence of heterotopic ossification which was conservatively managed. No residual elbow instability was observed and no reoperations were performed.@*CONCLUSION@#Buttress plate fixation via a medial approach of coronoid process fractures that contribute to persistent elbow instability represents a reliable method of treatment that produces satisfactory and predictable outcomes.
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Objective The application of hinged scaffold in the terrible triad of the elbow has been widely accepted by or-thopedic trauma physicians. We discussed whether to repair the collateral ligament or not of terrible triad of the elbow under hinged ex-ternal fixator in this study. Methods 23 patients with terrible triad of the elbow,who had been admitted in Foshan Hospital of tradi-tional Chinese Medicine from June 2011 to August 2016 were selected. In the surgeries, we firstly repaired and fixed the coronoid and radial head fractures,and the repairments of the lateral collateral ligament complex(LCLC) was based on the severity of injury and the stability of the elbow joint. All the patients were treated with hinged external fixator in flexion 90°,forearm neutral position and the medial collateral ligament complex (MCLC) was not repaired. The patients were followed up from 8 to 26 months with an average of 13.7 months. Elbow flexion and extension amplitude and forearm rotation amplitude were measured at the time of follow-up. The clinical effects were eval-uated according to HSS scoring of elbow joint function. Results Their average elbow range of flexion and extension at the last follow-up is (122.2 ± 11.9)°,LDLC insertion site reconstruction and non-reconstruction has the flexion and extension range of (120.3 ± 13.1)°,(125.6±9.0)°;their average forearm rotation amplitude was(118.7±14.3)°,LDLC insertion site reconstruction and non-re-construction has the forearm rotation amplitude of (116.0±13.1)°,(123.8±16.0)°. HSS score was (82.0±12.6) points.The results were excellent in 7 cases,good in 11. The excellent-good rate was 78.3%. After surgery,1 case developed radial head subluxation,1 case developed nonunion of radial head without recurrent dislocation of elbow joint,6 cases developed ectopic ossification of the elbow joint. Conclusion With the use of hinged external fixator,it is not necessary to repair the MCLC. And the LCLC injury cannot be repaired when it does not cause severe instability of the elbow,with the use of hinged external fixator can get a good effect.
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Objective To analyze the clinical efficacy of lateral elbow approach combined with anterior median approach in the treatment of terrible triad of elbow.Methods Retrospectively analyzed 20 patients of terrible triad elbow who were admitted into our hospital from April 2012 to January 2015 and treated with lateral elbow approach combined with anterior median approach.The postoperative recovery of arthrosis,forearm rotation range,and range of motion were evaluated by Mayo score system.Results All patients wounds were with primary healing.There were 11 cases of excellent and 4 cases of good through Mayo score system,with the good rate of 75％.At the final follow-up,the range of motion was (122.06 ± 24.17) ° and the forearm rotation was (136.28 ± 8.9) °.Conclusion Lateral elbow approach combined with anterior median approach for the treatment of terrible triad of elbow has clear visual field,excellent surgical rate,without complications such as elbow instability and nerve damage.
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<p><b>OBJECTIVE</b>To investigate the clinical effects of medial and lateral approach in treating terrible triad of the elbow.</p><p><b>METHODS</b>From May 2010 from May 2014, 11 patients with terrible triad of the elbow were treated through medial and lateral approach. There were 6 males and 5 females, aged from 25 to 56 years with an average of 35.2 years old. The time from injury to operation was from 1 to 13 days with an average of 5.9 days. Fracture of radial head according to Mason typing, 2 cases were type I, 7 cases were type II, 2 cases were type III. Ulnar coronoid fracture according to Regan-Morrey typing, 3 cases were type I, 7 cases were type II, 1 case was type III. Postoperative complications were observed and Mayo elbow performance score(MEPS) was used to assess the elbow joint function.</p><p><b>RESULTS</b>All patients were followed up from 6 to 24 months with an average of 15.5 months. All fractures obtained healing with an average time of 14 weeks (ranged from 10 to 18 weeks). According to Mayo to assess the results, total score was 78.2±11.7, 2 cases got excellent results, 7 good, 1 fair, 1 poor. At final follow up, the mean range of motion was (108±21)° in flexion, (12±8)° in extension, (66±13)° in pronation, (28±18)° in supination. The varus angle of the elbow ranged from 5°to 8° in 3 cases and the valgus angle was 8° in 1 case.</p><p><b>CONCLUSIONS</b>Treatment of the terrible triad of the elbow through medial and lateral approach can obtain satisfactory clinical effects, restore the elbow stability, allow early motion postoperatively, and promote the joint functional rehabilitation.</p>
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The terrible triad of elbow is a kind of complex elbow fracture dislocation, after reduction, it should get a concentric circles joint reduction and elbow stability, if radial and coronoid process fractures is less piece, the conservative treatment can be performed, but regularly follow up is mandatory. If surgical treatment was chosen, radial head fractures and the lateral collateral ligament complex must be repaired. Single lateral approach can be used and also can be combined with anteromedial approach in surgery. Some problems are still controversial in the treatment of coronoid process fracture with Morry type I and type II, such as fixation or not, whether additional external fixation and repair of the medial collateral ligament injury at the same time.
