Elsevier

The Journal of Hand Surgery

Volume 40, Issue 11, November 2015, Pages 2297-2303
The Journal of Hand Surgery

Current concepts
Terrible Triad Injuries of the Elbow

https://doi.org/10.1016/j.jhsa.2015.04.039Get rights and content

The treatment of terrible triad injuries of the elbow continues to evolve. Radial head fixation and arthroplasty, coronoid process fixation, and repair of the lateral collateral ligament continue to be the mainstays of treatment. 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 may be needed. 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.

Section snippets

Clinical Picture

In general, terrible triad injuries are the result of a fall onto an outstretched hand. It is postulated that there is a posterolateral load upon the elbow during the fall, which results in tension failure of the LCL and the MCL, and a compressive load that fractures the radial head. Some circumstantial evidence supports this concept.

Patients generally present with pain, swelling, and limited range of motion of the elbow. Patients may or may not describe a subluxation or dislocation event.

Diagnosis

Radiographs of terrible triad injuries can be deceptive. In some cases, the elbow is reduced and there are small fragments of bone anterior to the ulnohumeral joint on a lateral radiograph and a radial head/neck fracture is noted on the anteroposterior view. The small triangular anterior fragment is a piece of the fractured coronoid tip and is a sign that a more substantial injury has occurred. Computed tomography scans are helpful for preoperative planning, especially for understanding the

Treatment and Outcomes

Upon presentation, if the ulnohumeral joint is dislocated, it should be reduced. In cases in which the elbow is unstable and re-dislocates easily, surgery is recommended to maintain a congruent elbow joint. In cases in which the elbow joint stays grossly congruent after reduction, operative intervention can maximize elbow function and prevent residual instability. Patients with a stable elbow after reduction may be considered for nonsurgical treatment, but stability and final elbow function

Complications

Complications of terrible triad surgical treatment include heterotopic ossification, stiffness, nerve injury, and recurrent subluxation or dislocation of the elbow. Because case series are relatively small, it is difficult to estimate the incidence of complications. The most challenging of these problems is recurrent subluxation or dislocation.

In patients who are treated longer than 2 weeks after injury, standard repairs are often insufficient to limit the risk of recurrent dislocation or

Discussion

Our understanding of terrible triad injuries is incomplete. Further biomechanical studies may be helpful in elucidating the relationship between the MCL and the coronoid in providing stability to the elbow. Future studies of in vitro varus loading of the elbow after terrible triad repair may refine our understanding of how to rehabilitate these injuries. In addition, we do not clearly know when radial head fractures can be fixed and preserved.

Continued improvement of arthroscopic techniques to

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    • Cited by (0)

    D.R. reports receiving grants from Skeletal Dynamics; royalties from Wright Medical; personal fees from Biomet, Acumed, universities and hospitals, and lawers; stock options from Illuminos; speaking honoraria from other universities and hospitals; and personal fees from being a deputy editor for Journal of Hand Surgery and Clinical Orthopaedics and Related Research.

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    Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.