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Fahs A, Waldron J, Afsari A, Best B. Management of Elbow Terrible Triad Injuries: A Comprehensive Review and Update. J Am Acad Orthop Surg 2024:00124635-990000000-01066. [PMID: 39151182 DOI: 10.5435/jaaos-d-24-00310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 07/15/2024] [Indexed: 08/18/2024] Open
Abstract
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.
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Affiliation(s)
- Adam Fahs
- From the Ascension St. John Medical Center, Detroit, MI (Fahs, Waldron, Afsari, and Best), Ascension Macomb-Oakland Hospital, Warren, MI (Fahs, Waldron, Afsari, and Best)
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Le GAT, To K, Dang NT, Nguyen VT, Phan TN, Nguyen VT, Ton TTT, Vo TT. The anconeus-triceps lateral flap approach in terrible triad of the elbow: good outcome in a series of ten cases. Ann Med Surg (Lond) 2024; 86:4352-4357. [PMID: 39118682 PMCID: PMC11305737 DOI: 10.1097/ms9.0000000000002211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/14/2024] [Indexed: 08/10/2024] Open
Abstract
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.
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Affiliation(s)
- Gia Anh Thy Le
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Kha To
- School of Medicine, Vietnam National University Ho Chi Minh City
- Trauma and Orthopedics Department, Thong Nhat Hospital
- Division of Surgery and Interventional Science
- Institute of Sport, Exercise and Health, University College London, London, UK
| | - Nghia Thanh Dang
- School of Medicine, Vietnam National University Ho Chi Minh City
| | - Viet Tan Nguyen
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Tri Nguyen Phan
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Van Thai Nguyen
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
- Department of Orthopaedics and Trauma, Pham Ngoc Thach Medical University, Ho Chi Minh City, Vietnam
| | - Thi Thanh Thao Ton
- Department of Upper Limbs, Hospital for Traumatology and Orthopaedics, Ho Chi Minh City
| | - Thanh Toan Vo
- Trauma and Orthopedics Department, Thong Nhat Hospital
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White NW, Matullo KS. Concomitant internal joint stabilizer augmentation with isometric lateral ulnar collateral ligament repair for unstable elbow dislocations: a surgical technique. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:235-240. [PMID: 38706670 PMCID: PMC11065737 DOI: 10.1016/j.xrrt.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
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Ahn YS, Woo SH, Kim S, Lim JH, An TH, Kim MS. Does the coronoid fracture in terrible triad injury always need to be fixed? BMC Surg 2024; 24:125. [PMID: 38664803 PMCID: PMC11044357 DOI: 10.1186/s12893-024-02394-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 03/20/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND The ideal treatment of terrble triad injuries and whether fixation of coronoid process fractures is needed or not are still debated. Therefore, we aimed to investigate if terrible triad injuries necessitate coronoid fracture fixation and evaluate if non-fixation treatments have similar efficacies and outcomes as fixation-treatments in cases of terrible triad injuries. METHODS From August 2011 to July 2020, 23 patients with acute terrible triad injuries without involvement of the anteromedial facet of the coronoid process were included to evaluate the postoperative clinical and radiological outcomes (minimum follow-up of 20 months). According to the preoperative height loss evaluation of the coronoid process and an intraoperative elbow stability test, seven patients underwent coronoid fracture fixation, and the other eight patients were treated conservatively. The elbow range of motion (ROM), Mayo Elbow Performance Score (MEPS), and modified Broberg-Morrey score were evaluated at the last follow-up. In addition, plain radiographs were reviewed to evaluate joint congruency, fracture union, heterotopic ossification, and the development of arthritic changes. RESULTS At the last follow-up, the mean arcs of flexion-extension and supination-pronation values were 118.2° and 146.8° in the fixation group and 122.5° and 151.3° in the non-fixation group, respectively. The mean MEPSs were 96.4 in the fixation group (excellent, nine cases; good, tow cases) and 96.7 in the non-fixation group (excellent, ten cases; good, two cases). The mean modified Broberg-Morrey scores were 94.0 in the fixation group (excellent, sevev cases; good, four cases) and 94.0 in the non-fixation group (excellent, ten cases; good, tow cases). No statistically significant differences in clinical scores and ROM were identified between the two groups. However, the non-fixation group showed a significantly lower height loss of the coronoid process than the fixation group (36.3% versus 54.5%). CONCLUSIONS There were no significant differences in clinical outcomes between the fixation and non-fixation groups in terrible triad injuries.
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Affiliation(s)
- Yeong-Seub Ahn
- Department of Orthopaedic Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 61469, South Korea
- Department of Orthopaedic Surgery, Good Morning General Hospital, Pyeongtaek, Republic of Korea
| | - Seong-Hwan Woo
- Department of Orthopaedic Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 61469, South Korea
| | - Sungmin Kim
- Department of Orthopaedic Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 61469, South Korea
| | - Jun-Hyuk Lim
- Department of Orthopaedic Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 61469, South Korea
| | - Tae-Hoon An
- Department of Orthopaedic Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 61469, South Korea
| | - Myung-Sun Kim
- Department of Orthopaedic Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, 42 Jebong-ro, Dong-gu, Gwangju, 61469, South Korea.
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Baker M, Eyre-Brook A, Gokaraju K, Jones V, Thyagarajan D, Ali A, Booker S. Non-operative management of terrible triad injuries of the elbow; not so terrible? Shoulder Elbow 2024; 16:200-205. [PMID: 38655413 PMCID: PMC11034474 DOI: 10.1177/17585732231190599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 07/04/2023] [Accepted: 07/09/2023] [Indexed: 04/26/2024]
Abstract
Introduction Terrible triad injuries (TTIs) of the elbow have traditionally been reported to have poor outcomes, hence requiring surgical stabilisation. We identified and reviewed patients with TTIs treated non-operatively within our department. Methods We retrospectively reviewed patients with TTI treated non-operatively with standardised elbow-instability rehabilitation from 2010 to 2020. We used Mason and Morrey classifications for radial head and coronoid fractures, respectively. Non-operative indications included a congruent joint on CT, significant co-morbidities pre-disposing to high-risk surgery and/or patient preference. Outcomes included Oxford Elbow Score (OES), ROM and complications. Results Nineteen patients were included (mean age 49; 37% female). At an average of 6 years (range 2-11 years) post-treatment, mean OES was 46 ± 7. At last clinic review, mean 6 months (2-15), average ROM was 131 ± 11° flexion, 8 ± 10° extension, 85 ± 12° supination and 85 ± 13° pronation. One patient required arthrolysis and another had an incongruent ulnohumeral joint which developed clicking with a functional ROM. Conclusion Our report suggests non-operatively managed and appropriately rehabilitated TTI injuries can achieve good function and ROM. We recommend conservative management as a viable option in cases with joint congruency and no mechanical block in patients with significant co-morbidities or those refusing surgery but patients must be assessed on a case-by-case basis.
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Affiliation(s)
- Megan Baker
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Alistair Eyre-Brook
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Kishan Gokaraju
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Valerie Jones
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - David Thyagarajan
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Amjid Ali
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Simon Booker
- Orthopaedic Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
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Cruz JP, Salazar B, van Niekerk M, Finlay AK, Van Rysselberghe NL, Goodnough LH, Bishop JA, Gardner MJ. The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1675-1681. [PMID: 38403660 DOI: 10.1007/s00590-024-03843-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 01/18/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting. METHODS This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up. RESULTS Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating room for stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69). CONCLUSIONS This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.
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Tedesco LJ, Noback PC, Paskey TL, Konigsberg M, Kadiyala RK. Suture Button Repair for Lateral Ulnar Collateral Ligament in Terrible Triad Injuries: Surgical Technique. Arthrosc Tech 2024; 13:102861. [PMID: 38435251 PMCID: PMC10907935 DOI: 10.1016/j.eats.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/08/2023] [Indexed: 03/05/2024] Open
Abstract
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.
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Affiliation(s)
| | - Peter C. Noback
- Columbia University Medical Center, New York, New York, U.S.A
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Barati H, Baroutkoub M, Zabeti Targhi N, Beheshti Fard S, Hajikarimloo B, Afzal S. Antibiotic-loaded spacer arthroplasty in a terrible triad injury with unreconstructable radial head fracture: a case report. J Med Case Rep 2023; 17:505. [PMID: 38062481 PMCID: PMC10704758 DOI: 10.1186/s13256-023-04258-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/09/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Radial head arthroplasty is a viable option in cases with terrible triad injuries of elbow, wherein the radial head sustains significant comminution that precludes reconstruction. Nevertheless, this alternative is not recommended for individuals with poor elbow skin conditions, accompanied neuropsychiatric disorders, or low patient compliance. This case report presents a patient with bilateral terrible triad injury, along with the aforementioned conditions. The report outlines the treatment challenges of such a case and proposes potential solutions. CASE PRESENTATION A 37-year-old Persian male patient presenting with a bilateral terrible triad fracture-dislocation and a history of psychoactive substance abuse, was admitted to our emergency department. The patient underwent radial head replacement using a cement spacer containing antibiotics, due to the comminuted radial head in the presence of a contaminated wound on the left elbow. The fracture of the right side was successfully fixed. Subsequent to discharge, the patient did not attend any follow-up appointments. After a period of 6 months, he was admitted to the psychiatric ward and orthopedic consultation was requested to evaluate the patient. CONCLUSION In acute terrible triad injuries with unreconstructable radial head fractures where arthroplasty with metallic prostheses may not be suitable due to contaminated wounds, unstable psychiatric condition, and low patient cooperation, temporary orthopedic cement spacers can maintain elbow biomechanics, stability, and sterility.
