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 … 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. Patterns of Traumatic Elbow Instability With Fracture . eCollection 2019 Dec. Medicine (Baltimore). During the study period, the radial head generally was internally fixed when there were fewer than four articular fragments; otherwise, it was replaced. Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach J Int Med Res . 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 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. Methods: [3] Choose treatment. Open reduction and internal fixation of radial head fractures: do outcomes differ between simple and complex injuries? 2020 Jun 21;2020:6508781. doi: 10.1155/2020/6508781. 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. HHS A bump is placed under the…, ( A ) AP and ( B ) lateral radiographs show a 22…, NLM Select Management. 2013 Apr;27(4):496-9. Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). 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. Level of evidence: Equipment. 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. Radial Head Fixation vs Replacement in Terrible Triad: Preliminary Results of a Prospective Cohort Study with Patient Reported Outcome. 2020 Jan 28;4(12):659-667. doi: 10.1302/2058-5241.4.180099. Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. 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 were the first to introduce it to China in 2005 6. eCollection 2020 Dec. Kodde IF, Viveen J, The B, van Riet RP, Eygendaal D. EFORT Open Rev. Fracture dislocation of the elbow, termed terrible triad, involves three anatomic injuries: coronoid fracture, radial head fracture, and posterior elbow dislocation. With the numbers available, there was no difference in reoperation rate between groups (p = 0.45). However, 11 patients who underwent arthroplasty demonstrated radiographic signs of arthrosis compared to none in the ORIF group (p = 0.04). 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. A terrible triad injury refers to a posterior dislocation of the elbow associated with radial head and coronoid process fractures. 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? This objective remains a challenge for surgeons due to the complexity of the lesion.5 Orthopedics | Terrible triad elbow injuries, consisting of fractures of the radial head and coronoid with ulnohumeral dislocation, are challenging to treat. Pugh and McKee 27 reported a mean arc of flexion of between 20° and 135° and mean rotation of 135°. Why does radial head arthroplasty fail today? Posterior elbow dislocation with fracture of the coronoid process and radial head fracture. Terrible triad injuries account for approximately 30% of all elbow dislocations. This site needs JavaScript to work properly. Clin Orthop Relat Res. Single-staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury. T 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 . 1 0 obj 472 (7):2128-35. 3 0 obj 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]. Attempts should be made to to preserve the radial head, otherwise radial head arthroplasty should be performed • 7. Authors of section Editors. 472 (7):2128-35. . "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. Complete followup was available on 87% (39 of 45 patients). Results: <>/Font<>/ProcSet[/PDF/Text/ImageB]/XObject<>>>/Rotate 0/TrimBox[0 0 595.27600 841.89001]>> %PDF-1.6 %���� 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. 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). 2020 Aug 1;5(7):398-407. doi: 10.1302/2058-5241.5.190055. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis?. Varus posteromedial rotational instability . 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] . Please enable it to take advantage of the complete set of features! O'Donoghue estimated the incidence rate in the traumatic sports knee to be 25%. 2018 Aug;46(8):3053-3064. doi: 10.1177/0300060518771263. See this image and copyright information in PMC. Share. Dr reports a "Terrible Triad Injury" which is, per the Op Note, Radial head fx, coroniodprocess avulsion fx and collateral ligament disruption. The weight of the hand and forearm acts as a dislocating force in this position of maximal instability. 2014; 472(7):2128-35 (ISSN: 1528-1132) Watters TS The terrible triad of the elbow is characterized by great potential for joint instability and an unfavorable prognosis. 2014 Jul. The injury is characterized by elbow instability and development of arthrosis and joint stiffness. Open reduction internal fixation. In the mornings when I stretch, I do feel it stretching out, which is kind of satisfying, as the terrible triad … Hotchkiss introduced this concept 1996 5; Zhang et al. Specifically, the question of whether to repair or replace the radial head remains controversial.  |  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. Open all credits. eCollection 2020. 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. 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. CONCLUSIONS: For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to … 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. This objective remains a challenge for surgeons due to the complexity of the lesion.5 ANYWAY, my elbow is 100% healed…it hasn’t caused me any inconvenience or pain in the longest time. 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). 2014 Jul. NIH In the realm of orthopaedics, the terrible triad of the elbow is infamous, not simply because the prognosis is poor for most patients, but also, maybe to a greater extent, because the unique name of this malady attracts considerable attention and interest in both doctors and patients. endobj A photograph demonstrates the hanging arm test. Legend Definition skills and equipment level. 1,2 The injury consists of a 336 R Seijas et al. Prediction and Potential Preventions for the Development of Posttraumatic Osteoarthritis after the Terrible Triad Injury: A Multicenter Risk Factors Study. Peter Trafton, Michael Baumgaertner. 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. Dislocation Injuries Disruption Injuries Terrible triad. Executive Editors. Conclusions: See the Instructions for Authors for a complete description of levels of evidence. 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 … A bump is placed under the humerus with the elbow extended and forearm supinated.  |  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. 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. 3), and is often associated with collateral ligaments injuries. Because case series are relatively small, it is difficult to estimate the incidence of complications. Gupta A, Barei D, Khwaja A, Beingessner D. Clin Orthop Relat Res. 