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

Management of Elbow Terrible Triad Injuries: A Comprehensive Review and Update

The "terrible triad" of the elbow, encompassing elbow dislocation, radial head fracture, and coronoid process fracture, remains a formidable challenge in orthopaedic practice. Typically, stabilizing structures in the elbow fail from lateral to medial through a posterolateral rotatory force after a fall onto an outstretched upper extremity. Surgery is often needed to repair the lateral ligamentous complex, replace or fix the radial head, possibly repair the anterior capsule or fix the coronoid, and consider medial repair or application of an internal versus external fixator. However, in some challenging cases persistent instability, complications, and loss of function may occur. Rehabilitation focuses on achieving early range of motion to prevent stiffness which can be common after these injuries. By integrating emerging approaches with established practices, this article aims to guide orthopaedic surgeons toward a fundamental understanding of terrible triad injuries and assist with informed management principles of these complex injuries.

The anconeus-triceps lateral flap approach in terrible triad of the elbow: good outcome in a series of ten cases

Introduction

Standard surgical management for the terrible triad of the elbow (TTE) has been established since 2004, yet postoperative complications are common and consensus on optimal management is absent. Different surgical algorithms for treating TTE and their efficacy have been reported worldwide, yet evidence from Vietnam remains limited.

Methods

Ten cases diagnosed with TTE admitted to the Hospital of Traumatology and Orthopedics, a tertiary orthopedic center in Ho Chi Minh City, were presented to demonstrate the effectiveness and rate of postoperative complications following our stepwise surgical procedures using the anconeus-triceps lateral flap approach. The intraoperative "drop sign", quantitative assessment of pain and level of upper arm disability (via VAS and QuickDASH score) was mentioned to assess the algorithm's benefit. All patients' information was retrieved from medical records from August 2022 to January 2024.

Results

All 10 cases required repair of the lateral ligament complex and underwent surgery within 2 days of hospitalization. Immediate postoperative imaging revealed no drop sign, and none of the patients experienced elbow dislocation nor the need for repeated surgery, and a full range of elbow motion was demonstrated at 3-6 months follow-up.

Conclusion

TTE is a challenging injury that almost always obligates surgical correction. The anconeus-triceps lateral flap approach, with its advantages of better visualization and preservation of certain essential stabilizing muscles of the elbow, was demonstrated to yield a high success rate and low postoperative complication rate.

Reported outcome measures in complex fracture elbow dislocations: a systematic review

BACKGROUND

Complex elbow fracture dislocations, dislocation with fracture of one or several surrounding bony stabilizers, are difficult to manage and associated with poor outcomes. While many studies have explored treatment strategies but a lack of standardization of patient-reported outcome measures (PROMs) makes cross-study comparison difficult. In this systematic review, we aim to describe what injury patterns, measured outcomes, and associated complications are reported in the complex elbow fracture dislocation literature to provide outcome reporting recommendations that will facilitate improved future cross-study comparison.

METHODS

A systematic review was performed per Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles published between 2010 and 2022 reporting on adult patients who had a complex elbow fracture dislocation. Pathologic fractures were excluded. A bias assessment using the methodological index for nonrandomized studies criteria was conducted. For each article, patient demographics, injury pattern, outcome measures, and complications were recorded.

RESULTS

Ninety-one studies reporting on 3664 elbows (3654 patients) with an elbow fracture and dislocation (weighted mean age 44 years, follow-up of 30 months, 41% female) were evaluated. Of these, the injury pattern was described in 3378 elbows and included 2951 (87%) terrible triad injuries and 72 (2%) transolecranon fracture-dislocations. The three most commonly reported classification systems were: Mason classification for radial head fractures, Regan and Morrey coronoid classification for coronoid fractures, and O'Driscoll classification for coronoid fractures. Range of motion was reported in 87 (96%) studies with most reporting flexion (n = 70), extension (n = 62), pronation (n = 68), or supination (n = 67). Strength was reported in 11 (12%) studies. PROMs were reported in 83 (91%) studies with an average of 2.6 outcomes per study. There were 14 outcome scores including the Mayo Elbow Performance Score (n = 69 [83%]), the Disabilities of Arm, Shoulder and Hand (DASH) score (n = 28 [34%]), the visual analog scale for pain (n = 27 [33%]), QuickDASH score (n = 13 [15.7%]), and Oxford Elbow score (n = 5 [6.0%]). No significance was found between the number of PROMs used per article and the year of publication (P = .313), study type (P = .689), complex fracture pattern (P = .211), or number of elbows included (P = .152).

CONCLUSION

There is great heterogeneity in reported PROMs in the complex elbow fracture dislocation literature. Although there is no gold standard PROM for assessing complex elbow fracture dislocations, we recommend the use of at least the Mayo Elbow Performance Score and DASH outcomes measures as well as visual analog scale pain rating scale in future studies to facilitate cross-study comparisons.

Ulnohumeral Cross-Pinning in the Management of Traumatic Elbow Instability

PURPOSE

Traumatic elbow instability (subluxation and dislocation) represents a challenging clinical entity that can be complicated by persistent intraoperative instability after attempted stabilization or recurrent postoperative instability. Both static and dynamic supplemental stabilization procedures have been described for cases where fracture fixation and ligament repair fail to restore stability. There is a paucity of prior studies involving ulnohumeral cross-pinning (UCP), which is a type of static supplemental stabilization. Our purpose was to assess complications and outcomes after UCP.

METHODS

We reviewed all surgical cases involving primary and revision UCP for traumatic elbow instability at a single center from 2017-2023. Baseline demographics were recorded. Outcomes including radiographs, range of motion, patient-reported outcome measures, and surgical complications were analyzed.

RESULTS

Fourteen patients undergoing UCP were included with a mean follow-up of 27 months. Five cross-pinnings (36%) were performed during revision procedures. Mean visual analog scale (VAS) pain, Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and the Single Assessment Numeric Evaluation (SANE) scores were 2.4, 34, and 69, respectively. The mean flexion-extension and pronation-supination arcs were 114° and 140°, with 85% achieving at least a 100° arc for flexion and forearm rotation. Five patients (36%) had complications, all of which required reoperation. Two complications involved postoperative instability: one radial head subluxation and one radial head dislocation. Both occurred in revision UCP cases indicated for recurrent postoperative instability.

CONCLUSIONS

Ulnohumeral cross-pinning for persistent and recurrent elbow instability results in maintained ulnohumeral joint alignment, functional arcs of elbow range of motion, and acceptable patient-reported outcome measures, particularly in the setting of a primary procedure indicated for persistent intraoperative instability. Ulnohumeral cross-pinning is a reasonable supplemental stabilization procedure for complex elbow instability.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Revision of Failed Radial Head Arthroplasty

BACKGROUND

Revision of radial head arthroplasty (RHA) may be indicated in cases of prosthesis loosening and malposition. Inherent difficulties in revision surgery include poor bone stock and disrupted soft tissue envelope. Although cases of RHA used for revision of failed RHA are rare, there is reasonable expectation for increasing frequency of these cases due to the increasing incidence of primary RHA. Furthermore, there is an increasing demand for postoperative recovery of function; thus, surgeons may consider revising a failed RHA to a new RHA. We report on series of failed RHA which were revised to a new radial head prosthesis.

