Terrible triad of the elbow: treatment protocol and outcome in a series of eighteen cases

doi:10.1016/S0020-1383(15)70004-5

Injury

Volume 46, Supplement 1, January 2015, Pages S8-S12

https://doi.org/10.1016/S0020-1383(15)70004-5 Get rights and content

Abstract

The terrible triad is an uncommon injury, which includes an elbow posterior dislocation with fractures of the radial head and coronoid process of the ulna. In addition there is rupture of the lateral and medial collateral ligaments. The short-term and long term results are historically poor, with a high rate of complications. The main objective of this study is to report the results of a multicentre study of patients who sustained the terrible triad injury focusing on surgical treatment in order to offer a standardized surgical protocol.

We retrospectively review the results of surgical treatment of eighteen terrible triads from a multicentre study of 226 elbow dislocations. At an average follow up of 31.5 months postoperatively, all eighteen patients returned for clinical examination, functional evaluation, and radiographs. The mean MEPS score value was 78 (25–100), which correspond to three excellent results, ten good results, three fair results, and two poor results. Five early and three late complications were reported.

This particular case of elbow dislocation is very unstable and leads to many complications. The surgeon should attempt to restore stability by preserving the radial head whenever possible or replacing it with prosthesis otherwise, by repairing the lateral collateral ligament and performing fixation of the coronoid fracture. If after anatomical restoration of stability elements, the elbow remains unstable, options include repair of the medial collateral ligament or stabilization assumed by hinged external fixator.

Introduction

Among elbow dislocations, the terrible triad is a specific injury described by Hotchkiss [1] with concomitant fractures of radial head and coronoid process of the ulna, ligamentous disruptions and posterior dislocation of the elbow. This injury is complex with rupture of elements of the different components of the elbow's stability: the anterior column by fracture of the coronoid process of the ulna and the medial and lateral columns by disruption of ligaments. In addition the presence of radial head fracture affects the lateral column. As a consequence, the terrible triad is an injury which damages the primary and secondary stabilizers of the elbow [2]. This injury generates a severe acute instability at the time of injury, and far away from the initial trauma, may induce chronic elbow instability, ectopic bone formation, chronic pain, stiffness and arthritis. Few clinical series have been published [3, 4, 5], and due to the difficulty of positive diagnosis and treatment protocol, there is a lack of information available regarding ideal techniques for treatment.

The purpose of this study is to report the results of a retrospective multicentre study of 18 patients with terrible triad injuries to evaluate surgical treatment modalities in order to offer a standardized surgical protocol.

Section snippets

Materials and methods

Between 2000 and 2008, screening a multicentre national database driven by the authors, 226 elbow dislocations were identified. The inclusion criteria were defined as follows: an elbow dislocation with at least a fracture of the coronoid and radial head, and a minimal follow-up of 6 months for evaluation. Exclusion criteria were: 1) others associated injuries such as olecranon fractures, 2) Monteggia fracture, 3) concomitant ipsilateral wrist, hand or shoulder injuries, or 4) an isolated closed

Results

In the eighteen patients included, the mean age of the 6 females and 12 male patients was 43.8 years (range, 19–56). None terrible triad had an associated ulnar nerve damage, open wound trauma or vascular compromise. The fractures of the radial head were type II in five cases and thirteen were type III. The fractures of the coronoid process were fourteen types I, three types II, and one type III.

All patients of this study were treated surgically (Table 1). Treatment was done as follows: manual

Discussion

The terrible triad of the elbow causes extensive damage to the ligaments and osseous structures, which provides acute elbow stability. For adequate evaluation of all injured items, complete radiographic evaluation must be done after reduction, and the best treatment protocol must be based on its results. Positive diagnosis may be difficult, as disruption of the ligaments is not seen on x-rays. Majority of terrible triads will require open repair and isolated closed management is not an adequate

Conclusion

Management of terrible triad of the elbow remains a significant challenge for orthopaedic surgeons. They must restore the integrity of the elbow repairing all structures, using a standardised surgical protocol, which gives the best results and prognosis by restoration of the elbow stability. If instability's persists after fixation or suture of the bony lesions and lateral collateral ligament, surgeon must consider an additional procedure repairing the medial collateral ligament or fixing the

Conflict of Interest Statement

The authors, immediate families, and any research foundation with which they are affiliated with did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

References (16)

B Chemama et al.
Terrible triad injury of the elbow: how to improve outcomes?
Orthop Traumatol Surg Res
(2010)
N Terada et al.
The importance of reducing small fractures of the coronoid process in the treatment of unstable elbow dislocation
J Shoulder Elbow Surg
(2000)
C Forthman et al.
Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament
J Hand Surg Am
(2007)
Hotchkiss R. Fractures and dislocation of the elbow. In: Fractures in adults. Rockwood CA, Green DP, editors;...
SW O'Driscoll et al.
The Unstable Elbow
J Bone Joint Surg Am
(2000)
DMW Pugh et al.
Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures
J Bone Joint Surg Am
(2004)
D Ring et al.
Posterior dislocation of the elbow with fractures of the radial head and coronoid
J Bone Joint Surg Am
(2002)
D Gill et al.
The Coonrad-Morrey Total Elbow Arthroplasty in Patients Who Have Rheumatoid Arthritis. A Ten to Fifteen-Year Follow-up Study
J Bone Joint Surg Am
(1998)

There are more references available in the full text version of this article.

