In: Jungbluth P, Frangen TM, Arens S, Muhr G, Kälicke T. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. The elbow dislocation is a frequent and an easily diagnosed pattern, at the opposite of the DRUJ dislocation, which is often missed in the emergency department if an adequate physical exam with the appropriate radiographs is not carried out [3]. The elbow is a 3-dimensionally complex joint where stiffness is poorly tolerated and instability is devastating. A sling was used for comfort for 2 weeks postoperatively with physiotherapy and ROM exercises initiated early. Surgical management is quite standardized according to Pugh et al. It is a complex trauma, associating … The aim is a stable concentrically guided elbow with early functional follow-up treatment. The case was managed with closed reduction of the elbow dislocation and distal radioulnar joint followed by open reduction and repair of the damaged structures in the elbow and an unloading of the interosseous membrane. 2013. The origins of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) complexes avulse from the epicondyles and the anterior capsule fails with a transverse fracture of the coronoid tip. 'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. Terrible; elbow; fracture; instability; triad. This may be done as below, or in a hinged range of motion brace or x-fix if applied. The terrible triad of the elbow is posterior or posterolateral dislocation of the ulnohumeral joint with fractures of the radial head and coronoid process.  |  (iii) The stability of the elbow is assessed; if still unstable, a hinged external fixator or repair of the MCL is discussed. should instability persist after addressing the radial head and the LCL complex in the presence of a small coronoid fracture, the next best step is MCL reconstruction. This site needs JavaScript to work properly. The syndrome of “terrible triad of the elbow”, which was first described by Hotchkiss in 1996 1 , is a severe pattern of elbow fracture‐dislocation injury that consists of posterior dislocation of the elbow associated with fractures of the radial head and the coronoid process of the ulna. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. No similar case has been found in the literature review. Zhongguo Gu Shang. NLM In some accidents, the elbow dislocates (the radius and ulna are pulled apart from the humerus) without any bones breaking; surgeons call this injury a “simple dislocation”. The stability was rechecked and upgrade of the stable range of motion (ROM) was assessed, the elbow was now stable from −20° extension to complete flexion. Initial lateral radiographs requested by the emergency doctor focused on the elbow and showed a posterior dislocation of the right elbow with a type II Mason radial head fracture with a small detached fragment <20%, associated to a proximal radioulnar joint (PRUJ) dislocation and a coronoid fracture type 2 according to the O’Driscoll classification with an anterior avulsion of an anteromedial coronoid small fragment (Fig. Following radial head replacement or ORIF the LCL should be repaired to the lateral condyle using suture anchors or transosseous sutures (Figs. Correspondence address. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Related Content AUTOPLAY ON. A computed tomography (CT) confirmed the stage 2 coronoid process fracture and a partial radial head fracture, the PRUJ dislocation was also demonstrated (Fig. When the radial head fracture is accompanied by an interosseous membrane lesion affecting the distal radioulnar joint (DRUJ), it is given the name Essex-Lopresti injury [ 4 ]. - Terrible triad injury of the elbow: how to improve outcomes? Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Characteristics/Clinical Presentation 2020 Oct 29;9(11):3500. doi: 10.3390/jcm9113500. Fractures and dislocations of the elbow.  |  In the past, most of these injuries were treated by manipulative reduction and cast immobilization. Mid-Term Postoperative Outcomes Following a Standardized Protocol. Treatment of terrible triad injuries at a mean follow-up of nine years. Development of a novel real-time simulation of human skeleton/muscles. Faculté de Medecine et de Pharmacie de Marrakech. Treatment: Open reduction and hinged external fixation . We used a TightRope device to stabilize the DRUJ as this tool enables forearm good ROM at the beginning of physical therapy, and there is no need to remove the device. Chan K, MacDermid JC, Faber KJ, King GJ, Athwal GS. Anteroposterior X-ray of the wrist showing the DRUJ reduction and the TightRope stabilization. [Progress in treatment of terrible triad of elbow]. Six months after the accident, the patient made a good recovery. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Shoulder Elbow. Keywords: An elbow dislocation associated with a displaced fracture of the radial head and coronoid process almost always renders the elbow unstable, making surgical fixation necessary. 3D reconstruction CT scan of the elbow shows a radioulnar proximal dislocation with O’Driscoll type 2-2 anteromedial fracture. 2014 Jul;472(7):2084-91. doi: 10.1007/s11999-014-3471-7. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications … 3). 