METHODS

A retrospective review was performed at multiple institutions for a single radial head prosthesis used for revision of a failed radial head prosthesis. Clinical and radiographic outcomes were collected with a minimum of 1 year of follow-up.

RESULTS

Across 11 patients at a mean follow-up of 45.1 months, the mean Mayo Elbow Performance Score was 81.7; mean Disabilities of the Arm, Shoulder, and Hand scores were 24.4; and mean Visual Analog Scale for pain was 0.6. Radiographic analysis yielded no evidence of capitellar wear or stem loosening.

CONCLUSION

A radial head prosthesis can produce satisfactory results when used for revision of a failed prosthesis. Inherent difficulties in revision surgery include the potential for reduced bone stock and a disrupted soft tissue envelope. Elements of prosthesis design which may contribute to effectively managing revision surgery include a long stem with in-growth surface and prosthetic head alignment to the axis of forearm rotation.

Postoperative mobilization after terrible triad injury: systematic review and single-arm meta-analysis

BACKGROUND

Terrible triad injury is a complex injury of the elbow, involving elbow dislocation with associated fracture of the radial head, avulsion or tear of the lateral ulnar collateral ligament, and fracture of the coronoid. These injuries are commonly managed surgically with fixation or replacement of the radial head and repair of the collateral ligaments with or without fixation of the coronoid. Postoperative mobilization is a significant factor that may affect patient outcomes; however, the optimal postoperative mobilization protocol is unclear. This study aimed to systematically review the available literature regarding postoperative rehabilitation of terrible triad injuries to aid clinical decision making.

METHODS

We systematically reviewed the PubMed, Embase, Cochrane, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The inclusion criteria were studies with populations aged ≥16 years with terrible triad injury in which operative treatment was performed, a clear postoperative mobilization protocol was defined, and the Mayo Elbow Performance Score (MEPS) was reported. Secondary outcomes were pain, instability, and range of motion (ROM). Postoperative mobilization was classified as either "early," defined as active ROM commencement before or up to 14 days, or "late," defined as active ROM commencement after 14 days.

RESULTS

A total of 119 articles were identified from the initial search, of which 11 (301 patients) were included in the final review. The most common protocols (6 studies) favored early mobilization, whereas 5 studies undertook late mobilization. Meta-regression analysis including mobilization as a covariate showed an estimated mean difference in the pooled mean MEPS between early and late mobilization of 6.1 (95% confidence interval, 0.2-12) with a higher pooled mean MEPS for early mobilization (MEPS, 91.2) than for late mobilization (MEPS, 85; P = .041). Rates of instability reported ranged from 4.5% to 19% (8%-11.5% for early mobilization and 4.5%-19% for late mobilization).

CONCLUSION

Our findings suggest that early postoperative mobilization may confer a benefit in terms of functional outcomes following surgical management of terrible triad injuries without appearing to confer an increased instability risk. Further research in the form of randomized controlled trials between early and late mobilization is advised to provide a higher level of evidence.

Suture Button Repair for Lateral Ulnar Collateral Ligament in Terrible Triad Injuries: Surgical Technique

Terrible triad injuries are typically treated surgically to restore elbow stability, as the radial head acts as a secondary stabilizer to valgus stress, while the coronoid provides stability against posterior elbow dislocations. The lateral ulnar collateral ligament (LUCL) is also commonly injured in terrible triad of the elbow injuries, and if not repaired, leads to posterolateral rotatory instability. Depending on the fracture pattern and size, the radial head fracture may be treated with open reduction internal fixation (ORIF), arthroplasty, or excision, whereas the coronoid fracture is most commonly treated with ORIF. If treated, these injuries are managed prior to LUCL fixation to avoid stressing the LUCL repair. We describe a technique for treatment of a LUCL injury with a suture button. When repairing the LUCL, a Kocher approach is used to visualize the LUCL footprint, which is then reattached to the insertion point on the lateral epicondyle using a suture button. The purpose of this study was to provide a step-by-step approach to using this surgical technique and an associated postoperative protocol.

Mid-term outcome following radial head arthroplasty in acute trauma: risk factors for poor outcome

BACKGROUND

The aims of this study were to evaluate the outcomes of a single type of radial head implant in a large cohort of patients at mid-term follow-up and to determine the associated risk factors for inferior functional outcomes.

METHODS

We performed a retrospective follow-up assessment of 65 patients (33 women and 32 men; mean age, 53.3 years [range, 22-81 years]) who underwent radial head arthroplasty (RHA) for acute trauma between 2012 and 2018, after a minimum follow-up period of 3 years. The Mayo Elbow Performance Score, Oxford Elbow Score, Disabilities of the Arm, Shoulder and Hand score, and Mayo Modified Wrist Score were evaluated, and all available radiographs were analyzed. All complications and revision procedures were assessed. Bivariate and multivariate regression analyses were performed to identify potential risk factors for a poor outcome following RHA.

RESULTS

After an average follow-up period of 4.1 years (range, 3-9.4 years), the mean Mayo Elbow Performance Score was 77.2 (standard deviation [SD], 18.9); mean Oxford Elbow Score, 32.0 (SD, 10.6); mean Mayo Modified Wrist Score, 74.6 (SD, 13.7); and mean Disabilities of the Arm, Shoulder and Hand score, 29.0 (SD, 21.2). Average range of motion measured 10° (SD, 15°) in extension, 125° (SD, 14°) in flexion, 81° (SD, 14°) in pronation, and 63° (SD, 24°) in supination. The overall complication and reoperation rates were 38.5% and 30.8%, respectively, with severe elbow stiffness being the most common reason for revision. Patient age >50 years, the use of an external fixator, the presence of accompanying medial collateral ligament injuries, and the development of higher-grade osteoarthritis were associated with a poor outcome.

CONCLUSION

Satisfactory medium-term outcomes can be achieved using a monopolar, long-stemmed RHA in patients with acute trauma. However, complication and revision rates are high, frequently leading to inferior outcome scores. Additionally, a higher patient age, the use of an external fixator, the presence of accompanying medial collateral ligament injuries, and the occurrence of higher-grade osteoarthritis were associated with a poor outcome; these factors should raise awareness by the treating trauma surgeon.

Radial neck osteolysis after radial head replacement: Functional impact and risk factors

INTRODUCTION

Onset of radial neck osteolysis (RNO) has been reported after radial head replacement (RHR), but data are sparse regarding impact and risk factors. We therefore conducted a retrospective study, 1) to quantify RNO after RHR, 2) to assess clinical and radiological impact, and 3) to identify risk factors.

