20:08. The unhappy triad is the name of a severe injury involving three crucial parts of your knee joint. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. 2014 Jul;472(7):2092-9. doi: 10.1007/s11999-014-3518-9. Abstract. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. Watters TS, Garrigues GE, Ring D, Ruch DS. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications … The syndrome of “terrible triad of the elbow”, which was first described by Hotchkiss in 1996 1 , is a severe pattern of elbow fracture‐dislocation injury that consists of posterior dislocation of the elbow associated with fractures of the radial head and the coronoid process of the ulna. Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. COVID-19 is an emerging, rapidly evolving situation. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. No ligament reconstruction . 2018 Jul;10(3):216-222. doi: 10.1177/1758573217713694.  |  Treatment: Open reduction and hinged external fixation . Historically, the combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture has had a consistently poor outcome; for this reason, it is called the terrible triad. Surgical technique - Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People's Hospital. Initial lateral radiographs requested by the emergency doctor focused on the elbow and showed a posterior dislocation of the right elbow with a type II Mason radial head fracture with a small detached fragment <20%, associated to a proximal radioulnar joint (PRUJ) dislocation and a coronoid fracture type 2 according to the O’Driscoll classification with an anterior avulsion of an anteromedial coronoid small fragment (Fig. The aim is a stable concentrically guided elbow with early functional follow-up treatment. [Selective neurotization of the median nerve in young patients with CV-CVIIcomplicated spinal cord injury]. Chronic Simple Elbow Dislocation . We used a TightRope device to stabilize the DRUJ as this tool enables forearm good ROM at the beginning of physical therapy, and there is no need to remove the device. Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series. A sling was used for comfort for 2 weeks postoperatively with physiotherapy and ROM exercises initiated early. Algorithm for surgical treatment of terrible triad elbow injuries. We present a particular case by the unique association of two rare injuries: a terrible triad of the elbow and an ipsilateral Essex-Lopresti entity. Clipboard, Search History, and several other advanced features are temporarily unavailable. 2019 Dec;11(6):450-458. doi: 10.1177/1758573218809375. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. The DRUJ and PRUJ dislocations were suggestive of a complete disruption of the interosseous membrane. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. The origins of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) complexes avulse from the epicondyles and the anterior capsule fails with a transverse fracture of the coronoid tip. Anteroposterior X-ray of the wrist showing the DRUJ reduction and the TightRope stabilization. 'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. Stable elbow, > 100 degrees motion in all patients Clin Orthop Relat Res. This may be done as below, or in a hinged range of motion brace or x-fix if applied. 2016 Jul 25;29(7):677-680. doi: 10.3969/j.issn.1003-0034.2016.07.021. Following radial head replacement or ORIF the LCL should be repaired to the lateral condyle using suture anchors or transosseous sutures (Figs. Closed reduction of the DRUJ was achieved but it was instable, a fixation with a TightRope was used (Fig. The treatment of terrible triad injuries of the elbow continues to evolve. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. According to that elbow stability status and the coronoid fracture stage, we decided a conservative treatment for the anteromedial coronoid fracture. HHS Tel: +212615994028; E-mail: Search for other works by this author on: Complex elbow dislocations and the “terrible triad” injury, An uncommon Essex-Lopresti fracture dislocation with radial displacement in distal direction: diagnosis and surgical treatment of a rare case, Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations, Nonsurgically treated terrible triad injuries of the elbow: report of four cases, Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures, Terrible triad of the elbow: treatment protocol and outcome in a series of eighteen cases. Correspondence address. Pre-operatively on the ward • Discuss post -operative rehab ’ Clinical assessment of the post-operative ROM (A and B). Faculté de Medecine et de Pharmacie de Marrakech. Treatment of terrible triad injuries at a mean follow-up of nine years. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. A terrible triad combines three injuries: dislocation of the elbow, fracture of the radial head, and fracture of the coronoid. Elbow dislocations are staged depending on the disruption of the following stabilizers: the ulnohumeral articulation, MCL, and LCL. The elbow dislocation is a frequent and an easily diagnosed pattern, at the opposite of the DRUJ dislocation, which is often missed in the emergency department if an adequate physical exam with the appropriate radiographs is not carried out [3]. Free active assisted flexion, free extension to -30 deg off full extension, lying with shoulder 90 deg of abduction. Generally these should commence around day 7-10 for a terrible triad or elbow dislocation unless otherwise specified in the operating report. What you’ve sustained is called the terrible triad injury, because you’ve broken your ulnar, radial head and also dislocated your entire elbow.’ A picture of this is below, and while I kinda just shrug my shoulders at it, anyone in the medical field just looks a bit uncomfortable and says ‘ouch’ when they see it, so I guess the gap in the bone is where I broke it. The goal of physiotherapy is to reduce pain and swelling, restore your elbow’s full range of motion, and strengthen muscles. The terrible triad includes a posterior dislocation of the elbow with radial head and coronoid fractures, concurrent ligament injuries are very common especially the LCL and medial collateral ligament (MCL), which can be the source of a definite instability [1, 2]. Shoulder Elbow. Terrible; elbow; fracture; instability; triad. A high index of suspicion with a detailed examination of the elbow, forearm and wrist associated to a comprehensive imaging were mandatory for a complete diagnosis and an adequate treatment. The “terrible triad of the elbow” is a notorious combination of elbow dislocation and fractures of the coronoid process and radial head that has historically been difficult to manage and had an unsatisfactory prognosis 36-38, almost unavoidably causing long‐standing postoperative pain, elbow instability and a range of complications. Terrible triad … Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Can we treat select terrible triad injuries nonoperatively? [Progress in treatment of terrible triad of elbow]. Unfallchirurg. The elbow was stable, and the grip strength was comparable to the contralateral side (Fig. Related Content AUTOPLAY ON. The case was managed with closed reduction of the elbow dislocation and distal radioulnar joint followed by open reduction and repair of the damaged structures in the elbow and an unloading of the interosseous membrane. 