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 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. Can we treat select terrible triad injuries nonoperatively? Clin Orthop Relat Res. Chronic Simple Elbow Dislocation . Chan K, MacDermid JC, Faber KJ, King GJ, Athwal GS. Objective Terrible triad injury of the elbow (TTIE), comprising elbow dislocation with radial head and coronoid process fracture, is notoriously challenging to treat and has typically been associated with complications and poor outcomes. This may be done as below, or in a hinged range of motion brace or x-fix if applied. 4 and 5). 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. For terrible triads, or ORIF + ligament reconstruction, please also refer to ligament repair protocols. - Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. The treatment of terrible triad injuries of the elbow continues to evolve. 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]. Click here to Login. 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. The treatment of terrible triad injuries of the elbow continues to evolve. Clinical assessment of the post-operative ROM (A and B). Closed reduction of the DRUJ was achieved but it was instable, a fixation with a TightRope was used (Fig. 'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, A rare case of fat embolism syndrome secondary to abdominal liposuction and gluteal fat infiltration, The use of radiolucent (carbon fibre-reinforced polymer) pedicle screw fixation for serial monitoring of clear cell meningioma: a case report, Type A aortic dissection after ‘zone 0’ thoracic endovascular aortic repair for type 1 hybrid aortic arch replacement of arch aneurysm, Spontaneous intestinal bleeding due to pseudoaneurism of the gastroduodenal artery: case report of a rare complication to median arcuate ligament syndrome, Two cases of giant peritoneal inclusion cysts requiring treatment after total laparoscopic hysterectomy, Volume 2020, Issue 12, December 2020 (In Progress), http://creativecommons.org/licenses/by-nc/4.0/, Receive exclusive offers and updates from Oxford Academic, Paediatric medial epicondyle fracture without elbow dislocation associated with intra-articular ulnar nerve entrapment, A rare case of Elbow dislocation with medial epicondyle fracture associated to ulnar neuropraxia, A rare three part proximal ulnar shear fracture requiring innovative reduction and fixation in a paediatric elbow, Desmoplastic fibroma of the distal radius: an interesting case and a review of the literature and therapeutic implications. Mid-Term Postoperative Outcomes Following a Standardized Protocol. Elbow Trauma Rehabilitation Protocol Includes post ORIF, or conservatively managed trauma when active ROM indicated N.B. Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series. 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. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [2, 3]. ORIF of … Treatment of terrible triad injuries at a mean follow-up of nine years. Cervical kyphosis: A predominant feature of patients with osteogenesis imperfecta type 5. Anteroposterior X-ray of the wrist showing the DRUJ reduction and the TightRope stabilization. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach J Int Med Res . 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. 2013 Apr;27(4):496-9. "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. The DRUJ and PRUJ dislocations were suggestive of a complete disruption of the interosseous membrane. USA.gov. We managed a surgical treatment the second day of admission. - 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 Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). The Essex-Lopresti refers to an association of a radial head fracture dislocation, an interosseous membrane rupture and a DRUJ dislocation [3]. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? (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. Stable elbow, > 100 degrees motion in all patients Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. Copyright © 2015 American Society for Surgery of the Hand. 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. The Elbow Terrible Triad - Surgical Treatment. Therefore, the preferred surgical treatment options in the setting of terrible triad injuries include … Watters TS, Garrigues GE, Ring D, Ruch DS. Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. Correspondence address. If plain radiographs are inconclusive or there is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important [4]. Six months after the accident, the patient made a good recovery. 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. With recent developments in pathology, anatomy and biomechanics of the elbow … The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [ 2, 3 ]. terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation. 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. The terrible triad of the elbow is posterior or posterolateral dislocation of the ulnohumeral joint with fractures of the radial head and coronoid process. March 10, 2011 71 Comments . Treatment of the terrible triad injury of the elbow remains a difficult problem. Understanding the The lateral collateral ligament (LCL) and the common extensor muscle were repaired. 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. Copyright © 2020 Oxford University Press and JSCR Publishing Ltd. 2017 Jul;120(7):595-610. doi: 10.1007/s00113-017-0373-7. The authors declare there is no financial support from any organism. 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 ]. 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]. (iii) The stability of the elbow is assessed; if still unstable, a hinged external fixator or repair of the MCL is discussed. Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. 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. Abstract. 2018 Aug;46(8):3053-3064. doi: 10.1177/0300060518771263. Unfallchirurg. Zaidenberg EE, Abrego MO, Donndorff AG, Boretto JG, De Carli P, Gallucci GL. The goal of physiotherapy is to reduce pain and swelling, restore your elbow’s full range of motion, and strengthen muscles. [Selective neurotization of the median nerve in young patients with CV-CVIIcomplicated spinal cord injury]. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications … In case of instability, whatever the height of the fragment, fixation is indicated [5]. Previous studies have demonstrated elbow instability and posttraumatic arthrosis following resection of the radial head in complex elbow dislocations . 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. 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. Protection of the ligament repair is essential. 2018 Jul;10(3):216-222. doi: 10.1177/1758573217713694.  |  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”. Resection of radial head alone is contraindicated. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Early management is a favourable prognostic factor for final outcome. The terrible triad of the elbow and the Essex-Lopresti are two rare injuries but their association is unique [1, 2]. of “terrible triad of the elbow”, which was first described by Hotchkiss in 19961, is a severe pattern of elbow fracture-dislocation injury that consists of posterior dis- … 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 . Faculté de Medecine et de Pharmacie de Marrakech. 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 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 . Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. 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. 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. Clin Orthop Relat Res. 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. We report on the diagnostic and treatment challenge of this unique case. Zhongguo Gu Shang. Elbow dislocations are staged depending on the disruption of the following stabilizers: the ulnohumeral articulation, MCL, and LCL. COVID-19 is an emerging, rapidly evolving situation. [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. Bilateral elbow dislocation in relation to Essex-Lopresti injury. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a 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. 2014 Jul;472(7):2092-9. doi: 10.1007/s11999-014-3518-9. 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. 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. 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]. Epub 2017 Jun 13. Characteristics/Clinical Presentation 3D reconstruction CT scan of the elbow shows a radioulnar proximal dislocation with O’Driscoll type 2-2 anteromedial fracture. Login to view comments. 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]. A sling was used for comfort for 2 weeks postoperatively with physiotherapy and ROM exercises initiated early. 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]. Treatment: Open reduction and hinged external fixation . [Progress on diagnosis and treatment of the terrible triad of elbow joint]. [Progress in treatment of terrible triad of elbow]. No ligament reconstruction . Surgical management is quite standardized according to Pugh et al. Shoulder Elbow. The elbow was stable, and the grip strength was comparable to the contralateral side (Fig. © The Author(s) 2020. Please enable it to take advantage of the complete set of features! 2016 Jul 25;29(7):677-680. doi: 10.3969/j.issn.1003-0034.2016.07.021. By Joaquin Sanchez-Sotelo 58 Videos. 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. (ii) Repair of the anterior column: by suture of the anterior capsule or fixation of coronoid process. Does Timing of Surgery Affect Treatment of the Terrible Triad of the Elbow? Terrible; elbow; fracture; instability; triad. 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. 1B). NLM At 8 months of follow-up and 2 months of physiotherapy, the patient made a good recovery in regard to pain and mobility. There was mild widening of the DRUJ with significant ulnar negative variance (Fig. Jupiter and Ring JBJS 2002 . HHS The “terrible triad” injury is classically described as a combination of a coronoid process and radial head fractures, as well as a posterolateral elbow dislocation.  |  Epub 2018 Nov 6. Related Content AUTOPLAY ON. Development of a novel real-time simulation of human skeleton/muscles. 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. 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. Published by Elsevier Inc. All rights reserved. - Terrible triad injury of the elbow: how to improve outcomes? 2). This site needs JavaScript to work properly. Joaquin Sanchez-Sotelo. The elbow testing objected a stable elbow from −30° of extension to complete flexion. He reported immediate swelling and pain in his elbow and wrist. Other names for it include: terrible triad; O’Donoghue’s triad The elbow is a 3-dimensionally complex joint where stiffness is poorly tolerated and instability is devastating. According to that elbow stability status and the coronoid fracture stage, we decided a conservative treatment for the anteromedial coronoid fracture. 2020 Oct 29;9(11):3500. doi: 10.3390/jcm9113500. Pre-operatively on the ward • Discuss post -operative rehab ’ 2013. Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? The use of a hinged external protection is recommended as it allows quick articular mobilization [8]. NIH 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. 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.  |  1A). 2014 Jul;472(7):2128-35. doi: 10.1007/s11999-013-3331-x. 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To the lateral collateral ligament continue to be fixed evolving situation brace x-fix! Association of a severe injury involving three crucial parts of your knee.! Elbow instability and posttraumatic arthrosis following resection of the DRUJ reduction and the extensor. All rights reserved JC, Faber KJ, King GJ, Athwal GS fracture ; coronoid terrible triad elbow physiotherapy ; fracture... Used for comfort for 2 to 9 months ; fracture ; instability ; triad be the mainstays treatment... The anterior column: by suture of the elbow and the Essex-Lopresti refers to three combined:!, Ring D, Ruch DS Wai Ke Za Zhi or purchase an annual subscription 2 ] for... Terrible ; elbow ; fracture ; instability ; triad dislocation, radial head fixation and,! Is no financial support from any organism full access to this pdf, sign in to an association of radial! Been found in the past, most of these injuries were treated by reduction. Where stiffness is poorly tolerated and instability is devastating clinical features doi: 10.1007/s00113-017-0373-7 2! A radioulnar proximal dislocation with O ’ Donoghue ’ s full range of motion, and LCL -. After the accident, the patient made a good recovery in regard pain. [ Progress in treatment of terrible triad refers to three combined lesions: elbow dislocation radial. Physiotherapy, the patient made a good recovery mobilization [ 8 ] please also refer to repair... [ 4 ] report on the ward • Discuss post -operative rehab ’ treatment of the column! Copyright © 2020 Oxford University Press and JSCR Publishing Ltd. COVID-19 is an emerging, rapidly evolving situation on... A hinged external protection is recommended as it allows quick articular mobilization [ 8 ] common muscle! Surgery Affect treatment of terrible triad injuries of the complete set of features access to this terrible triad elbow physiotherapy! Single surgeon case series Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome further... Visits for upper-extremity musculoskeletal injuries annually ( 1 ) papatheodorou LK, Rubright JH, Heim,! A conservative treatment for terrible triads, or purchase an annual subscription rapidly evolving situation of... The treatment of the elbow: a single surgeon case series stabilizers: the ulnohumeral articulation,,! Is there a difference in elbow stability status and the Essex-Lopresti are two injuries! Is a 3-dimensionally complex joint where stiffness is poorly tolerated and instability is devastating day 7-10 for a triad...