Management of the Terrible Triad Injury of the Elbow: A Case Series Retrospective Review

Authors

  • Carmen Cruz-Calvente Service of Rehabilitation and Physical Medicine, University Health Complex of Salamanca
  • Javier Nieto-Blasco Head of the Service of Rehabilitation and Physical Medicine, University Health Complex of Salamanca
  • Marcos E. Fernández-Cuadros Service of Rehabilitation and Physical Medicine, Santa Cristina University Hospital, Madrid, Service of Rehabilitation and Physical Medicine, Santísima Trinidad Hospital Foundation, Salamanca
  • Pelayo Fernández-Palacio Service of Rehabilitation and Physical Medicine, University Health Complex of Salamanca
  • Javier García-García Service of Orthopedic Surgery and Traumatology, University Health Complex of Salamanca
  • Juan Fco Blanco-Blanco Service of Orthopedic Surgery and Traumatology, University Health Complex of Salamanca

DOI:

https://doi.org/10.12974/2313-0954.2016.03.02.3

Keywords:

Dislocation, elbow, fracture, terrible triad, rehabilitation.

Abstract

Objectives: To expose our experience in the multidisciplinary management of patients with terrible triad injury of the elbow (TTIE) treated in our hospital.

Material and methods: A descriptive-retrospective study including all patients with TTIE treated surgically between January/2008-December/2014.

The analyzed variables were demographic, etiologic, type of fracture (Mason, Reagan and Morrey Scale), type of surgery/approaching technique, time between injury-surgery, immobilization period, range-of-movement (ROM) before/after treatment, and complications.

An assessment before/after the treatment using analogical visual scale (AVS), goniometry and Mayo Elbow Performance Index (MEPI) was carried out.

Results: A total of 12 patients were included. The most common cause was accidental fall (75%). All fractures were surgically treated (mean 4.6 days after injury) with subsequent detention (29 days average). The surgical approach was lateral (n=8), posterior (n=2), and both lateral and medial (n=2).

The increase in the flexion/extension ROM was 27.27º/24.09º, in pronation/supination was 23.65º/23.9º. The initial/final AVS was 4.46/2.16. In MEPI scale, 9 patients had excellent-good results, 2 regular, and one underwent bad response. Only one patient had complications during the follow up period.

All patients were treated surgically promptly and immobilized for a month. As the MEPI states, the results of our series are acceptable. This is in accordance with present day reports.

Conclusions: The clinical results of the series are consistent in relation to the literature. The results suggest that an integral, multidisciplinary approach (surgical and rehabilitation) for the TTIE must be achieved. Despite the small series and the infrequent appearance of the pathology, no cases were lost during the study. 

References

Morrey BF. Current concepts in the management of complex elbowtrauma. Surgeon 2009; 7(3): 151-61. http://dx.doi.org/10.1016/S1479-666X(09)80039-5

Chan K, Graham Kingi J, Kenneth W and Faberi J. Treatment of complex elbow fracture-dislocations. Curr Rev Musculoskelet Med 2016; 9: 185-189. http://dx.doi.org/10.1007/s12178-016-9337-8

Pike JM, Athwal GS, Faber KJ and King GJ. Radial head fractures-an update. JH and Surg Am 2009; 34(3): 557-65. http://dx.doi.org/10.1016/j.jhsa.2008.12.024

Kuschner SH, Sharpe F and Elbow Dislocations. In: Baker CL, Plancher KD, editors. Operative Treatment of Elbow Injuries. New York: Springer Verlag 2002; 253-8. http://dx.doi.org/10.1007/b97243

Chemama B, Bonnevialle N, Peter O, Mansat P and Bonnevialle P. Terrible triad injury of the elbow: How to improve outcomes? Orthop Traumatol Surg Res 2010; 96: 147-154. http://dx.doi.org/10.1016/j.otsr.2009.11.009

Rommens PM, Küchle R, Schneider RU and Reuter M. Olecranon fractures in adults: factors influencing outcome. Injury 2004; 35(11): 1149-57. http://dx.doi.org/10.1016/j.injury.2003.12.002

Barcelona Aparición, Gomá Alonso M, Miralles Rull I and MontullMorer S. Tratamiento fisioterapéutico de la rigidez de codo. Fisioterapia1999; 21: 2-9.

