PROGRESS IN TREATMENT OF TERRIBLE TRIAD OF ELBOW_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

MA Ning , YU Tao , YUAN Feng.

Department of Orthopedics, Tongji Hospital of Tongji University, Shanghai, 200065, P.R.China. Corresponding author: YUAN Feng, E-mail: yuanfengtj@yahoo.com.cn;

Corresponding author：

Keywords：

Terrible triad of the elbow; Fracture fixation; Ligament repair; Research progress

DOI：

10.7507/1002-1892.20130112

Video：

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Objective To review the injury mechanism and the treatment progress of terrible triad of the elbow, and to analyze the direction of further research. Methods Related literature concerning terrible triad of the elbow was extensively reviewed and comprehensively analyzed. Results The main treatment of terrible triad of the elbow is operation. The ultimate goal of treatment is to reconstruct sufficient stability of the elbow. The treatment includes fixation of the coronoid by suture, screw or plate; fixation of radial head by screw and plate, partial or complete replacement of the radial head; fixation of lateral collateral ligament and the medial collateral ligament by bone suture or anchors and the application of the external fixator. These surgical treatments have their own indications and advantages, most get satisfactory results. Conclusion Generally, surgery is needed to maintain the stability of the elbow for patients of terrible triad elbow. However, medial ligament repair or not, the choice of approach, and mechanism of injury still need further study.

Citation： MA Ning,YU Tao,YUAN Feng.. PROGRESS IN TREATMENT OF TERRIBLE TRIAD OF ELBOW. Chinese Journal of Reparative and Reconstructive Surgery, 2013, 27(4): 496-499. doi: 10.7507/1002-1892.20130112 Copy

1.	Bucholz RW, Heckman JD, Court-Brown CM. Rockwood & Green’s Fractures in Adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2010: 906-946.
2.	Mehta JA, Bain GI. Posterolateral rotatory instability of the elbow. J Am Acad Orthop Surg, 2004, 12(6): 405-415.
3.	Fitzpatrick MJ, Diltz M, McGarry MH, et al. A new fracture model for “terrible triad” injuries of the elbow: influence of forearm rotation on injury patterns. J Orthop Trauma, 2012, 26(10): 591-596.
4.	Guitton TG, Ring D. Nonsurgically treated terrible triad injuries of the elbow: report of four cases. J Hand Surg (Am), 2010, 35(3): 464-467.
5.	Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg, 2009, 17(3): 137-151.
6.	Cheung EV, Steinmann SP. Surgical approaches to the elbow. J Am Acad Orthop Surg, 2009, 17(5): 325-333.
7.	Ring D, Gulotta L, Chin K, et al. Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus. J Orthop Trauma, 2004, 18(7): 446-449.
8.	Garrigues GE, Wray WH 3rd, Lindenhovius AL, et al. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg (Am), 2011, 93(20): 1873-1881.
9.	匡新建, 蔡航, 鲍丰, 等. 肘关节恐怖三联征的手术治疗. 中国修复重建外科杂志, 2011, 25(8): 964-967.
10.	Reichel LM, Milam GS, Reitman CA. Anterior approach for operative fixation of coronoid fractures in complex elbow instability. Tech Hand Up Extrem Surg, 2012, 16(2): 98-104.
11.	Pai V, Pai V. Use of suture anchors for coronoid fractures in the terrible triad of the elbow. J Orthop Surg (Hong Kong), 2009, 17(1): 31-35.
12.	匡新建, 蔡航, 鲍丰, 等. 微型钢板治疗尺骨冠状突骨折. 中国修复重建外科杂志, 2010, 24(9): 1097-1099.
13.	Ring D, Guss D, Jupiter JB. Reconstruction of the coronoid process using a fragment of discarded radial head. J Hand Surg (Am), 2012, 37(3): 570-574.
14.	Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg, 2012, 21(10): 1336-1341.
15.	Turner RG, Rispoli D, Lopez-Gonzalez FM, et al. Partial allograft replacement of the radial head in the management of complex fracture-dislocations of the elbow. J Shoulder Elbow Surg, 2012, 21(3): 396-404.
16.	Pugh DM, Wild LM, Schemitsch EH, et al. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg (Am), 2004, 86-A(6): 1122-1130.
17.	Ring D, Hannouche D, Jupiter JB. Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow. J Hand Surg (Am), 2004, 29(3): 470-480.
18.	Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg (Am), 2002, 84-A(4): 547-551.
19.	Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg (Am), 2007, 32(8): 1200-1209.
20.	Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, et al. Outcomes after terrible triads of the elbow treated with the current surgical protocols. A review. Int Orthop, 2011, 35(6): 851-860.
21.	陈硕, 黄富国, 胡晓川, 等. 肘关节“恐怖三联征”的手术治疗. 中国修复重建外科杂志, 2009, 23(1): 45-48.
22.	Jeong WK, Oh JK, Hwang JH, et al. Results of terrible triads in the elbow: the advantage of primary restoration of medial structure. J Orthop Sci, 2010, 15(5): 612-619.
23.	张世民, 俞光荣, 袁锋, 等. 肘关节后脱位伴桡骨头和尺骨冠突骨折(恐怖三联征)5例初步报告. 中国矫形外科杂志, 2007, 15(14): 1069-1073.
24.	Toros T, Ozaksar K, Sugun TS, et al. The effect of medial side repair in terrible triad injury of the elbow. Acta Orthop Traumatol Turc, 2012, 46(2): 96-101.
25.	Chemama B, Bonnevialle N, Peter O, et al. Terrible triad injury of the elbow: how to improve outcomes. Orthop Traumatol Surg Res, 2010, 96(2): 147-154.
26.	Rhyou IH, Kim YS. New mechanism of the posterior elbow dislocation. Knee Surg Sports Traumatol Arthrosc, 2012, 20(12): 2535-2541.
27.	Chen NC, Julka A. Hinged external fixation of the elbow. Hand Clin, 2010, 26(3): 423-433, vii.
28.	Volkov MV, Oganesian OV. Restoration of function in the knee and elbow with a hinge-distractor apparatus. J Bone Joint Surg (Am), 1975, 57(5): 591-600.

