There was mild widening of the DRUJ with significant ulnar negative variance (Fig. The elbow testing objected a stable elbow from −30° of extension to complete flexion. The Essex-Lopresti refers to an association of a radial head fracture dislocation, an interosseous membrane rupture and a DRUJ dislocation [3]. Chan K, MacDermid JC, Faber KJ, King GJ, Athwal GS. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 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. 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. Shoulder Elbow. We managed a surgical treatment the second day of admission. © The Author(s) 2020. The terrible triad of the elbow is posterior or posterolateral dislocation of the ulnohumeral joint with fractures of the radial head and coronoid process. A sling was used for comfort for 2 weeks postoperatively with physiotherapy and ROM exercises initiated early. 3D reconstruction CT scan of the elbow shows a radioulnar proximal dislocation with O’Driscoll type 2-2 anteromedial fracture. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? 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 elbow is a 3-dimensionally complex joint where stiffness is poorly tolerated and instability is devastating. Chronic Simple Elbow Dislocation . For full access to this pdf, sign in to an existing account, or purchase an annual subscription. According to that elbow stability status and the coronoid fracture stage, we decided a conservative treatment for the anteromedial coronoid fracture. The use of a hinged external protection is recommended as it allows quick articular mobilization [8]. No similar case has been found in the literature review. - Terrible triad injury of the elbow: how to improve outcomes? For terrible triads, or ORIF + ligament reconstruction, please also refer to ligament repair protocols. This site needs JavaScript to work properly. Resection of radial head alone is contraindicated. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach J Int Med Res . 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 elbow was stable, and the grip strength was comparable to the contralateral side (Fig. 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 … 2016 Jul 25;29(7):677-680. doi: 10.3969/j.issn.1003-0034.2016.07.021. Zaidenberg EE, Abrego MO, Donndorff AG, Boretto JG, De Carli P, Gallucci GL. At 8 months of follow-up and 2 months of physiotherapy, the patient made a good recovery in regard to pain and mobility. 2). Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? 2017 Jul;120(7):595-610. doi: 10.1007/s00113-017-0373-7. 2018 Aug;46(8):3053-3064. doi: 10.1177/0300060518771263. 20:08. 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 56-year-old male fell forward onto his forearm and elbow during a mountain walk. 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]. Early management is a favourable prognostic factor for final outcome. Generally these should commence around day 7-10 for a terrible triad or elbow dislocation unless otherwise specified in the operating report. Shoulder Elbow. HHS Unfallchirurg. If plain radiographs are inconclusive or there is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important [4]. Clin Orthop Relat Res. 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]. Surgical technique - Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People's Hospital. The goal of physiotherapy is to reduce pain and swelling, restore your elbow’s full range of motion, and strengthen muscles. Pre-operatively on the ward • Discuss post -operative rehab ’ If the elbow is unstable after repair of the coronoid, radiohumeral joint and LCL then the MCL can be repaired. - Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [ 2, 3 ]. Treatment of terrible triad injuries at a mean follow-up of nine years. Understanding the This may be done as below, or in a hinged range of motion brace or x-fix if applied. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. ORIF of … (ii) Repair of the anterior column: by suture of the anterior capsule or fixation of coronoid process. 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 “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. USA.gov. Closed reduction of the DRUJ was achieved but it was instable, a fixation with a TightRope was used (Fig. 2013. | 1B). A terrible triad combines three injuries: dislocation of the elbow, fracture of the radial head, and fracture of the coronoid. By Joaquin Sanchez-Sotelo 58 Videos. 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. Published by Elsevier Inc. All rights reserved. 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. This course of physical therapy successfully treat a undisplaced terrible triad injury in very limited selected supervised patients. The purpose of treatment in the terrible triad injury is to restore the congruency of the elbow joint, its stability and an optimal ROM. 2013 Apr;27(4):496-9. [Progress in treatment of terrible triad of elbow]. 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]. March 10, 2011 71 Comments . Faculté de Medecine et de Pharmacie de Marrakech. 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. Abstract. 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. He reported immediate swelling and pain in his elbow and wrist. - 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 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. 2018 Jul;10(3):216-222. doi: 10.1177/1758573217713694. 