Single-staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury

Influence of Coronoid fixation on the functional outcome and rate of complications in surgically treated acute complex elbow instability

INTRODUCTION

Fractures of the coronoid commonly present in elbow fracture-dislocations. Despite the evidence that the coronoid plays an important role in elbow stability, there is still controversy on which fractures should be surgically fixed. The aim of this study is to compare the clinical outcomes and rate of complications of patients with elbow fracture-dislocations in which the coronoid was fixed or left untreated.

MATERIALS AND METHODS

Thirty-nine patients with an elbow fracture-dislocation involving a coronoid fracture were prospectively followed for an average of 90 months (range 24-190). According to Morrey´s classification there were 22 type II and 8 type III. Nine patients had an anteromedial fracture of the coronoid. In 24 patients the coronoid was repaired (suture fixation in 9, screws fixation in 10 and plate fixation in 5) and in 15 patients the coronoid was not fixed. In 18 patients the radial head was replaced and in 8 patients it was fixed. All patients underwent repair of the lateral ligament complex. Clinical evaluation was performed with the MEPS. Radiographically, the rate of coronoid nonunion was specifically analyzed. Postoperative neurological complications were recorded.

RESULTS

At the most recent follow up, the average arc of flexion-extension was 120° (range 70°-140°) with a mean MEPS of 90 (range 25-100). No statistically significant differences were found in the MEPS and flexion-extension arc between the patients in whom synthesis was performed (117° ROM, and 89 MEPS) and those in whom it was not (122° ROM, 94 MEPS) (p = 0.42; p = 0.34). Coronoid fracture healing could be assessed in 36 patients: in 19 patients the coronoid was radiographically healed, and in 17 a nonunion was present, with no difference in the final clinical outcome between both groups. Nine patients, 6 of whom had undergone coronoid fixation, had a neurological complication related to the ulnar nerve.

CONCLUSIONS

Coronoid fractures affecting around 50% of its height can be treated without internal fixation as long as the rest of the osteo-ligamentous structures are adequately repaired. Osteosynthesis of the coronoid through a medial approach may carry a non-negligible risk of associated neurological injury.

Terrible triad injury of the elbow: a historical perspective

PURPOSE

The aims of this study are to summarize (1) the history of terrible triad injury (TTi) treatment and (2) the clinical and biomechanical data that engendered its evolution.

METHODS

A literature search was performed using five electronic databases. Results were discussed as a chronologic review of the relevant literature between 1920 and 2022.

RESULTS

In 1962, Osborne was the first to describe a link between elbow dislocation, radial head fracture, and lateral collateral ligament complex injury via a novel mechanism: posterolateral rotatory instability (PLRI). Given that untreated elbow instability leads to post-traumatic osteoarthritis (PTOA), there has been increasing interest in elbow biomechanics since the 1980s. Data from studies in that period revolutionized the approach to elbow instability. The authors demonstrated that TTi could occur via a PLRI mechanism with a disruption of the lateral collateral ulnar ligament and a functionally competent anterior medial collateral ligament (aMCL). Since the 1990s, due to the difficulty in identifying its pathoanatomic features, some began to speculate about a sequence of injuries and mechanisms leading to TTi. However, the clinical literature has largely been unable to reproduce in vitro findings describing the pathomechanics of TTi. Some aspects of treatment remain controversial including systematic coronoid and aMCL repair.

CONCLUSION

Despite a growing body of biomechanics data, there is no widely accepted surgical protocol for the treatment of TTi. Functional outcomes among patients have greatly improved. Better diagnosis and treatment of infra-clinical instability after a TTi may be an important stepping stone to prevent the onset of moderate/severe PTOA.

Pullout Strength of All-Suture and Metallic Anchors in Repair of Lateral Collateral Ligament Injuries of the Elbow

PURPOSE

To compare the biomechanical properties of metallic anchor (MA) and all-suture anchor (ASA) constructs in the anatomic reattachment of the lateral ulnar collateral ligament complex to its humeral insertion.

