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JINJ-5607; No. of Pages 7 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
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Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People’s Hospital Chi Zhang, Biao Zhong *, Cong-feng Luo Orthopaedic Department, Shanghai Jiaotong University Affiliated No 6th People’s Hospital, 600 Yishan Road, Shanghai 200233, PR China
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 September 2013 Received in revised form 21 December 2013 Accepted 25 December 2013
Background: Terrible triad of the elbow can be a challenging injury to treat, with a history of well-known complications. The purpose of this study is to report the outcomes of a modification of the standard surgical protocol for the repair of terrible triad of the elbow injuries. Methods: We retrospectively reviewed terrible triad of the elbow injuries treated at our hospital using a modified surgical technique. Our surgical procedure includes fixation or replacement of the radial head and repair of the ruptured lateral collateral ligament (LCL) through a lateral approach. Simultaneous fixation of the coronoid process and repair of the common flexor muscle and medial collateral ligament (MCL) injury were performed through an anteromedial incision. Mayo Elbow Performance Score (MEPS) was determined for each patient at the final clinic visit. The Broberg and Morrey classification was used for evaluating traumatic arthritis. Results: There were 21 patients (21 elbows) included in the analysis, and the mean follow-up period was 32 months (range, 24–48 months). At the last follow-up the mean flexion–extension arc of the elbow was 1268 and the mean forearm rotation was 1398. The mean MEPS was 95 points (range, 85–100 points), with 19 excellent results and two good results. Concentric stability was restored in all cases. Two patients had heterotopic ossification, one patient had radial head nonunion, one patient had a superficial infection, and one patient had ulnar nerve neuropathy. Conclusion: Our surgical strategy for terrible triad of the elbow has the advantage of providing both bony and soft-tissue stability simultaneously, thereby allowing active early motion as well as functional recovery of the elbow. ß 2014 Published by Elsevier Ltd.
Keywords: Elbow Trauma Fracture and dislocation Terrible-triad injury Treatment Coronoid process Elbow approaches
Introduction Elbow dislocation with associated radial head and coronoid process fractures has been referred to as the terrible triad of the elbow by Hotchkiss[1] because of the difficulty of treatment and the consistently poor reported outcomes, especially compared with simple elbow dislocations or fractures.[2,3] Improved understanding of the injury mechanism, the relevant anatomy, and the factors associated with elbow stability have allowed application of a standard protocol for treatment.[4] This protocol is associated with good results with respect to elbow stability and function, and results in satisfactory outcomes in most patients. However, there are still differences of opinion among surgeons as to the best surgical procedure, the choice of fixation technique, and the need for medial collateral ligament (MCL) repair; factors that influence the overall management of these complex
* Corresponding author. Tel.: +86 021 64369181 58071. E-mail address: [email protected] (B. Zhong).
injuries.[5,6] The purpose of this study is to report the outcomes of a modification of the standard surgical protocol for the repair of terrible triad of the elbow injuries that has the advantage of providing both bony and soft-tissue stability of the elbow simultaneously, thus allowing active early motion as well as functional recovery of the elbow. Materials and methods Twenty-three consecutive cases of elbow dislocation associated with fractures of the radial head and coronoid process were identified as terrible triad of the elbow injuries at the Shanghai 6th People’s Hospital between July 2008 and January 2011. Two patients were lost to follow-up prior to definitive assessment of the outcome, leaving 21 patients (21 elbows) for evaluation. There were 17 males and 4 females with a mean age of 38.4 years (range, 17–63 years). The mechanisms of injury were fall from a height (15 cases), sports injury (4 cases), and traffic accident (2 cases). The 21 elbows were treated surgically at a mean of 4 days (range, 2–8 days) after the injury.
0020–1383/$ – see front matter ß 2014 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.injury.2013.12.012
Please cite this article in press as: Zhang C, et al. Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People’s Hospital. Injury (2014), http://dx.doi.org/10.1016/j.injury.2013.12.012
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Fig. 1. (A) Type I soft-tissue injury: only LCL complex injury. (B) Type II soft-tissue injury: LCL complex injury with partial tear of the MCL. (C) Type III soft-tissue injury: LCL complex injury combined with MCL avulsion injury.
