[Operative treatment of terrible triad of the elbow]

Shuo Chen, Fuguo Huang, Xiaochuan Hu, Shiqiang Cen, Zhou Xiang
Chinese Journal of Reparative and Reconstructive Surgery 2009, 23 (1): 45-8

OBJECTIVE: To retrospectively reviewed the operative therapy of the terrible triad of the elbow.

METHODS: From October 2003 to September 2007, 10 cases of terrible triad were treated, with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. There were 3 males and 7 females with the age of 18-66 years. The injury was caused by traffic accidents in 4 cases, falling from a height in 4 cases, and tumbling in 2 cases. The coronoid process fractures of the patients were 5 cases of type I, 3 cases of type II and 2 cases of type III according to Regan-Morrey classification. The radial head fractures of the patients were 1 case of type I, 6 cases of type II and 1 case of type III according to Mason classification, and their radial heads of the other 2 patients were resected before they were in hospital. The general approach was to repair the damaged structures sequentially from deep to superficial, from coronoid to anterior capsule to radial head to lateral ligament complex to common extensor origin. And selected cases were repaired of the medial collateral ligaments and assisted mobile hinged external fixation to keep the forearm fixed in functional rotation position. The function of the elbows were evaluated with the criteria of the HSS2 score system.

RESULTS: The other wounds healed by first intention except 1 case which had infection 7 days after operation and whose soft tissue defect in posterior elbow were repaired with the pedicle thoracoumbilical flap. The patients were followed up 6 to 51 mouths (mean 24.9 mouths). The fracture healing time was 6 to 20 weeks (mean 9.6 weeks). Six mouths postoperatively, the mean flexion-extension arc of the elbow was 106.5 degrees (85-130 degrees), and the mean pronation-supination arc of the forearm was 138 degrees (100-160 degrees) respectively. According to the criteria of the HSS2 score, the results were excellent in 4 cases, good in 4 cases, and fair in 2 cases. No complications such as stiffness and ulnohumeral arthrosis occurred. The radial nerve injury was found in 1 patient 1 day after operation who was treated with neurolysis, and the nerve function was recovered after 4-6 months. And heterotopic ossification occurred in 6 patients 6 months after operation and radiographic subluxation developed in 1 patient 36 months after operation, and conservative treatment were given.

CONCLUSION: The terrible triad of the elbow can lead to serious elbow instability and should be treated with operation to restore the anatomic structures, to repair the articular capsule and the collateral ligament, using the adjuvant hinged external fixation and early exercise to avoid immobilization and recover the articular function.

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