Cited by (36)

Influence of Coronoid fixation on the functional outcome and rate of complications in surgically treated acute complex elbow instability
2023, Injury
Fractures of the coronoid commonly present in elbow fracture-dislocations. Despite the evidence that the coronoid plays an important role in elbow stability, there is still controversy on which fractures should be surgically fixed. The aim of this study is to compare the clinical outcomes and rate of complications of patients with elbow fracture-dislocations in which the coronoid was fixed or left untreated.
Thirty-nine patients with an elbow fracture-dislocation involving a coronoid fracture were prospectively followed for an average of 90 months (range 24–190). According to Morrey´s classification there were 22 type II and 8 type III. Nine patients had an anteromedial fracture of the coronoid. In 24 patients the coronoid was repaired (suture fixation in 9, screws fixation in 10 and plate fixation in 5) and in 15 patients the coronoid was not fixed. In 18 patients the radial head was replaced and in 8 patients it was fixed. All patients underwent repair of the lateral ligament complex. Clinical evaluation was performed with the MEPS. Radiographically, the rate of coronoid nonunion was specifically analyzed. Postoperative neurological complications were recorded.
At the most recent follow up, the average arc of flexion-extension was 120° (range 70°-140°) with a mean MEPS of 90 (range 25–100). No statistically significant differences were found in the MEPS and flexion-extension arc between the patients in whom synthesis was performed (117° ROM, and 89 MEPS) and those in whom it was not (122° ROM, 94 MEPS) (p = 0.42; p = 0.34). Coronoid fracture healing could be assessed in 36 patients: in 19 patients the coronoid was radiographically healed, and in 17 a nonunion was present, with no difference in the final clinical outcome between both groups. Nine patients, 6 of whom had undergone coronoid fixation, had a neurological complication related to the ulnar nerve.
Coronoid fractures affecting around 50% of its height can be treated without internal fixation as long as the rest of the osteo-ligamentous structures are adequately repaired. Osteosynthesis of the coronoid through a medial approach may carry a non-negligible risk of associated neurological injury.
Modern Treatment Protocols in the Management of Terrible Triad Elbow Injuries
2023, Operative Techniques in Orthopaedics
The ‘terrible triad' (TT) elbow fracture-dislocation is a form of complex elbow instability which includes an elbow dislocation with concomitant radial head and coronoid process fractures. As the name suggests, early attempts at managing this injury complex often resulted in high rates of unsatisfactory outcomes and complications. As our understanding of this injury has grown, modern approaches and surgical treatment protocols have yielded more reliable results. Today, goals of treatment are to obtain a concentric reduction with restoration of joint stability to allow for early-motion rehabilitation. However, many controversies still exist concerning the treatment of this complex injury.
Terrible triad injury of the elbow: A PROCESS-compliant surgical case series from Eastern Morocco
2022, Annals of Medicine and Surgery
The terrible triad of the elbow (TTE) is a lesion associating a dislocation of the elbow, a fracture of the radial head, and a fracture of the coronoid process, with a high potential of complication. The treatment is based on the restoration of bone lesions and external capsular ligament repair. The systematic repair of the medial collateral ligament (MCL) is still debated in the literature. The aim of this study is to evaluate the clinical and functional results of the surgical treatment in a real-world series from Easter Morocco.
This was a retrospective study of 6 cases of TTE operated by isolated external approach or combined approach (internal or anterior) of the elbow in the department of Traumatology-Orthopedics of the Mohammed VI University Hospital (Oujda Morocco), over a period of 7 years from 2013 to 2020. Radial head and coronoid process fractures were classified according to the Mason and Morrey-Regan classifications, respectively. The following clinical parameters were evaluated: Mayo Clinic Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder and Hand (DASH), Visual Analog Scale (VAS), and arc of mobility in flexion-extension and prono-supination.