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PURPOSE: The purpose of this study was to evaluate the use of hinged external fixation in management of complex elbow injury. MATERIALS AND METHODS: We retrospectively reviewed clinical outcomes in 10 patients with elbow dislocation and associated fractures of both the radial head and the coronoid process from January 2007 to December 2013. All ten patients were treated by hinged external fixation after open reduction and internal fixation. The indication for use of a hinged external fixator was persistent instability after fixation of the fractures. Early mobilization was started at 1 week (6.5 days) after surgery. The external fixator was removed at 6 weeks after surgery. Cassebaum classification and Mayo elbow performance score were used for clinical and functional evaluation. The follow-up period was at least 1 year. RESULTS: At the last follow-up, the average further flexion was 127degrees, and the average flexion contracture was 16degrees. The average pronation was 83degrees and the average supination was 78degrees. By the Cassebaum classification after 1 year follow-up, patients were classified as 4 excellent, 4 good, and 2 poor. According to the Mayo elbow performance score, the average score was 87 points (65-100 points) with 3 excellent, 6 good, and 1 fair. Stability was restored in all patients at the last follow-up. There was no case of nonunion and the average union period was 11.5 weeks. CONCLUSION: This study advocated the additional use of a hinged external fixator in the treatment of complex elbow instability, especially when fixation of fractures and repair of soft tissues were not sufficient. Providing adequate stability and allowing early motion, additional external fixation could improve the functional outcome.
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Humans , Classification , Contracture , Joint Dislocations , Early Ambulation , Elbow , External Fixators , Follow-Up Studies , Head , Pronation , Retrospective Studies , SupinationABSTRACT
In this study, we aimed to evaluate the results of coronoid fracture fixation, in terrible triad of elbow injury with retrograde screws. Patients between 2008 and 2012 were reviewed. Six were men and 2 were women. Mean age was 44.5(21-62). Mean follow-up period was 25.25 months (8-50). According to Regan and Morrey classification, 6 of the fractures were Type 3 and 2 were Type 2. All cases were operated with single lateral incision. For coronoid fracture, reduction was maintained from anterior aspect and fixed with posterior percutaneous screws which were single 4.5 mm screw in 3 patients and double 3.5 mm screws in 5 patients. Mini and micro cannulated screws for 4 patients and anatomic radial head plates for 4 patients were used for radial head fractures. All lateral ligament complex repairs were performed with bone tunnel technique. The results of the treatment were evaluated with Mayo elbow performance scoring system. All the fractures were united and mean union time was 4 months (3-6). Mean active elbow flexion – extension range of motion at last visit was 108.2º (70º-130º). Mean Mayo elbow performance score of the patients was 87.5 (70-100). With retrograde screw fixation of coronoid fractures in terrible triad, we achieved a stable fixation.