HYPOTHESIS

RNO prevalence is high, but functional impact is limited.

MATERIAL AND METHOD

A single-center retrospective study included all patients undergoing RHR for acute radial head fracture between 2008 and 2017: 53 patients, with a mean age of 53.8±15.7 years [range, 21-85 years]. At a minimum 2 years' follow-up, patients were assessed clinically on joint range of motion and Mayo Elbow Performance Score (MEPS) and radiologically on standard radiographs. Associations between RNO and various parameters were assessed.

RESULTS

At a mean 46.7±19.8 months' follow-up [range, 24-84 months], RNO was found in 54.7% of cases (29/53), with mean 4.0 ±2.8mm distal extension [range, 1.2-13.4mm], corresponding to 13.4±7.3% of stem height [range, 2.7-27.7%]. RNO at last follow-up was not significantly associated with reduced flexion-extension (121.9° versus 114.0°; p=0.11), pronation-supination (152.6° versus 138.3°; p=0.25) or MEPS (84.7 versus 84.8; p=0.97), or with higher rates of postoperative complications (11/29 (37.9%) versus 7/24 (29.2%); p=0.782) or surgical revision (11/29 (37.9%) versus 10/24 (41.7%); p=0.503). RNO was significantly associated with cementless fixation (19/29 (65.5%) versus 7/24 (29.2%); p=0.01), unipolar prosthesis (21/29 (72.4%) versus 7/24 (29.2%); p=0.002), high filling-ratio, whether proximal (88% versus 77%; p=0.002), middle (84% versus 75%; p=0.007) or distal (69% versus 59%; p=0.032), and shorter radial stem (33.2mm versus 46.3mm; p=0.011). No demographic parameters showed significant association with RNO at last follow-up.

CONCLUSION

RNO was frequent after RHR, but without clinical or radiological impact in the present series. The risk factors identified here argue for involvement of stress shielding.

LEVEL OF EVIDENCE

IV, cohort study.

A novel and superior Lasso-plate technique in treatment for coronoid process fracture in the terrible triad of elbow

The treatment of ulna coronal process fractures in the terrible triad of elbow, especially type I and II Regan-Morrey coronoid fractures, still have been controversial. The purpose of this retrospective study was to evaluate the novel Lasso-plate technique to have a more reliable fixation and a well clinical outcomes for type I and II Regan-Morrey coronoid fractures in a terrible triad of the elbow (TTE). Patients with simple TTE, closed fracture, aged > 18 years, duration of injury < 2 weeks, type I and II Regan-Morrey coronoid process fracture fixed by the Lasso-plate technique or ORIF were enrolled in the study. Total 144 patients with type I and II Regan-Morrey coronoid fracture in TTE were included in the Lasso-plate group or ORIF (open reduction and internal fixation) group in the Xi'an Honghui Hospital from January 2017 to December 2020. Eighty-six patients in Lasso-plate group underwent surgery using a novel Lasso-plate technique. And other 58 patients in ORIF group underwent surgery using ORIF. The data of two groups, including the X-ray films, Computed tomography (CT), the range of elbow motion, Mayo Elbow Performance Score (MEPS) and the surgical complications, were extracted from the hospital's patient records. All patients in both groups were followed up at least 12 months. The mean operation time (88.2 ± 12.3 min) in Lasso-plate group is shorter than that of ORIF group (109.1 ± 13.0 min). There was one patient with injury of deep branch of radial nerve and one patient with superficial surgical incision infection in Lasso-plate group. There were two patients with surgical incision infection in ORIF group. There were three heterotopic ossifications in Lasso-plate group and eight heterotopic ossifications in ORIF group. There were 5 elbow joints stiffness in Lasso-plate group and 12 in ORIF group. At 12 months follow up, the mean range of flexion-extension motion in Lasso-plate group was 122.9° ± 13.4° versus 113.2° ± 18.1° in ORIF group (p < 0.01), the mean 89.7 ± 5.6 MEPS in Lasso-plate group versus mean 83.7 ± 6.1 MEPSin ORIF group. The fixation of coronoid process fracture in TTE by the Lasso-plate technique, especially type I and II Regan-Morrey coronoid fracture, could be easier to master and operate, could provide the sufficient stability of elbow joint to enable early functional exercise, along with a better clinical outcome, a lower surgical complication. For the treatment of TTE, we recommend the fixation of type I and II Regan-Morrey coronoid fracture with the Lasso-plate technique, which would result in a better clinical outcome.

Coronoid tip fractures in terrible triad injuries can be safely treated without fixation

INTRODUCTION

The optimal treatment of terrible triad injuries of the elbow (TTI) remains topic of ongoing discussion. The aim of this study was to determine whether different treatment strategies for coronoid tip fractures in terrible triad injuries influences the clinical and radiological results in a mid-term follow-up.

METHODS

A total of 62 patients with surgical treatment of a TTI including a coronoid tip fracture (37 women, 25 men; mean age, 51 years) were available for follow-up assessment after an average of 4.2 years (range 24-110 months). Thirteen patients had O'Driscoll 1.1 and 49 O'Driscoll 1.2 coronoid fractures, of which 26 were treated with and 36 without fixation. Range of motion, the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder and Hand (DASH) score as well as grip strength were evaluated. Radiographs were analyzed for all participants.

RESULTS

No significant benefit in outcome variables could be detected between patients, whose coronoid had been fixed, compared to patients without fixation of the coronoid. In the coronoid fixation group, patients had mean outcome scores of 81.5 ± SD 19.1 (range 35-100) for MEPS, 31.0 ± SD 12.5 (range 11-48) for OES and 27.7 ± SD 23 (range 0-61) for DASH score, while in the no-fixation group, mean MEPS was 90.8 ± SD 16.5 (range 40-100), mean OES was 39.0 ± SD 10.4 (range 16-48) and mean DASH score was 14.5 ± SD 19.9 (range 0-48). Mean range of motion was 116° ± SD 21° (range 85-140°) versus 124° ± SD 24° (range 80-150°) in extension-flexion and 158° ± SD 23° (range 70-180°) versus 165° ± SD 12° (range 85-180°) in pronation-supination. Overall complication rate was 43.5% and revision rate was 24.2%, with no significant differences between both groups. Suboptimal results were more frequently seen in patients who had degenerative or heterotopic changes on their latest radiograph.

CONCLUSIONS

Sufficient elbow stability and good outcomes can be achieved in most patients with TTI and coronoid tip fractures. Although some bias in treatment allocation and group heterogeneity cannot be completely omitted, our analysis detected no significant benefit in outcome when the coronoid tip fracture has been fixed compared to patients with non-fixed coronoid tip. Therefore, we would suggest a no-fixation approach for coronoid tip fractures as primary treatment in TTI of the elbow.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Lateral Ulnar Collateral Ligament Repair With Suture-Tape Augmentation for Traumatic Elbow Instability

PURPOSE

Ligament repair with suture-tape augmentation has been used in the operative treatment of joint instability and may have advantages with respect to early motion and stability. The purpose of this investigation was to describe the clinical results of traumatic elbow instability treated with lateral ulnar collateral ligament repair with suture-tape augmentation.