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Affiliation(s)
- Hasan Barati
- Department of Orthopedic Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mojtaba Baroutkoub
- Department of Orthopedic Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nikaein Zabeti Targhi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Bardia Hajikarimloo
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sina Afzal
- Department of Orthopedic Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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de Klerk HH, Ring D, Boerboom L, van den Bekerom MP, Doornberg JN. Coronoid fractures and traumatic elbow instability. JSES Int 2023; 7:2587-2593. [PMID: 37969528 PMCID: PMC10638561 DOI: 10.1016/j.jseint.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
The coronoid process is key to concentric elbow alignment. Malalignment can contribute to post-traumatic osteoarthritis. The aim of treatment is to keep the joint aligned while the collateral ligaments and fractures heal. The injury pattern is apparent in the shape and size of the coronoid fracture fragments: (1) coronoid tip fractures associated with terrible triad (TT) injuries; (2) anteromedial facet fractures with posteromedial varus rotational type injuries; and (3) large coronoid base fractures with anterior (trans-) or posterior olecranon fracture dislocations. Each injury pattern is associated with specific ligamentous injuries and fracture characteristics useful in planning treatment. The tip fractures associated with TT injuries are repaired with suture fixation or screw fixation in addition to repair or replacement of the radial head fracture and reattachment of the lateral collateral ligament origin. Anteromedial facet fractures are usually repaired with a medial buttress plate. If the elbow is concentrically located on computed tomography and the patient can avoid varus stress for a month, TT and anteromedial facet injuries can be treated nonoperatively. Base fractures are associated with olecranon fractures and can usually be fixed with screws through the posterior plate or with an additional medial plate. If the surgery makes elbow subluxation or dislocation unlikely, and the fracture fixation is secure, elbow motion and stretching can commence within a week when the patient is comfortable.
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Affiliation(s)
- Huub H. de Klerk
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - David Ring
- Department of Surgery and Perioperative Care, The University of Texas at Austin, TX, USA
| | - Lex Boerboom
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Michel P.J. van den Bekerom
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, the Netherlands
- Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Job N. Doornberg
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Lu S, Wang Y, Rui B, Ding J. Comparison of different treatment approaches for coronoid process fracture in terrible triad injury: a multicenter, randomized controlled study. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05864-0. [PMID: 37338546 DOI: 10.1007/s00264-023-05864-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE The purpose of the study was to compare the functional results of different treatment approaches for the fracture of the coronoid process in terrible triad injury (TTI). METHODS This prospective randomized controlled trial included participants from seven level-1 trauma centres in China. All patients were randomly assigned to three groups, wherein different approaches were applied to treat coronoid fracture: group A) internal fixation of the coronoid process without external fixation or splint (ORIF group), B) external fixation using a hinged fixator without internal fixation (Exfix group), and C) long-arm plaster for two to three weeks postoperatively without internal fixation of coronoid process (Plaster group). Early active motion exercises within the limits of pain were started immediately after surgery under the supervision of a physical therapist. Outcomes were evaluated at regular intervals over the subsequent 12 months. RESULTS A total of 65 patients (22 patients in Group A, 21 in Group B, and 22 in Group C) were included in this trial from January 2016 to January 2019. The average arc of elbow motion was 114.1° ± 8.92°. The average flexion and flexion contracture were 126.4° ± 11.2° and 12.3° ± 7.7°, respectively. The arcs of forearm rotation of the elbow for each group were 145.41° ± 9.36°, 143.38° ± 9.79°, and 143.86° ± 10.95°, respectively. The MEPS for each group were 86.82 ± 9.7, 86.67 ± 9.92, and 85.23 ± 8.66, respectively. The DASH score for each group were 18.26 ± 19.31, 18.85 ± 15.02, and 20.19 ± 13.59, respectively. CONCLUSION All three approaches in our trial showed similar functional results in the long-term survey. Patients treated with external fixation without internal fixation of the coronoid process showed less pain during early mobilization and acquired maximum flexion within a short duration after surgery.
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Affiliation(s)
- Shengdi Lu
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanmao Wang
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Biyu Rui
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Ding
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Waterworth R, Finlayson G, Franklin M, Jabbal M, Faulkner A, Gallagher B. Current concepts in the management of "Terrible Triad" injuries of the elbow. Injury 2023:110889. [PMID: 37353449 DOI: 10.1016/j.injury.2023.110889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
Terrible triad injuries of the elbow are complex injuries which can result in long term complications and significant disability. They must be identified correctly, and managed appropriately in order to maximise functional outcomes. A clear understanding of the bony and ligamentous anatomy is essential to plan appropriate surgical reconstruction to provide elbow stability. Urgent reduction of the elbow, followed by 3-dimensional imaging and surgical repair or replacement of the injured structures is the mainstay of treatment in the majority of cases. This review presents a summary of the relevant anatomy and the evidence for the management of these complex injuries.
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Affiliation(s)
- Rebecca Waterworth
- Department of Trauma and Orthopaedics, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB, United Kingdom.
| | - Graham Finlayson
- Department of Trauma and Orthopaedics, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB, United Kingdom
| | - Marieta Franklin
- Department of Trauma and Orthopaedic Surgery, Whiston Hospital, Warrington Rd, Rainhill, Prescot, L35 5DR, United Kingdom
| | - Monu Jabbal
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SA, United Kingdom
| | - Alastair Faulkner
- Department of Trauma and Orthopaedics Surgery, Ninewells Hospital, Dundee, DD1 9SY, United Kingdom
| | - Brendan Gallagher
- Department of Trauma & Orthopaedics, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB, United Kingdom
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Salwan A, Saoji A, Pisulkar G, Awasthi AA, Taywade S. Use of Endobutton for Small Avulsion Fracture of Coronoid in the Terrible Triad of the Elbow: A Case Report. Cureus 2023; 15:e38119. [PMID: 37252569 PMCID: PMC10212725 DOI: 10.7759/cureus.38119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/25/2023] [Indexed: 05/31/2023] Open
Abstract
The terrible triad (TT) of the elbow consists of coronoid process (CP) fracture, fracture of the radial head (RH), and posterior dislocation. Although the coronoid is an important anterior stabilizer, it is still unclear how to treat comminuted coronoid fractures. Poor fixation of the CP tends to result in posterolateral instability at the elbow joint and often in chronic instability. The ligamentous injuries also cause instability in elbow dislocations and should be suspected. There are various techniques available for coronoid fracture fixation. In this case report, we want to highlight our experience managing a 47-year-old male with posterior dislocation of the elbow after computed tomography (CT) confirmed that the patient had an RH fracture with an avulsion fracture of the coronoid. This TT of the elbow was managed with the help of an endobutton and a Herbert screw for coronoid avulsion fracture and RH fracture, respectively, through a lateral (Kocher) approach in our tertiary care hospital with satisfactory results. The use of endobutton is recommended in type 1 and type 2 coronoid fractures with no or minimal capsular attachment for good suspensory effect, and it emphasizes the possibility of associated coronoid fracture in case of posterior elbow dislocation. This case report emphasizes the fixation of even small fragments of the coronoid fracture for better stability and early mobilization. Postoperative rehabilitation involved using a hinged brace and early mobilization to avoid a stiff elbow and periodic X-rays to check the heterotopic ossification risk.
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Affiliation(s)
- Ankur Salwan
- Department of Orthopaedics and Traumatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Amit Saoji
- Department of Orthopaedics and Traumatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Gajanan Pisulkar
- Department of Orthopaedics and Traumatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhiram A Awasthi
- Department of Orthopedics and Traumatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shounak Taywade
- Department of Orthopaedics and Traumatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Low SL, Spence SA, Low JX, Baratz ME. The spin move to facilitate antegrade coronoid fixation in terrible triad injuries. J Shoulder Elbow Surg 2023; 32:738-743. [PMID: 36584867 DOI: 10.1016/j.jse.2022.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 11/15/2022] [Accepted: 11/20/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND The role of the coronoid process in elbow instability has been established. When necessary, coronoid fixation can be challenging. Placing fixation perpendicular to the fracture requires achieving a trajectory as close as possible to the midline axis of the proximal ulna, either from anterior to posterior or vice versa. The aim of this study was to determine whether coronoid exposure-and the ability to place fixation from anterior to posterior-is improved via a lateral extensor-splitting approach with forearm supination, that is, the "spin move," with progressive stages of lateral elbow instability. METHODS The lateral extensor-splitting approach was performed on 9 cadaveric upper extremities. A 0.157-mm (0.062-inch) wire was drilled perpendicularly into the lateral aspect of the humerus just proximal to the lateral epicondyle. A second wire was drilled into the tip of the coronoid, aiming for a drill trajectory as close as possible to the midline axis. The angle between the 2 wires was measured as the initial angle. Three stages of progressive lateral elbow instability were produced by sequential release of the lateral ulnar collateral ligament (LUCL), common extensor origin (CEO), and posterior capsule. At each stage, the spin move was performed and the angle between the 2 wires was measured. The difference between this angle and the initial angle was calculated, with the average value reported as the Δ angle for each stage. The average difference between each stage and the next stage was reported. RESULTS The spin move resulted in Δ angles of 10.3° with the LUCL released, 20° with the CEO released, and 29.1° with the posterior capsule released. Progressing from LUCL release to CEO release to posterior capsule release, the Δ angle between the K-wires increased an average of 9.6° from the LUCL stage to the CEO stage and 9.1° from the CEO stage to the posterior capsule stage. CONCLUSION The spin move is a simple maneuver that can improve exposure of the coronoid process regardless of the degree of elbow instability. This may facilitate a more perpendicular screw, bone tunnel, or suture anchor trajectory via the lateral approach, reducing the need for posterior-to-anterior fixation. The improved exposure is inferred from the differences in the K-wire angles with and without the spin move. This study has also quantified the change in coronoid exposure using the angles of the wires with progressive release of the LUCL, CEO, and posterior capsule. If necessary, releasing the CEO or posterior capsule with eventual repair may allow improved coronoid fixation from the lateral approach.
