Terrible Triad Injuries of the Elbow: Does the Coronoid Always Need to Be Fixed?

Abstract

Background The ''terrible triad'' of the elbow is a complex injury that can lead to pain, stiffness, and posttraumatic arthritis if not appropriately treated. The primary goal of surgery for these injuries is to restore stability of the joint sufficient to permit early motion. Although most reports recommend repair and/or replacement of all coronoid and radial head fractures when possible, a recent cadaveric study demonstrated that type II coronoid fractures are stable unless the radial head is removed and not replaced. Questions/purposes The purposes of this study were to determine the (1) range of motion; (2) clinical scores using the Disabilities of the Arm, Shoulder and Hand (DASH) and the Broberg-Morrey questionnaires; and (3) rate of arthritic changes, heterotopic ossification (HO), or elbow instability postoperatively in patients whose terrible triad injuries of the elbow included Reagan-Morrey type I or II coronoid fractures that were treated without fixation. Methods Between April 2008 and December 2010, 14 consecutive patients were treated for acute terrible triad injuries that included two Regan-Morrey type I and 12 Regan-Morrey type II coronoid fractures. Based on the senior author's (DGS) clinical experience that coronoid fractures classified as such do not require fixation to restore intraoperative stability to the posterolaterally dislocated elbow, all injuries were treated by the senior author with a surgical protocol that included radial head repair or prosthetic replacement and repair of the lateral ulnar collateral ligament (LUCL) followed by intraoperative fluoroscopic examination through a range of 20°to 130°of elbow flexion to confirm concentric reduction of the ulnohumeral joint. Using this protocol, intraoperative stability was confirmed in all cases without any attempt at coronoid or anterior capsular repair. Repair of the medial collateral ligament or application of external fixation was not performed in any case. All patients were available for followup at a minimum of 24 months (mean, 41 months; range, 24-56 months). The mean patient age was 52 years (range, 32-58 years). At the followup all patients were evaluated clinically and radiographically by the senior author. Outcome measures included elbow range of motion, forearm rotation, elbow stability, and radiographic evidence of HO or arthritic changes using the Broberg and Morrey scale. Elbow instability was defined as clinical or radiographic evidence of recurrent ulnohumeral dislocation or subluxation at final followup. Clinical outcomes were assessed with the patient-reported DASH questionnaire and the physician-administered Broberg-Morrey elbow rating system. Results The mean arc of ulnohumeral motion at final followup was 123°(range, 75°-140°) and mean forearm Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connectio...

Rehabilitation protocol after radial head arthroplasty – a single centre experience and narrative review of the literature

“…Type i fractures account for about 82% of injuries and are treated conservatively. The indications for surgical treatment are fractures of ii-iV type with the displacement of fragments, limitation of mobility, and elbow instability [1,12,17,18]. Factors that influence the decision to implant a radial head prosthesis include a large number of fractured fragments (more than 3 fragments), the risk of osteonecrosis after osteosynthesis, fracture of the head associated with dislocation within the radial-ulnar joint, and the patient's age (in younger patients, osteosynthesis of the broken head is preferred) [1,8,12,14].…”

Treatment of complex elbow fracture-dislocations

“…None of the patients received fixation of the coronoid fracture, required MCL repair, or had an external fixator applied for residual stability. At an average follow-up of 41 months, Papatheodorou et al [22] reported good outcomes with no cases of late instability.…”

“…In contrast, type 3 coronoid fractures were unstable, even with intact collateral ligaments and radial head [21]. Papatheodorou et al [22] evaluated the clinical outcomes in patients with terrible triad injuries and Regan-Morrey types 1 and 2 coronoid fractures. In their series, all patients underwent either radial head fixation or arthroplasty and a LCL repair.…”

Operative Therapie der Terrible-Triad-Verletzung des Ellenbogens

“…Einigkeit besteht über die Rekonstruktions-/Ersatznotwendigkeit des Radiuskopfs und die Naht des LCL [10]. Inwieweit die Koronoidspitze und damit die vordere Gelenkkapsel readaptiert werden soll [11], ob das MCL bei persistierender Instabilität direkt vernäht oder ob eine Sicherung der Gelenkführung durch einen Bewegungsfixateur genügt, um den medialen Eingriff zu ersparen, wird basierend auf retrospektiven Studien und biomechanischen Arbeiten unterschiedlich postuliert [12][13][14]. Abb.…”