Terrible Triad of the Elbow: Functional Results of Surgical Treatment

Ikemoto, Roberto Yukio; Murachovsky, Joel; Bueno, Rogério Serpone; Nascimento, Luis Gustavo Prata; Carmargo, Adriano Bordini; Corrêa, Vitor Elias

doi:10.1590/1413-785220172506168821

Cited by 7 publications

(6 citation statements)

References 19 publications

(28 reference statements)

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“…8 From the available literature, surgical treatment for TT achieves mean post-operative ROM of 130 ± 7° flexion, 15 ± 6° extension, 66 ± 10° supination and 69 ± 11° pronation. 9–16 Sixteen of our patients treated without surgery achieved a functional ROM, adequate for their activities of daily living (ADL). Our outcomes demonstrate managing these injuries non-operatively in selective cases results not only in similar flexion–extension arcs to operative management but improved prono-supination, while additionally negating the risks of an anaesthetic and complications directly related to surgery.…”

Section: Discussionmentioning

confidence: 97%

Non-operative management of terrible triad injuries of the elbow; not so terrible?

et al. 2023

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Introduction Terrible triad injuries (TTIs) of the elbow have traditionally been reported to have poor outcomes, hence requiring surgical stabilisation. We identified and reviewed patients with TTIs treated non-operatively within our department. Methods We retrospectively reviewed patients with TTI treated non-operatively with standardised elbow-instability rehabilitation from 2010 to 2020. We used Mason and Morrey classifications for radial head and coronoid fractures, respectively. Non-operative indications included a congruent joint on CT, significant co-morbidities pre-disposing to high-risk surgery and/or patient preference. Outcomes included Oxford Elbow Score (OES), ROM and complications. Results Nineteen patients were included (mean age 49; 37% female). At an average of 6 years (range 2–11 years) post-treatment, mean OES was 46 ± 7. At last clinic review, mean 6 months (2–15), average ROM was 131 ± 11° flexion, 8 ± 10° extension, 85 ± 12° supination and 85 ± 13° pronation. One patient required arthrolysis and another had an incongruent ulnohumeral joint which developed clicking with a functional ROM. Conclusion Our report suggests non-operatively managed and appropriately rehabilitated TTI injuries can achieve good function and ROM. We recommend conservative management as a viable option in cases with joint congruency and no mechanical block in patients with significant co-morbidities or those refusing surgery but patients must be assessed on a case-by-case basis.

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Section: Discussionmentioning

confidence: 97%

Non-operative management of terrible triad injuries of the elbow; not so terrible?

et al. 2023

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“…Така назва була обумовлена негативними результатами лікування, які супроводжувались нестабільністю (вивихами), контрактурами, розвитком посттравматичного артрозу та больовим синдромом [1,2]. Лікування травм ліктьового суглобу, що попозначають як «нещаслива тріада», викликає багато питань стосовно діагностики та хірургічної тактики, що відповідно негативно відбивається і на результатах лікування таких пацієнтів [3,4,5].…”

Section: вступunclassified

“…Тому, відносно способів хірургічного відновлення вінцевого відростку точаться дискусії, які в основному стосуються показань до відновлення переломів вінцевого відростку 1 та 2 ступеня. Так [Ikemoto RY et al, 2017; Kim BS et al, 2020] вважають, що переломи вінцевого відростку 1 та 2 ступеня синтезувати непотрібно [3,23], але у переважній більшості публікацій автори пропонують фіксувати переломи 2 та 3 ступеню [14,16,19,4], є також прибічники фіксації перед ньої капсули ліктьового суглоба при переломах вінцевого відростку 1 ступеню [10,24]. При переломах вінцевого відростку 1 ступеня (за Regan) невеликий фрагмент вінцевого відростку можна вилучити, але розглядається також доцільність відновлення передньої капсули ліктьового суглоба шляхом накладання черезкісткового шва [19].…”

Section: обговоренняunclassified

“…В такий ситуації буде актуальним бічний доступ (медіальний або латеральний) [25,4,19]. Ряд авторів вважають, що ушкодження переднього вінцево-плечового комплексу при переломах вінцевого відростку 1 ступеня доцільно лікувати консервативно [3,6], натомість є публікації, де підкреслюється необхідність відновлення та стабілізації вінцево-плечового комплексу навіть і при переломах вінцевого відростку 1 ступеню [26]. Ми притримуємось тактики черезкісткового зшивання переднього вінцевоплечового комплексу при переломах вінцевого відростку 1 ступеня у пацієнтів з «нещасливою тріадою», і виходимо з тих міркувань, що повноцінна стабілізація ліктьового суглобу після таких ушкоджень, є запорукою ранньої реабілітації і відповідно важливою передумовою у досягненні позитивних результатів.…”

Section: обговоренняunclassified

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Surgical Treatment of the Terrible Triad of the Elbow