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Affiliation(s)
- Sara L Low
- Orthopaedic Specialists-UPMC, UPMC Passavant-McCandless, Pittsburgh, PA, USA.
| | - Sean A Spence
- Orthopaedic Specialists-UPMC, UPMC Passavant-McCandless, Pittsburgh, PA, USA
| | | | - Mark E Baratz
- Orthopaedic Specialists-UPMC, UPMC Passavant-McCandless, Pittsburgh, PA, USA
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14
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Corbet C, Boudissa M, Dao Lena S, Ruatti S, Corcella D, Tonetti J. Surgical treatment of terrible triad of the elbow: Retrospective continuous 50-patient series at 2 years' follow-up. Orthop Traumatol Surg Res 2023; 109:103057. [PMID: 34536597 DOI: 10.1016/j.otsr.2021.103057] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 10/02/2020] [Accepted: 12/31/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Terrible triad (TT) of the elbow is an association at high risk of instability. Treatment aims to restore joint stability. Lateral collateral ligament (LCL) repair is systematic, whereas medial collateral ligament (MCL) repair is only exceptionally necessary. The main aim of the present study was to assess clinical results in TT surgery. The secondary objective was to compare clinical progression with versus without MCL repair. MATERIAL AND METHODS A retrospective study included 50 TTs operated on via an isolated lateral or combined medial-lateral approach. Clinical assessment comprised MEPS, QuickDASH, VAS, flexion-extension and pronation-supination, and return to work and sport. Subgroup analysis was made according to associated MCL repair. RESULTS Fifty patients (19 female, 31 male) were operated on between January 2006 and January 2017. Mean follow-up was 24 months. At last follow-up, mean MEPS was 89.1, VAS 0.7, QuickDASH 16, flexion-extension 114°, and pronation-supination 137°. Only MEPS was significantly improved by MCL repair (p=0.02), with no significant difference in complications. DISCUSSION TT surgery with immediate mobilization gave good long-term functional results, not significantly improved by MCL repair. The lateral approach should be adopted in first line, with the medial approach in second line in case of persistent instability after lateral osteo-ligamentous repair. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Clémentine Corbet
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France.
| | - Mehdi Boudissa
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | | | - Sébastien Ruatti
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | - Denis Corcella
- Service de Chirurgie de la Main et des Brûlés, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
| | - Jérôme Tonetti
- Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne, 38700 La Tronche, France
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15
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Blanco-Barrio A, Moreno-Pastor A, Lozano-Ros M. Fractures of the limbs: basic concepts for the emergency department. RADIOLOGIA 2023; 65 Suppl 1:S42-S52. [PMID: 37024230 DOI: 10.1016/j.rxeng.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/05/2022] [Indexed: 04/08/2023]
Abstract
Traumatic injuries of the limbs are very common and account for a large number of imaging examinations, especially in emergency departments. These injuries can often be resolved if they are recognized and treated appropriately. Their diagnosis requires a complete clinical assessment and the correct interpretation of the appropriate imaging tests. Radiologists play an important role, especially in diagnosing lesions that can go undetected. To this end, radiologists need to know the normal anatomy and its variants, the mechanisms of injury, and the indications for different imaging tests, among which plain-film X-rays are the main technique for the initial evaluation. This article aims to review the relevant characteristics of limb fractures in adults and of lesions that can be associated with these fractures, as well as how to describe them to ensure appropriate clinical management.
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Affiliation(s)
- A Blanco-Barrio
- Servicio de Radiodiagnóstico, Sección Radiología de Urgencias, Hospital Universitario Morales Meseguer, Murcia, Spain.
| | - A Moreno-Pastor
- Servicio de Radiodiagnóstico, Sección Radiología de Urgencias, Hospital Universitario Morales Meseguer, Murcia, Spain
| | - M Lozano-Ros
- Servicio de Radiodiagnóstico, Sección Radiología de Urgencias, Hospital Universitario Morales Meseguer, Murcia, Spain
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16
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Chiu YC, Wu CH, Tsai KL, Jou IM, Tu YK, Ma CH. Using an Internal Joint Stabilizer Through a Single Posterior Approach for Elderly Patients With Terrible Triad Injury. Geriatr Orthop Surg Rehabil 2023; 14:21514593231162193. [PMID: 36896295 PMCID: PMC9989442 DOI: 10.1177/21514593231162193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 03/08/2023] Open
Abstract
Introduction Treating a terrible triad injury of the elbow remains a challenge for orthopedic surgeons, especially in elderly patients due to the poor quality of the surrounding soft tissue and bony structures. In the present study, we propose a treatment protocol using an internal joint stabilizer through a single posterior approach and analyze the clinical results. Materials and Methods We retrospectively reviewed 15 elderly patients with terrible triad injuries of the elbow who underwent our treatment protocol from January 2015 to December 2020. The surgery involved a posterior approach, identification of the ulnar nerve, bone and ligament reconstruction, and the application of the internal joint stabilizer. A rehabilitation program was initiated immediately after the operation. Surgery-related complications, elbow range of motion (ROM), and functional outcomes were evaluated. Results The mean follow-up period was 21.7 months (range, 16-36 months). ROM at the final follow-up was 130° in extension to flexion and 164° in pronation to supination. The mean Mayo Elbow Performance Score was 94 at the final follow-up. Major complications included breaking of the internal joint stabilizer in 2 patients, transient numbness over the ulnar nerve territory in one, and local infection due to irritation of the internal joint stabilizer in one. Conclusions Although the current study involved only a small number of patients and the protocol comprised two stages of operation, we believe that such a technique may be a valuable alternative for the treatment of these difficult cases. Level of Clinical Evidence 4.
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Affiliation(s)
- Yen-Chun Chiu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chin-Hsien Wu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Kun-Ling Tsai
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - I-Ming Jou
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Ching-Hou Ma
- Department of Orthopaedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.,School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
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17
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Fallah Y, Baghianimoghadam B, Daneshi SA. Elbow dislocation with lateral condyle and coronoid fractures. Case Reports Plast Surg Hand Surg 2022; 9:185-188. [PMID: 35979195 PMCID: PMC9377225 DOI: 10.1080/23320885.2022.2109473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Elbow dislocations are simple or complex types. We introduce a patient with the elbow dislocation, lateral condyle fracture and coronoid fracture and their surgical management. This type of fracture is rare in adults. Particular attention should pay to coronoid fracture repair during the treatment.
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Affiliation(s)
- Yousef Fallah
- Department of Orthopedic Trauma Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Baghianimoghadam
- Department of Orthopedic and Trauma Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed-Aref Daneshi
- Department of Orthopedic Trauma Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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18
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Gonzalez LJ, Shields CN, Leucht P, Konda SR, Egol KA. Fracture-Dislocations of the Elbow: A Comparison of Monteggia and Terrible Triad Fracture Patterns. Orthopedics 2022; 46:158-163. [PMID: 36476213 DOI: 10.3928/01477447-20221129-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Fracture-dislocations of the elbow are a spectrum of injuries that have varying outcomes and complications, such as limited range of motion and long-term pain. The Monteggia fracture-dislocation and terrible triad fracture-dislocation are 2 such injury patterns that occur secondary to different mechanisms. This study sought to compare complication profiles and patient outcomes associated with these 2 distinct injury patterns. A retrospective chart review of all adult patients treated by 1 of 3 orthopedic traumatologists at a major academic center for operative fixation for either a Monteggia fracture-dislocation or a terrible triad elbow fracture-dislocation over a 12-year period was performed. Data collected included demographics, surgical data, patient-reported pain and elbow stiffness, elbow range of motion, presence of elbow joint contracture, nerve injuries, healing complications, and need for reoperation. The review included 105 patients, 58 with Monteggia injury and 47 with terrible triad injury, who had complete follow-up and radiographic imaging available. At latest follow-up, the 2 groups had similar rates of pain, reoperation, and ultimate elbow range of motion in flexion, extension, pronation, and supination. Elbow contractures requiring operative release were more commonly associated with terrible triad injury, and the incidence of nonunion was significantly greater in Monteggia fractures. A Monteggia fracture-dislocation portends a higher risk of ulna nonunion, whereas terrible triad injury is associated with elbow contracture. Despite their unique complications, both patterns ultimately have high rates of reoperation as their unique complications are both indications for operative repair. Patients should be appropriately counseled on the complication profile of their unique injury pattern. [Orthopedics. 202X;XX(X):xx-xx.].
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19
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VURAL N, DUYAN M. Bilateral Elbow Dislocation Without Fracture After Minor Trauma in a Healthy Adult Man. JOURNAL OF EMERGENCY MEDICINE CASE REPORTS 2022. [DOI: 10.33706/jemcr.1139501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The elbow is the second most frequently dislocated major joint in adults. Elbow dislocation is a common traumatic injury, occurring in approximately 20% of all joint dislocations. Falling onto an outstretched hand is the most prevalent cause of elbow dislocation. Simultaneous bilateral elbow dislocation is a rare presentation, and reports of similar injuries are very limited. A 21-year-old male patient was brought to the emergency department after landing on both hands with flexed elbows from a height of one meter while doing home decoration work. The posterolateral dislocations was detected in both elbows without a fracture on the plain radiographs. The patient's elbows were reduced under procedural sedation analgesia in the emergency department. The patient's splints were removed in the orthopedics outpatient clinic after a 2-week follow-up, and he had no complications. It should be noted that serious bilateral dislocations can occur even in minor traumas like this. Procedural sedation not only prevents the delay of the procedure and the occurrence of complications, especially during the treatment of such multiple dislocations, but also increases patient comfort.
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20
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Salazar LM, Koso RE, Dutta AK. Unique indications for internal joint stabilizer for elbow instability. J Shoulder Elbow Surg 2022; 31:2308-2315. [PMID: 35562031 DOI: 10.1016/j.jse.2022.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 04/01/2022] [Accepted: 04/09/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Treatment of elbow instability remains challenging despite advancements in surgical techniques. The objective of this study was to evaluate obesity, advanced age or frailty, and altered cognitive function (because of mental handicap, stroke, dementia, or traumatic brain injury) as unique indications for the use of the internal joint stabilizer (IJS) to augment surgical treatment of elbow instability. METHODS This was a retrospective review of all patients 18 years and older with elbow instability who were managed with an IJS along with standard measures of care for their specific injury, such as fracture fixation and collateral ligament reconstruction. Patients were excluded if they did not have a minimum follow-up of 3 months. All patients were treated by a single shoulder and elbow fellowship-trained orthopedic traumatologist at an urban university-based level 1 trauma center. RESULTS Twenty-two patients were included in the study. Five patients were 60 years of age or older. Nine patients had a body mass index of 30 or greater. Five patients had a history of 1 or more cerebral insults or cognitive impairment. The majority of patients (21/22; 95%) regained elbow stability after the index surgery. At last follow-up, 14 of 22 patients (63%) regained a functional arc of motion, defined as at least 100° arc of motion, and 77% of patients had at least 90° of motion. Complications requiring revision surgery included culture-negative recurrent elbow instability (n = 1), deep infection (n = 1), and IJS failure without recurrent instability (n = 1). The IJS was removed in all 3 cases. Twelve patients underwent delayed IJS removal >2 months after the index surgery to grant additional time for bony and ligamentous healing and to permit secondary contracture release at the time of IJS removal. No complications were seen from delayed IJS removal. CONCLUSION The IJS may be used to create elbow stability in complex patients, regardless of weight, frailty, cognitive function, neurologic insult, or other comorbidities. Unlike external fixation, the IJS does not require pin site care and is relatively light and low-profile. When augmenting surgical fixation for elbow instability, the IJS may be preferable for patients with complex comorbidities or social dynamics.
