The terrible triad of the elbow is characterized by great potential for joint instability and an unfavorable prognosis.1, 5Surgical treatment is the therapy of choice in the vast majority of cases, with the aims of restoration of the anatomy and early mobility. Maintenance of concentric reduction on a lateral fluoroscopic view indicates stability. View This Abstract Online Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? treatment of the “terrible triad of the elbow”. eCollection 2020. The terrible triad primarily occurs in adults; the flexibility of ligaments in children … Varus posteromedial rotational instability . Specifically, the question of whether to repair or replace the radial head remains controversial. Methods: Eight patients identified with “terrible triad” injury patterns, including posterior elbow dislocation, radial head fracture and coronoid fracture, were available for a minimum of 11 months follow-up. Why does radial head arthroplasty fail today? Clin Orthop Relat Res. The adjective terrible is bestowed on an elbow triad that comprises three coexisting complicated traumas; namely, radial head and ulnar coronoid process fractures and posterior dislocation of the elbow joint. <>stream Terrible Triad . 5.2 3-Dimensional reconstruction CT scan of a right elbow with a terrible triad injury, as viewed (a) laterally and (b) medially The individual components of… Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Peter Kloen, David Ring. Share. T A diagram outlines the treatment algorithm used for radial head management in the…, A photograph demonstrates the hanging arm test. CONCLUSIONS: For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to ORIF. Because case series are relatively small, it is difficult to estimate the incidence of complications. Relatively few studies have documented the outcomes of terrible triad injuries of the elbow. The terrible triad of the elbow is characterized by great potential for joint instability and an unfavorable prognosis.1, 5Surgical treatment is the therapy of choice in the vast majority of cases, with the aims of restoration of the anatomy and early mobility. As these injuries commonly occur in younger patients, longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. MCL avulsion is likely to be present in many terrible triad injuries, and there is no consensus as to the need for a medial exposure in a terrible triad injury. Olecranon Fracture-Dislocations . Evaluation included the DASH score, the Broberg-Morrey index, measurements of elbow stability and motion, and radiographic assessment for signs of arthrosis; chart review was performed for complications and reoperations. The individual components of the terrible triad can be individually classified to aid in the evaluation of this injury: Fractures of the Radial Head The radial head is an important secondary stabilizer of the elbow to valgus stress and the radiocapitellar joint … There were no differences between groups in terms of ROM or elbow scores. O'Donoghue estimated the incidence rate in the traumatic sports knee to be 25%. Legend Definition skills and equipment level. )�|�j���Ә�7��{���Gdn��{��i�U�m.��0.Wl���?d�?��!jʺ=`ï@�p��7���ۏ~R��d5��"��Q�d j Z�\Ҡ?�/j�'>7` Open reduction internal fixation. <>/Font<>/ProcSet[/PDF/Text/ImageB]/XObject<>>>/Rotate 0/TrimBox[0 0 595.27600 841.89001]>> The elbow is prone to stiffness, as such operative stabilization of complex injuries is imperative to allow for early mobilization. Main indications. The terrible triad of the elbow is defined as the combination of fractures of the radial head and ulnar coronoid process and dislocation of the elbow joint 4 (Fig. 1 and 5 Surgical treatment is the therapy of choice in the vast majority of cases, with the aims of restoration of the anatomy and early mobility. Complete followup was available on 87% (39 of 45 patients). But if … Equipment. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis?. The terrible triad of the elbow is a difficult injury with historically poor outcomes. Abstract. This objective remains a challenge for surgeons due to the complexity of the lesion.5 The weight of the hand and forearm acts as a dislocating force in this position of maximal instability. Dislocation Injuries Disruption Injuries terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation. 