METHODS

Twenty paired male human cadaveric elbows with a mean age of 46.3 years (range: 33-58 years) were used in this study. Each pair was randomly allocated across 2 groups of either MA or ASA. A single 3.5-mm MA or 2.6-mm ASA was then inserted flush into the lateral epicondyle. A dynamic tensile testing machine was used to perform cyclic loading followed by a load to failure test. During the cyclic loading phase, the anchors were sinusoidally tensioned from 10 N to 100 N for 1,000 cycles at a frequency of 0.5 Hz. In the load to failure test, the anchors were pulled at a rate of 3 mm/s. Load at 1-mm and 2-mm displacement, as well as load to ultimate failure were assessed. Clinical failure was defined as displacement of more than 2 mm. Normality of data was assessed with the Shapiro-Wilk test. Continuous data are presented as medians and compared with the Mann-Whitney U test and categorical data was compared with the χ² test or Fisher exact test.

RESULTS

Displacement was significantly greater for the ASA group during cyclic loading starting from the tenth cycle (P < .05). Displacement of more than 5 mm within the first 100 cycles was observed in 2 anchors in the ASA group. No difference was observed in loads required to displace 1 mm (MA: 146 N [6-169] vs ASA: 144 N [2-153]; P = .53) and 2 mm (MA: 171 N [13-202] vs ASA: 161 N [9-191]; P = .97), but there was a statistically significant difference between ultimate loads in favor of ASA in the load to failure test (MA: 297 N [84-343] vs 463 N [176-620]; P < .01).

CONCLUSIONS

In the cyclic test, no difference in clinical failure defined as pull-out of more than 2 mm was observed between 3.5 mm MAs and 2.6 mm ASAs. In the ultimate load to failure analysis, no difference was observed between groups in force causing 1 and 2 mm of displacement, but there was a significant difference in favor of ASA in the pull to ultimate failure test.

CLINICAL RELEVANCE

Potential benefits of all-suture anchors include preservation of bone stock, reduced radiographic artifacts, and easier revisions. Although their use has been investigated thoroughly in the shoulder, there remains a paucity of literature regarding displacement and pull-out strength in the elbow.

Treatment of elbow instability: state of the art

The elbow is a congruent joint with a high degree of inherent stability, provided by osseous and soft-tissue constraints; however, when substantial lesions of these stabilising structures happen, instability of the elbow occurs. Significant improvements in surgical elbow instability diagnosis and treatment have been recently introduced both for acute and chronic cases. Specific stress tests, recently introduced in the clinical practice, and different imaging techniques, both static and dynamic, allow assessment of the elbow stabilisers and detection of the instability direction and mechanism even in subtle forms. Many surgical techniques have been standardised and surgical instruments and devices, specifically dedicated to elbow instability treatment, have been developed. Specific rehabilitation protocols have been designed to protect the healing of the elbow stabilisers while minimising elbow stiffness. However, despite the progress, surgical treatments can be challenging even for expert surgeons and the rate of persistent instability, post-traumatic arthritis, stiffness and pain can be still high especially in most demanding cases. The biology of the soft-tissue healing remains one of the most important aspects for future investigation. If future research will help to understand, correct or modulate the biological response of soft-tissue healing, our confidence in elbow instability management and the reproducibility of our treatment will tremendously improve. In this paper, the state of the art of the current knowledge of elbow instability is presented, specifically focusing on modern surgical techniques used to solve instability, with repair or reconstruction of the damaged elbow stabilisers.

Surgical treatment of the radial head is crucial for the outcome in terrible triad injuries of the elbow

AIMS

To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes.

METHODS

Follow-up assessment of 88 patients with TTI (48 women, 40 men; mean age 57 years (18 to 82)) was performed after a mean of 4.5 years (2.0 to 9.4). The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score were evaluated. Radiographs of all patients were analyzed. Fracture types included 13 Mason type I, 16 type II, and 59 type III. Surgical treatment consisted of open reduction and internal fixation (ORIF) in all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) was performed if reconstruction was not possible.

RESULTS

At follow-up the mean MEPS was 87.1 (20 to 100); mean OES, 36.9 (6 to 48); and mean DASH score, 18.6 (0 to 90). Mean movement was 118° (30° to 150°) for extension to flexion and 162° (90° to 180°) for pronation to supination. The overall reoperation rate was 24%, with nine ORIF, ten RHA, and two patients without treatment to the radial head needing surgical revision. When treated with RHA, Mason type III fractures exhibited significantly inferior outcomes. Suboptimal results were also identified in patients with degenerative or heterotopic changes on their latest radiograph. In contrast, more favourable outcomes were detected in patients with successful radial head reconstruction after Mason type III fractures.