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Affiliation(s)
- Luis M Salazar
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA.
| | - Riikka E Koso
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
| | - Anil K Dutta
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
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21
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Chen J, Zhang W, Chen P. Three-dimensional printed bone cement prostheses can be used to treat bone defects in the distal humerus. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:584-591. [PMID: 37588462 PMCID: PMC10426601 DOI: 10.1016/j.xrrt.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Jiaxin Chen
- Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, China
| | - Wendong Zhang
- Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, China
| | - Pengtao Chen
- Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou, China
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22
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Blanco-Barrio A, Moreno-Pastor A, Lozano-Ros M. Fracturas de las extremidades: conceptos básicos para la urgencia. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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23
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Cooper TB, Luo X, Chen Y, Chen X, Yan H, Zhou F. Anteroposterior Cannulated Screw Fixation of Coronoid Fractures in Terrible Triad Injuries: A Simple Syringe-guided Technique. Orthop Surg 2022; 14:2591-2597. [PMID: 36065502 PMCID: PMC9531109 DOI: 10.1111/os.13463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 07/08/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The fixation of the coronoid fractures in terrible triad injuries is quite challenging. In this study, we introduce a minimally invasive technique using a syringe as a guide for insertion of the cannulated screw in an anterior to posterior fashion to fix the coronoid fracture in patients with terrible triad injuries. METHODS In this retrospective study, clinical data of patients suffering from terrible triad injuries between 2012 and 2019 were analyzed. Fifteen patients with an average age of 38.2 years old (21-56 years) were enrolled in this study, of which 12 were males and three were females. The Regan-Morrey type II and type III coronoid fractures in these patients were treated with cannulated screws, inserted anteriorly using a 1 mL syringe as a guide. Outcome measures included pain, range of motion, stability and daily function using Mayo Elbow Performance scores (MEPs). The anteroposterior and lateral radiographs were used for evaluating a healing fracture. RESULTS After a mean follow up of 44.2 months (range 13-80), the mean elbow flexion was 128.2°, extension was 12.3°, forearm pronation was 74.6° and supination was 73.6°. A concentric reduction was maintained without severe pain, stiffness, and radiographic evidence of instability in all patients during the follow-up period. The mean MEPs was 89.7 points. CONCLUSION The anteroposterior cannulated screw fixation via simple syringe guide is a minimally invasive and safe option for surgical treatment of coronoid fractures in terrible triad injuries.
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Affiliation(s)
- Tokai B Cooper
- Department of Orthopedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and YuYing Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaobin Luo
- Department of Orthopedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and YuYing Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yiheng Chen
- Department of Orthopedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and YuYing Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xinglong Chen
- Department of Orthopedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and YuYing Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hede Yan
- Department of Orthopedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and YuYing Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Feiya Zhou
- Department of Orthopedics (Division of Plastic and Hand Surgery), The Second Affiliated Hospital and YuYing Children's Hospital of Wenzhou Medical University, Wenzhou, China
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24
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Yan R, Wu Y, Xiang Z, Li S, Qi Y, Li H, Zhuang C, Feng G. A Novel Suture-Preset Spring Plate System (SSPS) for Comminuted Coronoid Process Fracture in the Elbow. Orthop Surg 2022; 14:2580-2590. [PMID: 36065574 PMCID: PMC9531073 DOI: 10.1111/os.13460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This study is aimed to investigate the clinical outcomes of a novel SSPS for fixation of the comminuted coronoid fracture. METHODS A retrospective study was carried out in the patients with comminuted fractures of the coronoid treated by SPSS fixation between January 2014 and December 2018. A total of 17 patients (17 sides) was included in our study, including 11 male and six female, with a mean age range from 18 to 60. All cases started to functional rehabilitation immediately after the operation. Clinical outcomes were evaluated both radiographically and functionally at the follow-up visit, including the elbow instability, range of motion and Mayo elbow performance score (MEPS). RESULTS According to the O'Driscoll classification system, there was two side of type 1.2, two of type 2.1, four of type 2.2, three of type 2.3, two of 3.1 and four of type 3.2. The surgery was carried out by Kocher and anteromedial approach in 12 patients, posterior and anteromedial approach in four, anterior approach in one. The average operation time and intraoperative blood loss was 129.41±43.87 min and 115.29±104.65 ml. The median follow-up time was 9 months (range, 6 to 15 months). The mean flexion, extension, pronation and supination motion was 138.76±8.67 degrees, 20.00±13.58, 82.94±5.32and 74.12±14.39 respectively at final follow up. The mean MEPS score was 89.76±8.46, including 11 excellent, 3 good and 3 fair result. The mean VAS score was 1.94±0.97. The mean union time of coronoid fractures was 2.77±0.31 months according to the established standard of healing. There were no significant differences in clinical outcomes among groups according to the O'Driscoll classification (P > .05) and ligament repair strategy (P > .05). No patient underwent instability or dislocation of the elbow during follow up. There were two cases with mild ulnar nerve symptoms which recovered totally at follow up. Meanwhile, there were three cases with heterotopic ossification of the elbow. CONCLUSION Our findings demonstrated that the SSPS can provide a reliable fixation for the comminuted coronoid fracture with satisfactory clinical outcomes.
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Affiliation(s)
- Ruijian Yan
- Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, China
| | - Yifan Wu
- Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, China
| | - Zhihui Xiang
- Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, China
| | - Sihao Li
- Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, China
| | - Yiying Qi
- Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, China
| | - Hang Li
- Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, China
| | - Chengyu Zhuang
- Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Gang Feng
- Department of Orthopedic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, China
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25
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Cengiz T, Aydın Ş, Erdoğan F, Mraja HM, Coşkun HS. The Terrible Triad of the Elbow Accompanied by Capitellum and Humerus Shaft Fracture: A Rare Case Report. Cureus 2022; 14:e27658. [PMID: 36072163 PMCID: PMC9440344 DOI: 10.7759/cureus.27658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
The terrible triad of the elbow consists of radial head fracture and coronoid process fracture in addition to posterior dislocation of the elbow. It indicates high-risk complications such as instability, malunion, nonunion, and proximal radioulnar synostosis. We describe a rare case that was admitted to the emergency service with a terrible triad of the elbow with additional capitellum fracture, lateral collateral ligament (LCL) injury, and ipsilateral humeral shaft fracture. We treated the patient urgently by performing osteosynthesis of the humeral shaft fracture, radial head fracture, coronoid fracture, capitellum fractures, and repair of the LCL rupture. The terrible triad of the elbow also can be accompanied by adjacent column fractures, including the humeral shaft. In such complex cases, preoperative planning should be done well, and the entire anatomy should be demonstrated with additional imaging. Optimal treatment of all the fractured bones and ligaments is critical for early rehabilitation. The main aim of surgery is to acquire desired results by starting an early rehabilitation, including joint movement.
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Li XY, Wang YL, Yang S, Han PF. 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. Exp Ther Med 2022; 24:592. [PMID: 35949335 PMCID: PMC9353546 DOI: 10.3892/etm.2022.11529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/01/2022] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Xi-Yong Li
- Graduate School, Changzhi Medical College, Changzhi, Shanxi 046000, P.R. China
| | - Yun-Lu Wang
- Graduate School, Changzhi Medical College, Changzhi, Shanxi 046000, P.R. China
| | - Su Yang
- Graduate School, Changzhi Medical College, Changzhi, Shanxi 046000, P.R. China
| | - Peng-Fei Han
- Department of Orthopedics, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi 046000, P.R. China
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Distal Radius Fracture with Ipsilateral Elbow Dislocation: A Rare but Challenging Injury. J Pers Med 2022; 12:jpm12071097. [PMID: 35887594 PMCID: PMC9320308 DOI: 10.3390/jpm12071097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022] Open
Abstract
Distal radius fractures are common and account for approximately 14% to 18% of all adult extremity injuries. On rare occasions, ipsilateral elbow dislocation can be observed additionally. However, this can be missed without careful examination, especially in patients experiencing altered mental status. The aim of this study was to analyze the mechanism, level of injury, demographics, and associated injuries in distal radius fracture with ipsilateral elbow dislocation. Between 2012 and 2019, we searched our trauma database for distal radius fracture with ipsilateral elbow dislocation. All patients older than 18 years old were included. Data on demographics, mechanism of injury, level of energy, and subsequent treatment were collected. A total of seven patients were identified. The mean age in this cohort was 68.7 ± 13.3 years old, and the left side was involved in 71.4% of the patients. Females were affected in 85.7% (n = 6/7) of cases, all of whom suffered from low-energy monotrauma at a mean age of 71.5 ± 12.3 years old. One male patient suffered from high-energy trauma (52 years old). Mainly, posterior elbow dislocations were observed (66.7%; n = 4/6). Distal radius fracture patterns, in accordance with the AO classification, included two C2-, two C3-, one C1-, and one B1-type fractures. In the patient suffering from high-energy trauma, the closed distal radius fracture was classified as type C3. Associated injures included open elbow dislocation, ulnar artery rupture, and damage to the flexor digitorum superficialis. Although distal radius fracture with ipsilateral elbow dislocation is thought to be from high-energy trauma, this study shows that most patients were elderly females suffering from low-energy mechanisms. It is important for clinicians to maintain a high level of suspicion for any concomitant injury in this population.