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 . Some of the most common injury classification systems cited in … Retrospective review identified 39 patients with terrible triad injuries and minimum 18-month complete clinical and radiographic followup (mean, 24 months; range, 18-53 months). As to terrible triad injury of elbow joint, because of the complexity of the surrounding anatomy of the elbow joint, the limited biomechanical study, the difficult treatments, and the poor prognosis, the choice of the treatment scheme is Gupta A, Barei D, Khwaja A, Beingessner D. Clin Orthop Relat Res. Clin Orthop Relat Res. CONCLUSIONS: For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to … Specifically, the question of whether to repair or replace the radial head remains controversial. NIH Fracture of the anteromedial facet of the coronoid process with injuries to the anterior and posterior bundles of the ulnar collateral ligament and to the lateral ligaments, consistent with varus posteromedial rotatory instability of the elbow (PMRI). A bump is placed under the humerus with the elbow extended and forearm supinated. A bump is placed under the…, ( A ) AP and ( B ) lateral radiographs show a 22…, NLM eCollection 2020 Dec. Kodde IF, Viveen J, The B, van Riet RP, Eygendaal D. EFORT Open Rev. 3 0 obj Background: Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical problem. Background: A systematic review of recent literature. During the study period, the radial head generally was internally fixed when there were fewer than four articular fragments; otherwise, it was replaced. 1 0 obj 肘関節Terrible Triad 損傷の治療経験－鉤状突起骨折の骨接合は必須か - 174 - 【結 果】 橈骨頭骨折は，H 分類I 型では放置・骨片切除各 1 例，II 型は全例headless screw 固定を，III 型では 骨頭置換術を施行した．鉤状突起骨折 2013 Apr;27(4):496-9. Orthopedics | Terrible triad elbow injuries, consisting of fractures of the radial head and coronoid with ulnohumeral dislocation, are challenging to treat. Terrible triad injuries account for approximately 30% of all elbow dislocations. In this review, the classification, treatment principles and prognosis for different forms eCollection 2020 Jul. [Progress in treatment of terrible triad of elbow]. Dislocation of the elbow associated with radial head and coronoid fracture, the so-called "terrible triad" of the elbow, is challenging to treat and has a history of complicated outcomes. Patients were managed with a standard algorithm consisting of (1) repair (n = 9) or replacement (n = 30) of the radial head, (2) repair of the lateral ulnar collateral ligament, and (3) repair of the coronoid fracture. The terrible triad of the elbow is characterized by great potential for joint instability and an unfavorable prognosis. The “terrible triad injury” of the elbow, as named by Hotchkiss, is the combination of an elbow dislocation, a radial head fracture and a coronoid process fracture The main objective in the management of such injuries is to restore the stabilizing bony structures of the elbow to convert a complex dislocation of the elbow joint into a simple one. Diagnosis. 2014; 472(7):2128-35 (ISSN: 1528-1132) Watters TS Abstract: Operative treatment for complex elbow injuries has evolved. were the first to introduce it to China in 2005 6. Li J, Lu D, Lin W, Li Q, Hu J, Xu D, Zhao Y, Guo W. Biomed Res Int. 5.1 (a) AP and (b) Lateral radiographs of a right elbow demonstrating the three components of the terrible triad: posterior dislocation, radial head fracture, and coronoid process fracture Fig. Methods: USA.gov. It is a complex trauma, associating … Viveen J, Kodde IF, Heijink A, Koenraadt KLM, van den Bekerom MPJ, Eygendaal D. EFORT Open Rev. The most challenging of these problems is recurrent subluxation or dislocation. Dislocation with Articular Fracture . Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). [Medline] . Questions/purposes: 1,2 The injury consists of a 336 R Seijas et al. This objective remains a challenge for surgeons due to the complexity of the lesion.5 All patients who underwent radial head arthroplasty at the index procedure had a stable elbow at final followup whereas three of nine patients who underwent ORIF were unstable (p = 0.009). Prediction and Potential Preventions for the Development of Posttraumatic Osteoarthritis after the Terrible Triad Injury: A Multicenter Risk Factors Study. J Hand Surg Am. 2014 Jul;472(7):2075-83. doi: 10.1007/s11999-014-3475-3. terrible triad of the elbow.6,7 Its prognosis remains uncertain, especially over the long term.6 The objective of the present study was to evaluate the results from surgical treatment of the terrible triad of the elbow, with at least six the Elbow dislocation associated with both radial head and coronoid fractures, termed the “terrible triad injury” (TTI) by Hotchkiss, was notoriously challenging for decades because of the difficulties inherent in treatment and the consistently poor prognosis [2-4]. 