1. Bucholz RW, Heckman JD, Court-Brown CM. Rockwood & Green’s Fractures in Adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2010: 906-946.
2. Mehta JA, Bain GI. Posterolateral rotatory instability of the elbow. J Am Acad Orthop Surg, 2004, 12(6): 405-415.
3. Fitzpatrick MJ, Diltz M, McGarry MH, et al. A new fracture model for “terrible triad” injuries of the elbow: influence of forearm rotation on injury patterns. J Orthop Trauma, 2012, 26(10): 591-596.
4. Guitton TG, Ring D. Nonsurgically treated terrible triad injuries of the elbow: report of four cases. J Hand Surg (Am), 2010, 35(3): 464-467.
5. Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg, 2009, 17(3): 137-151.
6. Cheung EV, Steinmann SP. Surgical approaches to the elbow. J Am Acad Orthop Surg, 2009, 17(5): 325-333.
7. Ring D, Gulotta L, Chin K, et al. Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus. J Orthop Trauma, 2004, 18(7): 446-449.
8. Garrigues GE, Wray WH 3rd, Lindenhovius AL, et al. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg (Am), 2011, 93(20): 1873-1881.
9. 匡新建, 蔡航, 鲍丰, 等. 肘关节恐怖三联征的手术治疗. 中国修复重建外科杂志, 2011, 25(8): 964-967.
10. Reichel LM, Milam GS, Reitman CA. Anterior approach for operative fixation of coronoid fractures in complex elbow instability. Tech Hand Up Extrem Surg, 2012, 16(2): 98-104.
11. Pai V, Pai V. Use of suture anchors for coronoid fractures in the terrible triad of the elbow. J Orthop Surg (Hong Kong), 2009, 17(1): 31-35.
12. 匡新建, 蔡航, 鲍丰, 等. 微型钢板治疗尺骨冠状突骨折. 中国修复重建外科杂志, 2010, 24(9): 1097-1099.
13. Ring D, Guss D, Jupiter JB. Reconstruction of the coronoid process using a fragment of discarded radial head. J Hand Surg (Am), 2012, 37(3): 570-574.
14. Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg, 2012, 21(10): 1336-1341.
15. Turner RG, Rispoli D, Lopez-Gonzalez FM, et al. Partial allograft replacement of the radial head in the management of complex fracture-dislocations of the elbow. J Shoulder Elbow Surg, 2012, 21(3): 396-404.
16. Pugh DM, Wild LM, Schemitsch EH, et al. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg (Am), 2004, 86-A(6): 1122-1130.
17. Ring D, Hannouche D, Jupiter JB. Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow. J Hand Surg (Am), 2004, 29(3): 470-480.
18. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg (Am), 2002, 84-A(4): 547-551.
19. Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg (Am), 2007, 32(8): 1200-1209.
20. Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, et al. Outcomes after terrible triads of the elbow treated with the current surgical protocols. A review. Int Orthop, 2011, 35(6): 851-860.
21. 陈硕, 黄富国, 胡晓川, 等. 肘关节“恐怖三联征”的手术治疗. 中国修复重建外科杂志, 2009, 23(1): 45-48.
22. Jeong WK, Oh JK, Hwang JH, et al. Results of terrible triads in the elbow: the advantage of primary restoration of medial structure. J Orthop Sci, 2010, 15(5): 612-619.
23. 张世民, 俞光荣, 袁锋, 等. 肘关节后脱位伴桡骨头和尺骨冠突骨折(恐怖三联征)5例初步报告. 中国矫形外科杂志, 2007, 15(14): 1069-1073.
24. Toros T, Ozaksar K, Sugun TS, et al. The effect of medial side repair in terrible triad injury of the elbow. Acta Orthop Traumatol Turc, 2012, 46(2): 96-101.
25. Chemama B, Bonnevialle N, Peter O, et al. Terrible triad injury of the elbow: how to improve outcomes. Orthop Traumatol Surg Res, 2010, 96(2): 147-154.
26. Rhyou IH, Kim YS. New mechanism of the posterior elbow dislocation. Knee Surg Sports Traumatol Arthrosc, 2012, 20(12): 2535-2541.
27. Chen NC, Julka A. Hinged external fixation of the elbow. Hand Clin, 2010, 26(3): 423-433, vii.
28. Volkov MV, Oganesian OV. Restoration of function in the knee and elbow with a hinge-distractor apparatus. J Bone Joint Surg (Am), 1975, 57(5): 591-600.

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