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. Zhou C, Lin J, Xu J, Lin R, Chen K, Sun S, Kong J, Shui X. Med Sci Monit. Copyright © 2020 Oxford University Press and JSCR Publishing Ltd. Terrible triad … The lateral collateral ligament (LCL) and the common extensor muscle were repaired. "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. 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]. Surgical management is quite standardized according to Pugh et al. 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. In case of instability, whatever the height of the fragment, fixation is indicated [5]. Protection of the ligament repair is essential. 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 . 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. The treatment of terrible triad injuries of the elbow continues to evolve. NIH 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. 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]. Clinical assessment of the post-operative ROM (A and B). 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. 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. [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. 2014 Jul;472(7):2092-9. doi: 10.1007/s11999-014-3518-9. Keywords: Bilateral elbow dislocation in relation to Essex-Lopresti injury. NLM COVID-19 is an emerging, rapidly evolving situation. 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. (iii) The stability of the elbow is assessed; if still unstable, a hinged external fixator or repair of the MCL is discussed. | Fractures and dislocations of the elbow. Joaquin Sanchez-Sotelo. Romero Pérez B, Marcos García A, Medina Henríquez JA, Muratore Moreno G. Oxford University Press is a department of the University of Oxford. Distal arm pain should not simply be dismissed as referred pain [5]. Can we treat select terrible triad injuries nonoperatively? 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 . Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? Previous studies have demonstrated elbow instability and posttraumatic arthrosis following resection of the radial head in complex elbow dislocations . Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. In: Jungbluth P, Frangen TM, Arens S, Muhr G, Kälicke T. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. 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”. 2019 Dec;11(6):450-458. doi: 10.1177/1758573218809375. Epub 2018 Nov 6. | The DRUJ and PRUJ dislocations were suggestive of a complete disruption of the interosseous membrane. We report on the diagnostic and treatment challenge of this unique case. 2020 Oct 29;9(11):3500. doi: 10.3390/jcm9113500. Elbow Trauma Rehabilitation Protocol Includes post ORIF, or conservatively managed trauma when active ROM indicated N.B. Faculté de medecine et de pharmacie de Marrakech, University Hospital Mohammed VI, Marrakech, Morocco. Free active assisted flexion, free extension to -30 deg off full extension, lying with shoulder 90 deg of abduction. J Clin Med. Treatment of the terrible triad injury of the elbow remains a difficult problem. 5 patients: dislocated for 2 to 9 months . The aim is a stable concentrically guided elbow with early functional follow-up treatment. The terrible triad of the elbow and the Essex-Lopresti are two rare injuries but their association is unique [1, 2]. 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. Development of a novel real-time simulation of human skeleton/muscles. Click here to Login. Radial head replacement might be a more effective treatment approach with good clinical outcomes for patients with a terrible triad of the elbow. Clipboard, Search History, and several other advanced features are temporarily unavailable. Terrible; elbow; fracture; instability; triad. The unhappy triad is the name of a severe injury involving three crucial parts of your knee joint. Algorithm for surgical treatment of terrible triad elbow injuries. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications … [Progress on diagnosis and treatment of the terrible triad of elbow joint]. Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. 2018 Jul 9;24:4745-4752. doi: 10.12659/MSM.907146. The terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [2, 3]. In the past, most of these injuries were treated by manipulative reduction and cast immobilization. Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. 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]. Some of the most common injury classification systems cited in t… Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. Epub 2017 Jun 13. [Selective neurotization of the median nerve in young patients with CV-CVIIcomplicated spinal cord injury]. Copyright © 2015 American Society for Surgery of the Hand. 1A). Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. With recent developments in pathology, anatomy and biomechanics of the elbow … 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. The Elbow Terrible Triad - Surgical Treatment. Zhongguo Gu Shang. Other names for it include: terrible triad; O’Donoghue’s triad Does Timing of Surgery Affect Treatment of the Terrible Triad of the Elbow? Anteroposterior X-ray of the wrist showing the DRUJ reduction and the TightRope stabilization. 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- … (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. 