METHODS

All cases of acute and chronic elbow instability treated surgically between 2018 and 2020 were included if they underwent ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament as part of the procedure. Cases with <6 months of follow-up were excluded. A manual chart review was performed to record patient demographics as well as injury and surgery characteristics. Radiographic outcomes, range of motion, and patient-reported outcome measures, including the visual analog pain scale and Disabilities of the Arm, Shoulder, and Hand, were recorded. Range of motion measurements were recorded at the end of the clinical follow-up, as were surgical complications.

RESULTS

Eighteen cases were included with a mean follow-up of 20 months. Five (28%) cases involved a high-energy mechanism, and 11 (62%) cases involved terrible triad fracture dislocations. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire and visual analog pain scale scores were 17 and 2, respectively. The mean flexion-extension arc was 124°, and 2 (11%) cases had <100° flexion-extension arc. There were 2 (11%) postoperative complications, and both cases had postoperative instability requiring reoperation. We observed no cases of capitellar erosion from the suture-tape material.

CONCLUSIONS

For complex elbow instability, ligament repair with suture-tape augmentation of the lateral ulnar collateral ligament results in acceptable functional outcomes and a reoperation rate comparable with other joint stabilization procedures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The comparative performance of radial head prostheses in patients younger than and older than 50 years: a systematic review

Background

Patient age may play a role in the surgeon's decision between radial head arthroplasty (RHA) and open reduction internal fixation in radial head fracture treatment. Though large sample reports have detailed outcomes of radial head replacement for a mean age younger than 50 years, the age ranges are widely distributed. Patient outcomes are not uniform across a broad age distribution. Therefore, treatment decisions should be evaluated within the confines of a narrower age bracket. An understanding of clinical outcomes for radial head replacement in younger adults will provide value for guiding treatment decisions. We performed a systematic review comparing the clinical outcomes for radial head replacement in patients younger and older than 50 years of age. Further analysis compared outcomes between RHA performed as a primary procedure and as a secondary procedure in patients younger and older than 50 years of age.

Methods

PubMed was queried for articles which delineated individual patient data for age, surgical treatment, and appropriate outcome metrics. Articles were grouped based on patient age of under 50 and over 50 years and within those age groups, based on the arthroplasty being performed as a primary or as a secondary procedure.

Results

There were no significant differences between the under 50 and the over 50 groups for Mayo Elbow Performance Score (P = .79) and for implant revision/removal (P = .32). In the under 50 group, RHA done as a primary procedure had significantly higher (P = .001) mean Mayo Elbow Performance Score than RHA done as a secondary procedure. In the over 50 group, relative risk was 2.39 (95% confidence interval, 2.12-2.69) for implant revision/removal (P = .11) when comparing primary and secondary procedures.

Discussion

At a mean follow-up of 48 months, RHA in patients under the age of 50 years had satisfactory outcomes which were comparable to outcomes in patients over the age of 50 years. Across both age groups, arthroplasty performed as a primary procedure demonstrated superior outcomes compared to arthroplasty performed as a secondary procedure. Our findings provide guidance to surgeons who face a multifaceted decision when encountering younger adult patients with radial head fracture patterns that may not be amenable to fixation. Awareness of the age-specific performance of radial head implants is an important component of the decision for surgical treatment.

Single Modified Posterior Approach through the Space of the Proximal Radioulnar Joint for Terrible Triad Injury: A Comparative Study

Objective

In order to reduce surgical scars and the risk of neurovascular injury for the treatment of terrible triad injuries of the elbow (TTI), minimally invasive and better therapeutic effect approaches are being explored to replace the conventional combined lateral and medial approach (CLMA). This study was performed to compare the clinical effect and security of the modified posterior approach (MPA) through the space of the proximal radioulnar joint vs the CLMA for treatment of TTI.

Methods

This study retrospectively analyzed 76 patients treated for TTI from January 2009 to December 2020 (MPA: n = 44; CLMA: n = 32). Treatment involved plate and screw fixation or Steinmann pin fixation for the radial head and ulnar coronoid process fractures. Surgeons only sutured the lateral ligament because the medial collateral ligament was usually integrated in the TTI. The continuous variables were compared by the independent Student t‐test and the categorical variables by the χ²‐test or Fisher's exact test.

Results

Both groups of patients attained a satisfactory MEPS after the operation. The MEPS (MPA: 96.82 ± 6.04 vs CLMA: 96.56 ± 5.51) was not significantly different between the two groups (p > 0.05). However, the MPA resulted in better elbow flexion and extension (MPA: 123.98 ± 10.09 vs CLMA: 117.66 ± 8.29), better forearm rotation function (MPA: 173.41 ± 6.81 vs CLMA: 120.00 ± 12.18), and less intraoperative hemoglobin (MPA: 9.34 ± 5.64 vs CLMA: 16.5 ± 8.75) and red cell volume loss (MPA: 3.09 ± 2.20 vs CLMA: 6.70 ± 2.97) (All p < 0.05). Although the CLMA had a shorter surgery time (MPA: 171.73 ± 80.68 vs CLMA: 130.16 ± 71.50) (p < 0.05), it had a higher risk of neurologic damage (MPA: 0 vs CLMA: 4) (p < 0.05). Four patients developed forearm or hand numbness after the CLMA, but no patients developed numbness after the MPA. All 76 patients were followed up for 15 months postoperatively.

Conclusion

The MPA through the space of the proximal radioulnar joint has more prominent advantages than the CLMA for TTI, including single scar, clear exposure, good fixation, lower risk of neurovascular injury, and better elbow joint motion. It is a safe and effective surgical approach that is worthy of clinical promotion.

