Motion must be started a few days postoperatively; varus stress should be avoided during early motion. The terrible triad of the elbow is a serious and potentially disabling injury. 2020 Jan;8(1):4-9. doi: 10.29252/beat-080102. The terrible triad of the elbow is a difficult injury with historically poor outcomes. Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. The treatment of terrible triad injuries of the elbow continues to evolve. Lastly, we shed light on the rationality of the designation “the terrible triad”. The accomplishments achieved recently have reportedly resulted in enhanced prognoses in the last two or three years compared with previous years. If posterior or posterolateral elbow instability is noticed, the coronoid process, radial head and LCLC should be examined to ascertain whether they have been fully repaired. Fig. 2011 Dec;15(4):198-208. doi: 10.1097/BTH.0b013e31822911fd. Please check your email for instructions on resetting your password. It is rarely possible to provide the patient with a completely normal elbow after the “terrible triad” injury pattern. have suggested that the LCLC and pronator muscles should be repaired at the same stage9. However, you should only perform the exercises that are ordered by your surgeon. USA.gov. Nonetheless, in recent years a series of anatomical mechanical studies on the elbow joint have been published and there have been several breakthroughs in surgical techniques for managing this elbow triad. Methods: Eight patients identified with “terrible triad” injury patterns, including posterior elbow dislocation, radial head fracture and coronoid fracture, were available for a minimum of 11 months follow-up. 3), and is often associated with collateral ligaments injuries. Many more serious illnesses such as cancer and some deadly infectious diseases have no emotionally evocative elements in their designations. doi: 10.1097/MD.0000000000013836. Elbow dislocations make up between 11-28% of all elbow injuries. Structures are repaired from deep to superficial from the coronoid process and radial head to the lateral collateral ligament. In this modified version of Mason–Johnson classification, type II and type III are the more frequently found in the terrible triad injury. COVID-19 is an emerging, rapidly evolving situation. With Morrey type II and type III coronoid process fractures, fixation to the coronoid process in an adverse direction with two or three lag screws is recommended. Please enable it to take advantage of the complete set of features! For terrible triads, or ORIF + ligament reconstruction, please also refer to ligament repair protocols. Technically, the surgeon must bring every skill to bear, as soft tissue techniques, fracture repair, and joint arthroplasty are routinely required to adequately treat these complex constellations of injury. 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 prognosis36-38, almost unavoidably causing long‐standing postoperative pain, elbow instability and a range of complications. The terrible triad of the elbow is a severe elbow fracture-dislocation pattern and is so-called because it has poor medium-to-long term outcome.. 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. HHS Figure 5: The olecranon process of the ulna is most likely to glide out of the trochlea of humerus and thus dislocate posteriorly, causing successive injuries to muscles, ligaments and joint capsules7. NIH Displaced fractures of the radial head: internal fixation or excision? Enveloped by a common joint capsule, the elbow joint comprises three sub‐joints, namely the humeroradial, humeroulnar and superior radioulnar joints. Most patients feel that their knee is completely healed and start more rigorous activities to early. The short-term and long term results are historically poor, with a … The mean age was 38 years and … In terrible triad injuries, injury of the LCLC often occurs at its origin at the lateral condyle of the humerus; other parts of the LCLC tear less frequently31. reported that Regan–Morrey type I coronoid process fractures have little impact on elbow stability compared with the normal elbow20. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username, Based on these widely acknowledged data, Rodriguez‐Martin, I have read and accept the Wiley Online Library Terms and Conditions of Use, The normal carrying angle of the elbow. One terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation ; coronoid fractures involving less than 10% of the coronoid do not confer elbow stability in cadaveric studies and therefore do not require repair Schemitsch et al. Morrey stated that elbow instability occurs when there is ≥50% bone loss from the coronoid process24. The stability of the elbow largely depends on the functions of the radial head, coronoid process of the ulnar, LCLC and anterior medial collateral ligament3. Papatheodorou et al. With recent developments in pathology, anatomy and biomechanics of the elbow joint, a standard management protocol has gradually been established. This leads to new injuries. Working off-campus? This corresponds to a good–excellent rating (as measured by the Mayo Elbow Performance Index ) in a…  |  TERRIBLE TRIAD OF THE ELBOW: FUNCTIONAL RESULTS OF SURGICAL TREATMENT. 