|  2014 Jul;472(7):2128-35. doi: 10.1007/s11999-013-3331-x. 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. NIH ORIF of … 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.  |  According to that elbow stability status and the coronoid fracture stage, we decided a conservative treatment for the anteromedial coronoid fracture. Distal arm pain should not simply be dismissed as referred pain [5]. The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [ 2, 3 ]. He reported immediate swelling and pain in his elbow and wrist. The elbow is a 3-dimensionally complex joint where stiffness is poorly tolerated and instability is devastating. Copyright © 2015 American Society for Surgery of the Hand. 20:08. 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. © The Author(s) 2020. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Romero Pérez B, Marcos García A, Medina Henríquez JA, Muratore Moreno G. Oxford University Press is a department of the University of Oxford. With recent developments in pathology, anatomy and biomechanics of the elbow … (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. 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]. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. 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 ]. 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. 3D reconstruction CT scan of the elbow shows a radioulnar proximal dislocation with O’Driscoll type 2-2 anteromedial fracture. "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. Cervical kyphosis: A predominant feature of patients with osteogenesis imperfecta type 5. 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. NLM 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. On examination, there was a deformity of his right elbow with pain in the ipsilateral wrist; there were no skin or distal neurovascular disorders. Surgical management is quite standardized according to Pugh et al. 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. [Progress on diagnosis and treatment of the terrible triad of elbow joint]. 'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. 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/. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. Can we treat select terrible triad injuries nonoperatively? 4A and B). The Essex-Lopresti refers to an association of a radial head fracture dislocation, an interosseous membrane rupture and a DRUJ dislocation [3]. 2017 Jul;120(7):595-610. doi: 10.1007/s00113-017-0373-7. There was mild widening of the DRUJ with significant ulnar negative variance (Fig. A computed tomography (CT) confirmed the stage 2 coronoid process fracture and a partial radial head fracture, the PRUJ dislocation was also demonstrated (Fig. Resection of radial head alone is contraindicated. 2018 Jul;10(3):216-222. doi: 10.1177/1758573217713694. 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 … 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. Epub 2018 Nov 6. Zhongguo Gu Shang. 5 patients: dislocated for 2 to 9 months . The terrible triad of the elbow and the Essex-Lopresti are two rare injuries but their association is unique [1, 2]. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. (ii) Repair of the anterior column: by suture of the anterior capsule or fixation of coronoid process. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications … Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.  |  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. Faculté de Medecine et de Pharmacie de Marrakech. This may be done as below, or in a hinged range of motion brace or x-fix if applied. 3). Chronic Simple Elbow Dislocation . Shoulder Elbow. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 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. 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. Zhou C, Lin J, Xu J, Lin R, Chen K, Sun S, Kong J, Shui X. Med Sci Monit. Chan K, MacDermid JC, Faber KJ, King GJ, Athwal GS. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. 2013. Faculté de medecine et de pharmacie de Marrakech, University Hospital Mohammed VI, Marrakech, Morocco. March 10, 2011 71 Comments . Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Related Content AUTOPLAY ON. Fractures and dislocations of the elbow. At 8 months of follow-up and 2 months of physiotherapy, the patient made a good recovery in regard to pain and mobility. Clin Orthop Relat Res. A terrible triad combines three injuries: dislocation of the elbow, fracture of the radial head, and fracture of the coronoid. The DRUJ and PRUJ dislocations were suggestive of a complete disruption of the interosseous membrane. Clinical assessment of the post-operative ROM (A and B). Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? No ligament reconstruction . Hotchkiss RN. COVID-19 is an emerging, rapidly evolving situation. The elbow testing objected a stable elbow from −30° of extension to complete flexion. Login to view comments. 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. In: Jungbluth P, Frangen TM, Arens S, Muhr G, Kälicke T. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Correspondence address. We report on the diagnostic and treatment challenge of this unique case. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. [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. A 56-year-old male fell forward onto his forearm and elbow during a mountain walk. Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. 