Kurinnyi,

Strafun

2023

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Summary. The so called “terrible triad” injury of the elbow, which includes a combination of posterolateral dislocation of the forearm with fractures of the radial head and coronoid process, accounts for 10%-11% of all elbow fractures in adults. This type of elbow injury remains difficult to treat and is often accompanied by a high level of complications: instability, contractures, deformable arthrosis, and pain syndrome. Objective: to assess the effectiveness of surgical treatment of patients with the terrible triad of the elbow, depending on the duration of the injury and the features of osteosynthesis of the coronoid process using certain approaches. Material and Methods. The surgical treatment of 87 patients with the terrible triad of the elbow was analyzed. The age of the patients was 40.9±2.6 years. The average term of admission to treatment was 5.5±4.1 months after the injury. 59 patients were admitted in less than 30 days and 28 patients were admitted after 30 days. The preoperative examination included X-ray and CT; sonographic and EMG studies were performed if necessary. Surgical treatment consisted of repositioning and osteosynthesis of the coronoid process, osteosynthesis or prosthetics of the radial head, and restoration of the damaged lateral ligaments of the elbow joint. In cases of consequences of injury, in addition, mobilization of the elbow joint was performed, osteosynthesis was supplemented with bone autograft, and damaged ligaments were restored plastically. After the surgery, the elbow joint was immobilized in the extension position of 30-20 degrees. Postoperative rehabilitation begins on the first day after surgery and involves one cycle of flexion and extension during the day from the extension position of 20-30° to flexion position of 100-120°. Immobilization in the extension position of 20-30° is basic and is used in the evening and at night. Results. The results were evaluated according to the MEPS system in 56±6.2 months. In the group of patients who underwent surgery within 30 days, the MEPS function index was 90.3±2.1 points; when surgery was performed more than 30 days after the injury, statistically worse results were achieved (83.5±2.9 points). We also compared the outcomes of treatment depending on the access to osteosynthesis of the coronoid process. When performing an anterior approach to the coronoid process, the MEPS index was 90.1±3.2 points, which was better than in case of other approaches. Conclusions. Thus, it has been proven that better results in the surgical treatment of the terrible triad are obtained in the group of patients who underwent surgery up to 30 days after the injury compared to later admission to treatment. The advantages of the anterior approach for grade 2-3 coronoid process fractures have been proven. Our proposed early dosed rehabilitation plays an important role in the treatment of such patients.

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“…These complex elbow fracture dislocations can result from both high-or low-energy mechanisms and often involve a fall on an outstretched hand [1]. These injuries have historically resulted in poor functional outcomes and high rates of surgical complications, often due to recurrent instability and elbow stiffness [1][2][3]. More recent standardized surgical protocols focusing on early operative intervention, stable osseous fixation, and ligament repair have resulted in improved outcomes and decreases in complication rates [4][5][6].…”

Section: Introductionmentioning

confidence: 99%

Learning Curve Associated With Operative Treatment of Terrible Triad Elbow Fracture Dislocations

Ozdag¹,

Luciani²,

Delma³

et al. 2022

Cureus

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Purpose: To assess the outcomes of operatively treated terrible triad (TT) elbow injuries for a single surgeon at the start of clinical practice. We aimed to define postoperative patient reported outcome measures (PROMs), range of motion (ROM), and complications during the period immediately following fellowship training, in order to describe the learning process for surgical treatment of TT.Methods: All operatively treated TTs from 2017 to 2020 were included. All cases were performed by a single, fellowship-trained upper-extremity surgeon and represented a consecutive series at the start of clinical practice. Baseline demographics, injury characteristics, and surgical details were recorded for each case. PROMs [QuickDisability of arm, shoulder, and hand (DASH) and (visual analog scale) pain scale], ROM, and complications were recorded at the time of final follow-up. A perioperative glucocorticoid protocol was used in all cases without diabetes.Results: There was a total of 21 included TT cases with a mean follow-up of 20 months. The operative time averaged 89 min for the first 10 cases and 83 min for the subsequent 11 cases. The mean QuickDASH and VAS pain score at final follow-up were 19 and 2.3, respectively. The mean flexion-extension arc was 122° and two cases (9%) had < 100° arc of motion. The mean pronation-supination arc was 145°. Three cases (14%) had a postoperative complication, all of which underwent reoperation. Of the 21 included cases, these reoperations represented cases #1, #14, and #17 respectively. Conclusions: Upper-extremity surgeons at the start of clinical practice may be able to achieve outcomes similar to more experienced surgeons for operatively treated TT elbow fracture dislocations. There does not appear to be a substantial "learning curve" after fellowship training with respect to PROMs, complication rates, or operative time associated with surgical treatment of TT elbow injuries.

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Terrible Triad of the Elbow: Functional Results of Surgical Treatment

Cited by 7 publications

References 19 publications

Non-operative management of terrible triad injuries of the elbow; not so terrible?

Non-operative management of terrible triad injuries of the elbow; not so terrible?

Surgical Treatment of the Terrible Triad of the Elbow

Learning Curve Associated With Operative Treatment of Terrible Triad Elbow Fracture Dislocations

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