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Terrible Triad of Elbow

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Other Names

  • Terrible Triad Injury of Elbow
  • Elbow Fracture-dislocation

Background

History

Epidemiology

  • Male more common than female[1]
  • Average age is 45.9 (range 13 to 79 years)[1]

Pathophysiology

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

Pathoanatomy


Risk Factors

  • Unknown

Differential Diagnosis


Clinical Features


Evaluation

Radiographs

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


See Also


References


  1. 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.
  2. 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.
  3. 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.
  4. https://www.orthobullets.com/trauma/1021/terrible-triad-injury-of-elbow
  5. 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.
  6. 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
Authors:
Last edited:
25 August 2021 18:56:51
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