Radial head arthroplasty vs. open reduction and internal fixation for the treatment of terrible triad injury of the elbow: A systematic review and meta‑analysis update

Terrible triad injury of the elbow (TTIE) is a severe high-energy injury to the elbow, mainly including elbow dislocation, coronoid fracture and radial head fracture. It is difficult to maintain the stability of the elbow joint using traditional conservative treatment, and there is a high risk of redislocation and various complications. Therefore, surgical treatment is currently advocated, mainly for repairing damaged ligaments and reconstructing bony structures, but there is still controversy about the treatment plan for the radial head. The current meta-analysis was conducted to compare the differences in efficacy of radial head arthroplasty (RHA) and open reduction internal fixation (ORIF) in the treatment of TTIE. Published literature related to the treatment (either ORIF or RHA) of TTIE was searched for in Embase, PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ProQuest Dissertations and Theses, Cochrane Library and Chinese Biomedical Literature Database. According to the search strategy, a total of 1,928 related publications were retrieved. The patient must have been diagnosed with TTIE and required surgery on the radial head. The interventions were RHA and ORIF. Non-case-control studies, case reports, review articles, letters, duplicate reports and literature without sufficient relevant data were excluded. The quality of the literature was evaluated according to the Cochrane systematic review methodology and the Jadad scale. After data extraction, meta-analysis was performed using ReviewManager 5.4 software (Cochrane). A total of 15 studies involving 455 patients (189 who underwent RHA and 266 who underwent ORIF) were included. Range of motion (ROM) of the forearm (pronation-supination arc) after surgery in the RHA group [95% CI (0.28, 9.59); P=0.04] was found to be significantly superior to the ORIF group, with a lower incidence of complications [95% CI (0.22, 0.84); P=0.01]. However, there was no statistically significant difference for the Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand Score nor for ROM of the elbow (flexion-extension arc). Overall, compared with the ORIF group, the RHA group had better forearm rotational ROM and fewer complications after surgery. Therefore, RHA was found to be superior to ORIF in the treatment of TTIE.

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

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. 

Does an Internal Joint Stabilizer and Standardized Protocol Prevent Recurrent Instability in Complex Persistent Elbow Instability?

BACKGROUND

The treatment of complex persistent elbow instability after trauma is challenging. Previous studies on treatments have reported varied surgical techniques, which makes it difficult to establish a therapeutic algorithm. Furthermore, the surgical procedures may not sufficiently restore elbow stability, even with an additional device, and a noted high rate of arthritis progression.While a recently developed internal joint stabilizer effectively treats elbow instability, its clinical application for complex persistent elbow instability is limited and the standardized protocol is not well described. Additionally, we want to know whether the arthritis progression will cause a negative impact on the functional outcomes of complex persistent elbow instability.

QUESTIONS/PURPOSES

(1) Does treatment of complex persistent elbow instability with a hinged internal joint stabilizer and a standardized protocol prevent recurrent instability and other complications? (2) What are the pre- to postoperative improvements in pain, disability, elbow performance, and ROM? (3) Is the development of post-traumatic arthritis associated with worse pain, disability, elbow performance, and ROM?

METHODS

Between September 2014 and October 2019, we treated 22 patients for persistent dislocation or subluxation after initial treatment of traumatic elbow fracture-dislocations. Of those, we considered patients who were at least 20 years of age, with an interval of 6 weeks or more between the injury (initial treatment) and the index reconstructive procedure, which had been performed at our institute, as potentially eligible. During that time, we used an internal joint stabilizer with a standardized protocol for posttraumatic complex persistent elbow instability. We performed total elbow replacements in patients older than 50 years who had advanced elbow arthritis. Based on that, 82% (18 of 22) of patients were eligible; 14% (3 of 22) were excluded because total elbow replacements was undertaken, and another 5% (1 of 22) were lost before the minimum study follow-up of 1 year (median 24 months [range 12 to 63]), leaving 64% (14 of 22) for analysis in this retrospective study. We treated 14 patients (14 elbows) with posttraumatic complex persistent elbow instability with an internal joint stabilizer and a standardized protocol that comprised debridement arthroplasty with ulnar neurolysis, restoration of bony and ligamentous (reattachment) structures, application of an internal joint stabilizer, and early rehabilitation. There were eight men and six women in this study, with a median (range) age of 44 years (21 to 68). The initial elbow fracture-dislocation injury pattern was a terrible triad injury in seven patients, a posterolateral rotatory injury in four patients, and a posterior Monteggia fracture in three patients. Preoperative and follow-up radiographs were reviewed for evidence of recurrent instability and arthritis. Complications such as wound infection, seroma, neurovascular injury, and hardware complications were ascertained through chart review. Preoperative and postoperative VAS score for pain, DASH, and Mayo Elbow Performance Scores (MEPS) were collected and compared. Furthermore, extension-flexion and supination-pronation arcs were collected by chart review. We divided the patients into two groups according to whether or not they developed posttraumatic arthritis. We then presented the differences between pain, disability, elbow performance, and ROM. The hinged internal joint stabilizer was removed using another open procedure under general anesthesia 6 to 8 weeks after surgery.

RESULTS

There were no recurrent instability during and after device removal. Seven patients developed complications, including wound infection, seroma, neurovascular injury, hardware complications, and heterotopic ossification. Two patients had complications related to internal joint stabilizers and three had complications linked to radial head prostheses. Median (range) preoperative to postoperative changes included decreased pain (VAS 5 [2 to 9] to 0 [0 to 3], difference of medians -5; p < 0.001), decreased disability (DASH 41 [16 to 66] to 7 [0 to 46], difference of medians -34; p < 0.001), improved function (MEPS 60 [25 to 70] to 95 [65 to 100], difference of medians 35; p < 0.001), improved extension-flexion arc (40° [10° to 70°] to 113° [75° to 140°], difference of medians 73°; p < 0.001), and supination-pronation arc (78° [30° to 165°] to 148° [70° to 175°], difference of medians 70°; p < 0.001). Between patients with and without development of post-traumatic arthritis, there were no differences in postoperative pain (VAS 0 [0 to 3] to 0 [0 to 1], difference of medians 0; p = 0.17), disability (DASH 7 [0 to 46] to 7 [0 to 18], difference of medians 0; p = 0.40), function (MEPS 80 [65 to 100] to 95 [75 to 100], difference of medians 15; p = 0.79), extension-flexion arc (105° [75° to 140°] to 115° [80° to 125°], difference of medians 10°; p = 0.40), and supination-pronation arc (155° [125° to 175°] to 135° [70° to 160°], difference of medians -20°; p < 0.18).

CONCLUSION

In this small, retrospective study, we found that an internal joint stabilizer with a standardized treatment protocol could maintain concentric reduction while allowing early functional motion, and that it could improve clinical outcomes for patients with complex persistent elbow instability. However, patients must be counseled that the complications related to the radial head prostheses may occur, and that the benefits of early motion must compensate for an additional removal procedure and the risk of seroma formation.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Management of Geriatric Elbow Injury

Approximately 4.1% of all fractures in the elderly involve the elbow. Most elbow injuries in geriatric patients occur as the result of low-energy mechanisms such as falls from standing height. Elbow injuries in elderly patients present complex challenges because of insufficient bone quality, comminution, articular fragmentation, and preexisting conditions, such as arthritis. Medical comorbidities and baseline level of function must be heavily considered in surgical decision making.

Analysis of Fracture Characteristic and Medial Collateral Ligament Injury Relationships in Terrible Triad Elbow Injuries

PURPOSE

The objectives of this study were to identify the relationship between fracture characteristics and medial collateral ligament (MCL) injuries in terrible triad injuries of the elbow.