Rivera-Garcia VE, Geanini-Yagüez A, Martin-Fraile ME, Idoate-Gil A and Díaz-González P. Valoración functional de la fractura-luxación de codo. Rehabilitación (Madr) 2000; 34(5): 354-358.

Macdermid JC, Vicent JI, Kieffer L, Kieffer A, Demaiter J and Macintosh S. A survey of practice patterns for rehabilitation post elbow fracture. Open Orthop J 2012; 6: 429-39. http://dx.doi.org/10.2174/1874325001206010429

Wang YL, Chang WN, Hsu CJ, SUN SF, Wang JL and Wong CY. The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children. J OrthopTrauma 2009; 23(2): 120-5. http://dx.doi.org/10.1097/BOT.0b013e318193c2f3

Uresh S. Type 4 Capitellum fractures: Diagnosis and treatment strategies. Indian J Orthop 2009; 43(3): 286-91. http://dx.doi.org/10.4103/0019-5413.53460

Morrey BF and O’Driscoll SW. Fractures of the coronoid and complex Instability of the Elbow. In: Morrey BF, editor. Master Techniques in Orthopaedic Surgery: The Elbow. 2nd ed. Philadelphia: Lippincott Williamsand Wilkins 2002; 128-38.

Brigato RM, Mouraria GG, Kikuta FK, Coelho SP, Cruz MA and Zoppi Filho A. Functional evaluation of patients with surgically treated terrible triad of the elbow. Acta Ortop Bras.

[online] 2015; 23(3): 138-41. http://dx.doi.org/10.1590/1413-78522015230301008

Ozel O and Demircay E. Review of management of unstable elbow fractures. World J Orthop 2016; 7(1): 50-54 http://dx.doi.org/10.5312/wjo.v7.i1.50

Johnston GW. A follow–up of one hundred cases of fractures of the head of the radius with a review of the literature. Ulster Med J 1962; 31: 51-6.

Regan W and Morey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am 1989; 71: 1348-54.

Gill DR and Morrey BF. The Conrad-Morey total elbow arthroplasty in patients who have rheumatoid arthritis. A ten to fifteen-year follow–up study. J Bone Joint Surg Am 1998; 80: 1327-35.

Pipicelli JG, Chinchalkar SJ, Grewal R and Athwal GS. Rehabilitation considerations in the management of terrible Triad Injury to the Elbow. Tech Hand Surg 2011; 15: 198-208. http://dx.doi.org/10.1097/BTH.0b013e31822911fd

Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM and Larrainzar-Garijo R. Outcomes after terrible triads of the elbow treated with the current surgical protocols. Int Orthop 2011; 35: 851-860. http://dx.doi.org/10.1007/s00264-010-1024-6

Lee S, Park MS, Chung CY, Kwon DG, Sung KH, Kim TW, et al. Consensus and different perspectives on treatment of supracondylar fractures in children. Clin Orthop Surg 2012; 4(1): 91-7. http://dx.doi.org/10.4055/cios.2012.4.1.91

Bano KY and Kahlon RS. Radial head fractures—advanced techniques in surgical management and rehabilitation. J Hand Ther 2006; 19(2): 114-35. http://dx.doi.org/10.1197/j.jht.2006.02.011

Armstrong A. The terrible triad injury of elbow. CurrOpinOrthop 2005; 16: 267-70. http://dx.doi.org/10.1097/01.bco.0000169387.61611.28

Pugh DM, Wild LM, Schemitsch EH, King GJ and McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am 2004; 86A: 1122-1130.

Pugh D and McKee M. The Terrible triad injury. Tech hand up extreme Surg 2002; 6: 21-29.

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Published

2016-09-04

How to Cite

Cruz-Calvente, C. ., Nieto-Blasco, J. ., Fernández-Cuadros, M. E. ., Fernández-Palacio, P. ., García-García, J. ., & Blanco-Blanco, J. F. . (2016). Management of the Terrible Triad Injury of the Elbow: A Case Series Retrospective Review. International Journal of Orthopedics and Rehabilitation, 3(2), 58–66. https://doi.org/10.12974/2313-0954.2016.03.02.3

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