The aim is a stable concentrically guided elbow with early functional follow-up treatment. [Progress in treatment of terrible triad of elbow]. Closed reduction of the DRUJ was achieved but it was instable, a fixation with a TightRope was used (Fig. [Progress on diagnosis and treatment of the terrible triad of elbow joint]. [6, 7]: (i) the humeroradial joint: LCL complex must be repaired in all cases eventually with the common extensor origin, radial head fractures are either treated functionally if minimally displaced, fixed, or if comminuted, replaced by an implant. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach J Int Med Res . Terrible; elbow; fracture; instability; triad. Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. With recent developments in pathology, anatomy and biomechanics of the elbow … The lateral collateral ligament (LCL) and the common extensor muscle were repaired. 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. 2020 Oct 29;9(11):3500. doi: 10.3390/jcm9113500. As emergency treatment, we realized a closed reduction of the elbow dislocation under general anaesthesia with X-ray control, the limb was stabilized in a posterior brachiopalmar splint. Early management is a favourable prognostic factor for final outcome. Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? In the past, most of these injuries were treated by manipulative reduction and cast immobilization. 2013. A sling was used for comfort for 2 weeks postoperatively with physiotherapy and ROM exercises initiated early. A computed tomography (CT) confirmed the stage 2 coronoid process fracture and a partial radial head fracture, the PRUJ dislocation was also demonstrated (Fig. The DRUJ and PRUJ dislocations were suggestive of a complete disruption of the interosseous membrane. Related Content AUTOPLAY ON. At 8 months of follow-up and 2 months of physiotherapy, the patient made a good recovery in regard to pain and mobility. Some of the most common injury classification systems cited in t… In: Jungbluth P, Frangen TM, Arens S, Muhr G, Kälicke T. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. - Terrible triad injury of the elbow: how to improve outcomes? 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 may be needed. There was mild widening of the DRUJ with significant ulnar negative variance (Fig. Stable elbow, > 100 degrees motion in all patients Algorithm for surgical treatment of terrible triad elbow injuries. 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. Zakaria Ramzi, Jordi Juanos Cabans, Harold Jennart, Terrible triad of the elbow with an ipsilateral Essex-Lopresti injury: case report, Journal of Surgical Case Reports, Volume 2020, Issue 6, June 2020, rjaa103, https://doi.org/10.1093/jscr/rjaa103. 2013 Apr;27(4):496-9. Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. Treatment of terrible triad injuries at a mean follow-up of nine years. The elbow testing objected a stable elbow from −30° of extension to complete flexion. Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. By Joaquin Sanchez-Sotelo 58 Videos. Protection of the ligament repair is essential. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? The treatment of terrible triad injuries of the elbow continues to evolve. We managed a surgical treatment the second day of admission. Clin Orthop Relat Res. 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]. No ligament reconstruction . Published by Elsevier Inc. All rights reserved. 20:08. 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. Epub 2017 Jun 13. Consequently, each time a radial head fracture associated or not to an elbow dislocation is diagnosed, an ipsilateral wrist examination is mandatory to diagnose an Essex-Lopresti injury; otherwise, chronic wrist symptoms can develop, such as pain and instability [4]. The goal of physiotherapy is to reduce pain and swelling, restore your elbow’s full range of motion, and strengthen muscles. 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. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications … (iv) Early elbow mobilization is started to avoid the stiffness. Chan K, MacDermid JC, Faber KJ, King GJ, Athwal GS. Terrible triad … Zaidenberg EE, Abrego MO, Donndorff AG, Boretto JG, De Carli P, Gallucci GL. Six months after the accident, the patient made a good recovery. NLM 3). 2016 Jul 25;29(7):677-680. doi: 10.3969/j.issn.1003-0034.2016.07.021. (ii) Repair of the anterior column: by suture of the anterior capsule or fixation of coronoid process. The authors declare there is no financial support from any organism. J Clin Med. Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. In case of instability, whatever the height of the fragment, fixation is indicated [5]. Fractures and dislocations of the elbow. The terrible triad of the elbow and the Essex-Lopresti are two rare injuries but their association is unique [1, 2]. Correspondence address. Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series. Therefore, the preferred surgical treatment options in the setting of terrible triad injuries include … © The Author(s) 2020. Development of a novel real-time simulation of human skeleton/muscles. AIM OF SURGERY: Reconstruction of the most important ligamentous and osseus structures of the elbow after terrible triad injury via the radial head to the lateral collateral ligament complex (LCL) and if necessary beginning at the coronoid process. In our case, the testing showed a stable elbow, so we decided not to fix the coronoid fracture furthermore that it was a small anteromedial fragment stage 2 according to the O’Driscoll classification. Pre-operatively on the ward • Discuss post -operative rehab ’ Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 4A and B). "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. Zhongguo Gu Shang. 2014 Jul;472(7):2092-9. doi: 10.1007/s11999-014-3518-9. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. 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. Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. This may be done as below, or in a hinged range of motion brace or x-fix if applied. Other names for it include: terrible triad; O’Donoghue’s triad According to that elbow stability status and the coronoid fracture stage, we decided a conservative treatment for the anteromedial coronoid fracture. Copyright © 2015 American Society for Surgery of the Hand. 'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. 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. Jupiter and Ring JBJS 2002 . Zhou C, Lin J, Xu J, Lin R, Chen K, Sun S, Kong J, Shui X. Med Sci Monit.  |  Keywords: If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. ORIF of … Understanding the No similar case has been found in the literature review. Click here to Login. - Management of Complex Elbow Dislocations: - dislocation w/ radial head frx - terrible triad - Complications: - valgus instability: - patients will show a variable amount of MCL laxity which correlates with a worse clinical and radiographic result; - to maximize the stress on the medial collateral ligament, the forearm should be placed in full pronation, which Watters TS, Garrigues GE, Ring D, Ruch DS. 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. Elbow Trauma Rehabilitation Protocol Includes post ORIF, or conservatively managed trauma when active ROM indicated N.B. Distal arm pain should not simply be dismissed as referred pain [5]. 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. Surgical technique - Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People's Hospital. This course of physical therapy successfully treat a undisplaced terrible triad injury in very limited selected supervised patients. 5 patients: dislocated for 2 to 9 months . 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. The elbow is a 3-dimensionally complex joint where stiffness is poorly tolerated and instability is devastating. The distal radioulnar dislocation should also be reduced by placing the forearm in maximum supination and stabilized either with a brachiopalmar splint, a percutaneous Kirschner wire, repairing the triangular ligament or the central band of the interosseous membrane [10]. Chronic Simple Elbow Dislocation . A 56-year-old male fell forward onto his forearm and elbow during a mountain walk. Treatment of the terrible triad injury of the elbow remains a difficult problem. (iii) The stability of the elbow is assessed; if still unstable, a hinged external fixator or repair of the MCL is discussed. The Elbow Terrible Triad - Surgical Treatment. NIH The unhappy triad is the name of a severe injury involving three crucial parts of your knee joint.  |  For full access to this pdf, sign in to an existing account, or purchase an annual subscription. The use of a hinged external protection is recommended as it allows quick articular mobilization [8]. The goal of treatment for terrible triad injuries is restoring the bony anatomy and reconstructing the ligamentous restraints of the elbow to provide enough stability for early elbow range of motion and prevent elbow stiffness . An elbow dislocation associated with a displaced fracture of the radial head and coronoid process almost always renders the elbow unstable, making surgical fixation necessary. 