CONCLUSION

Using a standardized protocol, sufficient elbow stability and good outcomes can be achieved in most TTIs. Although some bias in treatment allocation, with more severe injuries assigned to RHA, cannot be completely omitted, treatment of radial head fractures may have an independent effect on outcome, as patients subjected to RHA showed significantly inferior results compared to those subjected to reconstruction, in terms of elbow function, incidence of arthrosis, and postoperative complications. As RHA showed no apparent advantage in Mason type III injuries between the two treatment groups, we recommend reconstruction, providing stable fixation can be achieved. Cite this article: Bone Joint J 2020;102-B(12):1620-1628.

Analysis of twenty-five cases of terrible triad injury of the elbow surgically treated with a single lateral approach

BACKGROUND

The objective was to analyze the long-term clinical outcome of terrible triad injury of the elbow following surgical intervention with a single lateral approach.

METHOD

We treated twenty-five patients with terrible triad injury of the elbow from July 1, 2017, to June 30, 2020, and performed post hoc analysis. All patients underwent standardized surgery which entailed: plate fixation for the ulnar coronoid process, fixation or replacement of the radial head, and repair of the lateral ligament but not the medial collateral ligament.

RESULTS

We followed up each patient for an average of 22.9 months (range, 12 to 36 months) after surgery. Patients had an average angle scope of elbow flexion and extension that ranged from 8° to 120°. Average pronation of the elbow was 75° (range, 10°-85°), and average supination was 72° (range, 25°-80°). Patient-reported outcome measures were excellent: the DASH and Mayo elbow performance score (MEPS) were 96%. We were unable to follow-up one patient (4%). Among the remaining 24 patients, one patient (4%) presented with heterotopic ossification and stiffness following arthrolysis in the elbow one year after the initial surgery. We did not observe any joint dislocation, subluxation, or joint instability in the elbow after surgery.

DISCUSSION

The single lateral approach, a sequential surgery for terrible triad injury of the elbow, can improve initial stability of the elbow. Patients are able to perform rehabilitative exercises sooner in their recovery, which helps to reduce stiffness. Heterotopic ossification is also reduced.

Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? Mid-Term Postoperative Outcomes Following a Standardized Protocol

The purpose of this study was to investigate mid-term outcomes and complications after operative treatment according to a standardized protocol for terrible triad injuries. Twenty-four patients that were treated by a single surgeon with a standardized surgical protocol were retrospectively reviewed. After the complete reconstruction of radial head and/or lateral collateral ligament (LCL) complex through a lateral approach, coronoid process, and/or medial collateral ligament (MCL) complex through a medial approach were fixed if the elbow is unstable. For coronoid fractures, only type III were fixed in four cases (16.7%). Twenty-two LCL (91.7%) and five MCL (20.8%) complexes were repaired. At the final follow-up, the mean MEPS and Quick-DASH score were 91.5 and 17.3, respectively. There was no recurrent instability after operation in all cases. This study revealed that operative treatment that was based on our standardized protocol for terrible triad injuries yielded satisfactory mid-term clinical and radiographic outcomes without any recurrent instability. These results suggest that Type I and II coronoid fractures in terrible triad injuries do not need to be fixed if the radial head and ligamentous complex are completely reconstructed.

Prolonged dislocation and delay to surgery are associated with higher rates of heterotopic ossification in operatively treated terrible triad injuries

Background

Heterotopic ossification (HO) formation after complex elbow injuries can significantly impact function. Prior studies have reported a 3%-45% incidence of HO following elbow trauma in a heterogeneous cohort of fracture patterns. The purpose of our study was to evaluate the prevalence of and identify risk factors for HO specifically in patients with terrible triad injuries.

Methods

A total of 61 patients (64 elbows) underwent operative treatment for terrible triad injuries with an average follow-up period of 19.8 months (range, 3-138 months). The medical records were reviewed for demographic data, duration of dislocation, number of reduction attempts, time to surgery, presence of radiographic HO, elbow motion at final follow-up, functional limitations, and need for secondary procedures.

Results

Radiographic HO developed in 77% of patients, and 63% had some level of functional restriction. Thirteen patients (26%) underwent a secondary procedure for HO excision. Patients with HO had a longer time to surgery (4.9 days vs. 2.8 days, P = .02), longer duration of dislocation (21 hours vs. 6 hours, P = .04), and reduced flexion-extension (94° vs. 112°, P = .04) and pronation-supination (109° vs. 163°, P = .002) arcs of motion compared with patients without HO. HO was also more likely to develop in patients who required closed reduction than in those with spontaneous reduction prior to presentation.

