The “Terrible Triad” of the Elbow

HISTORICAL PERSPECTIVE The results of elbow dislocations with associated radial head and coronoid fractures (the so-called “terrible triad” of the elbow) are often poor as a result of arthrosis, recurrent instability, and/or stiffness from prolonged immobilization. 1–6 Difficulty in treating patients with this injury is compounded by the lack of information available regarding techniques, results, and complications. Unfortunately, there is no single study in the literature that has specifically evaluated this condition, and what is available must be extrapolated from the subgroups of patients with this injury that are included in other larger series (such as elbow dislocations). 3–5 In 1989, Josefsson et al. published the long-term outcomes of 23 patients who sustained an elbow dislocation with a displaced radial head fracture. 5 They noted that redislocations occurred in four patients, all of whom had had an untreated associated coronoid process fracture. Three of these patients had undergone primary radial head excision. Of the 19 patients who had primary radial head excision, 12 developed arthrosis of the elbow. They noted that osteoarthritis tended to occur in patients who had displaced fractures of the coronoid or radial head (or both) that had not been reconstructed. Their final recommendations were to reconstruct the radial head and the coronoid process with repair of the lateral ligaments if possible. In 1987, Broberg and Morrey published similar findings to the findings of Josefsson et al. 1 They found that arthrosis occurred in 22 of 24 patients who had experienced a fracture-dislocation of the elbow managed without repair or replacement of the radial head at an average 10-year follow-up examination. In 1989, Regan and Morrey published the Mayo Clinic experience with coronoid process fractures. 7 Regan and Morrey classified coronoid process fractures into three groups: type I, fracture of the tip of the olecranon; type II, < 50% of the coronoid process; and type III, > 50% of the coronoid process. Among type II fractures, the worst results were obtained in patients with associated radial head fractures and elbow instability (the terrible triad of the elbow). Of the five type III fractures in this study, four had poor results secondary to stiffness, pain, and recurrent elbow instability. Two of their conclusions were that prolonged immobilization of the elbow in this situation leads to stiffness and should be avoided if possible, and that all type III fractures and type II fractures associated with elbow instability should be repaired. These observations essentially demonstrate the dilemma of dealing with this injury in a nonsurgical fashion. Even though it may be possible to obtain a reasonable reduction in a closed fashion, prolonged immobilization (typically in a position of excessive flexion) results in severe stiffness and a nonfunctional elbow range of motion. Earlier mobilization, in an attempt to restore a functional arc, often results in prompt posterior subluxation or redislocation. There remains some controversy over the mechanism of coronoid fracture seen in these cases. In the past, these fractures have been termed “avulsion” fractures and have been postulated to be from avulsion by the anterior elbow capsule and brachialis muscle. However, the tip of the coronoid is an intraarticular structure, can be clearly visualized during elbow arthroscopy, and is devoid of soft-tissue attachments. We believe that the coronoid fracture typically occurs from a “shearing” mechanism and results as it is driven against the unyielding distal humerus as the radius and ulna dislocate or subluxate posteriorly. 8–10 Thus, in our opinion, a coronoid fracture is a pathognomonic sign of an episode of elbow instability. Questioned carefully, patients with what appears to be an isolated coronoid fracture on radiographs may volunteer that they felt or saw their elbow “clunk” back into joint as part of an episode of subluxation or dislocation with spontaneous reduction. In 1998, Heim published a review of the AO experience with combined radius and ulna fractures at the elbow. 3 Of 120 total cases, 25 cases involved fractures of the coronoid process and radial head. Of these 25 cases, 11 patients were treated with primary radial head resection. Eight of these patients developed premature arthrosis, and another eight demonstrated valgus instability. An additional 41 cases involved a fracture of the olecranon in addition to radial head and coronoid fractures. Thirty-six of these patients developed arthrosis, especially after radial head resection. Heim recommended restoration of the radial head by open reduction, internal fixation with consideration for prosthetic replacement if severe radial comminution or ulnar instability is present. The salvage of these injuries is difficult, and conventional treatment is often inadequate to restore sufficient stability to allow early motion, especially if previous surgical intervention has complicated matters (i.e. through injudicious radial head excision). In these situations, hinged external fixation of the elbow can be very rewarding. McKee et al. and Cobb and Morrey described series of unstable elbow dislocations, many associated with radial head and coronoid fractures, that had failed initial management. 2,11 Application of a hinge fixator to the elbow restored concentric stability and allowed early motion while ligamentous healing occurred. However, the authors point out that this is a specialized technique with a high complication rate, and that successful primary management is preferable. It is apparent from these reports that elbow dislocations with associated fractures of the radial head and coronoid process often result in poor results with conservative management. Similarly, surgical intervention has a high failure rate if certain principles are not followed. In an attempt to improve the outcome of the treatment of patients with these injuries, we have developed a management protocol that concentrates on restoration of the damaged structures (radial head, coronoid process, elbow ligaments) and initiates early elbow motion. Advanced techniques, such as articulated elbow fixation, are reserved for cases that fail primary management or conventional management. In our practice, adherence to these principles has significantly improved the functional outcome of these patients with this potentially devastating injury. 