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Nitikman M, Kilb B, Mwaturura T, Pahuta M, Bicknell RT, Daneshvar P. The coronoid opening angle: a novel radiographic technique to assess bone loss in coronoid trauma. J Shoulder Elbow Surg 2022; 31:e302-e307. [PMID: 35121119 DOI: 10.1016/j.jse.2021.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 12/17/2021] [Accepted: 12/25/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Elbow fracture dislocations are complex injuries that often require surgical treatment in order to obtain a stable and congruent elbow joint. The coronoid plays a key role in the stability of this joint. Accurately identifying the degree of coronoid bone loss in the setting of traumatic elbow injuries is challenging. The purpose of this study is to describe a new radiographic measure, the coronoid opening angle (COA), to assist in estimating bone loss in these challenging fractures. METHODS Radiographs were drawn from a regional database in a consecutive fashion. Candidate radiographs were excluded on the basis of radiographic evidence of degenerative changes, previous surgery or injury, bony deformity, and inadequate lateral view of the elbow. Normal COA, coronoid height, and calculated COA at varying amounts of bone loss were determined by 3 reviewers. RESULTS A total of 120 subjects were included. The normal coronoid opening angle was 34° (95% CI 32.9°-34.0°) and the coronoid height, 18.8 mm (18.1-19.6). Ninety-five percent of the population had an opening angle greater than 29° (95% CI 27.2°-29°). The COA limit was calculated at 20%, 33%, and 50% of baseline coronoid height corresponding to degree of bone loss. Coronoid opening angles of 24°, 20°, and 16°, respectively, indicate the minimum bone loss of interest in 95% of the population. The intraclass correlation coefficient was found to be 0.89 or higher. CONCLUSION In the setting of elbow trauma, it is often challenging to predict the amount of coronoid bone loss. The coronoid opening angle is a new technique and an adjunct for lateral elbow radiographs to predict the minimum coronoid bone loss. This can be used to guide clinical decision making, aid in predicting instability, and guide treatment. Future research will aim to validate this tool in the clinical trauma setting.
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Affiliation(s)
- Michael Nitikman
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Brett Kilb
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Tendai Mwaturura
- Division of Distal Extremities, University of British Columbia, Vancouver, BC, Canada
| | - Mark Pahuta
- Department of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Ryan T Bicknell
- Department of Orthopaedic Surgery, Queen's University, Kingston, ON, Canada
| | - Parham Daneshvar
- Department of Orthopaedic Surgery, Queen's University, Kingston, ON, Canada.
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Makihara K, Takeda S, Mitsuya S, Yamauchi KI. Surgical fixation of ulnar coronoid process fractures via mesh plate: A case report. Trauma Case Rep 2022; 39:100634. [PMID: 35340356 PMCID: PMC8942840 DOI: 10.1016/j.tcr.2022.100634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction The coronoid process of the ulna is the primary stabilizer of the elbow joint. There has not yet been an accurate off-the-shelf dedicated implant because fragments of coronoid process fractures are often small and diverse. The variable angle locking compression mesh plate 2.4/2.7 (Depuy Synthes, West Chester, PA, USA) acts as a versatile, low-profile implant that can be cut to suit the specific fracture pattern and fits anatomically. Case presentations We report two cases of Regan–Morrey type II ulnar coronoid process fractures in terrible triad elbow injuries. In both cases, persistent instability was fluoroscopically diagnosed after repair of the lateral structures. We performed osteosynthesis for the ulnar coronoid process fractures using a mesh plate, which we cut into a rhombus-like shape and used as a buttress plate. Here we report the good results obtained thereof. Conclusion Considering our positive experience with using mesh plates, the mesh plate may be a good method of fixation for ulnar coronoid process fractures.
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Stambulic T, Desai V, Bicknell R, Daneshvar P. Terrible triad injuries are no longer terrible! Functional outcomes of terrible triad injuries: a scoping review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:214-218. [PMID: 37587961 PMCID: PMC10426592 DOI: 10.1016/j.xrrt.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background The terrible triad injury (TTI) of the elbow is a combination of a posterolateral dislocation of the elbow joint combined with fractures of the radial head and coronoid process most often caused by a fall on an outstretched hand. The injury pattern was named for its poor outcomes and high complication rates following surgical repair, but increased understanding of elbow anatomy and biomechanics has led to the development of standardized surgical protocols in an attempt to improve outcomes. Most existing literature on terrible triad injuries is from small retrospective cohort studies and surgical techniques to improve outcomes. Therefore, the purpose of this scoping review is to provide an overview of the functional outcomes, prognosis, and complications following current surgical treatment of TTIs. Methods A scoping review was performed to evaluate the literature. In total, 617 studies were identified and screened by 2 reviewers, with 43 studies included for qualitative analysis. These 43 studies underwent data extraction for functional outcomes using the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder, and Hand score (DASH) and were stratified accordingly. Secondary outcome measures assessed in the study were a range of motion (ROM) and complication rate. Results The average MEPS was 90 (excellent) from a total of 37 studies with 1609 patients, and the average DASH score was 16 from 16 studies with 441 patients. Another 6 studies with a total of 127 patients reported a mean Q-DASH score of 13. A total of 39 studies consisting of 1637 patients had a mean forearm rotation of 135 degrees, and 36 studies consisting of 1606 patients had a mean flexion-extension arc of 113 degrees. Among the studies, there was a 30% complication rate with a need for revision surgery in 7.8% of cases. The most common complications were radiographic evidence of heterotopic ossification (11%) and ulnar nerve neuropathy (2.6%). Discussion/Conclusions This study shows that current surgical treatment for terrible triad injuries has resulted in improved outcomes. Based on primary outcome measures using MEPS and DASH scores, almost all of the studies have highlighted good or excellent functional outcomes. This highlighted the marked improvement in outcome scores since the term was coined, suggesting that terrible triad injuries may no longer be so terrible.
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Affiliation(s)
| | - Veeral Desai
- School of Medicine, Queen's University, Kingston, ON, Canada
| | - Ryan Bicknell
- Department of Othopaedic Surgery, Queen's University, Kingston, ON, Canada
| | - Parham Daneshvar
- Department of Othopaedic Surgery, Queen's University, Kingston, ON, Canada
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Al-Ani Z, Tham JL, Ooi MWX, Wright A, Ricks M, Watts AC. The radiological findings in complex elbow fracture-dislocation injuries. Skeletal Radiol 2022; 51:891-904. [PMID: 34480618 DOI: 10.1007/s00256-021-03900-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/17/2021] [Accepted: 08/28/2021] [Indexed: 02/02/2023]
Abstract
Elbow fracture-dislocation is a complex injury which can lead to significant bony and soft tissue damage. Surgical intervention is guided towards restoring joint stability, allowing early mobilization and preventing long-term joint stiffness. The most common types are posterolateral, posteromedial, Monteggia type (and variants), and anterior trans-olecranon fracture-dislocations. Posterolateral fracture-dislocation is characterized by a radial head fracture (± anterolateral coronoid fracture) and typically capsuloligamentous disruption (lateral collateral ligaments injury is the most common). A posterolateral fracture-dislocation with radial head and coronoid anterolateral facet fractures is termed a terrible triad injury. In posteromedial fracture-dislocation, there is a fracture of the anteromedial facet of the coronoid, typically with proximal avulsion of the lateral collateral ligaments (± injury to the posterior bundle of the ulnar collateral ligament). Monteggia fracture-dislocation injuries demonstrate proximal ulnar fracture (with possible involvement of the olecranon and the coronoid) and radial head dislocation. These can be divided into apex anterior or apex posterior variants. The latter are commonly associated with radial head fractures and lateral ligamentous injury, and have a worse prognosis. In trans-olecranon fracture-dislocation, there is significant disruption of the greater sigmoid notch and the olecranon, with various involvement of the coronoid and the proximal ulna. The article describes the radiological findings and outlines the management principles in complex elbow fracture-dislocation injuries.
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Affiliation(s)
- Zeid Al-Ani
- Radiology Department, Wrightington, Wigan and Leigh NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN, UK.
| | - Jun-Li Tham
- Radiology Department, Wrightington, Wigan and Leigh NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN, UK
| | - Michelle Wei Xin Ooi
- Radiology Department, Wrightington, Wigan and Leigh NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN, UK
| | - Andrew Wright
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Matthew Ricks
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
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Lin KC, Lai WY, Yang YP, Lin YY, Lin TW, Wang CL, Tai HY, Tsai FT, Tsai YC, Tarng YW. Single pulley double-strand anchor suture fixation of the coronoid process in terrible triad of the elbow injury. J Chin Med Assoc 2022; 85:222-227. [PMID: 34643618 DOI: 10.1097/jcma.0000000000000633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Terrible triad of the elbow injury is difficult to manage, and the role of the coronoid process in instability is very important. We describe a simple, modified suture technique to fix a coronoid process fragment using suture anchor fixation. METHODS Eight patients (three female and five male) with coronoid process injuries with the fragment involving <50% of the total height (Regan-Morrey type I/II) in terrible triad of elbow injury were included. Patients were treated operatively via a lateral Kocher's approach, and coronoid process fractures were repaired with a single pulley double-strand suture technique. Structures were addressed in a sequential fashion-the coronoid process, radial head, lateral ulnar collateral ligament. RESULTS All patients were treated with the single pulley double-strand anchor suture technique and the coronoid process fragment was found to be in good contact with the original avulsion site using the method. The final Mayo Elbow Performance Score was excellent (> 90) in six patients and good (between 85 and 89) in two patients after operation 6 months. CONCLUSION The single pulley double-strand suture tie method using a suture anchor is a less invasive and simpler fixation method for the repair of coronoid process fractures in patients with terrible triad of the elbow injuries and results in good outcomes.