6 male patients treated between May 2013 and December 2020 were included. The median follow-up was 48 months. All patients had frontal and lateral standard X-ray of over and under joints, and computed tomography (CT)-scan was delivered for 5 cases. The elbow dislocation was posterolateral in five cases, and posteromedial in only one patient. Radial head fractures were classified as type I in one case, type II in two cases, and type III in three cases. Coronoid fractures were type I in three cases, type II in one case, and type III in two cases. At the last follow up, the mean MEPS, Quick DASH, and VAS was 81, 28, 0.8, respectively. The mean arc of mobility in flexion was 120° and it was deficient by 20° in extension. In addition, the mean arc of mobility in protonation was 80°, while in supination it was 75°. Regarding complications, we noticed an instability of the elbow on valgus in a single case, elbow stiffness with heterotopic ossification in a single case, ulnar nerve damage in a single case during medial collateral ligament anchoring, and elbow hygroma in one single case.
The surgical management of TTE can provide good and long-term functional results after restoration of the stabilization of bone structures and the lateral ligament complex, without the need to repair the medial collateral ligament.
Analysis of Fracture Characteristic and Medial Collateral Ligament Injury Relationships in Terrible Triad Elbow Injuries
2021, Journal of Hand Surgery
The objectives of this study were to identify the relationship between fracture characteristics and medial collateral ligament (MCL) injuries in terrible triad injuries of the elbow.
Between 2010 and 2018, 60 patients who underwent surgery for terrible triad elbow injuries were retrospectively reviewed. Using magnetic resonance imaging (MRI) assessments, patients were stratified into those who had intact or low-grade partial MCL tears (low-grade MRI-MCL group) and those who had high-grade partial or full-thickness MCL tears (high-grade MRI-MCL group). We also analyzed patients according to whether they underwent MCL repair surgery. Fractures of the radial head were assessed according to Mason’s classification system and measurements of fracture fragment arc on axial cuts. Fractures of the coronoid processes were assessed according to the system of Regan and Morrey and measurements of coronoid process volumes.
Patients in the high-grade MRI-MCL group (28 patients) had a more comminuted and higher fragment arc of radial head fractures than those in the low-grade MRI-MCL group (32 patients) (143º ± 45º vs 119º ± 31º). However, the volume of coronoid fracture fragments was smaller in the high-grade MRI-MCL than in the low-grade MRI-MCL group (359 ± 325 mm³ vs 722 ± 448 mm³). The MCL repair group (22 patients) also had a more comminuted and higher fragment arc in radial head fractures (153º ± 44º vs 117º ± 31º) and a smaller coronoid process fracture volume (236 ± 224 mm³ vs 735 ± 419 mm³) than the non-MCL repair group (38 patients).
Our results demonstrated that high-grade MCL injuries are associated with comminuted and larger-sized radial head fractures, as well as smaller-sized coronoid process fractures in terrible triad injuries. In making a decision regarding surgical treatment, these fracture characteristics could help to predict the severity for MCL injury in terrible triad injuries.
Prognostic IV.
Results of standardized treatment of elbow fracture dislocations as per their injury pattern: a retrospective cohort of 89 patients
2021, JSES International
Citation Excerpt :
This surgical approach of radial head fracture is similar to ours with 81% radial head arthroplasty owing to the highly comminuted fractures, following recommendations made by King.7 In another retrospective study, Pierrart et al20 reported a series of 18 terrible triads with a mean follow-up of 31 months achieving an average MEPS of 78 points and a mean ROM of 114° flexion extension (135°-21°) with complete prone supination except for 3 patients. In an interesting study of twelve terrible triad with a long-term follow-up, Zaidenberg et al24 reported a mean ROM at 1 year of 140° of flexion, 10° of extension, 90° of pronation, and 90° of supination, with an average MEPS of 97.5, with no significative difference during a 9-year follow-up.
Elbow fracture dislocations represent difficult injuries to treat, with a high percentage of complications. Classically, they are divided into posterolateral, posteromedial and transulnar pattern. It is essential to distinguish them to guide intraoperative treatment to achieve an anatomic and stable reduction that allows early mobility.
A retrospective study of 89 adult patients diagnosed with elbow fracture dislocations who underwent a standardized surgery between 2013 and 2018 with a minimum follow-up of 12 months. Demographic data, characteristics of the injury, and associated procedures were collected. Patients were evaluated with functional scores (Mayo elbow performance score/Broberg and Morrey score) and ranges of movement at the end of the follow-up.