11 INDICATIONS/CONTRAINDICATIONS As a general rule, the majority of unstable fracture dislocations of the elbow will require open repair, as opposed to the majority of simple elbow dislocations, which can be treated closed. 12 The main goal of operative intervention is to re-establish sufficient elbow stability so that early movement can be instituted to restore a functional arc of motion (100° of flexion–extension, 100° of pronation–supination). An extensive operative procedure followed by prolonged immobilization (greater than 3 weeks) usually results in significant stiffness and is to be avoided if possible. Initial management of the “terrible triad” should consist of a gentle closed reduction under intravenous sedation or general anesthesia. This is useful from a number of standpoints: it improves the patient's pain, reduces tension on soft-tissue structures, decreases swelling, and allows for postreduction radiographs that are usually easier to interpret and base treatment decisions on. If the reduction has been done under general anesthesia, then the elbow can be put through a range of motion and have its stability tested. The decision to operate is based on good-quality postreduction anteroposterior and lateral radiographs. A number of criteria must be met if the elbow is to be treated conservatively: 1) there must be concentric reduction of the ulnohumeral and radiocapitellar joints 2) the radial head fracture must be relatively small (< 25% of the head) or nondisplaced and not block forearm rotation and 3) there must be sufficient stability that motion can be initiated within 2–3 weeks. It is rare that these criteria are met in this injury, and the radiographs must be examined critically. One potential pitfall is subtle posterolateral rotatory subluxation of the joint, most easily identified as a loss of the colinearity of the radial head/neck and the capitellum on the lateral view. 13 Vigilance must be maintained if the patient is nonoperatively treated; a loss of reduction on radiographs should initiate a change in the patient's treatment plan. Even though we do not routinely use computed tomography scanning or tomography for these injuries, it can be useful when uncertainty persists regarding the nature of the injury despite adequate plain radiographs. The size and shape of the coronoid fragment is typically well-visualized on the computed tomography scan (Figs. 1 and 2).FIG. 1.: Lateral tomogram of an elbow with posterior dislocation, coronoid fracture, and radial head fracture, the so-called “terrible triad” of the elbow. Tomograms can often be very useful in defining bony fragments of the radial head (seen on this section) or coronoid. They are also useful in that there is not as much “scatter” or artifact (when compared with computed tomography scanning) in revision cases with previously implanted hardware.FIG. 2.: A three-dimensional computerized tomographic (CT) reconstruction of a patient with a “terrible triad” injury of the elbow. The fragments of coronoid and radial head can be clearly seen anteriorly as the elbow dislocates posteriorly. This illustration clearly shows how the normal bony restraints of the coronoid and radial head are lost, contributing to posterior elbow instability.In conclusion, although the occasional patient may have an absolute (medical) contraindication to surgery, or meet the criteria for conservative management, the majority will require operative treatment of the “terrible triad.” TECHNIQUE General Considerations Once the decision has been made to proceed with operative repair, there are essentially two choices with regards to operative approach. The choice of approach will depend on the individual case and the structures that the operating surgeon has decided to repair. However, regardless of the injuries that are diagnosed, the surgeon must be prepared to visualize the medial and lateral sides of the elbow joint if necessary. This can be done through a posterior by the medial and lateral or through combined medial and lateral A posterior approach is our choice in these for a number of The main is the of the elbow and the to the medial and lateral structures that it a hinged external fixator can be or other from this approach. 11 Thus, if as a result of failed previous or injury it is that it will be to restore elbow stability with conventional techniques, a posterior approach possible hinge is of the posterior approach is the position of the the approach is with the patient in the lateral the forearm the for the elbow to subluxate in a posterior If it is that the majority of can be done on the lateral (radial head, lateral an lateral approach is our It is often possible to restore stability to the elbow to allow early motion through this approach If there is associated ulnar then of the is and can be done through a medial approach. This also an to and repair the medial soft-tissue injury and/or approach it must be that the goal of is to sufficient stability to allow early motion, prolonged elbow immobilization after repair in this situation will result in elbow We use general for these cases. the patients are and the is on an A is on the and to A is under the elbow to it from the and the a posterior approach is we the patient in the lateral position with the of a A and are on the as the case may be of the the is over a that is to the the lateral a lateral is and the and is The lateral to the are with this injury. We have noted that the most of this injury is the of the lateral capsule and the ligaments of the posterolateral of the which a on the of the lateral and or a lateral bony The is of the If possible, it is to to the joint