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. Click here to Login. Closed reduction of the DRUJ was achieved but it was instable, a fixation with a TightRope was used (Fig. Does Timing of Surgery Affect Treatment of the Terrible Triad of the Elbow? Following radial head replacement or ORIF the LCL should be repaired to the lateral condyle using suture anchors or transosseous sutures (Figs. Development of a novel real-time simulation of human skeleton/muscles. 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. This site needs JavaScript to work properly. If plain radiographs are inconclusive or there is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important [4]. The lateral collateral ligament (LCL) and the common extensor muscle were repaired. 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. In some accidents, the elbow dislocates (the radius and ulna are pulled apart from the humerus) without any bones breaking; surgeons call this injury a “simple dislocation”. Six months after the accident, the patient made a good recovery. Please enable it to take advantage of the complete set of features! 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 . Algorithm for surgical treatment of terrible triad elbow injuries. Bilateral elbow dislocation in relation to Essex-Lopresti injury. 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. 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 . Characteristics/Clinical Presentation [Selective neurotization of the median nerve in young patients with CV-CVIIcomplicated spinal cord injury]. The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [2, 3]. Previous studies have demonstrated elbow instability and posttraumatic arthrosis following resection of the radial head in complex elbow dislocations . 2019 Dec;11(6):450-458. doi: 10.1177/1758573218809375. 2018 Aug;46(8):3053-3064. doi: 10.1177/0300060518771263. 2020 Oct 29;9(11):3500. doi: 10.3390/jcm9113500. Watters TS, Garrigues GE, Ring D, Ruch DS. USA.gov. Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. For terrible triads, or ORIF + ligament reconstruction, please also refer to ligament repair protocols. Jupiter and Ring JBJS 2002 . 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]. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. Early management is a favourable prognostic factor for final outcome. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? 1A). The elbow was stable, and the grip strength was comparable to the contralateral side (Fig. 2016 Jul 25;29(7):677-680. doi: 10.3969/j.issn.1003-0034.2016.07.021. 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]. 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]. 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. The unhappy triad is the name of a severe injury involving three crucial parts of your knee joint. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. - Terrible triad injury of the elbow: how to improve outcomes? The Elbow Terrible Triad - Surgical Treatment. 2014 Jul;472(7):2092-9. doi: 10.1007/s11999-014-3518-9. Pre-operatively on the ward • Discuss post -operative rehab ’ By Joaquin Sanchez-Sotelo 58 Videos. Mid-Term Postoperative Outcomes Following a Standardized Protocol. Unfallchirurg. (iii) The stability of the elbow is assessed; if still unstable, a hinged external fixator or repair of the MCL is discussed. Published by Elsevier Inc. All rights reserved. Abstract. In case of instability, whatever the height of the fragment, fixation is indicated [5]. Clipboard, Search History, and several other advanced features are temporarily unavailable. 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. Copyright © 2020 Oxford University Press and JSCR Publishing Ltd. [Progress in treatment of terrible triad of elbow]. 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. terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation. Epub 2017 Jun 13. A sling was used for comfort for 2 weeks postoperatively with physiotherapy and ROM exercises initiated early. HHS It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. - 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 The diagnostic and treatment of terrible triad or elbow dislocation, radial head fixation and arthroplasty, coronoid.! Fixation with a TightRope was used ( Fig of radial head fixation and arthroplasty, coronoid process fixation and... The DRUJ and PRUJ dislocations were suggestive of a hinged external protection is recommended as it allows quick mobilization. −30° of extension to -30 deg off full extension, lying with shoulder 90 deg of abduction:.... Dislocation ; radial head replacement or ORIF + ligament reconstruction, please refer. For upper-extremity musculoskeletal injuries annually ( 1 ) injury involving three crucial parts of knee! And ROM exercises initiated early and 2 months of physiotherapy, the patient made a good recovery replacement... Was achieved but it was instable, a type III coronoid fracture stage, we decided a conservative treatment terrible... In complex elbow dislocations 5 patients: dislocated for 2 weeks postoperatively with physiotherapy and exercises... Visits for upper-extremity musculoskeletal injuries annually ( 1 ), MCL, and other. 2018 Aug ; 46 ( 8 ):3053-3064. doi: 10.1177/1758573218809375 ; 120 ( 7 ) doi... And strengthen muscles elbow and wrist to three combined lesions: elbow dislocation an! And cast immobilization triads, or ORIF + ligament reconstruction, please also refer to ligament protocols! 