Terrible Triad of Elbow
(Redirected from Terrible Triad Elbow Injury)
Other Names
- Terrible Triad Injury of Elbow
- Elbow Fracture-dislocation
Background
- This page describes the so-called 'Terrible Triad' fracture dislocation of the Elbow Joint
- This includes Elbow Dislocation, Radial Head or Neck Fracture, and Coronoid Fracture
History
Epidemiology
Pathophysiology
- General
- Terrible triad defined by Elbow Dislocation, Radial Head or Neck Fracture, and Coronoid Fracture
- Most commonly due to fall on extended arm and outstretched hand from a standing position
- The elbow may spontaneously reduce prior to initial evaluation
Mechanism
- Fall on outstretched arm, slightly flexed with forearm in supination
- Forces valgus stress, axial load and posterolateral rotator forces
- Subsequent posteroloateral dislocation
- Can be fall from standing or greater height[2]
Associated Injuries
- 39.9% of terrible triad injuries have additional fractures[1]
- Lateral Collateral Ligament Injury (Elbow)
- Ulnar Collateral Ligament Injury
Pathoanatomy
- Injury destabilizes the relationship between the Humerus and forearm bones
- Injured structures:
- Lateral Collateral Ligament
- Joint Capsule
- Proximal Radius, specifically Radial Head
- Proximal Ulna, specifically Coronoid Process
- Can also injury Ulnar Collateral Ligament
Risk Factors
- Unknown
Differential Diagnosis
- Fractures
- Adult
- Pediatric
- Dislocations & Instability
- Tendinopathies
- Bursopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Other
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
Clinical Features
- History
- Patients will endorse trauma
- Complain of pain, clicking, locking
- Physical: Physical Exam Forearm
- Tenderness, swelling, bruising
- If elbow has not been reduced (spontaneously or manually), deformity will be obvious
- Special Tests
- Elbow Valgus Stress Test: Evaluate integrity of Ulnar Collateral Ligament
- Elbow Varus Stress Test: Evaluate integrity of Lateral Collateral Ligament
Evaluation
Radiographs
- Standard Radiographs Elbow
- Strongly consider extending to humerus, shoulder, forearm and wrist
CT
- Helpful to better evaluate fracture pattern
- Useful for surgical planning
Classification
- N/A
Management
Acute Management
- Critical to identify on initial evaluation
- If missed and treated conservatively, patients develop recurrent dislocations and multiple future surgeries[3]
- Elbow Dislocation Reduction
- Typically performed under procedural sedation in the Emergency Department or Operating Room
- Immobilize with Posterior Long Arm Splint
Nonoperative
- Indications
- Almost universally a surgical injury pattern
- Decision should be made by orthopedic surgeon for non-operative management
- Consider in patients who are poor surgical candidates
Operative
- Technique[4]
- Radial Head Arthroplasty
- LCL Reconstruction
- Coronoid ORIF
- UCL Reconstruction
Rehab and Return to Play
Rehabilitation
- At discretion of surgeon
- Slow recovery due to high rate of failure
- Postoperative immobilization
- Splint at 90 for 2-5 days postop
- Forearm is kept in full supination (protect lateral repair) vs neutral (medial structures repaired)
- Early motion with a stable joint
- Patients with prolonged immobilization have been shown to have generally poor results compared with those with early activity[5]
Return to Play/ Work
- Needs to be updated
Complications and Prognosis
Prognosis
- Overall prognosis is poor with high likelihood of complications
- Delayed treatment vs acute treatment
- Earlier treatment is more straightforward surgically, associated with better outcomes[6]
Complications
- Instability and recurrent subluxation
- Roughly 7.9% in patients treated acutely, 24.4% in patients treated subacutely[1]
- Stiffness/ loss of ROM
- Post Traumatic Elbow Arthritis
- Heterotopic Ossification
- Ulnar Nerve Injury
See Also
- Internal
- External
- Sports Med Review Elbow Pain: https://www.sportsmedreview.com/by-joint/elbow/
References
- ↑ 1.0 1.1 1.2 1.3 Ebraheim, Nabil A., Craig J. Raberding, and Jiayong Liu. "A review of terrible triad injury of the elbow." Techniques in Shoulder & Elbow Surgery 13.3 (2012): 101-106.
- ↑ 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):1200–9.
- ↑ Ring D, Jupiter JB, Ziberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. 2002; 84-A:547–551.
- ↑ https://www.orthobullets.com/trauma/1021/terrible-triad-injury-of-elbow
- ↑ Ka¨licke T, Muhr G, Frangen TM. Dislocation of the elbow with fractures of the coronoid process and radial head. Arch Orthop Trauma Surg. 2007;127:925–931.
- ↑ Lindenhovius AL, Jupiter JB, Ring D. Comparison of acute versus subacute treatment of terrible triad injuries of the elbow. J Hand Surg Am. 2008;33:920–926
Created by:
John Kiel on 25 November 2019 18:44:51
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Last edited:
13 October 2022 13:24:35
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