through the by the injury, than a or surgical of This will the easier and the soft-tissue repair this lateral approach the anterior of the joint the radial head and coronoid process can be instability to valgus or ulnar based that should be If a medial approach is it is done through a medial The ulnar is and the If surgery, the is anteriorly in the If the which may be is identified and for repair. The medial is typically and can be for repair. If it is the coronoid can be found by the if it is the coronoid can be found by the If it is the base of the coronoid fragment may the of the The coronoid can then be under if it has been to from the lateral The radial head is and is to visualize the fracture If there is an associated radial fracture, the posterior is in and should be and the It can be found the brachialis and the and the forearm the the and the operative fixation or replacement of the radial head, the posterior should be One must be very when the radial head or they should be on the as into the may the Even though of radial head fragments is not recommended it is possible to small fragments that 25% or of the head with The main goal of the radial head fracture in the patient with the “terrible triad” is to restore elbow stability and allow early motion. Thus, the surgeon must that this fragment not the stability of the elbow joint If it then a approach is This patient had a “terrible triad” type of elbow injury and treated by joint and radial head excision. This anteroposterior after early instability with medial subluxation of the We believe that radial head is in this primary goal is to the radial head/neck fracture in these cases. However, this is not possible. must be to allow early motion and not with the may to be a very simple fracture on radiographs may in be significantly than It should be that most series of radial head fracture fixation that in of cases in which fixation comminution or other in some other In our practice, the most for to replacement fracture comminution with severe associated radial head and fractures, or previous radial head by another of the radial head that are are managed in a similar to the management of other fractures. The fracture is and of there is very if soft-tissue to the fracture this is rare if fixation is and bony A fragment is with a or fracture of choice for these fractures is the its small and head are in this in the of the of the radial head (the so-called can be if necessary. This is the that not with the This can be by by the forearm after radial head fixation This is the as the arc by through the radial and If there is an associated radial fracture, than this can be with a or it is to this the of the radial head that not with the ulna to motion after reduction of the fracture is If there is an after fixation, it can a and the radial head through a much arc in an fashion, forearm 19 If the fracture is in a then instability may result This patient experienced “terrible triad” injuries in a of a The lateral of the elbow posterior subluxation of the The treating surgeon the radial head/neck fracture in a position and not repair the lateral soft-tissue It is this revision situation that an articulated hinge fixator is most decision to proceed to radial head replacement is an individual based on the operating to restore stability to the radial head. If this is not possible, we believe that of the head is in the of the “terrible triad.” The radial head is an that posterior of the elbow and is to valgus stability if the is The authors have seen cases of early and recurrent instability in patients with this injury who have had injudicious radial head excision. or had poor over the We radial head The of radial head has improved the to restore the of the of head and and The head size is by the bony fragments to radial head This also to that all fragments have been from the are then to the radial head and It has been our experience that the of the is to in of anteroposterior and valgus The of the head will also depend on the of the on the radial a to the position of the will require a radial head. The fixation of the coronoid fracture is typically the of the case and on the size of the fragment and associated it is the structure, especially if the approach has been from the lateral it is with so that there is a repair from to In of there are essentially two that can be to visualize and the coronoid. the lateral approach described it is typically possible to the coronoid. to improve a over the medial of the distal humerus and the If there has been a fracture of the radial head, then through the will improve If the radial head excision, then the improves the of the coronoid and If inadequate of the coronoid is seen from the lateral then a medial approach can be It is to that there is typically a significant of soft-tissue and surgical may to be to of than to conventional The ulnar is identified and We do not routinely the there is a or injury that occurs surgery, in which case an anterior is or the the coronoid. The can also be identified in this fashion. The coronoid can then be and under repair is We use for the capsule and and for the If the coronoid fracture is part of a ulnar fracture then it is to the fracture fragments in If the ulnar fracture is then to the coronoid fragment is The coronoid fragment is to the distal and with or and then the main fracture is A posterior the ulna is The coronoid fragment fixation can then be with through the if necessary. coronoid fractures are small to significant in stability through fixation and are routinely especially if they are within the However, there is often a significant of soft-tissue injury in the anterior and the anterior capsule is of the coronoid. In this repair of the anterior capsule through in the ulna can significantly This is by a through the anterior capsule at the of The of the is sufficient to in the not to the brachialis and This is then through in the position of the can be by through the anterior of the of an allows the in the anterior capsule to be through the ulna it can be