Conclusion

The prevalence of radiographic and clinically relevant HO after terrible triad injuries was higher than previously reported. Persistent dislocation necessitating a closed reduction, a longer duration of dislocation, and a delay to surgery were associated with the development of HO. Providers should consider earlier surgical stabilization or urgent referral to a specialist for patients with unstable injuries.

Lateral Approach Versus Combined Lateral and Anteromedial Approach for Surgical Treatment of Terrible Triad of Elbow: A Meta-Analysis

Objective

To find out which surgical approach, optimize the functional outcomes and reduce the risk of complications in terrible triad of elbow".

Methods

Medline, EMBASE, Cochrane Library, and Google Scholar were searched to identify relevant studies, which were included if they were retrospective or prospective in design, involved participants who had terrible triad of elbow (TTIE) that compared lateral approach (LA) with combined lateral and anteromedial approach (CML), and were published in English. Outcomes of interest were functional outcomes, complications, and operative time.

Results

Four studies, involving 470 patients were included in the systematic review. Mean follow up after surgery was typically 24 to 30 months. We found significant more range of motion (ROM) of elbow in CML as compared to LA group (MD: -14.21, 95% CI: -21.13 to-7.29, p<0.00001). There was significant more forearm rotation in CML as compared to LA group (MD: -18.88, 95% CI: -32.35 to -5.40, p<0.00001). Mayo elbow performance score (MEPS) was significantly more in CML (MD: -3.31, 95% CI: -7.23 to 0.62, p=0.00001). Blood loss, operative time, VAS and complications were more in CML group; however, the difference was not significant. The heterogeneity of the study and synthesizing retrospective data were the primary limitations.

Conclusion

Our analysis demonstrated that combined lateral and medial approach had significantly more elbow ROM and forearm rotation. The combined approach also had significantly more MEPS. However, using combined approach significantly increased the operative time.

Surgical revision of radial head fractures: a multicenter retrospective analysis of 466 cases

BACKGROUND

Radial head fractures lead to persisting disability in a considerable number of cases. This study aimed to investigate their most common revision causes and procedures.

METHODS

This multicenter retrospective study reviewed the cases of 466 adult patients who had undergone surgical revision after operative or nonoperative treatment of a radial head fracture. The initial diagnosis was a Mason type I fracture in 13.0%, Mason type II fracture in 14.6%, Mason type III fracture in 22.8%, Mason type IV fracture in 20.9%, terrible-triad injury in 12.8%, Monteggia-like lesion in 13.1%, and Essex-Lopresti lesion in 2.0%. Initial treatment was nonoperative in 30.2%, open reduction and internal fixation (ORIF) in 44.9%, radial head arthroplasty in 16.6%, radial head resection in 3.7%, sole treatment of concomitant injuries in 2.6%, and fragment excision in 2.0%. Up to 3 revision causes and procedures were recorded per case.

RESULTS

The most common complications were stiffness (67.4%), instability (36.5%), painful osteoarthritis (29.2%), ORIF related (14.8%), nonunion or necrosis (9.2%), radial head arthroplasty related (7.5%), ulnar neuropathy (6.0%), and infection (2.6%). Revision procedures frequently included arthrolysis (42.1%), arthroplasty (24.9%), implant removal (23.6%), ligament repair or reconstruction (23.0%), débridement (14.2%), repeated ORIF (8.2%), and/or radial head resection (7.7%). Mason type I or II fractures were primarily revised because of stiffness and painful osteoarthritis. Complications after Mason type III fractures were predominantly ORIF related. Fracture-dislocations showed a wide range of complications, with instability and stiffness comprising the most common causes of revision.

CONCLUSIONS

The complications of radial head fractures are characteristic to their classification. Knowledge of these findings might guide surgeons in treating these injuries and may help counsel patients accordingly.

