- Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. 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. Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. Fractures and dislocations of the elbow. Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Zhongguo Gu Shang. 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]. Clipboard, Search History, and several other advanced features are temporarily unavailable. NIH Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? 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 objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications … 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. Characteristics/Clinical Presentation 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. NLM This course of physical therapy successfully treat a undisplaced terrible triad injury in very limited selected supervised patients. In: Jungbluth P, Frangen TM, Arens S, Muhr G, Kälicke T. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach J Int Med Res . For terrible triads, or ORIF + ligament reconstruction, please also refer to ligament repair protocols. 2014 Jul;472(7):2092-9. doi: 10.1007/s11999-014-3518-9. Chronic Simple Elbow Dislocation . The lateral collateral ligament (LCL) and the common extensor muscle were repaired. Elbow Trauma Rehabilitation Protocol Includes post ORIF, or conservatively managed trauma when active ROM indicated N.B. The terrible triad of the elbow is posterior or posterolateral dislocation of the ulnohumeral joint with fractures of the radial head and coronoid process. | Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. The DRUJ and PRUJ dislocations were suggestive of a complete disruption of the interosseous membrane. Six months after the accident, the patient made a good recovery. The terrible triad of the elbow and the Essex-Lopresti are two rare injuries but their association is unique [1, 2]. 3). In case of instability, whatever the height of the fragment, fixation is indicated [5]. Clin Orthop Relat Res. Zaidenberg EE, Abrego MO, Donndorff AG, Boretto JG, De Carli P, Gallucci GL. We managed a surgical treatment the second day of admission. Surgical technique - Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People's Hospital. 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. Does Timing of Surgery Affect Treatment of the Terrible Triad of the Elbow? 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. Unfallchirurg. 2018 Aug;46(8):3053-3064. doi: 10.1177/0300060518771263. Click here to Login. [Selective neurotization of the median nerve in young patients with CV-CVIIcomplicated spinal cord injury]. Additionally, it restores the lateral column of the elbow, acting to tension the repaired lateral ligaments resisting varus and posterolateral rotatory instability. 4A and B). 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. Watters TS, Garrigues GE, Ring D, Ruch DS. 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. No ligament reconstruction . Therefore, the preferred surgical treatment options in the setting of terrible triad injuries include … 2020 Oct 29;9(11):3500. doi: 10.3390/jcm9113500. Romero Pérez B, Marcos García A, Medina Henríquez JA, Muratore Moreno G. Oxford University Press is a department of the University of Oxford. Hotchkiss RN. Previous studies have demonstrated elbow instability and posttraumatic arthrosis following resection of the radial head in complex elbow dislocations . Chan K, MacDermid JC, Faber KJ, King GJ, Athwal GS. Published by Elsevier Inc. All rights reserved. Shoulder Elbow. 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. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 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. | (ii) Repair of the anterior column: by suture of the anterior capsule or fixation of coronoid process. 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. We report on the diagnostic and treatment challenge of this unique case. Faculté de medecine et de pharmacie de Marrakech, University Hospital Mohammed VI, Marrakech, Morocco. 2017 Jul;120(7):595-610. doi: 10.1007/s00113-017-0373-7. The elbow was stable, and the grip strength was comparable to the contralateral side (Fig. - 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 terrible triad refers to three combined lesions: elbow dislocation, radial head and coronoid fractures [2, 3]. COVID-19 is an emerging, rapidly evolving situation. (iv) Early elbow mobilization is started to avoid the stiffness. 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/. 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”. Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. 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 ]. 1B). There was mild widening of the DRUJ with significant ulnar negative variance (Fig. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Can we treat select terrible triad injuries nonoperatively? 5 patients: dislocated for 2 to 9 months . 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 . 'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. 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. He reported immediate swelling and pain in his elbow and wrist. [Progress in treatment of terrible triad of elbow]. Cervical kyphosis: A predominant feature of patients with osteogenesis imperfecta type 5. Protection of the ligament repair is essential. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. USA.gov. Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series. Clinical assessment of the post-operative ROM (A and B). 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]. Terrible triad … Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. 2018 Jul;10(3):216-222. doi: 10.1177/1758573217713694. (iii) The stability of the elbow is assessed; if still unstable, a hinged external fixator or repair of the MCL is discussed. The authors declare there is no financial support from any organism. Early management is a favourable prognostic factor for final outcome. "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. 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 … The unhappy triad is the name of a severe injury involving three crucial parts of your knee joint. Pre-operatively on the ward • Discuss post -operative rehab ’ Correspondence address. Jupiter and Ring JBJS 2002 . 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. A sling was used for comfort for 2 weeks postoperatively with physiotherapy and ROM exercises initiated early. 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. Include: terrible ; elbow ; fracture ; clinical features be fixed in terrible refers. 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