[Treatment of the old terrible triad of the elbow without operative history]

Y J Zha, X Y Jiang, M Q Gong
Beijing da Xue Xue Bao. Yi Xue Ban, Journal of Peking University. Health Sciences 2016 April 18, 48 (2): 224-9

OBJECTIVE: To introduce the surgical techniques and treating results of the old "terrible triad" of the elbow.

METHODS: A retrospective analysis of 11 cases of old "terrible triad" of the elbow treated by the author from March 2009 to February 2014 were performed, with 9 males and 2 females; mean age was (31.82±8.66) years (17-45 years). The average time after injury was (6.36±2.50) weeks (4-12 weeks), with 7 cases on the left and 4 right. The combined injury included 2 cases with distal radius fractures, 1 with ankle fractures, fractures of the distal radius and the head injury (minor epidural hematoma, no surgery), and 1 with Pilon fractures and L4 fractures (fixed at local hospital). All the patients had elbow stiffness and joint dislocation, and 2 patients had symptoms of ulnar nerve. Mason classification of radial head fractures: 2 cases were type I, 5 were type II, 4 were type III. Classification of the coronoid process: Regan & Morrey: 1 was type I, 10 were type II; according to O'Driscoll classification, all the fractures were tip fracture, one was the first subtype, 10 were the second subtype. The elbow were released, the coronoid process were fixed by lasso suture combined with Kirschner wires. Radial head fractures were resected in 1 case, and replaced in 1 case, 3 cases with no treatment, 6 cases with osteotomy and 3.0 mm headless compression screw (HCS) fixation. The lateral collateral ligament complex and the common extensor tendon were repaired to the humeral lateral epicondyles, No.2 Ethibon was used in 2 cases through bone holes, and suture anchorsin the other 9 cases. All the patients were fixed by Stryker DJD II hinged external fixator to protect the bone and soft tissue.

RESULTS: The average follow-up time was (38.36±21.92) months (19-77 months). All the patients had no obvious pain, instability and ulnar nerve symptoms in the last follow-up. The average elbow flexion was 134.09°±12.41° (100°-140°), average extension was -15.91°±14.46 ° (-40°-0°), range of flexion and extension was 118.18°±23.80° (70°-140°). Average pronation was 70.91°±26.63° (20°-90°), supination was 70.91°±26.63° (20°-100 °). The range of motion (ROM) of forearm rotation was 150.91°±43.00° (40°-180°). Average Mayo elbow performance score (MEPS) was 96.36±5.04 (85- 100).X-ray showed that no degenerative changes. Five patients had heterotopic ossifications, according to Hastings and Graham grading: 1 case was grade I, 3 cases were grade IIA, 1 case was IIB.

CONCLUSION: The old "terrible triad" of elbow with no operative history is difficult to treat. The elbow's functions and stabilization can be recovered by thorough elbow release, repair of coronoid process and anterior capsule, radial head fractures, lateral collateral ligament and the common extensor tendon insertion, combined with hinged external fixator. Joint stiffness and heterotopic ossification are common complications.

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