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Affiliation(s)
- Kai-Cheng Lin
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Wei-Yi Lai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yi-Ping Yang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yi-Yin Lin
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tzu-Wei Lin
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chia-Lin Wang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hsiao-Yun Tai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Fu-Ting Tsai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Ching Tsai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yih-Wen Tarng
- Department of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopaedics, National Defense Medical Center, Taipei, Taiwan, ROC
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Current concepts in diagnosis, classification, and treatment of acute complex elbow dislocation: a review. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Carroll PJ, Morrissey DI. Posterior (Boyd) approach to terrible triad injuries. JSES Int 2021; 6:315-320. [PMID: 35252933 PMCID: PMC8888163 DOI: 10.1016/j.jseint.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background A ‘terrible triad injury of the elbow’ (TTIE) refers to an injury pattern involving posterior dislocation of the ulnohumeral joint, fracture of the radial head, and fracture of the coronoid process of the ulna. It is a complex injury to the elbow joint and can result in long-term elbow instability, pain, stiffness, and arthritis. In specific cases, it may be treated conservatively, but in most circumstances, surgical stabilization is advised. The ‘drop sign’ is an objective static radiographically measured ulnohumeral distance of ≥4 mm seen intraoperatively and postoperatively. Although controversial, it may portend postoperative instability and arthritis. The senior author repairs these injuries in a standardized fashion through a modified Boyd rather than a lateral approach. Our aim was to assess the number of cases demonstrating an intraoperative drop sign after surgical treatment of a TTIE with this approach. Methods We retrospectively analyzed 22 consecutive patients with 23 acute TTIEs. These injuries were treated by a single surgeon using a modified Boyd (posterior) approach to the elbow. Intraoperative image intensifier x-rays were analyzed by the two authors to assess for a ‘drop sign’. Results None of the 23 cases had ‘drop signs’ on intraoperative imaging after stabilization. No patient has redislocated, underwent reoperation, or had symptoms of instability at follow-up. Conclusion None of our patient cohort had an intraoperative ‘drop sign’ after standardized stabilization for a TTIE injury using a modified Boyd approach.
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Du S, Wei L, He B, Fang Z, Zhou E, Ma X, Li J. Dynamic fixation using rigid tape in rehabilitation after surgery of terrible triad injury of the elbow: A randomized trial. J Back Musculoskelet Rehabil 2021; 34:957-964. [PMID: 34092597 DOI: 10.3233/bmr-200279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of the study was to identify the efficacy of dynamic fixation using rigid tape (RT) in rehabilitation after surgery of terrible triad injury of the elbow (TTIE). METHODS Sixty patients who underwent surgery of TTIE were equally randomly divided into RT group and hinged external fixation brace (HEFB) group. Dynamic fixations were applied for 8 weeks. General rehabilitation programs were performed for 3 months, 5 times a week. Follow-up (FU) was at six months. Main outcomes included pain (Visual Analogue Scale, VAS), muscle strength, range of motion (ROM), Elbow Function (Mayo Elbow Performance Index, MEPI), Quality of Life (QOL) (Short Form 36 Questionnaire, SF-36). RESULTS There were significant time x group interactions for pain, ROM, MEPI, SF-36 (all p= 0.000), which demonstrated positive efficacy of both the two interventions. Difference at each time-point (except for baseline) of pain and ROM between the two groups was statistically significant (all p< 0.05). Some differences between the two groups were not statistically significant which at 14d on MEPI (p= 0.108) and at 21d (p= 0.259) and FU (p= 0.402) on QOL. Moreover, the increased muscle strength at each time-point had no statistically significant difference between the two groups (all p> 0.05). CONCLUSIONS Both RT and HEFB could significantly improve the postoperative functional outcomes of the TTIE. However, early rehabilitation intervention could increase pain, which affected the corresponding function (MEPI) and QOL. Note that this kind of impact was short-term and reversible. The muscle strength and ROM were not affected by the increased severe pain, maintaining a trend of improvement. In addition, the subjects in the RT group improved faster and more efficiently and had better results with pain, ROM, MEPI, and QOL compared to the subjects in the HEFB group.
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Affiliation(s)
- Shenxing Du
- Department of Rehabilitation, Dongyang People's Hospital, Dongyang, Zhejiang, China
| | - Lihong Wei
- Department of Orthopedics, Dongyang People's Hospital, Dongyang, Zhejiang, China
| | - Bangjian He
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhen Fang
- Department of Rehabilitation, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Eryuan Zhou
- Department of Rehabilitation, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xiaoxiao Ma
- Department of Rehabilitation, Dongyang People's Hospital, Dongyang, Zhejiang, China
| | - Ju Li
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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Page RS, Paltoglou NG, Arora V, Eng K, Gill SD. Retrospective review of pyrocarbon radial head replacement. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:376-380. [PMID: 37588705 PMCID: PMC10426669 DOI: 10.1016/j.xrrt.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Radial head arthroplasty is the preferred surgical management for complex, unreconstructable radial head fractures. There has been increasing use of pyrocarbon prostheses, with potential tribology and modulus advantages over metallic counterparts. This study aims to assess clinical and radiological outcomes for radial head replacement after trauma using a modular, uncemented pyrocarbon prosthesis. Materials and Methods Between September 2009 and March 2020, a consecutive series of 22 trauma cases were available for review. Patients underwent radial head arthroplasty using a pyrocarbon prosthesis (Ascension Modular Radial Head System, Austin, TX). Recorded outcomes included clinical assessment, radiological evaluation, and patient-reported outcome measures specific to elbow function. Results Twenty-two patients (7 male, 15 female) with an average age of 51 years (range 21-64) were analyzed with a minimum 12 months of follow-up. All patients had complex radial head fractures, categorized as a Mason 3 or 4 injury. At follow-up, mean elbow range of motion included flexion 130° (range 100°-150°), extension 19° (0-50°), pronation 73° (30°-90°), and supination 70° (10°-90°). The mean Mayo Elbow Performance Index score was 83 (55-100), and Disabilities of the Arm, Shoulder and Hand score was 22 (2.5-60). Radiological evaluation showed 14 patients with asymptomatic proximal neck resorption and two patients with radiological stem loosening. In total, 3 of 22 implants were revised-2 were excised, and 1 revised to a long stem for traumatic implant fracture. Conclusion Pyrocarbon radial head arthroplasty provided reliable functional results for patients after unreconstructable radial head fracture. The unique potential for fracture of the prosthesis should be considered in long-term follow-up, with appropriate activity advice to patients.
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Affiliation(s)
- Richard S. Page
- Barwon Centre for Orthopaedic Research and Education (B-CORE), University Hospital Geelong, Geelong, VIC, Australia
- St. John of God Hospital Geelong, Geelong, VIC, Australia
| | - Nicholas G. Paltoglou
- Barwon Centre for Orthopaedic Research and Education (B-CORE), University Hospital Geelong, Geelong, VIC, Australia
- St. John of God Hospital Geelong, Geelong, VIC, Australia
| | - Varun Arora
- Barwon Centre for Orthopaedic Research and Education (B-CORE), University Hospital Geelong, Geelong, VIC, Australia
- St. John of God Hospital Geelong, Geelong, VIC, Australia
| | - Kevin Eng
- Barwon Centre for Orthopaedic Research and Education (B-CORE), University Hospital Geelong, Geelong, VIC, Australia
- St. John of God Hospital Geelong, Geelong, VIC, Australia
| | - Stephen D. Gill
- Barwon Centre for Orthopaedic Research and Education (B-CORE), University Hospital Geelong, Geelong, VIC, Australia
- St. John of God Hospital Geelong, Geelong, VIC, Australia
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Reichert ILH, Ganeshamoorthy S, Aggarwal S, Arya A, Sinha J. Dislocations of the elbow - An instructional review. J Clin Orthop Trauma 2021; 21:101484. [PMID: 34367909 PMCID: PMC8321949 DOI: 10.1016/j.jcot.2021.101484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 06/20/2021] [Indexed: 11/27/2022] Open
Abstract
Dislocations of the elbow require recognition of the injury pattern followed by adequate treatment to allow early mobilisation. Not every injury requires surgery but if surgery is undertaken all structures providing stability should be addressed, including fractures, medial and lateral ligament insertion and the radial head. The current concepts of biomechanical modelling are addressed and surgical implications discussed.
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Affiliation(s)
- Ines LH. Reichert
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Saurabh Aggarwal
- Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, UK
| | - Anand Arya
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
| | - Joydeep Sinha
- King's College Hospital, Denmark Hill, King's College Hospital NHS Foundation Trust, London, UK
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Zha YJ, Xiao D, Hua KH, Sun WT, Gong MQ, Li T, Chen C, Jiang XY. Lateral minimal approach to the terrible triad of the elbow: a treatment protocol in Beijing Jishuitan Hospital. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1232. [PMID: 34532369 PMCID: PMC8421974 DOI: 10.21037/atm-21-2542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/01/2021] [Indexed: 12/02/2022]
Abstract
Background This study aimed to report the surgical techniques and results of treating coronoid process and radial head fracture combined with dislocation of the elbow (terrible triad of the elbow) using a single lateral incision, known as the extensor digitorum communis (EDC) split approach. Methods A retrospective analysis was performed of 109 patients with terrible triad of the elbow who had been treated by the authors from January 2013 to December 2019. The participants included 67 males and 42 females, with a mean age of 42.2 years (14–71 years). All participants were treated via a single lateral approach. The coronoid process was fixated with Kirschner wires combined with anterior capsule suture lasso fixation. For the radial head fracture, 58 cases were fixated by AO headless cannulated screw (AO HCS) and 51 cases by acumed radial head replacement. In repair of the lateral collateral ligament (LCL) complex and the common extensor tendon, 28 cases used ETHIBOND suture through bone holes at the humeral lateral epicondyle, and the other 81 cases used suture anchors. No medial collateral ligament was repaired. A total of 46 participants were fixated with a Stryker dynamic joint distractor (DJD) II hinged external fixator to protect the bone and soft tissue. Results All participants were followed up from 6 to 60 months (mean, 36.1 months). Their elbow range of flexion and extension averaged 123.4°±20.7°, forearm rotation 151.0°±25.6°, and Mayo elbow performance score (MEPS) 92.3±8.8. There were 22 participants (19.5%) with ulnar nerve symptoms, 16 (14.7%) who had elbow stiffness, and 7 underwent secondary surgery, including 6 removals of internal fixation, 5 arthrolyses of the elbow, and 2 ulnar neurolyses. Conclusions Coronoid fractures, radial head fractures, and LCL injuries of the terrible triad of the elbow can be treated satisfactorily through a lateral minimal incision, combined with a hinged external fixation if necessary.