3). - Terrible triad injury of the elbow: how to improve outcomes? Bilateral elbow dislocation in relation to Essex-Lopresti injury. The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [2, 3]. In patients who undergo treatment after the acute injury period, the coronoid may require reconstruction using radial head autograft, iliac crest autograft, olecranon autograft, or allograft. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. The stability was rechecked and upgrade of the stable range of motion (ROM) was assessed, the elbow was now stable from −20° extension to complete flexion. Surgical management is quite standardized according to Pugh et al. Shoulder Elbow. 2020 Oct 29;9(11):3500. doi: 10.3390/jcm9113500. In the elbow with persistent instability after repair of these elements, application of a static external fixation, hinged external fixation, ulnohumeral joint pinning, or an internal hinge … The lateral collateral ligament (LCL) and the common extensor muscle were repaired. This site needs JavaScript to work properly. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Clin Orthop Relat Res. Jupiter and Ring JBJS 2002 . The purpose of treatment in the terrible triad injury is to restore the congruency of the elbow joint, its stability and an optimal ROM. Early management is a favourable prognostic factor for final outcome. A 56-year-old male fell forward onto his forearm and elbow during a mountain walk. Epub 2017 Jun 13. Other names for it include: terrible triad; O’Donoghue’s triad Development of a novel real-time simulation of human skeleton/muscles. Previous studies have demonstrated elbow instability and posttraumatic arthrosis following resection of the radial head in complex elbow dislocations . NLM USA.gov. Epub 2018 Nov 6. (ii) Repair of the anterior column: by suture of the anterior capsule or fixation of coronoid process.  |  2). When the radial head fracture is accompanied by an interosseous membrane lesion affecting the distal radioulnar joint (DRUJ), it is given the name Essex-Lopresti injury [ 4 ]. March 10, 2011 71 Comments . This course of physical therapy successfully treat a undisplaced terrible triad injury in very limited selected supervised patients. The authors declare there is no financial support from any organism. Whereas the importance of early recognition of neurovascular compromise is well described and nearly universally recognized, the importance of timely and correct treatment in preventing delayed complications and potential instability is often less emphasized in the radiology literature. A computed tomography (CT) confirmed the stage 2 coronoid process fracture and a partial radial head fracture, the PRUJ dislocation was also demonstrated (Fig. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? On examination, there was a deformity of his right elbow with pain in the ipsilateral wrist; there were no skin or distal neurovascular disorders. © The Author(s) 2020. Please enable it to take advantage of the complete set of features! Distal arm pain should not simply be dismissed as referred pain [5]. Cervical kyphosis: A predominant feature of patients with osteogenesis imperfecta type 5. NIH 1A). Copyright © 2015 American Society for Surgery of the Hand. (iv) Early elbow mobilization is started to avoid the stiffness. 2014 Jul;472(7):2128-35. doi: 10.1007/s11999-013-3331-x. In: Jungbluth P, Frangen TM, Arens S, Muhr G, Kälicke T. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. J Clin Med. By Joaquin Sanchez-Sotelo 58 Videos. We managed a surgical treatment the second day of admission. The terrible triad of the elbow is posterior or posterolateral dislocation of the ulnohumeral joint with fractures of the radial head and coronoid process. The treatment of terrible triad injuries of the elbow continues to evolve. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. 5 patients: dislocated for 2 to 9 months . For terrible triads, or ORIF + ligament reconstruction, please also refer to ligament repair protocols. No similar case has been found in the literature review. Login to view comments. 2013 Apr;27(4):496-9. Zaidenberg EE, Abrego MO, Donndorff AG, Boretto JG, De Carli P, Gallucci GL. should instability persist after addressing the radial head and the LCL complex in the presence of a small coronoid fracture, the next best step is MCL reconstruction. Faculté de medecine et de pharmacie de Marrakech, University Hospital Mohammed VI, Marrakech, Morocco. Protection of the ligament repair is essential. Elbow Trauma Rehabilitation Protocol Includes post ORIF, or conservatively managed trauma when active ROM indicated N.B. Mobility of the right elbow was −20° for extension and 100° for flexion; the wrist mobility was respectively 60° and 20° of flexion and extension. (A) X-ray of elbow profile shows the posterior elbow dislocation with a detached anterior fragment from the coronoid; (B) three-fourth X-ray of the forearm before the reduction demonstrates significant ulnar negative variance. 1 Introduction Fracture dislocation of the elbow , termed terrible triad , involves three anatomic injuries: coronoid fracture, radial head fracture , and posterior elbow dislocation. A study [9] has shown that coronoid fractures do not need to be fixed if there is stability in the ROM after repair of lateral structures. The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [ 2, 3 ]. Elbow dislocation associated with both radial head and coronoid fractures, termed the “terrible triad injury” (TTI) by Hotchkiss [1], was notoriously challenging for decades because of the difficulties inherent in treatment and the consistently poor prognosis [2-4]. 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