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Objective To analyze and evaluate the effect of the elbow posterior dislocation with radial head and coronoid fractures (the terrible triad of the elbow). Methods Nine patients of the terrible triad of the elbow were treated from January 2004 to March 2009. Among of them, according to Schatzker-Tile classification, the radial head fractures were 4 in type I , 3 in type II , 2 in type Ⅲ. According to Rogan-Morrey classification, the ulnar coronoid fractures were 2 in type I , 5 in type II , 2 in type Ⅲ. The general approach was to repair the damaged structures sequentially from deep to superficial, from coronoid to anterior capsule to radial head to lateral ligament complex to common extensor origin. If there was valgus instability in the elbow after the operation, repaired medial ligament with nonabsorption suture. Plaster was applied for 7-10 days,in position of with elbow flexion in 90° and the forearm in full pronation. Unrestricted morion was then begun, and strengthening was initiated at 8 weeks. Returned to regular occupation depended on the degree of physical activity required, and it typically taken 3 months for heavy physical laborers to return to work. , Results All patients were followed up for 6-60 (31 ± 6) months. Three months postoperatively, the flexion-extension arc of the elbow was 80° -110° (102° ± 3° ), and the pronation-supination arc of the forearm was 100° -150° (135° ±6°) respectively. According to the criteria of the Mayo score, the results were excellent in 5 cases, good in 3 cases, and fair in 1 case. Three cases were heterotopic ossification 6 months postoperatively, 2 cases of them didn't impact the elbow function, didn't treat, 1 case impact the flexion-extension of the elbow, cut the heterotopic ossification from the lateral approach, Mayo score improved from fair to good. Conclusion The key points for treating the terrible triad of the elbow are recovering the elbow normal anatomy and starting early functional exercises in order to avoid the elbow stiff.
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[Objective]To introduce the new concept of "terrible triad of the elbow",and report the preliminary results of 5 clinical cases.[Method]From April 2004 to March 2007,five cases met the diagnosis of terrible triad,with posterior dislocation of elbow complicated with radial head and ulnar coronoid fractures.The radial head fractures were 4 in type Ⅱ and I in type Ⅲ according to Mason classification,and Ⅰ in type Ⅰ,Ⅲ in type Ⅱ and 1 in type Ⅲ according to Schatzker classification.The ulnar coronoid fractures were Ⅰ in type Ⅰ,Ⅳ in type Ⅱ according to Regan-Morrey classification,and all 5 in type Ⅰ according to O'Driscoll classification.Four patients underwent surgical operations.The fractured radial head and ulnar coronoid were reduced and fixed with 3mm titanic lag screws or K wires,the lateral and medial collateral ligaments were repaired with Krachow sutures.A plaster of Paris was applied for 3 weeks after operation,in position with elbow flexion in 90 degrees and forearm rotation in neutral.Then physical exercise and rehabilitation program were carried out.[Result]Four operated patients were followed up for 3 months to 3 years,with healed fractures,stable elbow and no pain movement.The average range of elbow flexion-extension were 120 degrees,and forearm pronationsupination were 110 degrees,respectively.The functional outcome in 3 cases that followed up more than Ⅰ year was excellent in 2 and good in Ⅰ according to Mayo Elbow Performance Score(MEPS).The result of the un-operated case was poor in MEPS evaluation.Elbow instability and pain was the main complaint.[Conclusion]Terrible triad of posterior dislocation with radial head and ulnar coronoid fractures is a severe trauma to the elbow.Operative osteosythesis and ligament repair is mandatory for concentric reduction and elbow stability.
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PURPOSE: To evaluate the clinical outcome for terrible triad injury of the elbow joint. MATERIAL AND METHODS: We reviewed consecutive 10 cases retrospectively among 12 terrible triad injuries, which had been followed up for a minimum 1 year. The average age at the time of injury was 45 years (range, 32~72). All cases were dislocated posteriorly. The 3 cases had fracture of olecranon. Combined medial and lateral approach was performed in 3 cases, medial and lateral approach after extensile posterior approach in 4 cases, transolecranon approach using existed olecranon fracture in 2 cases, and transolecranon approach in 1 case were done. RESULTS: The average Mayo elbow performance score was 87, with 5 excellent, 4 good, and 1 poor results. Results by Riseborough and Radin's rating criteria include 9 good and 1 fair. The 8 cases were stable. But 2 cases were classified with moderate and severe instability; these cases had been performed by radial head allograft and excision respectively. CONCLUSION: A stable, functional elbow can be restored in terrible triad injury by early active rehabilitation after anatomic reduction and firm internal fixation.