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Affiliation(s)
- Ye-Jun Zha
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, China
| | - Dan Xiao
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, China
| | - Ke-Han Hua
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, China
| | - Wei-Tong Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, China
| | - Mao-Qi Gong
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, China
| | - Ting Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, China
| | - Chen Chen
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, China
| | - Xie-Yuan Jiang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, China
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Rhyou IH, Lee JH, Cho CH, Park SG, Lee JH, Kim KC. Patterns of injury mechanism observed in terrible triad. J Shoulder Elbow Surg 2021; 30:e583-e593. [PMID: 33545337 DOI: 10.1016/j.jse.2020.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The purpose of this study was to classify the injury mechanism of terrible triad (TT) and suggest a treatment method according to the mechanism. MATERIALS AND METHODS Forty TTs with magnetic resonance imaging (MRI) scans and 3-dimensional computed tomography (3D CT) were enrolled. 3D CT scans of coronoid fractures were used for classifying into O'Driscoll type representing injury mechanisms and measuring sizes. In MRI scans, lateral collateral ligament complex (LCLC) injuries were classified into distraction (D) type caused by varus force and stripping (S) type caused by forearm external rotation force. Using these findings, possible injury mechanisms were speculated and classified into groups. Characteristic soft tissue injury patterns of collateral ligaments and overlying muscles, direction of dislocation in simple radiographs, and the amount of involvement of radial head fracture were investigated. Ulnar- and radial-side instabilities of soft tissues were newly defined and investigated. RESULTS There were 29 (73%) cases by posterolateral external rotation (PLER), 5 (13%) cases by posteromedial external rotation (PMER), and 6 (14%) cases by posteromedial internal rotation (PMIR). Simple radiographs showed all posterolateral dislocations in PLER TT compared to posteromedial or pure posterior dislocations in PMER or PMIR TT. Regarding LCLC and overlying extensor muscle, they were all completely torn with D type in all PLER compared to D type in PMER or PMIR. The ulnar collateral ligament was spared in 5 (17%) cases among 29 PLER in contrast to complete rupture in all PMER and PMIR. In PLER, PMER, and PMIR, involvement ratios of radial head fracture were 82% (range, 27%-100%), 61% (range, 25%-100%), and 61% (range, 25%-100%), respectively, and sizes of coronoid fractures were 7 mm (range, 1-14 mm), 6 mm (range, 2-11 mm), and 10 mm (range, 2-16 mm), respectively. In PLER, PMER, and PMIR, percentages of ulnar-side instabilities were 17%, 20%, and 17%, respectively, and those of radial-side instabilities were 59%, 60%, and 83%, respectively. CONCLUSIONS TT is caused by at least 3 mechanisms (PLER, PMER, and PMIR) with characteristic soft tissue injuries and fracture patterns. PLER is the main mechanism of injury. It is always observed in the form of posterolateral dislocation on simple radiographs compared with pure posterior or posteromedial dislocation of PMER or PMIR. It should be managed individually based on injury mechanisms presenting different instability patterns.
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Affiliation(s)
- In Hyeok Rhyou
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea.
| | - Jung Hyun Lee
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea
| | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sam-Guk Park
- Department of Orthopedic Surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Ji-Ho Lee
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea
| | - Kyung Chul Kim
- Department of Orthopaedic Surgery, Upper Extremity and Microsurgery Center, Pohang Semyeong Christianity Hospital, Pohang, Republic of Korea
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Al-Ani Z, Wright A, Ricks M, Watts AC. The three-column concept of elbow joint stability and the Wrightington elbow fracture-dislocation classification, emphasizing the role of cross-sectional imaging. Emerg Radiol 2021; 29:133-145. [PMID: 34403038 DOI: 10.1007/s10140-021-01978-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/08/2021] [Indexed: 11/28/2022]
Abstract
Elbow fracture-dislocation is a complex injury with a combination of osseous and soft tissue disruption. Different classification systems have been used to describe the injury pattern and help guide the management. The article describes the important cross-sectional findings in complex elbow fracture-dislocation injuries based on the relatively new Wrightington classification. This includes the various elements and patterns seen in elbow fracture-dislocations providing a simple and comprehensive system to classify these injuries and help guide the surgical management. The article also describes the three-column concept of elbow joint stability, dividing the elbow joint osseous structures into lateral, middle and medial columns. Detailed radiological assessment of the fractures pattern is vital to understand the mechanism of injury, allowing clinicians to predict the associated capsuloligamentous injury and help guide the management decisions. The Wrightington elbow fracture-dislocation classification categorizes the injuries according to the ulnar coronoid process and radial head fractures. Type A is an anteromedial coronoid fracture. Type B is a bifacet or basal coronoid fracture, with B + indicating associated radial head fracture. Type C is a combined anterolateral facet and radial head or comminuted radial head fractures. Type D is a diaphyseal ulnar fracture, with D + indicating associated radial head fracture.
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Affiliation(s)
- Zeid Al-Ani
- Radiology Department, Wrightington, Wigan and Leigh NHS Foundation Trust, Royal Albert Edward Infirmary, Wigan Lane, Wigan, WN1 2NN, UK.
| | - Andrew Wright
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Matthew Ricks
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
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Noorzad AS, Jelani Z, Rinaldi J, Abdie R, Zikria BA. Arthroscopic Repair of a Coronoid Process Fracture: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00069. [PMID: 35102029 DOI: 10.2106/jbjs.cc.20.00715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
CASE A 68-year-old woman sustained an isolated type III left coronoid fracture after mechanical ground-level fall. The patient underwent left elbow arthroscopy with minimally invasive arthroscopic reduction and internal fixation of the coronoid fracture using Arthrex Mini TightRope. The patient achieved successful elbow stabilization with a postoperative Mayo Elbow Score of 100. CONCLUSION We present a case report of a novel technique in coronoid fracture management with stable fixation, minimal soft-tissue violation, and restoration of highly functional elbow range of motion. Minimal soft-tissue violation with use of arthroscopy and suture button was the key element in successful surgical treatment and outcome.
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Affiliation(s)
- Ali S Noorzad
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Zohal Jelani
- University of San Francisco Fresno, Fresno, California
| | - Joseph Rinaldi
- Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
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Jung HS, Lee JS, Kim JY, Baek SH, Lee GY, Choi JH. Analysis of Fracture Characteristic and Medial Collateral Ligament Injury Relationships in Terrible Triad Elbow Injuries. J Hand Surg Am 2021; 46:713.e1-713.e9. [PMID: 33795153 DOI: 10.1016/j.jhsa.2021.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 11/09/2020] [Accepted: 01/20/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
| | - Jae Sung Lee
- Department of Orthopaedic Surgery, Seoul, Korea.
| | | | - Suk Ho Baek
- Department of Orthopaedic Surgery, Seoul, Korea
| | | | - Jin Hwa Choi
- Department of Radiation Oncology, Medical Center of Chung-Ang University School of Medicine, Seoul, Korea
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Antoni M, Mereb T, Ginot G, Meyer N, Clavert P. Prognostic factors for traumatic elbow osteoarthritis after terrible triad surgery, and functional impact. Orthop Traumatol Surg Res 2021; 107:102826. [PMID: 33516892 DOI: 10.1016/j.otsr.2021.102826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Maxime Antoni
- Pôle de chirurgie orthopédique et de traumatologie, service de chirurgie du membre supérieur, CHU de Strasbourg, Hôpital Hautepierre 2, avenue Molière, 67000 Strasbourg, France.
| | - Thomas Mereb
- Pôle de chirurgie orthopédique et de traumatologie, service de chirurgie du membre supérieur, CHU de Strasbourg, Hôpital Hautepierre 2, avenue Molière, 67000 Strasbourg, France
| | - Geoffrey Ginot
- Pôle de chirurgie orthopédique et de traumatologie, service de chirurgie du membre supérieur, CHU de Strasbourg, Hôpital Hautepierre 2, avenue Molière, 67000 Strasbourg, France
| | - Nicolas Meyer
- Pôle de santé publique, secteur méthodologie et biostatistiques, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - Philippe Clavert
- Pôle de chirurgie orthopédique et de traumatologie, service de chirurgie du membre supérieur, CHU de Strasbourg, Hôpital Hautepierre 2, avenue Molière, 67000 Strasbourg, France
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Ni Q, Yang X, Pan Z, Wang J. The pronator teres and the flexor carpi radialis interval approach for operative fixation of ulna coronoid process fractures. Orthop Traumatol Surg Res 2021; 107:102610. [PMID: 32418740 DOI: 10.1016/j.otsr.2020.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/15/2020] [Accepted: 04/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The optimal approach for the fixation of coronoid process fractures is unknown. We present the advantages and the clinical effect of the pronator teres and the flexor carpi radialis interval approach for the treatment of ulna coronoid process fractures. METHODS The patients, who had operative treatment of closed ulna coronoid process fracture by the pronator teres and the flexor carpi radialis interval approach between January 2011 to December 2016, were studied retrospectively. Seventeen consecutive patients had received surgical fixation by screws or a mini-plate through the above approach, of whom were 16 males and one female with an average age of 36.7 years (range, 21-58 years). There were 11 cases of type II and 6 cases of type III according to the O'Driscoll classification, of which, 6 patients had combined elbow dislocation, 2 patients showed elbow instability after fixation, and one had another incision to repair the lateral collateral ligament, and received a hinged external fixator. The other patient only received a hinged external fixator for 4 weeks. Mayo Elbow Performance Score (MEPS) was used to assess the function of elbow for each patient at the final follow-up. RESULTS Mean follow-up was 28.7 months (range, 24-38 months). Fracture union was achieved in each patient; the average time to radiologic union was 14.2 weeks (range, 12-16 weeks). At the final follow-up, the elbow extension degree of the affected side was (3.88±2.96°), reaching 98.1% of the normal side, and the flexion degree was (131.59±4.93°), reaching 98.16% of the normal side. The forearm pronation was (82.94±3.86°), reaching 94.31% of the normal side, and the supination activity was (82.12±3.82°), reaching 93% of the normal side. According to the MEPS, the functional recovery of the injured arm was assessed as excellent in 16 cases, and good in one. None of the patients showed any neurovascular or deep infections and no heterotopic ossification was found. CONCLUSIONS The pronator teres and the flexor carpi radialis interval approach has the advantages of simplicity, safety, minimal invasion, excellent exposure, and good postoperative function recovery for ulna coronoid process fracture.