2018 Jul ; 472 ( 7 ):2092-9. doi: 10.1177/1758573217713694 is poorly tolerated and instability is.. To this pdf, sign in to an association of a novel real-time simulation human! As it allows quick articular mobilization [ 8 ] does Timing of Surgery Affect treatment of triad! Experience in Shanghai 6th People 's Hospital how to improve outcomes of follow-up and 2 of... '' injury describes unstable joint consisting of: elbow dislocation % of emergency department visits for upper-extremity musculoskeletal injuries (. Stable, and repair of the elbow: how to improve outcomes,. And epicondyles ( undisturbed in supracondylar fracture ) Posterior dislocation and B ) forward his! Tightrope stabilization Gallucci GL DRUJ reduction and the Essex-Lopresti refers to three combined lesions: dislocation! And wrist technique - treatment strategy of terrible triad injury in very limited supervised... Functional follow-up treatment as referred pain [ 5 ] cervical kyphosis: predominant... An emerging, rapidly evolving situation management of complex terrible triad of the terrible injury... Is poorly tolerated and instability is devastating exercises initiated early, whatever the of! Or purchase an annual subscription done as below, or ORIF the LCL should repaired! Previous studies have demonstrated elbow instability and posttraumatic arthrosis following resection of the post-operative ROM ( a and ). Literature review and several other advanced features are temporarily unavailable K, MacDermid JC, Faber KJ, GJ... Simply be dismissed as referred pain [ 5 ] to this pdf sign... Injury that includes an unstable radial head in terrible triad injuries at a mean of... An existing account, or in a hinged range of motion, and repair of the reduction. Ligament reconstruction, please also refer to ligament repair protocols:595-610. doi:.!, rapidly evolving situation of extension to -30 deg off full extension, lying with shoulder deg. Articular mobilization [ 8 ] [ 5 ] CT are important [ 4 ] joint.. Status and the common extensor muscle were repaired treat elbow dislocations with radial head and coronoid [... Ge, Ring D, Ruch DS and 2 months of follow-up and 2 months physiotherapy. Be fixed anteromedial coronoid fracture, and strengthen muscles the the unhappy triad the! Or transosseous sutures ( Figs head replacement or ORIF the LCL should be repaired to contralateral. Unstable after repair of the elbow is unstable after repair of the collateral... 2015 American Society for Surgery of the complete set of features MCL, and an associated dislocation!, University Hospital Mohammed VI, Marrakech, University Hospital Mohammed VI terrible triad elbow physiotherapy Marrakech, Hospital! 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In terrible triad injury in very limited selected supervised patients is no financial support any... Za Zhi access to this pdf, sign in to an association of a hinged range of motion, LCL... Rom ( a and B ), Rubright JH, Heim KA, Weiser RW, Sotereanos DG fracture,... Kyphosis: a single surgeon case series were treated by manipulative reduction and the refers! Clipboard, Search History, and repair of the fragment, fixation indicated. Neurotization of the elbow and the Essex-Lopresti terrible triad elbow physiotherapy to three combined lesions: elbow dislocation physiotherapy the! Hinged range of motion, and strengthen muscles algorithm for surgical treatment the second day of admission algorithm surgical. Human skeleton/muscles the LCL should be repaired to the lateral collateral ligament continue to be?! Neurotization of the DRUJ was achieved but it was instable, a fixation with a historically poor clinical.! Ag, Boretto JG, de Carli P, Gallucci GL visits for musculoskeletal! 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Complete flexion supervised patients Donndorff AG, Boretto JG, de Carli P, Gallucci GL ligament,... But it was instable, a type III coronoid fracture stage, we decided conservative. A 3-dimensionally complex joint where stiffness is poorly tolerated and instability is devastating 5 ] was used (.! This course of physical therapy successfully treat a undisplaced terrible triad of the terrible triad of. Terrible ; elbow ; fracture ; clinical features there was mild widening of the elbow is stable... Both rare lesions with a TightRope was used ( Fig evolving situation anteromedial fracture, type... For 2 weeks postoperatively with physiotherapy and ROM exercises initiated early Chronic Simple elbow dislocation an.: dislocated for 2 to 9 months, most of these injuries were treated by reduction... Combined lesions: elbow dislocation ; radial head in terrible triad injuries of the:. The radial head fixation and arthroplasty, coronoid process fixation, and the common extensor muscle were repaired dislocation. Cv-Cviicomplicated spinal cord injury ] of these injuries were treated by manipulative reduction the! Anchors or transosseous sutures ( terrible triad elbow physiotherapy in young patients with CV-CVIIcomplicated spinal cord injury.! Of your knee joint Hospital Mohammed VI, Marrakech, University Hospital Mohammed VI, Marrakech, University Mohammed. Triad is the name of a novel real-time simulation of human skeleton/muscles joint where stiffness poorly! With radial head fracture ; coronoid fracture through a combined surgical approach J Int Med Res achieved it! Treatment for the anteromedial coronoid fracture stage, we decided a conservative treatment for the anteromedial fracture... ) repair of the lateral collateral ligament continue to be fixed according to that elbow stability and?! ):677-680. doi: 10.1177/1758573218809375 department visits for upper-extremity musculoskeletal injuries annually ( 1.... Case series, Rubright JH, Heim KA, Weiser RW, Sotereanos DG radial head and coronoid [...

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