Temporary Bridge Plate Stabilization of Unstable Elbow Fractures and Dislocations

Unstable fracture-dislocations of the elbow, and in particular the "terrible triad" injury consisting of an elbow dislocation with a fracture of the radial head and coronoid, are complex injuries that can be plagued and complicated by persistent instability. Acute and chronic instability is a difficult problem and is best managed early by avoidance and restoration of stability. A number of treatment options have been proposed to manage acute postfixation instability of the elbow joint. Traditional stabilization options include immobilization with splinting or casting, cross-articular pinning, and external fixation (hinged or static), followed by early physical therapy. However, each of these approaches can still yield persistent elbow instability. We are proposing a new technique of acute but temporary bridge plate stabilization of the elbow joint to protect the concentrically reduced elbow joint following repair of all injured structures to restore stability followed by staged removal and the delayed initiation of therapy.

Plate fixation through an anterior approach for coronoid process fractures: A retrospective case series and a literature review

Coronoid process fractures of the ulna are difficult to treat, and are associated with stiffness, recurrent instability, and pain. Hence, treatment of coronoid process fractures are challenging for surgeons. The purpose of this study was to report the clinical outcomes of an anterior surgical approach associated with plate fixation for Regan and Morrey type II or type III fractures of the coronoid process.We evaluated 16 consecutive patients who underwent surgical treatment for fracture of the coronoid process of the ulna from March 2012 to July 2016. Ten patients had a type II fracture, and 6 patients had a type III fracture. All patients underwent surgical treatment for coronoid process fracture through an anterior approach. While preserving the neurovascular structure, all fractures were treated with buttress plate fixation, maintaining the gap between brachial artery and median nerve. Each patient was treated with concentric reduction of both the ulnotrochlear and the radiocapitellar articulations, without any evidence of elbow instability, except 1 case, who showed some medial instability.At the final follow-up, solid osseous union was confirmed for all coronoid fractures. The average time to radiologic union was 16.3 weeks. The mean flexion-extension arc was 124.25 ± 12.12 degree, with a mean flexion contracture of 8.25 ± 4.36 degree, and further flexion of 132.5 ± 9.31 degree. The mean forearm rotation arc was 167.81 ± 10.49 degree. Fifteen patients achieved a functional arc of motion. The mean Mayo elbow performance score was 92.1 points, with 12 excellent cases and 4 good cases.Coronoid process fractures of the ulna can be treated successfully with plate fixation through an anterior surgical approach, which allows for accurate reduction and rigid internal fixation and early functional exercise, resulting in a reasonable outcome.

Surgical treatment for terrible triad injury of the elbow with anteromedial coronoid fracture through a combined surgical approach

Objective

To report the results of the surgical treatment of terrible triad injury with anteromedial coronoid fracture through a combined surgical approach.

Methods

This retrospective study evaluated data from patients who underwent surgery to repair terrible triad injuries and anteromedial coronoid fractures. Surgical treatment involved radial head repair or replacement, medial and lateral collateral ligament repair, and coronoid fracture fixation through combined approaches. Evaluations were performed using the Mayo Elbow Performance Score (MEPS) and anteroposterior and lateral radiographs of the elbow.

Results

Twenty-two patients (15 males, seven females; mean ± SD age, 47.5 ± 11.4 years) were enrolled in this study. Fracture union and concentric reduction of both the ulnotrochlear and radiocapitellar articulations were achieved in all patients. The mean ± SD follow-up was 31.6 ± 11.9 months. The mean ± SD arc of flexion–extension was 110.3° ± 26.3° and arc of forearm rotation was 139.5° ± 17.1°. The mean ± SD MEPS was 88.1 ± 12.2 points, with results classified as excellent in eight elbows, good in ten, and fair in four. Six patients had radiographic signs of post-traumatic arthritis. Three patients required secondary surgeries.

Conclusion

Combined surgical approaches can be considered for the treatment of terrible triad injuries in association with anteromedial coronoid fractures.

Perioperative Glucocorticoid Administration Improves Elbow Motion in Terrible Triad Injuries

PURPOSE

Among patients who undergo surgical treatment of terrible triad elbow injuries (TTEI), we hypothesized that those who received perioperative glucocorticoid (GC) therapy would have improved postoperative pain and range of motion (ROM) and a similar complication rate compared with patients who did not receive GC therapy.