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. The most challenging of these problems is recurrent subluxation or dislocation. The elbow is prone to stiffness, as such operative stabilization of complex injuries is imperative to allow for early mobilization. If the elbow dislocates in 30°–45° of extension, the medial collateral ligament should be repaired. Viveen J, Kodde IF, Heijink A, Koenraadt KLM, van den Bekerom MPJ, Eygendaal D. EFORT Open Rev. Peter Kloen, David Ring. treatment of the “terrible triad of the elbow”. Elbow extension with forearm supination and added valgus stress puts most strain on the ulnohumeral joint, radial head and MCL respectively, causing a posterolateral rotational instability pattern of fracture-dislocation which includes posterior dislocation with a radial head fracture and the terrible triad injury with an added coronoid fracture. 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. Epub 2015 Oct 1. But if … 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. eCollection 2020 Jul. �),�@�3���`�b�Є%�����P�qd�C�7. Epidemiology. 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 [ 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. 2013. <>stream The four injuries that will be discussed include Monteggia fracture-dislocation, distal humerus fracture, terrible triad, and transolecranon fracture. Abstract. There were no differences between groups in terms of ROM or elbow scores. 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). Elbow held in 45 degree of flexion; Olecranon is prominent posteriorly BACKGROUND: The terrible triad of the elbow comprises an ulnar coronoid process fracture, a radial head (RH) fracture and posterior dislocation of the elbow. 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.  |  BACKGROUND: The terrible triad of the elbow comprises an ulnar coronoid process fracture, a radial head (RH) fracture and posterior dislocation of the elbow. Terrible triad injuries account for approximately 30% of all elbow dislocations. USA.gov. Some of the most common injury classification systems cited in … COVID-19 is an emerging, rapidly evolving situation. Olecranon Fracture-Dislocations . 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/. 2015 Nov;40(11):2297-303. doi: 10.1016/j.jhsa.2015.04.039. Questions/purposes: Clipboard, Search History, and several other advanced features are temporarily unavailable. In 1950, O'Donoghue described the unhappy triad as: (1) rupture of the medial collateral ligament, (2) damage to the medial meniscus and (3) rupture of the anterior cruciate ligament. Li J, Lu D, Lin W, Li Q, Hu J, Xu D, Zhao Y, Guo W. Biomed Res Int. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Clin Orthop Relat Res . Level III, therapeutic study. 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. Clin Orthop Relat Res. 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. Eleven patients (28%) underwent reoperation (seven arthroplasty, four ORIF) for various reasons. 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. Skill level. Background: Swelling may be severe; Displaced equilateral triangle of olecranon and epicondyles (undisturbed in supracondylar fracture) Posterior dislocation. doi: 10.1097/MD.0000000000013054. 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. It is considered severe by many clinicians because it is difficult to repair Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Specifically, the question of whether to repair or replace the radial head remains controversial. )�|�j���Ә�7��{���Gdn��{��i�U�m.��0.Wl���?d�?��!jʺ=`ï@�p��7���ۏ~R��d5��"��Q�d j Z�\Ҡ?�/j�'>7` terrible triad elbow injury that includes an unstable radial head fracture, a type III coronoid fracture, and an associated elbow dislocation. 2014 Jul;472(7):2120-7. doi: 10.1007/s11999-014-3519-8. A study was conducted to evaluate the diagnosis and surgical treatment of the terrible triad of the elbow. For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to ORIF. 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 He performed a radial head arthroplasty, collateral ligament repair and "fiberwire stitches were placed in a lasso technique around the coronoid avulsed fracture. Pike JM, Grewal R, Athwal GS, Faber KJ, King GJ. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Dislocation with Articular Fracture . [Medline] . Management of the failed radial head arthroplasty. Fig. Clin Orthop Relat Res. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. 2019 Feb;98(6):e13054. J Hand Surg Am. 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. Complications of terrible triad surgical treatment include heterotopic ossification, stiffness, nerve injury, and recurrent subluxation or dislocation of the elbow. With the improvement of knowledge on elbow biomechanics and pathoanatomy, the current standard strategy appeared to have yielded more favorable outcomes [ 2 , 3 ]. Given the poor prognosis for such injuries, they have been given the name of the "terrible triad of the elbow". View This Abstract Online Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Posterior . Prognosis of Terrible Triad Injuries • 6. Replacement or repair of terrible triad of the elbow: A systematic review and meta-analysis. 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 … 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). 27 patients from Beijing, China, with the terrible triad of the elbow were retrospectively evaluated. In this review, the classification, treatment principles and prognosis for different forms Elbow dislocation associated with both radial head and coronoid fractures earned its eponym “terrible triad injury” (TTI) for decades because of the poor prognosis []. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis?. Specifically, the question of whether to repair or replace the radial head remains controversial. 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 - 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 Diagnosis. A systematic review of recent literature. It is a complex trauma, associating … Maintenance of concentric reduction on a lateral fluoroscopic view indicates stability. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Stability should be evaluated intraoperatively after reconstruction. Terrible Triad . Main indications. Journal of Orthopaedic Surgery Capitellum fractures are uncommon, but their prompt diagnosis and management are crucial due to the severity of the consequent functional impairment resulting from these intra-articular elbow fractures. A delay in treatment or revision surgery resulted in a 20% greater loss of … Relatively few studies have documented the outcomes of terrible triad injuries of the elbow. An unhappy triad injury is one of the most severe sports injuries. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 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. T 2020 Mar 19;54(Suppl 2):254-259. doi: 10.1007/s43465-020-00090-x. Dislocation + radial head fracture . 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… Anterior . Abstract: Operative treatment for complex elbow injuries has evolved. The terrible triad of the elbow is a difficult injury with historically poor outcomes. Indian J Orthop. The terrible triad primarily occurs in adults; the flexibility of ligaments in children … 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. [Progress in treatment of terrible triad of elbow]. Most cases require surgery and a recovery period of six to nine months. 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 ORIF. 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