2A), whereas the LCLC is made up of four small ligaments: the lateral ulnar collateral ligament (LUCL), the lateral radial collateral ligament (LRCL), the annular ligament and the accessory lateral ligament2 (Fig. Number of times cited according to CrossRef: Analysis of twenty-five cases of terrible triad injury of the elbow surgically treated with a single lateral approach. The adjective terrible is bestowed on an elbow triad that comprises three coexisting complicated traumas; namely, radial head and ulnar coronoid process fractures and posterior dislocation of the elbow joint. Elbow Trauma Rehabilitation Protocol Includes post ORIF, or conservatively managed trauma when active ROM indicated N.B. The terrible triad of the elbow is characterized by great potential for joint instability and an unfavorable prognosis.1, 5 Surgical treatment is the therapy of choice in the vast majority of cases, with the aims of restoration of the anatomy and early mobility. All four patients treated by resection of the radial head re‐dislocated after operative treatment, whereas four of the five patients who underwent radial head repair achieved satisfactory prognoses with follow‐up of two to seven years. Type I are transverse fractures of the coronoid tip in which the fracture lines are confined to the coronoid tip and do not extend past the sublimus tubercle. Compared with many other medical terms, the terrible triad of the elbow attracts attention and is relatively easy to remember. Mellema et al. Ikemoto RY, Murachovsky J, Bueno RS, Nascimento LGP, Carmargo AB, Corrêa VE.  |  He also pointed out that, because these injuries are commonly seen in younger patients, longer‐term studies are needed to determine whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. The terrible triad injury of the elbow, dislocation of the ulnohumeral joint with fractures of the coronoid process and radial head, is difficult to treat and has a historically poor outcome. Type I are non‐displaced radial head fractures (or small marginal fractures); Type II are partial articular fractures with displacement (>2 mm); Type III are comminuted fractures involving the entire radial head; and Type IV are fractures of the radial head with dislocation of the elbow joint. In addition there is rupture of the lateral and medial collateral ligaments. 10 Anatomically, These findings are similar to those previously reported by Rodriguez‐Martin who studied 137 cases and found mean Mayo scores of 85.6 points, mean Broberg–Morrey scores of 85 points and average flexion of 132.5° with forearm rotation of 135.5°35. were the first to introduce it to China in 20056. Watters et al. Pre-operatively on the ward • Discuss post -operative rehab ’ This injury is commonly seen in accidents that involved great force, such as vehicle crashes or falls from heights. (B) Anterior view of the elbow bone structures. When the patient is deemed medically fit, surgery is indicated for failure to meet nonsurgical treatment criteria, for open wounds, and/or for neurologic or vascular injury. performed radial head repair on five patients and radial head resection on four patients with the terrible triad injury12. As mentioned previously, there has been rapid progress in the diagnosis and treatment of terrible triad injuries in recent years and the prognosis is accordingly much less terrible than it used to be. Lastly, we may safely conclude that the terrible triad of the elbow is much less terrible than previously, provided the commonly approved clinical approaches are undertaken. Rehabilitation considerations in the management of terrible triad injury to the elbow. Cohen proposed that there is no need to further repair Regan–Morrey type I coronoid process fractures beyond reconstructing the stability of the radial head and LCLC22. The steps involved in surgical management are presented as an algorithm in Figure 5. Residual instability was only seen in the physical examination in 7 elbows (33%), but none of these patients were symptomatic. What's more, the word “terrible” probably causes patients and their relatives considerable unnecessary anxiety. Elbow dislocations are staged depending on the disruption of the following stabilizers: the ulnohumeral articulation, MCL, and LCL. 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/. 2017 Nov-Dec;25(6):283-286. doi: 10.1590/1413-785220172506168821. Pathology A terrible triad injury refers to a posterior dislocation of the elbow associated with radial head and coronoid process fractures. If instability persists, hinged external fixation should be applied35. The terrible triad primarily occurs in adults; the flexibility of ligaments in children make this constellation unlikely 4.. Ring et al. Improved experience, techniques, and implants have advanced to the point where restoration of elbow stability can be expected. A definition of primary and secondary constraints, Outcomes after terrible triads of the elbow treated with the current surgical protocols. 