2014 Jul;472(7):2092-9. doi: 10.1007/s11999-014-3518-9. Cervical kyphosis: A predominant feature of patients with osteogenesis imperfecta type 5. "Terrible Triad" injury describes unstable joint consisting of: Elbow dislocation; Radial head fracture; Coronoid fracture; Clinical Features. Watters TS, Garrigues GE, Ring D, Ruch DS. 2013 Apr;27(4):496-9. Stable elbow, > 100 degrees motion in all patients In our case, the testing showed a stable elbow, so we decided not to fix the coronoid fracture furthermore that it was a small anteromedial fragment stage 2 according to the O’Driscoll classification. Tel: +212615994028; E-mail: Search for other works by this author on: Complex elbow dislocations and the “terrible triad” injury, An uncommon Essex-Lopresti fracture dislocation with radial displacement in distal direction: diagnosis and surgical treatment of a rare case, Longitudinal instability of the forearm: anatomy, biomechanics, and treatment considerations, Nonsurgically treated terrible triad injuries of the elbow: report of four cases, Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures, Terrible triad of the elbow: treatment protocol and outcome in a series of eighteen cases. Surgical technique - Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People's Hospital. The 'terrible triad of the elbow' refers to a combination of elbow dislocation and radial head and coronoid process fracture - it is notoriously difficult to manage although a systematic review found that whilst complications are common, functional outcomes are generally satisfactory . We present a particular case by the unique association of two rare injuries: a terrible triad of the elbow and an ipsilateral Essex-Lopresti entity. The “terrible triad of the elbow” is a notorious combination of elbow dislocation and fractures of the coronoid process and radial head that has historically been difficult to manage and had an unsatisfactory prognosis 36-38, almost unavoidably causing long‐standing postoperative pain, elbow instability and a range of complications. Therefore, the preferred surgical treatment options in the setting of terrible triad injuries include … 1B). Joaquin Sanchez-Sotelo. 1 Introduction Fracture dislocation of the elbow , termed terrible triad , involves three anatomic injuries: coronoid fracture, radial head fracture , and posterior elbow dislocation. Distal arm pain should not simply be dismissed as referred pain [5]. The distal radioulnar dislocation should also be reduced by placing the forearm in maximum supination and stabilized either with a brachiopalmar splint, a percutaneous Kirschner wire, repairing the triangular ligament or the central band of the interosseous membrane [10]. A terrible triad combines three injuries: dislocation of the elbow, fracture of the radial head, and fracture of the coronoid. In the elbow with persistent instability after repair of these elements, application of a static external fixation, hinged external fixation, ulnohumeral joint pinning, or an internal hinge … Click here to Login. NIH The treatment of terrible triad injuries of the elbow continues to evolve. Terrible triad … For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Does the Coronoid Always Need to Be Fixed in Terrible Triad Injuries of the Elbow? Pre-operatively on the ward • Discuss post -operative rehab ’ Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Zhou C, Lin J, Xu J, Lin R, Chen K, Sun S, Kong J, Shui X. Med Sci Monit. We managed a surgical treatment the second day of admission. Free active assisted flexion, free extension to -30 deg off full extension, lying with shoulder 90 deg of abduction. In patients who undergo treatment after the acute injury period, the coronoid may require reconstruction using radial head autograft, iliac crest autograft, olecranon autograft, or allograft. Please enable it to take advantage of the complete set of features! National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. There was mild widening of the DRUJ with significant ulnar negative variance (Fig. A high index of suspicion with a detailed examination of the elbow, forearm and wrist associated to a comprehensive imaging were mandatory for a complete diagnosis and an adequate treatment.  |  The Essex-Lopresti refers to an association of a radial head fracture dislocation, an interosseous membrane rupture and a DRUJ dislocation [3]. Elbow dislocations are staged depending on the disruption of the following stabilizers: the ulnohumeral articulation, MCL, and LCL. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. 2018 Jul;10(3):216-222. doi: 10.1177/1758573217713694. Consequently, each time a radial head fracture associated or not to an elbow dislocation is diagnosed, an ipsilateral wrist examination is mandatory to diagnose an Essex-Lopresti injury; otherwise, chronic wrist symptoms can develop, such as pain and instability [4]. Can we treat select terrible triad injuries nonoperatively? Clinical assessment of the post-operative ROM (A and B). Published by Elsevier Inc. All rights reserved. Whereas the importance of early recognition of neurovascular compromise is well described and nearly universally recognized, the importance of timely and correct treatment in preventing delayed complications and potential instability is often less emphasized in the radiology literature. Understanding the Algorithm for surgical treatment of terrible triad elbow injuries. 2014 Jul;472(7):2128-35. doi: 10.1007/s11999-013-3331-x. Romero Pérez B, Marcos García A, Medina Henríquez JA, Muratore Moreno G. Oxford University Press is a department of the University of Oxford. Closed reduction of the DRUJ was achieved but it was instable, a fixation with a TightRope was used (Fig. 5 patients: dislocated for 2 to 9 months . - Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. With recent developments in pathology, anatomy and biomechanics of the elbow … Zakaria Ramzi, Jordi Juanos Cabans, Harold Jennart, Terrible triad of the elbow with an ipsilateral Essex-Lopresti injury: case report, Journal of Surgical Case Reports, Volume 2020, Issue 6, June 2020, rjaa103, https://doi.org/10.1093/jscr/rjaa103. The terrible triad of the elbow and the Essex-Lopresti are two rare injuries but their association is unique [1, 2]. © The Author(s) 2020. Early management is a favourable prognostic factor for final outcome. Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. 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