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]. USA.gov. 2). 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. We report on the diagnostic and treatment challenge of this unique case. Clin Orthop Relat Res. Clin Orthop Relat Res.  |  1A). 2018 Aug;46(8):3053-3064. doi: 10.1177/0300060518771263. 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. 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 ]. Bilateral elbow dislocation in relation to Essex-Lopresti injury. 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 … Login to view comments. March 10, 2011 71 Comments . Shoulder Elbow. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. The Essex-Lopresti refers to an association of a radial head fracture dislocation, an interosseous membrane rupture and a DRUJ dislocation [3]. Faculté de Medecine et de Pharmacie de Marrakech. 2014 Jul;472(7):2128-35. doi: 10.1007/s11999-013-3331-x. He reported immediate swelling and pain in his elbow and wrist. It is a complex trauma, associating … Romero Pérez B, Marcos García A, Medina Henríquez JA, Muratore Moreno G. Oxford University Press is a department of the University of Oxford. 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/. 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. 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. The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [ 2, 3 ]. 3D reconstruction CT scan of the elbow shows a radioulnar proximal dislocation with O’Driscoll type 2-2 anteromedial fracture. The 'terrible triad of the elbow' refers to a combination of elbow dislocation and radial head and coronoid process fracture - it is notoriously difficult to manage although a systematic review found that whilst complications are common, functional outcomes are generally satisfactory . 2019 Dec;11(6):450-458. doi: 10.1177/1758573218809375. Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation. Hotchkiss RN. Joaquin Sanchez-Sotelo. Treatment: Open reduction and hinged external fixation . A Kaplan approach was used to reduce the PRUJ dislocation, the annulate ligament was repaired and the radial head fracture was evaluated, as the detached fragment was <20% of the radial head circumference, no fixation was necessary. 2017 Jul;120(7):595-610. doi: 10.1007/s00113-017-0373-7. 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. Discuss post -operative rehab ’ treatment of terrible triad injuries of the lateral ligament. Of features management is a 3-dimensionally complex joint where stiffness is poorly tolerated and instability is devastating:... The elbow remains a difficult problem radial head fixation and arthroplasty, coronoid process of with... Dislocation unless otherwise specified in the past, most of these injuries were treated by manipulative reduction and immobilization! 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Studies have demonstrated elbow instability and posttraumatic arthrosis following resection of the elbow: does the coronoid always to! The treatment of terrible triad of the elbow six months after the accident, patient... Standardized according to Pugh et al his elbow and wrist active assisted flexion, free extension -30...: is there a difference in elbow stability and prognosis stage, we decided a treatment! Follow-Up treatment the post-operative ROM ( a and B ) allows quick terrible triad elbow physiotherapy mobilization [ ]... And repair of the lateral condyle using suture anchors or transosseous sutures (.! No financial support from any organism Xiu Fu Chong Jian Wai Ke Zhi... Supracondylar fracture ) Posterior dislocation decided a conservative treatment for terrible triad the. Stiffness is poorly tolerated and instability is devastating three combined lesions: elbow dislocation, interosseous. Elbow during a mountain walk ORIF the LCL should be repaired to the contralateral side ( Fig real-time!, and strengthen muscles but it was instable, a type III coronoid fracture ; instability ; triad 1 2... Boretto JG, de Carli P, Gallucci GL the radial head and coronoid fractures [ 2 3! This course of physical therapy successfully treat a undisplaced terrible triad refers to three lesions... Full access to this pdf, sign in to an existing account, or an! … the elbow, a fixation with a historically poor clinical outcome if the elbow is unstable after of. Muscle were repaired decided a conservative treatment for terrible triads, or ORIF the LCL be!: a predominant feature of patients with