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Affiliation(s)
- Qubo Ni
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuchang District, Wuhan 430071, China
| | - Xu Yang
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuchang District, Wuhan 430071, China
| | - Zhengqi Pan
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuchang District, Wuhan 430071, China
| | - Jianping Wang
- Department of Orthopaedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuchang District, Wuhan 430071, China.
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High-Energy Blast Injury Requiring Transradial Amputation with Associated Essex Lopresti and Terrible Triad Injuries of the Elbow: A Rare Presentation. Case Rep Orthop 2021; 2021:6645082. [PMID: 33763272 PMCID: PMC7952166 DOI: 10.1155/2021/6645082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/09/2021] [Accepted: 02/24/2021] [Indexed: 11/25/2022] Open
Abstract
Case Blast injuries to the upper extremity can be devastating and emotionally stressful injuries. We describe a case of a high-energy blast injury to an upper extremity from an explosive. The transfer of energy caused severe soft tissue/bony damage to the hand, but also led to associated Essex Lopresti and terrible triad injuries. The patient required emergent transradial amputation by hand surgery as well as definitive fixation by our orthopaedic team. Conclusion We describe a unique salvage operation that established forearm pronosupination, elbow flexion, and proper prosthetic fitting. We feel that describing our technique could help others in treating this injury if encountered.
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Oh WT, Do WS, Oh JC, Koh IH, Kang HJ, Choi YR. Comparison of arthroscopy-assisted vs. open reduction and fixation of coronoid fractures of the ulna. J Shoulder Elbow Surg 2021; 30:469-478. [PMID: 32750532 DOI: 10.1016/j.jse.2020.06.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE The purpose of this study was to compare clinical and radiographic outcomes and complications for arthroscopy-assisted vs. open reduction and fixation of coronoid fractures in patients with complex elbow fracture-dislocations. METHODS This retrospective study analyzed patients with complex elbow fracture-dislocations who underwent surgical fixation for coronoid fractures of the ulna from March 2009 to January 2016. Subjects included those who received either arthroscopy-assisted (group A) or open surgery (group O) for coronoid fractures and concurrent reconstruction of the lateral column (radial head and/or lateral ulnar collateral ligament) with follow-up for at least 2 years. Clinical outcomes were assessed using the visual analog scale for pain, range of motion, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder, and Hand score at 2 years after surgery. For radiographic assessment, union of the coronoid, development of heterotopic ossification, and arthritic changes were evaluated. We also reviewed surgery-related complications. RESULTS Twenty-five patients (mean age, 40.0 ± 12.4 years) were enrolled in this study (group A, 15 patients; group O, 10 patients), and there were no statistical differences in baseline data between the 2 groups. Clinical outcomes did not differ between the 2 groups. All fractures were united and that the prevalence of heterotopic ossification and arthritic changes were similar between the 2 groups. However, operation-related complications were more common in group O than in group A (group A, 13.3%; group O, 40.0%), including 1 patient who underwent ulnar nerve neurolysis and anterior transposition at 3 months after the initial operation. CONCLUSIONS Eliciting fewer complications, arthroscopy-assisted reduction and fixation of coronoid fractures shows union rates and clinical results comparable to open fixation in patients with complex elbow fracture-dislocation.
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Affiliation(s)
- Won-Taek Oh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Woo-Sung Do
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Jin-Chul Oh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Il-Hyun Koh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Ho-Jung Kang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea
| | - Yun-Rak Choi
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Republic of Korea.
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Results of standardized treatment of elbow fracture dislocations as per their injury pattern: a retrospective cohort of 89 patients. JSES Int 2021; 5:588-596. [PMID: 34136875 PMCID: PMC8178606 DOI: 10.1016/j.jseint.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Elbow fracture dislocations represent difficult injuries to treat, with a high percentage of complications. Classically, they are divided into posterolateral, posteromedial and transulnar pattern. It is essential to distinguish them to guide intraoperative treatment to achieve an anatomic and stable reduction that allows early mobility. Methods A retrospective study of 89 adult patients diagnosed with elbow fracture dislocations who underwent a standardized surgery between 2013 and 2018 with a minimum follow-up of 12 months. Demographic data, characteristics of the injury, and associated procedures were collected. Patients were evaluated with functional scores (Mayo elbow performance score/Broberg and Morrey score) and ranges of movement at the end of the follow-up. Results The mean age was 41 ± 12 years, mostly men (82%), with an average follow-up of 29 months. We present 42 patients with posterolateral fracture dislocation (47%), 21 posteromedial (24%) and 26 transulnar (29%). The average range of motion at the end of follow-up was −12 ± 11° extension, 124 ± 20° flexion, 76 ± 16° pronation, and 73 ± 20° supination, with a Mayo elbow performance score of 88.7 ± 12 points and 87.2 ± 12 points in the Broberg and Morrey scale. Reoperation rate was 23%, with no infection or heterotopic ossification cases. Transulnar fracture dislocations have significantly worse extension and supination. As per the functional result (Mayo elbow performance score/Broberg and Morrey scale), there are no significant differences between the different patterns. Conclusion Proper injury pattern recognition and a standardized surgical management lead to a stable joint and good results in range of motion. Functional results are encouraging at least at short term, despite the high reoperations rate.
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Almalki T, AlMarshad AY, Beidas K, Alshurafa K, Al Bassam H. Surgical management of medial and lateral elbow instability secondary to acute atypical complex elbow dislocation: Case report and literature review. Int J Surg Case Rep 2021; 79:222-226. [PMID: 33485170 PMCID: PMC7820299 DOI: 10.1016/j.ijscr.2021.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/06/2021] [Accepted: 01/09/2021] [Indexed: 11/30/2022] Open
Abstract
The patient presented with an atypical complex elbow dislocation with fracture. The patient underwent lateral collateral ligament repair. The patient also underwent medial collateral ligament reconstruction. Elbow stability improved and the patient experienced improved functionality. Care is needed to identify and manage the underlying injury in this type of case.
Introduction and importance Elbow dislocation is common in adults, and complex elbow dislocations are generally associated with bone fractures. Anteromedial coronoid fracture, in association with lateral collateral ligament (LCL) disruption, often results from varus posteromedial forces. “Terrible triad” injuries are more likely to result from valgus posterolateral forces. However, our case presentation has combined medial and lateral elbow instability in addition to “terrible triad” injury of the elbow with no radial head injury. Case presentation The patient was a 38-year-old man with an atypical complex elbow dislocation. He was successfully treated by stabilizing the medial epicondyle and coronoid anterolateral facet fractures, in addition to LCL repair and medial collateral ligament (MCL) reconstruction. A radial head fracture was unnoted. The procedure yielded satisfactory functional outcome, with a stable and painless full elbow range of motion. Clinical discussion Multi-ligament injuries with coronoid fractures result in highly unstable elbow joints, forming a variant of the “terrible triad” injury. Surgical options vary according to the surgeon’s experience and equipment availability. In this case, direct LCL repair and MCL reconstruction were performed and were well tolerated. Elbow stability improved and the patient experienced improved functionality with minimal pain. However, it may be premature to report a definite outcome in this case because of short follow-up time postoperatively. Conclusion The injury described in this case has a unique presentation as a multi-ligamentous injury will make the elbow very unstable. Thus, careful clinical judgment, knowledge, and experience are needed to identify the underlying injury and for optimal management.
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Affiliation(s)
- Talal Almalki
- Security Forces Hospital Program, Department of Orthopedics, Riyadh, Saudi Arabia
| | - Abdullah Y AlMarshad
- King Faisal Specialist Hospital and Research Centre, Department of Orthopedics, Riyadh, Saudi Arabia.
| | - Khalid Beidas
- Security Forces Hospital Program, Department of Orthopedics, Riyadh, Saudi Arabia
| | - Khaled Alshurafa
- Prince Muhammad Bin Abdul-Aziz, Department of Orthopedics, Riyadh, Saudi Arabia
| | - Hamad Al Bassam
- Ministry of Health, Department of Emergency Medicine, Saudi Arabia
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Shinohara I, Takahara S, Uefuji A, Inui A, Mifune Y, Ichimura K, Nishihara H, Kishimoto K, Aoki K, Takayama H, Nakagawa N, Harada T. Floating forearm associated with terrible triad injury and Essex-Lopresti injury: a case report and literature review. JSES Int 2020; 5:320-327. [PMID: 33681857 PMCID: PMC7910748 DOI: 10.1016/j.jseint.2020.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Issei Shinohara
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan
| | - Shunsuke Takahara
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan
| | - Atsuo Uefuji
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan
| | - Atsuyuki Inui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yutaka Mifune
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Katsuhito Ichimura
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan
| | - Hirotaka Nishihara
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan
| | - Kenta Kishimoto
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan
| | - Kenji Aoki
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan
| | - Hiroyuki Takayama
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan
| | - Natsuko Nakagawa
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan
| | - Toshihiko Harada
- Department of Orthopaedic Surgery, Hyogo Prefectural Kakogawa Medical Center, Hyogo, Japan
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50
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Hou F, Liang X, Fan W, Zhao F, Li D. Analysis of twenty-five cases of terrible triad injury of the elbow surgically treated with a single lateral approach. INTERNATIONAL ORTHOPAEDICS 2020; 45:241-246. [PMID: 33230605 DOI: 10.1007/s00264-020-04891-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Fushan Hou
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan, 030001, Shanxi, People's Republic of China
| | - Xiao Liang
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan, 030001, Shanxi, People's Republic of China
| | - Wei Fan
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan, 030001, Shanxi, People's Republic of China
| | - Feng Zhao
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan, 030001, Shanxi, People's Republic of China
| | - Dong Li
- Department of Orthopedics, The Second Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan, 030001, Shanxi, People's Republic of China.
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