METHODS

Between 2010 and 2018, 60 patients who underwent surgery for terrible triad elbow injuries were retrospectively reviewed. Using magnetic resonance imaging (MRI) assessments, patients were stratified into those who had intact or low-grade partial MCL tears (low-grade MRI-MCL group) and those who had high-grade partial or full-thickness MCL tears (high-grade MRI-MCL group). We also analyzed patients according to whether they underwent MCL repair surgery. Fractures of the radial head were assessed according to Mason's classification system and measurements of fracture fragment arc on axial cuts. Fractures of the coronoid processes were assessed according to the system of Regan and Morrey and measurements of coronoid process volumes.

RESULTS

Patients in the high-grade MRI-MCL group (28 patients) had a more comminuted and higher fragment arc of radial head fractures than those in the low-grade MRI-MCL group (32 patients) (143º ± 45º vs 119º ± 31º). However, the volume of coronoid fracture fragments was smaller in the high-grade MRI-MCL than in the low-grade MRI-MCL group (359 ± 325 mm³ vs 722 ± 448 mm³). The MCL repair group (22 patients) also had a more comminuted and higher fragment arc in radial head fractures (153º ± 44º vs 117º ± 31º) and a smaller coronoid process fracture volume (236 ± 224 mm³ vs 735 ± 419 mm³) than the non-MCL repair group (38 patients).

CONCLUSIONS

Our results demonstrated that high-grade MCL injuries are associated with comminuted and larger-sized radial head fractures, as well as smaller-sized coronoid process fractures in terrible triad injuries. In making a decision regarding surgical treatment, these fracture characteristics could help to predict the severity for MCL injury in terrible triad injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Prognostic factors for traumatic elbow osteoarthritis after terrible triad surgery, and functional impact

INTRODUCTION

Terrible triad (TT) of the elbow almost always requires surgery to prevent progression to chronic instability and more or less inevitable osteoarthritis. Progression toward osteoarthritis after well-conducted surgery and associated risk factors have been little reported. We performed a retrospective study: (1) to assess rates of post-traumatic elbow osteoarthritis after surgical treatment of TT; (2) to assess functional impact; and (3) to identify prognostic factors.

HYPOTHESIS

Prevalence of osteoarthritis after surgical treatment of TT is high, impairing functional results.

MATERIAL AND METHOD

A single-center retrospective study included 53 patients, with a mean age of 50±17.8 years (range, 21-84 years), undergoing surgery for acute TT in our department. All received clinical examination with ranges of motion and Mayo Elbow Performance Index (MEPI) and radiographic assessment at a minimum 1 year's follow-up. Osteoarthritis at last follow-up was assessed on elbow X-ray in the humero-ulnar and radio-condylar compartments on the Broberg-Morrey classification. Functional impact on range of motion and MEPI and prognostic factors were assessed on Student test or ANOVA and Chi² or Fisher test.

RESULTS

Prevalence of Broberg-Morrey grade 2 or 3 osteoarthritis was 45.3% (24/53) in the humero-ulnar compartment and 50% (25/50) in the radio-condylar compartment. Humero-ulnar osteoarthritis impaired MEPI (76.3 points with versus 88.4 points without; p=0.003), flexion-extension (102.3° versus 115.2°; p=0.043) and pronation-supination (138.8° versus 159.3°; p=0.006). Radio-condylar osteoarthritis had no significant impact on MEPI (81.4 points with and 84.4 points without; p=0.47), flexion-extension (104.8° and 113°; p=0.23) or pronation-supination (141.8° and 156.4°; p=0.2). Humero-ulnar osteoarthritis at last follow-up was associated with dislocation or subluxation on immediate postoperative lateral view (45.8% with versus 10.3% without; p=0.004) and at last follow-up (20.8% versus 3.4%; p=0.047) and with postoperative complications (54.2% and 27.6%; p=0.049). Radio-condylar osteoarthritis at last follow-up was associated with radial head replacement rather than internal fixation (respectively, 92% and 48%; p=0.0007) and excessively high radial head implant positioning (47.8% versus 0%; p=0.023).

CONCLUSION

Prevalence of traumatic osteoarthritis after TT surgery was high, at 45.3% in the humero-ulnar compartment and 50% in the radio-condylar compartment, with clinical impact in humero-ulnar involvement.

LEVEL OF EVIDENCE

IV; cohort study without control group.

Surgical treatment of terrible triad of the elbow

Terrible triad of the elbow associates posterior dislocation, radial head fracture and coronoid process fracture. It is a complex trauma, associating severe bone and ligament lesions, with high more-or-less long-term risk of residual instability, stiffness, pain and osteoarthritis. During the last 20 years, pathologic, biomechanical and clinical knowledge has greatly progressed. Prevention of these severe complications requires initial understanding of the lesion mechanism and precise analysis of all lesions. Surgery aims to restore perfect stability by sequential anatomic repair, enabling early mobilization to prevent onset of stiffness. The aims of the present paper were to summarize the anatomic and pathophysiological bases, highlight the crucial importance of the humeroradial column and lateral collateral ligament, and to determine the importance of the coronoid process. Some aspects of treatment are controversial: systematic medial collateral ligament repair, or use of an articulated external fixator. Finally, we propose a simple algorithm to guide repair.

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.

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.

Prediction and Potential Preventions for the Development of Posttraumatic Osteoarthritis after the Terrible Triad Injury: A Multicenter Risk Factors Study

Objective

A multicenter study to evaluate risk factors for the development of moderate or severe posttraumatic osteoarthritis (PTOA) and to find potential preventions.

Methods

We conducted a retrospective multicenter study including the terrible triad injury (TTI) patients with surgical treatment from January 2007 to November 2014. Demographics, injury information, and treatment history were obtained retrospectively. According to the Broberg and Morrey criterion, 198 included patients were sorted into two groups: the mild or no PTOA and moderate or severe PTOA. Uni- and multivariate logistic regression analyses were used to identify risk factors for moderate or severe PTOA.

Results

Moderate or severe PTOA was present in 64 patients (32.3%). Significant risk factors were Mason III radial head fracture (OR 4.049, 95% CI 1.877-8.736, p < 0.001), medial collateral ligament injury (OR 5.120, 95% CI 1.261-20.790, p = 0.022), and heavy use of elbow (OR 2.333, 95% CI 1.060-5.136, p = 0.035). Besides, patients suffered subluxation (p = 0.007) and those with more risk factors had a higher risk to develop moderate or severe PTOA.

Conclusions

Moderate or severe PTOA was common after the TTI. Patients need to be counseled about avoiding heavy use of the elbow, especially for those with Mason III radial head fractures. Surgeons should be aware of the recurrent instability of the elbow.

Treatment of terrible triad injuries at a mean follow-up of nine years

BACKGROUND

To evaluate the sustainability of the early clinical and radiological outcomes of terrible triad injuries at long-term follow-up.