4). Lateral Approach Versus Combined Lateral and Anteromedial Approach for Surgical Treatment of Terrible Triad of Elbow: A Meta-Analysis. Most terrible triad elbow injuries are managed surgically. The anterior band of the MCLC plays an essential role in valgus stability of the elbow33, whereas the posterior band of the MCLC is critical in maintaining elbow posterolateral rotation stability34. Bone destruction in the terrible triad injury: the terrible triad of the elbow is defined as a combination of radial head and ulnar coronoid process fractures and the dislocation of the elbow joint. Prior to surgery, all equipment potentially needed for the reconstruction must be prepared, including screws, suture anchors, plates, prosthesis, external fixators and so on. considered that coronoid process fixation is unnecessary for Regan–Morrey type I and II fractures if elbow stability has already been achieved by radial head repair or replacement and reconstruction of the LUCL30. Chirurg. Located at the anterior facet of the proximal end of the ulnar, the coronoid process is a triangular‐shaped protrusion and plays a major role in keeping the elbow stable because it slides into the coronoid fossa of humerus when the forearm is in flexion. This review examines some memorable millstones and unveils trends in the current clinical norm for this triad. 2020 Jun 15;21(1):381. doi: 10.1186/s12891-020-03394-z. A review, Medial complex elbow dislocation: an unusual pattern of injury, Outcome of lateral humeral condylar mass fractures in children associated with elbow dislocation or olecranon fracture, Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Type II are fractures of the anteromedial facet in which the fracture lines run past the coronoid tip and the anteromedial facet. All in all, the term “terrible triad of the elbow” is no longer accurate. In the realm of orthopaedics, the terrible triad of the elbow is infamous, not simply because the prognosis is poor for most patients, but also, maybe to a greater extent, because the unique name of this malady attracts considerable attention and interest in both doctors and patients. A typical surgery for a blown knee includes: Patellar tendon autograft (An autograft is a graft that comes from the patient) ... including the terrible triad of the elbow and shoulder. It is important that this be carefully carried out under the supervision of a therapist. Physical therapy (or physiotherapy) literally means “attempted remediation of a health problem that is related to the body (as opposed to the mind).” It involves the use of exercises, assistive devices and other methods (such as massage or electrotherapy) for the preservation, enhancement or restoration of movement and physical function. Thus the term “terrible triad of the elbow’ has morphed into a readily recognized symbol that has somewhat lost its significance. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. If they have, the pronator muscles and MCLC should be repaired through a medial surgical approach. First they would heat up my elbow for several minutes and then stretch my arm to try to lengthen the muscles and tendons. Hartzler et al. The injury is most likely to occur when the following three factors are present simultaneously: the elbow joint is in extension and abduction, the forearm is in supination, and a great force is imposed in an axial direction. The pathoanatomy of lateral ligamentous disruption in complex elbow instability, Valgus stability of the elbow. This course of physical therapy successfully treat a undisplaced terrible triad injury in very limited selected supervised patients. We present the case of a unique association of the two injuries with an elbow dislocation, radial and coronoid process fractures and a distal radioulnar joint dislocation due to an interosseous membrane rupture. Zhang et al. Regan–Morrey classification for coronoid process fractures: Type I, avulsion of the tip of the process; Type II, fragment involving ≤50% of the process; Type III, fragment involving >50% of the process. Pipicelli JG, Chinchalkar SJ, Grewal R, Athwal GS. Egol et al. A new fracture model for "terrible triad" injuries of the elbow: influence of forearm rotation on injury patterns. The fractures are further subclassified into A and B groups according to whether the patient does or does not have elbow joint dislocation. The terrible triad of the elbow is defined as the combination of fractures of the radial head and ulnar coronoid process and dislocation of the elbow joint4 (Fig. performed a meta‐analysis of 312 such cases and reported satisfactory functional outcomes with Mayo elbow performance scores of 78–95 points, the Broberg–Morrey scores of 76–90 points and DASH scores of 9–31 points39. In this review, the classification, treatment principles and prognosis for different forms of management of the radial head and ulnar coronoid process fractures and the ligaments lesions are introduced sequentially and various surgical procedures and their efficacy are discussed. If the elbow dislocates in 30°–45° of extension, the medial collateral ligament should be repaired. AL, annular ligament. 2012 Oct;26(10):591-6. doi: 10.1097/BOT.0b013e31824135af. Type III are large fractures involving ≥50% of the coronoid height in which the fracture lines travel into the body and basal part of the coronoid (Fig. As the body approaches the ground, the elbow is then subjected to an external rotary force and valgus moment. Coronoid process fractures are almost always accompanied by other severe elbow joint injuries17, and the Regan–Morrey classification18 is commonly adopted in clinical practice. Attempts should be made to to preserve the radial head, otherwise radial head arthroplasty should be performed. have reported that almost all patients with dislocation of the elbow joint have some degree of tearing of the MCLC and LCLC9. Meena MK, Singh K, Meena S, Kumbhare C, Chouhan D. Bull Emerg Trauma. 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