over the posterior of the ulna through a small This is done after the radial head fracture, it can II and III coronoid fractures are larger fragments than the fragments that can significantly to stability when The type III fracture is also in that it may the of the at its of fixation for these fractures is to and the reduction with a if possible, a The fragment is then with from a These are through on the posterior of the and their from the coronoid fragment can be seen under One and two are then over these as We use so that is obtained at the fracture must be not to these or they will in the coronoid during elbow it may be possible to the coronoid with from the lateral of the fragment into the this is usually possible if the radial head has been as there is improved in this and lateral radiographs of a patient with a posterior elbow dislocation, radial head/neck fractures, and coronoid fracture The operative repair of coronoid fracture fixation with two from the posterior of the ulna after failed at fixation, radial head The lateral from the distal humerus and to motion instituted after radiographs concentric reduction of the joint with coronoid The patient had a Mayo of at 1 there is comminution of this fragment that fixation then a technique similar to the technique that is for the anterior capsule in type fractures, is than a is This is easier to than Lateral The lateral are then the lateral ligamentous specifically the lateral of the ulnar has the distal This can be and back to the distal humerus or in the lateral reconstruction an is not in the as the are of In the or recurrent can be to we to use a hinged stability is then the forearm the elbow is through a The radial head can be the lateral If the radial head to or if instability of the ulna is then consideration must be to the hinged external if instability is noted in with the elbow at of then sufficient instability to early motion is present. this of instability occur in the We to use the to allow early motion and a concentric reduction. 2,11 The hinge is with the patient in a lateral position and the over a is very to instability and hinge The hinge is after reconstruction and management of the radial head, coronoid process, and lateral ligaments as previously and A is through the of the distal rotation and its position the joint another is through the olecranon to the ulnohumeral The is then closed in fashion. The is for the and to the Two are in the humerus with to to the to the radial Two additional are in the ulna and the fixator The of a reduction is a of the elbow is so that the operating surgeon has a of the stability and instability is and are not A posterior is The is at of with the forearm in this is usually the most position and posterolateral The is and motion is after The position and of immobilization may on the injury what is described to the majority of cases. The position of instability is usually and and this position is the we allow and to be done with the forearm in and we allow forearm rotation to be done with the elbow at to the lateral soft-tissue repair. motion is then and is initiated at weeks. can be in cases of motion is to on the of and it typically 3 for to to are after the treatment of patients with this injury. In the past, recurrent instability, prolonged and have to the high of The main goal of surgical intervention is to sufficient stability so early motion can be This functional outcome and range of motion. If an extensive open repair is and the elbow in as a result of instability, a will often We have found that a of immobilization can to and soft-tissue healing and This is followed by the of a as described A patient treated with the surgical described has a range of motion, a arc of of and forearm rotation of can be on in a series of such If severe stiffness results in a nonfunctional range of motion, elbow is usually successful if concentric joint stability has been instability is managed with the of a hinged external than prolonged immobilization in a position of 2,11 Even with surgical techniques, fracture soft-tissue structures after failed previous at surgical or patient may this The complication is typically on the lateral that is after surgery, as posterior subluxation of the radial head and/or of the ulnohumeral joint are It is very to motion with the reduction. If not managed stiffness and will as a result of and early osteoarthritis can recurrent posterolateral rotatory instability as a of this injury. can be managed in the with reconstruction if it is head or can occur if radial head fixation has been as the initial treatment of patients with radial head fracture and as elbow and stiffness in the and of the radial head are normal rare we typically this complication with radial head and a This is done out of for of instability, especially of the radius and posterior subluxation of the elbow. the there is a of information regarding when sufficient healing has occurred to allow radial head in this and we have seen cases of forearm and elbow instability after radial head excision. this we are in a replacement after excision. significant is relatively after this injury, especially if the patient's primary treatment is or of the medial and lateral is often is sufficient to motion and is usually seen in patients with head injury, or who have failed initial surgical We the use of for such is may occur especially after revision If the is are usually if the joint is then prompt and are The principles of surgical are and is while fixation is It is usually possible to radial head if prompt and of the joint is and are It is possible to the patient with a normal elbow after the “terrible triad” injury However, with of injury and improved if not results can be experience with this injury the arc of to be from with forearm rotation This to a by the Mayo in of treatment of patients with the injury or for revision results in a loss of motion of as compared with the treated is in of patients, usually for stiffness, recurrent instability, or

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