METHODS

Twelve consecutive patients who underwent fixation of terrible triad injuries with minimum of seven years of follow-up. Functional and radiological outcomes at one year and final follow-up were compared. We assessed Mayo Elbow Performance Score, Quick-Disability of the Arm Shoulder and Hand, and modified-American Shoulder and Elbow Surgeons Scores. Radiological evaluation included Broberg and Morrey classification and Hastings classification for heterotopic ossification.

RESULTS

The mean age of patients was 55 years, with a median follow-up of 9.3 years. At final evaluation, mean flexion, extension, supination, and pronation were 145°, 6°, 82°, and 80°, respectively; mean Mayo Elbow Performance Score, modified-American Shoulder and Elbow Surgeons Scores, and Quick-Disability of the Arm Shoulder and Hand scores were, respectively, 97, 92, and 4.9 points. There was no statistical difference between early and final follow-up range of motion, Mayo Elbow Performance Score, and Quick-Disability of the Arm Shoulder and Hand. However, radiological changes were observed in 66% of the patients at final follow-up. Two patients underwent reoperation, with final satisfactory results.

CONCLUSION

Our results suggested that using a standardized protocol, satisfactory clinical outcomes at early follow-up could be maintained over time. However, early complications and osteoarthritic changes at long-term follow-up can be expected.

LEVEL OF EVIDENCE

Therapeutic IV Cases series.

Anterior capsule re-attachment in terrible triad elbow injury with coronoid tip fracture

BACKGROUND

During the surgical treatment of terrible triad elbow injury (TTEI), the usefulness of re-attaching the anterior joint capsule when the coronoid tip is fractured remains unclear. The primary objective of this study was to assess potential benefits during surgery for TTEI of re-attaching the joint capsule when the coronoid tip is fractured.

HYPOTHESIS

Re-attaching the anterior joint capsule in TTEI with a fractured coronoid tip improves clinical and radiological outcomes and decreases the complication and revision rates.

MATERIALS AND METHODS

This single-centre retrospective study included patients who underwent surgery at the acute phase of TTEI with a fractured coronoid tip. In all patients, a physical examination and elbow radiographs were performed at least 1year after surgery. A statistical analysis was done to compare the groups with vs. without re-attachment of the anterior capsule and coronoid tip.

RESULTS

The study included 30 patients, 16 females and 14 males, with a mean age of 51years (range: 21-84years). Among them, 11 did and 19 did not undergo re-attachment. The two groups were comparable regarding demographic features and follow-up duration. No significant differences were found at last follow-up for flexion-extension motion arc (p=0.75), pronation-supination motion arc (p=0.3051), or the Mayo Elbow Performance Score (p=0.19). Radiographic evidence of humero-radial osteoarthritis was significantly more common in the absence of re-attachment (p=0.04), whereas no differences were evidenced regarding humero-ulnar osteoarthritis (p=0.73), the occurrence of subluxation or dislocation (p=0.43), or loosening of the radial head implant (p=0.47). The complication and revision rates were similar in the two groups.

CONCLUSION

In our experience, re-attaching the anterior capsule during the surgical treatment of TTEI with a coronoid tip fracture did not improve the clinical or radiographic outcomes after a mean follow-up of 54months.

LEVEL OF EVIDENCE

IV, retrospective study.

The Emergent Evaluation and Treatment of Elbow and Forearm Injuries

This article provides an updated review of the emergent evalution and treatment of elbow and forearm injuries in the emergency department. Clinically necessary imaging is discussed. Common and uncommon injuries of the elbow and forearm are reviewed with an emphasis on early recognition, efficient management, and avoidance of complications. The astute emergency physician will rely on a focused history and precise examination, applied anatomic knowledge, and strong radiographic interpretative skills to avoid missed injuries and complications.

Risk Factors That Influence Subsequent Recurrent Instability in Terrible Triad Injury of the Elbow

OBJECTIVE

To identify risk factors associated with subsequent recurrent instability and to identify predictors of poor outcomes in terrible triad injury of the elbow.

DESIGN

Retrospective cohort study.

SETTING

University trauma center.

PATIENTS/PARTICIPANTS

Seventy-six patients who were surgically treated for terrible triad injury of the elbow.

INTERVENTION

Review of charts and standardized x-ray images before surgery and 2 years after surgery. Patients were categorized into 2 groups: recurrent instability (group A) or concentric stability (group B).

MAIN OUTCOME MEASUREMENT

Primary outcome measures were injury mechanism, time between injury and operation, fracture type, ligament injury, radial head fixation, coronoid fixation, ligament repair, period of postoperative immobilization, joint space restoration, healing progress, secondary operation, functional outcomes, and complications. Secondary outcome measures were age, sex, height, body mass index, bone mineral density, and comorbidities (hypertension and diabetes). Outcomes were measured before surgery and 2 years after surgery and were compared between groups.

RESULTS

Recurrent instability occurred in 19.7% of cases; revision surgeries were performed in 12 cases (80%). High-energy trauma (P = 0.012), time between injury and operation (P = 0.001), radial head comminution (P = 0.001), medial collateral injury (P = 0.041), and coronoid nonrepair (P = 0.030) were associated with recurrent instability. Posttraumatic arthritis developed more often in group A (P = 0.001).

CONCLUSIONS

Recurrent instability was associated with high-energy trauma, time between injury and operation, Mason type III radial head fracture, medial collateral injury, and coronoid nonrepair. Patients with recurrent instability were more likely to require secondary surgery and develop posttraumatic arthritis than those with concentric stability.

LEVEL OF EVIDENCE

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

Terrible triad injuries of the elbow

Terrible triad injury of the elbow is a complex injury that is classically defined as elbow dislocation along with fractures of the coronoid process of the ulna and the radial head. The injury is usually associated with typical soft-tissue disruptions (with common involvement of the lateral collateral ligament complex, elbow joint capsule, as well as the common extensor and flexor-pronator tendons) that are best understood in the context of injury mechanism as well as the role and relevance of the various elbow stabilizers. The goals of this article are to review the pertinent anatomy, mechanism of injury, classification and imaging of terrible triad injuries of the elbow with brief descriptions of treatment, and complications of this complex injury.

Radial head replacement versus reconstruction for the treatment of the terrible triad injury of the elbow: a systematic review and meta-analysis

INTRODUCTION

The terrible triad injury of the elbow (TTIE) remains challenging to manage and has been associated with high complication rates and poor outcomes. There is a trend towards performing radial head replacement (REP) in preference to radial head reconstruction (REC) as arthroplasty provides early stability and may allow mobilisation sooner, potentially resulting in a better functional outcome. This systematic review compares the outcome of patients with TTIE treated with either REC or REP.

MATERIALS AND METHODS

MEDLINE, Embase, and CINAHL were searched for studies published in English involving at least ten patients exclusively with a TTIE managed operatively, including both patients with either REC or REP. Data collection was in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis protocol. The outcomes of interest were Mayo Elbow Performance Score (MEPS) and range of motion (ROM). Post-operative complications were also compared.