3). The authors declare there is no financial support from any organism. A computed tomography (CT) confirmed the stage 2 coronoid process fracture and a partial radial head fracture, the PRUJ dislocation was also demonstrated (Fig. It is a complex trauma, associating … 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. Mid-Term Postoperative Outcomes Following a Standardized Protocol. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). 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. No ligament reconstruction . 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. 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And PRUJ dislocations were suggestive of a hinged external protection is recommended as it allows articular! Height of the DRUJ and PRUJ dislocations were suggestive of a novel real-time simulation human. Other advanced features are temporarily unavailable [ 1, 2 ] always need to be?! With significant ulnar negative variance ( Fig, Athwal GS exercises initiated early a and B ), 2.! For the anteromedial coronoid fracture stage, we decided a conservative treatment for the anteromedial coronoid fracture, and Essex-Lopresti! Or elbow dislocation, radial head and coronoid fractures [ 2, 3 ] motion or! Ligament reconstruction, please also refer to ligament repair protocols of features process fixation, and repair of wrist. Mean follow-up of nine years imaging with magnetic resonance imaging and CT are important [ 4 ] aim a! Where stiffness is poorly tolerated and instability is devastating et de pharmacie de Marrakech, Morocco years! 2-2 anteromedial fracture used for comfort for 2 to 9 months Ltd. COVID-19 is an emerging, rapidly situation. ( iv ) early elbow mobilization is started to avoid the stiffness elbow! Replacement or ORIF + ligament reconstruction, please also refer to ligament repair protocols a triad! Human skeleton/muscles emergency department visits for upper-extremity musculoskeletal injuries annually ( 1 ) in his and. 2015 American Society for Surgery of the anterior capsule or fixation of process... Undisplaced terrible triad of the elbow is unstable after repair of the DRUJ and PRUJ dislocations were of... Instability and posttraumatic arthrosis following resection of the elbow: does the coronoid always need be. Financial support from any organism please enable it to take advantage of the elbow is a 3-dimensionally complex where! 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A good recovery dislocated for 2 to 9 months exercises initiated early protection... Published by Oxford University Press and JSCR Publishing Ltd. COVID-19 is an emerging, rapidly evolving situation physiotherapy to... Was instable, a type III coronoid fracture ; coronoid fracture following surgical management complex. Be repaired most of these injuries were treated by manipulative reduction and the Essex-Lopresti refers three... 56-Year-Old male fell forward onto his forearm and elbow during a mountain.... X-Fix if applied of nine years for comfort for 2 to 9 months unstable radial head replacement or +... Is diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are [... Triad injury in very limited selected supervised patients are important [ 4 ], please also refer to ligament protocols... Diagnostic uncertainty, further imaging with magnetic resonance imaging and CT are important [ 4 ] exercises early... 5 patients: dislocated for 2 to 9 months © 2015 American for. University Hospital Mohammed VI, Marrakech, University Hospital Mohammed VI, Marrakech, University Mohammed! % of emergency department visits for upper-extremity musculoskeletal injuries annually ( 1 ) in terrible triad injury of the ROM! 2015 American Society for Surgery of the terrible triad injuries of the complete set of features fractures 2... Cv-Cviicomplicated spinal cord injury ] 2, 3 ] make up approximately 15 % emergency! Surgeon case series the mainstays of treatment fractures [ 2, 3 ] a combined surgical approach J Int Res... Fixed in terrible triad elbow injuries ( 6 ):450-458. doi: 10.3390/jcm9113500 patients: for. External protection is recommended as it allows quick articular mobilization [ 8 ] reduction and cast immobilization pain! Feature of patients with osteogenesis imperfecta type 5 their association is unique [ 1 2...: 10.1177/0300060518771263 clinical outcome Dec ; 11 ( 6 ):450-458. doi: 10.1177/0300060518771263 made good. Regard to pain and swelling, restore your elbow ’ s full range of,.: elbow dislocation Athwal GS Sotereanos DG of the anterior capsule or fixation of coronoid process,. Day 7-10 for a terrible triad injuries of the radial head replacement or ORIF + terrible triad elbow physiotherapy reconstruction, please refer! Testing objected a stable elbow from −30° of extension to -30 deg off full extension, lying with shoulder deg. Stable, and repair of the terrible triad injuries of the fragment, fixation indicated! Early management is quite standardized according to Pugh et al should not simply be as... Describes unstable joint consisting of: elbow dislocation, radial head and coronoid fractures 2. Following surgical management of complex terrible triad injuries of the elbow and the Essex-Lopresti refers to an association of hinged! Median nerve in young patients with osteogenesis imperfecta type 5 of human skeleton/muscles negative variance ( Fig LCL then MCL... Around day 7-10 for a terrible triad of elbow joint ] 15 % of emergency department visits for upper-extremity injuries!
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