Postoperative Functional Evaluation in Patients Undergoing Surgical Treatment of the Terrible Triad Injury of the Elbow / Avaliação funcional pós-operatória em pacientes submetidos a tratamento cirúrgico da tríade terrível do cotovelo

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.

Progress in the treatment of varus-posteromedial rotation instability of the elbow / 中华创伤骨科杂志

As varus posteromedial rotatory instability (VPMRI) is not common, its injury mechanisms are complex and presents no obvious dislocation on X-ray, it may be considered as a simple coronoid fracture, likely leading to a missed diagnosis or misdiagnosis. Moreover, the treatment of VPMRI is also controversial. Conservative treatment or improper treatment can cause serious complications. Therefore, this review expounds on the injury mechanisms, anatomical structure, O'Driscoll classification, imaging examination, treatment and postoperative rehabilitation of this complicated elbow injury which is rare and difficult to treat clinically.

Surgical treatment for terrible triad of the elbow through medial and lateral approach / 中国骨伤

<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>

Results of Posterior Dislocation of Elbow Associated with Bony and Soft Tissue Injury

Elbow trauma is challenging to manage by virtue of its complex articular structure and capsuloligamentous and musculotendinous arrangements. We included 17 patients with elbow dislocation and associated injuries in this study. The study protocol included early elbow reduction and planned fixation of the medial or lateral condyle, coronoid and radial head. The sample was 73% male and 27% female with mean duration follow-up of 8 months, and mean age of 37 years. The mean Mayo Elbow Performance Score was 96 points at conclusion of follow-up, indicating an excellent result in 14 patients. Whenever the radial head was excised, we performed a strong transosseous ligamentous repair of the medial and lateral collateral ligaments. Fixation of the coronoid is essential for elbow stability. A small avulsed fragment can be fixed using an ACL jig. We found this technique very useful. Early planned intervention, stable fixation, and repair provide sufficient stability and enhance functional outcomes.

Posterior dislocation of the elbow with radial head and ulnar coronoid fractures(terrible triad):a report of 5 cases / 中国矫形外科杂志

[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.