RESULTS

9 studies involving 210 patients were included (98 REPs and 112 RECs). There was no statistically significant difference (p = 0.51) demonstrated between in the mean MEPS of the REP group (mean 88.6) and REC group (mean 88.5). Similarly, there was no statistically significant difference demonstrated between the REP and REC groups in terms of ROM. The risk of re-operation was high in both the REP (18.4%) and REC (17.9%) group. The overall complication rate of all patients included in the study was high (65%).

CONCLUSIONS

Comparable results with good outcomes in terms of functional scores and ROM can be achieved with both REP and REC when treating TTIE, although the re-operation rate for both remains relatively high. Given there is no apparent clear advantage between the two treatment groups, we would suggest that REC should be performed when a satisfactory fixation can be achieved as the longevity of REP in young patients with a TTIE is currently uncertain.

Morbid obesity and 1-year costs after elbow dislocation

Background

Morbid obesity has been linked with serious associated injuries following dislocations of the knee. While similar devastating injuries have been observed following elbow dislocations in the obese, no study to date has characterized the financial impact of elbow dislocations in the morbidly obese population.

Purpose

The purpose of this study is to determine the impact of morbid obesity on 1-year costs related to elbow dislocation.

Methods

A retrospective query of the Medicare Standard Analytic Files database was performed for patients sustaining elbow dislocation from 2005 to 2014. 1-year reimbursement costs from the initial open or closed reduction procedures were compared for morbidly obese (BMI ≥ 40 kg/m²) patients versus those without morbid obesity (BMI < 40 kg/m²). Cohorts were matched based on age and gender. Total reimbursement costs associated with a diagnosis of elbow dislocation and/or reduction were analyzed.

Results

We identified 182 morbidly obese patients and 422 patients without morbid obesity who underwent open or closed reduction for elbow dislocation. 102 patients with 1-year cost data remained in each cohort after matching. Mean 1-year reimbursement costs related to elbow dislocation were significantly greater in morbidly obese patients ($6227.43 vs $4225.71, p = 0.006).

Conclusion

1-year costs related to elbow dislocation are significantly higher in morbidly obese patients. The increased costs likely reflect the complexity of managing dislocations in the obese population. Difficulties maintaining closed reduction, longer and more challenging surgeries with a higher likelihood on intra- and post-operative complications, and a higher risk of peri-operative medical complications may all contribute to these increased costs.

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.

Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series

BACKGROUND

Terrible triad injuries of the elbow are complex injuries to treat and we report our outcomes following surgical management.

METHODS

Twenty-two consecutive patients who underwent fixation of terrible triad injuries between 2007 and 2012 were identified. Clinical outcomes were assessed by examination, visual analogue scores (VAS), Oxford Elbow Score (OES), Mayo Elbow Performance Index (MEPI) and QuickDash score (QD).

RESULTS

The mean age of patients was 47 years, with a mean follow-up of 32 months. All patients underwent lateral ligament repair, with additional medial ligament repair in four cases. Thirteen patients required repair of the coronoid and 18 patients required surgery to the radial head. The mean flexion-extension arc was 113°, with mean prono-supination of 136°. The functional elbow scores revealed good outcomes in the majority (mean OES of 37, MEPI of 79 and QD of 21). The overall complication rate was 41%. In total, 23% required reoperation, with one patient requiring fasciotomy for acute compartment syndrome and four requiring subsequent removal of metalwork as a result of stiffness.

CONCLUSIONS

Recognition of this complex injury pattern and appropriate restoration of the joint stability are the prerequisites. Systematic surgical approach is effective and can provide both stability and good function, in most cases.

Terrible triad of the elbow: evaluation of surgical treatment

Objective

This study aims at analyzing retrospectively the clinical-functional and radiographic results of surgical treatment of the terrible elbow triad, with at least 12 months of postoperative follow-up evaluating elbow function.

Methods

A group of patients for retrospective analysis from 2004 to 2015 was defined, in which 12 patients were studied. They underwent surgery due to fracture of the radial head, coronoid fracture, and elbow dislocation; they were evaluated by the Disabilities of the Arm, Shoulder and Hand (DASH) score, the degree of patient satisfaction, the degree of trauma energy, radiographic images, range of motion, and complications.

Results

There was a higher incidence of Regan and Morrey type II coronoid process fractures; in relation to the injuries, nine patients had deinsertion of the brachialis. Half of the patients suffered a fall from their own height as the mechanism of trauma. The extent of elbow flexion and extension averaged 126.6 and 24.1 degrees, respectively; the averages for pronation and supination were 64.1 and 62.0 degrees, respectively. All patients presented muscle strength of grade IV or V. The mean DASH score was 14.3, the mean pain score was 2.5, and a majority of the patients were satisfied with the treatment.

Conclusion

Despite the total loss of range of motion of the elbow, especially in extension, the treatment was satisfactory for most patients.

Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol: Retrospective analysis of a prospective cohort

The aim of the present study was to investigate the efficacy of the surgical treatment of terrible triad injuries of the elbow using a modified standard surgical approach, and treatment determined by the mode and mechanism of injury, and intraoperative findings.The study was a retrospective analysis of a prospective cohort of patients presenting with terrible triad injuries of the elbow, who underwent surgical treatment between July 2009 and January 2014. All patients were treated surgically according to a modified Pugh standard protocol. Elbow functional status and range of movements were evaluated at 3 months, 6 months, 1 year, and 2 years or more after surgery. Radiographic signs of post-traumatic arthritis were rated according to the Broberg and Morrey system.Our series included a final cohort of 29 males and 13 females with a mean age of 48.23 ± 10.95 years at the time of injury. The mean follow-up period was 30.47 ± 7.65 months. The mean flexion-extension arc was 107° ± 22°, and the average forearm rotation arc was 145° ± 14°. The mean Mayo Elbow Performance Score was 88 ± 10 points (range 55 to 100 points), with excellent results in 24 elbows, good results in 16, and poor results in 2. Functional results of the elbow improved significantly from 3 months postoperatively (P < .05), but tended to plateau from 1 year after surgery. Thirteen patients had radiographic signs of arthrosis (9 grade 1, 4 grade 2). Postoperative complications were local infection around the incision (n = 1), transient postoperative median nerve paralysis (n = 1), and postoperative posterior interosseous nerve paralysis (n = 1). Four patients required further surgery. Five patients had evidence of heterotopic ossification.Overall, we show that slight modifications to Pugh standard protocol for the surgical treatment of terrible triad injuries can lead to good to excellent results, although there were a good number of complications. The ideal surgical approach and treatment should be based on the mode and mechanism of injury, and intraoperative findings, and modifying the standard surgical treatment approach for terrible triad elbow injuries may be beneficial.