2014 Jul. 2020 Mar 19;54(Suppl 2):254-259. doi: 10.1007/s43465-020-00090-x. Clipboard, Search History, and several other advanced features are temporarily unavailable. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. The “terrible” designation of these injuries is due to the fact that the elbow has lost all ligamentous and bony stability, leading to a high rate of recurrent instability if left untreated. The terrible triad of the elbow is a severe injury that is difficult to treat and has a poor prognosis in the medium to long term. However, 11 patients who underwent arthroplasty demonstrated radiographic signs of arthrosis compared to none in the ORIF group (p = 0.04). See this image and copyright information in PMC. Open all credits. Specifically, the question of whether to repair or replace the radial head remains controversial. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach J Int Med Res . Authors of section Editors. It is considered severe by many clinicians because it is difficult to repair With the improvement of knowledge on elbow biomechanics and pathoanatomy, the current standard strategy appeared to have yielded more favorable outcomes [ 2 , 3 ]. 472 (7):2128-35. . Clin Orthop Relat Res. With the numbers available, there was no difference in reoperation rate between groups (p = 0.45). The ‘terrible triad’ of the elbow is a severe injury that is difficult to treat and has a poor prognosis in the medium-to-long term.  |  The four injuries that will be discussed include Monteggia fracture-dislocation, distal humerus fracture, terrible triad, and transolecranon fracture. Fig. "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. Please enable it to take advantage of the complete set of features! Pugh and McKee 27 reported a mean arc of flexion of between 20° and 135° and mean rotation of 135°. Although terrible triad injuries have been traditionally described as having a poor long-term prognosis, good and excellent results have been achieved with increased understanding of elbow … Select Management. [ 3 – 8 , 25 ] Pugh et al [ 3 ] repaired the MCL in 6 (17%) of 36 patients with terrible triad elbow injuries, and only in cases where the patients showed residual posterior instability after repair. �),�@�3���`�b�Є%�����P�qd�C�7. Hotchkiss introduced this concept 1996 5; Zhang et al. Looking for the second injury: the coronoid process fracture and the “terrible triad” In suspected radial head and neck injuries, make sure to examine the coronoid process, or the anterior proximal portion of the ulna. %PDF-1.6 %���� Choose treatment. Posterior . Level III, therapeutic study. A diagram outlines the treatment algorithm used for radial head management in the treatment of terrible triad injuries, along with intraoperative assessment of stability with the hanging arm test. See the Instructions for Authors for a complete description of levels of evidence. Patterns of Traumatic Elbow Instability With Fracture . Single-staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury. HHS Clin Orthop Relat Res. A study was conducted to evaluate the diagnosis and surgical treatment of the terrible triad of the elbow. Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical problem. Radial Head Fixation vs Replacement in Terrible Triad: Preliminary Results of a Prospective Cohort Study with Patient Reported Outcome. 3), and is often associated with collateral ligaments injuries. Replacement or repair of terrible triad of the elbow: A systematic review and meta-analysis. Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. Eleven patients (28%) underwent reoperation (seven arthroplasty, four ORIF) for various reasons. BACKGROUND: The terrible triad of the elbow comprises an ulnar coronoid process fracture, a radial head (RH) fracture and posterior dislocation of the elbow. Elbow dislocation associated with both radial head and coronoid fractures earned its eponym “terrible triad injury” (TTI) for decades because of the poor prognosis []. Complications of terrible triad surgical treatment include heterotopic ossification, stiffness, nerve injury, and recurrent subluxation or dislocation of the elbow. Indian J Orthop. Key words：terrible triad injury（terrible triad injury），comminuted radial head fracture（橈骨頭粉砕骨折），elbow（肘関節） Corresponding author：Masao Nishiwaki, Hand and Elbow Surgery Center, Department of Orthopaedic Surgery, Kawasaki A delay in treatment or revision surgery resulted in a 20% greater loss of … 2013. 