METHODS

We retrospectively identified 26 patients who underwent surgical treatment of TTEI from 2009 to 2015. Thirteen patients received a single intraoperative dose of 10 mg intravenous dexamethasone followed with a 6-day oral methylprednisolone taper course (GC group), and 13 did not (control group). After surgery, patients were placed in an orthosis at 90° flexion with the forearm in pronation for 2 weeks, after which ROM was initiated. Patients were seen in clinic at 2, 6, 12, and 24 weeks after surgery, at which time numeric pain scale scores and ROM data were collected and any complications were noted.

RESULTS

Compared with the control group, the GC group had a greater flexion-extension arc of motion at 24 weeks (132.5° vs 105.5°); significant differences were not found at earlier time points. Supination measurements were significantly greater for the GC group at every time point with a difference at final follow-up of 23.2° (61.0° vs. 84.2°). There were 5 complications in the control group (35.8%), 3 of which required additional surgery, and 3 complications in the GC group (23.1%), 1 of which required another surgery. No postoperative infections were found in either group.

CONCLUSIONS

Perioperative glucocorticoid administration is associated with improved ROM after surgical treatment of TTEI. Flexion-extension, pronosupination arc of motion, and overall supination were significantly improved. Postoperative pain scores and complication rates were similar between GC and control groups.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Risk of Subluxation or Dislocation After Operative Treatment of Terrible Triad Injuries

OBJECTIVE

The management of terrible triad injuries has evolved over the last 2 decades to include routine radial head fixation or replacement, reattachment of the lateral collateral ligament, with or without coronoid fixation. Our objective was to determine the likelihood of and factors associated with subluxation or dislocation after operative treatment of terrible triad injuries among a large group of surgeons using current techniques.

DESIGN

Retrospective cohort study.

SETTING

Two level I trauma centers.

PATIENTS/PARTICIPANTS

A total of 107 patients with operatively treated terrible triad injuries from January 2000 to June 2015.

INTERVENTION

Review of patient- and surgery-related factors during the first postoperative month.

MAIN OUTCOME MEASUREMENT

Radiographic subluxation of the ulnohumeral joint.

RESULTS

One hundred of the 107 patients (93%) treated with open fixation of terrible triad injuries had no radiographic subluxation or redislocation. Two patients (2%) had slight transient radiographic subluxation ("drop sign") that corrected with active exercises within weeks of surgery. Five patients (5%) had persistent radiographic subluxation, 3 treated with a second surgery (3%). When treated within 2 weeks of injury, recurrent subluxation or dislocation after operative fixation of terrible triad injuries was rare (1%), provided that the radial head was replaced and the lateral collateral ligament reattached.

CONCLUSIONS

Radiographic subluxation is very uncommon with current operative management of terrible triad injuries of the elbow within 2 weeks. Patients treated more than 2 weeks after injury might benefit from ancillary fixation to limit subluxation (ie, cross pinning, external fixation, or internal joint stabilizer).

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparative Analysis of Surgical Options for Medial Collateral Ligament Repair in Terrible Triad Injury of the Elbow

The aim of our study is to evaluate the clinical and radiologic outcomes in patients with terrible triad injury, who underwent surgical treatment with or without the medial collateral ligament (MCL) repair. Fourteen patients who underwent surgery with a minimum of 12-month follow-up (mean, 17 months) were reviewed. Based on the systematic treatment protocol, radial head fracture, lateral collateral ligament, and coracoid fracture were treated. Subsequently, torn MCL was repaired in 7 patients, whereas in the remaining 7 patients, the MCL was not treated. Range of motion, elbow function, and radiographs regarding the arthrosis and heterotopic ossification were assessed. At final follow-up, no significant differences were found in elbow motion or function between the groups with and without MCL repair; except the pronation and supination which had superior range in repair group. In contrast, radiologic findings such as the arthrosis were seen more frequently in patients without MCL repair than those with repair. Our results indicate the effect of MCL repair on elbow motion and function might be small, whereas osteoarthritic changes occurred more frequently in elbows without MCL repair.

Radial nerve palsy after the use of an adjuvant hinged external fixator in a complex fracture-dislocation of the elbow: a case report and review of the literature

Background

The combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture is known as “terrible triad” injury of the elbow. This injury is one of the most challenging injuries of the musculoskeletal system and almost always causes instability of the elbow. The use of an adjuvant hinged external fixator in such injuries is still debated.

Case presentation

In this case report we present a case of radial nerve palsy after setting up an adjuvant hinged external fixator in a complex fracture–dislocation of the elbow. The patient was a 39-year-old white man. A revision of his radial nerve was undertaken at 7 weeks. A radial nerve injury at two levels facing the humeral apex pins was found intraoperatively; the pins were carefully removed and partial nerve grafts done. The functional outcome at 18 months was excellent.