The mean age was 41 ± 12 years, mostly men (82%), with an average follow-up of 29 months. We present 42 patients with posterolateral fracture dislocation (47%), 21 posteromedial (24%) and 26 transulnar (29%). The average range of motion at the end of follow-up was −12 ± 11° extension, 124 ± 20° flexion, 76 ± 16° pronation, and 73 ± 20° supination, with a Mayo elbow performance score of 88.7 ± 12 points and 87.2 ± 12 points in the Broberg and Morrey scale. Reoperation rate was 23%, with no infection or heterotopic ossification cases. Transulnar fracture dislocations have significantly worse extension and supination. As per the functional result (Mayo elbow performance score/Broberg and Morrey scale), there are no significant differences between the different patterns.
Proper injury pattern recognition and a standardized surgical management lead to a stable joint and good results in range of motion. Functional results are encouraging at least at short term, despite the high reoperations rate.
Prognostic factors for traumatic elbow osteoarthritis after terrible triad surgery, and functional impact
2021, Revue de Chirurgie Orthopedique et Traumatologique
Les triades terribles du coude (TTC) requièrent un traitement chirurgical dans la quasi-totalité de cas, au risque d’évoluer vers une instabilité chronique, synonyme d’évolution arthrosique quasi certaine. Après une prise en charge chirurgicale appropriée, l’évolution vers l’arthrose est peu documentée dans la littérature, de même que les facteurs favorisants. Aussi, nous avons mené une étude rétrospective afin : (1) de quantifier la prévalence de l’arthrose post-traumatique du coude après traitement chirurgical des triades du coude, (2) d’évaluer le retentissement fonctionnel et (3) d’identifier des facteurs pronostiques.
La prévalence de l’arthrose est élevée après traitement chirurgical des TTC, avec un impact fonctionnel négatif sur les résultats cliniques.
Étude rétrospective monocentrique, incluant 53 patients d’âge moyen 50 ± 17,8 (21–84) ans, opérés d’une TTC en aigu au sein de notre unité. Tous les patients ont eu un examen clinique (amplitudes articulaires et Mayo Elbow Performance Index – MEPI) et radiographique au recul minimum d’un an. L’arthrose au dernier recul était évaluée sur des radiographies du coude, au niveau des compartiments huméro-ulnaire et condylo-radial, selon la classification de Broberg et Morrey. Le retentissement fonctionnel (amplitudes articulaires et MEPI) et l’influence de facteurs favorisants potentiels étaient recherchés (test de Student ou ANOVA et Chi² ou Fisher).
La prévalence de l’arthrose (stades 2 ou 3 selon Broberg et Morrey) était de 45,3 % (24/53) pour le compartiment huméro-ulnaire et 50 % (25/50) pour le compartiment condylo-radial. La présence d’arthrose huméro-ulnaire avait une influence négative sur le MEPI (76,3 points en présence d’arthrose et 88,4 points en l’absence d’arthrose [p = 0,003]), l’arc d’amplitude en flexion-extension (respectivement 102,3° et 115,2° [p = 0,043]) et en prono-supination (respectivement 138,8° et 159,3° [p = 0,006]). La présence d’arthrose condylo-radiale n’avait pas d’influence statistique sur le MEPI (respectivement 81,4 points et 84,4 points [p = 0,47]), l’arc d’amplitude en flexion-extension (respectivement 104,8° et 113° [p = 0,23]) et en prono-supination (respectivement 141,8° et 156,4° [p = 0,2]). La présence d’arthrose huméro-ulnaire au dernier recul était associée à la présence d’une luxation ou subluxation sur les radiographies postopératoires immédiates de profil (respectivement 45,8 % et 10,3 % [p = 0,004]) ou sur les radiographies au dernier recul (respectivement 20,8 % et 3,4 % [p = 0,047]) et à la survenue d’une complication postopératoire (respectivement 54,2 % et 27,6 % [p = 0,049]). La présence d’arthrose condylo-radiale au dernier recul était associée à l’utilisation d’une prothèse de tête radiale plutôt qu’une ostéosynthèse (respectivement 92 % et 48 % [p = 0,0007]) et au positionnement trop haut de la PTR (respectivement 47,8 % et 0 % [p = 0,023]).
La prévalence de l’arthrose post-traumatique après traitement chirurgical des TTC était élevée (respectivement 45,3 % pour le compartiment huméro-ulnaire et 50 % pour le compartiment condylo-radial) avec un retentissement clinique lorsque le compartiment huméro-ulnaire était atteint.
IV ; Étude de cohorte sans groupe contrôle. IV.

View all citing articles on Scopus

View full text

Terrible triad of the elbow: treatment protocol and outcome in a series of eighteen cases

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Conflict of Interest Statement

Orthop Traumatol Surg Res

J Shoulder Elbow Surg

J Hand Surg Am

The Unstable Elbow

J Bone Joint Surg Am

Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures

J Bone Joint Surg Am

Posterior dislocation of the elbow with fractures of the radial head and coronoid

J Bone Joint Surg Am

The Coonrad-Morrey Total Elbow Arthroplasty in Patients Who Have Rheumatoid Arthritis. A Ten to Fifteen-Year Follow-up Study

J Bone Joint Surg Am