2014 Jul;472(7):2120-7. doi: 10.1007/s11999-014-3519-8. Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical problem. Terrible Triad Injury の治療経験 - 60 - 【症 例】 症例10．38 歳，男性．転落し左肘を受傷した． X 線およびCT 上，鉤状突起骨折はRegan 分類type IIB，O’Driscoll 分類type I subtype 2，橈骨頭骨折は IV 型の粉砕 … Dr reports a "Terrible Triad Injury" which is, per the Op Note, Radial head fx, coroniodprocess avulsion fx and collateral ligament disruption. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis?. Conclusions: 2015 Nov;40(11):2297-303. doi: 10.1016/j.jhsa.2015.04.039. T 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/. 27 patients from Beijing, China, with the terrible triad of the elbow were retrospectively evaluated. Terrible triad injuries account for approximately 30% of all elbow dislocations. The mechanism of injury usually involves a fall with the arm in semiflexion, supination of the forearm and an elbow in a valgus position (1). Terrible triad. An unhappy triad injury is one of the most severe sports injuries. BACKGROUND: The terrible triad of the elbow comprises an ulnar coronoid process fracture, a radial head (RH) fracture and posterior dislocation of the elbow. 2020 Aug 1;5(7):398-407. doi: 10.1302/2058-5241.5.190055. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. The terrible triad of the elbow remains a challenging injury that consists of a dislocation of the elbow with fractures of the radial head and coronoid process of the ulna. 2014 Jul. Elbow held in 45 degree of flexion; Olecranon is prominent posteriorly He performed a radial head arthroplasty, collateral ligament repair and "fiberwire stitches were placed in a lasso technique around the coronoid avulsed fracture. 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. Anterior . National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. S��0�B��{�^����vfB�!D'���r-I�lN���^�3>xDN����rzV�C��[SUx�k��jo�)GR�-wJt��i����U�&&���a_��v��X�wT�5��X=� :�p�o:Lî�7e�#$}p�)������Jy�����8Ng�nL��mm�j41> Q�� a���XS�0�B�=���OEFgW��?h�p��Z=�4%���a��MZ��1��~�;!�}{��P,��c��F�����t`�V�gQ��~����8��rB��ڋL@@�h ��1�~�W��-U-Nhm��1�G�(ʮ��y;] �K�Wɖ? Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. Clin Orthop Relat Res . 472 (7):2128-35. Results: Dislocation + radial head fracture . Most cases require surgery and a recovery period of six to nine months. The “terrible” designation of these injuries is due to the fact that the elbow has lost all ligamentous and bony stability, leading to a high rate of recurrent instability if left untreated. Peter Trafton, Michael Baumgaertner. eCollection 2019 Dec. Medicine (Baltimore). Posterior elbow dislocation with fracture of the coronoid process and radial head fracture. This lesion recently described by Hotchkiss and al, 3 lesions: Elbow dislocation with radial head and coronoid process fracture, these injuries are not frequent even in adults [3] . Pike JM, Grewal R, Athwal GS, Faber KJ, King GJ. We compared patients with terrible triad injuries of the elbow whose radial head fracture was treated with either internal fixation and internal fixation (ORIF) or radial head arthroplasty in terms of (1) clinical outcome measures (DASH and Broberg-Morrey scores, ROM), (2) elbow stability and radiographic signs of arthrosis, and (3) complications and reoperation rates. Management of the failed radial head arthroplasty. - 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 injury of the elbow, dislocation of the ulnohumeral joint with fractures of the coronoid process and radial head, is difficult to treat and has a historically poor outcome. Epub 2015 Oct 1. Fracture dislocation of the elbow, termed terrible triad, involves three anatomic injuries: coronoid fracture, radial head fracture, and posterior elbow dislocation. Prognosis of Terrible Triad Injuries • 6. 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. The injury is characterized by elbow instability and development of arthrosis and joint stiffness. If the elbow dislocates in 30°–45° of extension, the medial collateral ligament should be repaired. Attempts should be made to to preserve the radial head, otherwise radial head arthroplasty should be performed • 7. Executive Editors. Given the poor prognosis for such injuries, they have been given the name of the "terrible triad of the elbow". Level of evidence: Head arthroplasty should be repaired Prospective Cohort study with Patient Reported Outcome specifically, B... ) for various reasons subluxation or dislocation prone to stiffness, as such Operative stabilization of injuries. 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