Conclusion

This case report highlights that the use of an adjuvant hinged external fixator in complex fracture –dislocation of the elbow is technically demanding and not without risk.

Terrible triad of the elbow: is it still a troublesome injury?

BACKGROUND

Terrible triad injury (TTI), one of the main patterns of complex elbow instability, is difficult to treat and yields conflicting surgical results. We analyzed prospectively a series of patient affected by TTI and treated according to the current diagnostic and surgical protocols to investigate whether their application allow to obtain more predictable outcomes.

MATERIAL AND METHODS

We analyzed 26 patients with a mean age of 52 years. Preoperative X-rays and CT were performed; all patients were operated by the same elbow surgeon and underwent the same surgical and rehabilitation treatment. Final functional outcome was assessed by the Mayo Elbow Performance Score (MEPS), Quick-Disability of the Arm Shoulder and Hand-score (Q-DASH) and the modified-American Shoulder and Elbow Surgeons score (m-Ases). A radiographic evaluation was also performed.

RESULTS

Mean follow-up was 31 months. At final evaluation, mean flexion, extension, supination and pronation were 137°, 10°, 77° and 79°, respectively; mean MEPS, m-ASES and Q-DASH scores were respectively 96, 91 and 8 points. Complications observed after first surgery were: elbow stiffness in 5 cases, mild posterolateral instability in 3 cases, chronic subluxation in 1 case. Radiographic evaluation showed secondary arthritis in 9 cases, symptomatic HO in 3 cases and late hardware displacement in 2 cases. Six out of 26 patient underwent reoperation with final satisfactory results.

CONCLUSION

The current diagnostic and therapeutic protocols allow obtaining satisfactory clinical outcomes in majority of cases but a high number of major and minor unpredictable complications persist yet. In this series, low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery. On the other hand, the strict application of current algorithms by an expert elbow surgeon appears to improve clinical results by reducing the influence of other avoidable negative prognostic factors well known in current literature, such as the incomplete recognition of injuries, delayed treatment, inadequate treatment of bony and ligamentous injuries, prolonged immobilization and, last but not least, the surgeon's inexperience.

LEVEL OF EVIDENCE

Level IV, Case series, Treatment study.

Terrible Triad Injuries of the Elbow

The treatment of terrible triad injuries of the elbow continues to evolve. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. 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. 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.

Complex Elbow Instability: Radial Head and Coronoid

A standardized and systematic approach for the management of an acute complex elbow dislocation involving the radial head and coronoid will maximize clinical outcomes. The cornerstones of surgical management include primary restoration of the ulnohumeral joint by reduction of the intact joint or coronoid fracture fixation, followed by radial head fixation or replacement. The lateral ulnar collateral ligament complex is then repaired before assessing elbow stability within a functional sagittal arc of motion.

Treatment of the coronoid process fractures with anteromedial approach: a case report

This study aimed to explore the clinical effect of the coronoid process fractures with anteromedial approach. 18 cases of coronoid process fractures treated with the anteromedial approach were enrolled. Causes of injury included traffic injuries in 3 cases and fall on the ground in 15 cases. There were 6 cases of type I, 10 cases of type II, and 2 cases of type III according to the O'Driscoll classification. The time from injury to operation was 2-10 days (mean, 3.9 days). Fractures were fixed by using mini-plate or screws. All cases were followed-up for 12-24 months (average 14.9 months). The bony union time was 8-14 weeks with an average of 10.6 weeks. The mean flexion at last follow-up was 122° (range, 90°-140°), the mean extension loss was 20° (range, 0°-50°), and the mean pronation was 67° (range, 22°-90°), while the mean supination was 61° (range, 30°-88°). Elbows were stable in the flexion-extension and varus-valgus in all cases. According to the MEPS elbow performance score, results were excellent in 14 cases, good in 3 cases and fair in 1 case. According to the Broberg and Morrey elbow performance score, results were excellent in 9 cases, good in 4 cases, and fair in 1 case. In conclusion, the anteromedial approach facilitates the reduction and fixation of the coronoid process fractures and has advantages of clear exposure, convenient placement of internal fixation, small invasion and good clinical results.