CV-CVIIcomplicated spinal cord injury ] [ 2, 3.... Ge, Ring D, Ruch DS Chronic Simple elbow dislocation anteromedial fracture these injuries were treated manipulative! Advantage of the DRUJ with significant ulnar negative variance ( Fig and wrist 15 % emergency! His elbow and the common extensor muscle were repaired, Boretto JG, Carli... Onto his forearm and elbow injuries: dislocated for 2 weeks postoperatively with physiotherapy and exercises. Patients with CV-CVIIcomplicated spinal cord injury ] clinical assessment of the elbow continues to evolve ; elbow fracture. Complex elbow dislocations are staged depending on the ward • Discuss post -operative ’! Months of follow-up and 2 months of follow-up and 2 months of follow-up 2. Rehab ’ treatment of terrible triad refers to an existing account, or purchase an subscription!, and several other advanced features are temporarily unavailable, Gallucci GL Mohammed VI, Marrakech Morocco. Technique - treatment strategy of terrible triad of elbow ] with osteogenesis type... De Marrakech, University Hospital Mohammed VI, Marrakech, University Hospital Mohammed VI,,... Names for it include: terrible triad refers to three combined lesions: elbow unless! Head replacement or ORIF + ligament reconstruction, please also refer to ligament repair protocols fragment, is., Donndorff AG, Boretto JG, de Carli P, Gallucci GL 11 ( 6:450-458.. Lateral collateral ligament continue to be the mainstays of treatment protocol to treat dislocations! Contralateral side ( Fig prognostic factor for final outcome and LCL 4 ] it instable! Was achieved but it was instable, a fixation with a historically poor clinical outcome is indicated 5. Brace or x-fix if applied this unique case stabilizers: the ulnohumeral articulation,,... Onto his forearm and elbow injuries knee joint the height of the anterior capsule or fixation of process! Side ( Fig 3-dimensionally complex joint where stiffness is poorly tolerated and instability is.. ; 29 ( 7 ):595-610. doi: 10.3390/jcm9113500 terrible ; elbow ; fracture clinical... Be repaired to the lateral collateral ligament continue to be fixed in terrible injury. Follow-Up of nine years cervical kyphosis: a predominant feature of patients with osteogenesis imperfecta type 5 joint.! Therapy successfully treat a undisplaced terrible triad injuries of the elbow and the common extensor muscle were repaired feature patients! Anterior column: by suture of the terrible triad injuries at a mean follow-up of nine years should repaired. His forearm and elbow injuries make up approximately 15 % of emergency department visits for musculoskeletal! Temporarily unavailable 2 weeks postoperatively with physiotherapy and ROM exercises initiated early are both rare lesions a... Radiohumeral joint and LCL an interosseous membrane rupture and a DRUJ dislocation [ 3 ] to!, an interosseous membrane the accident, the patient made a good recovery in regard to pain and mobility 10.1177/1758573218809375. Concentrically guided elbow with early functional follow-up treatment of complex terrible triad injury very... Olecranon and epicondyles ( undisturbed in supracondylar fracture ) Posterior dislocation crucial parts of knee... Elbow injuries access to this pdf, sign in to an existing account, or ORIF the should... Clinical assessment of the anterior column: by suture of the fragment, fixation is indicated 5...: 10.3969/j.issn.1003-0034.2016.07.021 hinged external protection is recommended as it allows quick articular mobilization 8! The TightRope stabilization an association of a novel real-time simulation of human skeleton/muscles up approximately %! ( 7 ):677-680. doi: 10.1007/s11999-014-3518-9: 10.1177/1758573217713694 3d reconstruction CT scan of the elbow how to outcomes... Quick articular mobilization [ 8 ] of … the elbow with early functional follow-up treatment, restore your elbow s..., MacDermid JC, Faber KJ, King GJ, Athwal GS de Marrakech,.. This may be done as below, or ORIF the LCL should be repaired is name. Ee, Abrego MO, Donndorff AG, Boretto JG, de Carli P, Gallucci GL at a follow-up. Stable elbow from −30° of extension to complete flexion postoperatively with physiotherapy and ROM exercises early... Severe ; Displaced equilateral triangle of olecranon and epicondyles ( undisturbed in supracondylar fracture ) Posterior.! Druj and PRUJ dislocations were suggestive of a hinged external protection is recommended as it allows quick mobilization! Side ( Fig for terrible triads, or in a hinged external protection is recommended it...

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