Computed tomography (CT) was routinely used in cases of terrible triad injuries before surgery to identify fracture patterns, comminution, and displacement which may not be evident on plain radiographs. Three-dimensional CT was applied in difficult cases to improve the understanding of the injury. O’Driscoll et al.[7] classified coronoid fractures according to the location of the fracture in reference to local anatomy on CT scan, and we used this classification system in this study. Based on the MasonJohnston classification[8,9] all radial head fractures were type IV because they were associated with a dislocation. However, for the purposes of this study radial head fractures were classified according to the original Mason classification[8]: type I, nondisplaced radial head fractures (or small marginal fractures); type II, partial articular fractures with displacement (>2 mm); and type III, comminuted fractures involving the entire radial head. Soft-tissue injuries in all patients were evaluated with magnetic resonance imaging (MRI), and injuries were categorised into three types. Type I soft-tissue injuries were lateral collateral ligament (LCL) complex injuries without MCL injury; there was rupture or avulsion of the LCL from the lateral epicondyle, as well as the common extensor tendon and posterior capsule (Fig. 1A). Type II soft-tissue injuries were LCL complex injuries with MCL injury, but with the continuity of the MCL remaining complete (Fig. 1B). Type III soft-tissue injuries were LCL complex injuries with MCL body rupture or avulsion from the medial humeral attachment; in some cases the flexor–pronator tendons were torn at the
musculotendinous junction leaving some remaining soft tissue in the medial epicondyle (Fig. 1C). Fracture and soft-tissue details of each patient classification are recorded in Table 1.
Operative technique and protocol All procedures were performed by or under the direct supervision of one fellowship-trained orthopaedic surgeon. An extended lateral approach in combination with a separate medial approach was used in every patient. The radial head fracture was addressed first through a lateral approach (Kocher approach), with a preference for fixation over replacement even in Mason type III radial head fractures. Then, the LCL complex was temporarily sutured to the supra-lateral condyle to provide provisional stability of elbow joint to restore articulation of the humeroulnar joint to facilitate reduction and fixation of coronoid fracture. Next, an anteromedial skin incision was made (Fig. 2A), and an ‘‘overthe-top’’ approach was used to expose most of the coronoid fracture (Fig. 2B). In our approach, the flexor pronator mass is split, taking the anterior half anteriorly with the brachialis, and the anterior joint capsule off the anterior humerus to allow exposure of the coronoid fracture. After reduction, 3.0-mm cannulated screws and/or a T-type buttress plate that is usually used for metacarpal and phalangeal fractures was used for fixation of the coronoid fracture (Fig. 2C and D).
Please cite this article in press as: Zhang C, et al. Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People’s Hospital. Injury (2014), http://dx.doi.org/10.1016/j.injury.2013.12.012
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JINJ-5607; No. of Pages 7 C. Zhang et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx Table 1 Injury and treatment details. Radial head fracture
Coronoid fracture
Soft-tissue injury
Patient No.
Classification— treatment
Classification— treatment
Classification— treatment
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type
Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type
Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type
II ORIF III ORIF I ORIF III ORIF III ORIF II ORIF II ORIF III PR II ORIF II ORIF II ORIF II ORIF III ORIF III PR II ORIF II ORIF II ORIF II ORIF III ORIF I ORIF II ORIF
A1 CS A2 CS + BP A2 CS + BP A2 CS + BP B2 CS + BP A1 BP A2 BP A2 CS + BP A2 CS + BP B2 CS + BP A2 BP A2 CS + BP A2 BP A1 CS A2 CS + BP B2 CS + BP A1 CS + BP A2 CS + BP A2 BP B2 BP A1 BP
II LCL AS I LCL AS II LCL AS II LCL AS III LCL AS + MCL AS I LCL AS I LCL S III LCL AS + MCL AS II LCL AS II LCL AS II LCL AS II LCL AS + MCL AS I LCL AS II LCL AS III LCL AS + MCL AS II LCL AS II LCL AS + S I LCL AS II LCL AS + MCL AS II LCL S I LCL AS
ORIF, Open reduction and internal fixation; CS, cannulated screws; LCL, lateral collateral ligament; AS, avulsion suture; BP, buttress plate; MCL, medial collateral ligament; S, suture; PR, prosthesis replacement.
Once bony reconstruction was complete, the LCL complex injury, in which detachment of the lateral ligament complex from the humerus was common, was repaired using suture anchors. Mid-substance tears were repaired with direct suture using
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number 1 or 2 non-absorbable suture. Elbow stability was then evaluated with the goal being concentric stability with no observed posterior or posterolateral subluxation through a flexion–extension arc of 20–1308 with the forearm in neutral rotation. If posterior or posterolateral instability persisted, fixation of the radial head and coronoid process were checked and augmented suturing of the lateral ligament complex was performed if needed. Elbow valgus stability was then tested, and exploration of the medial side was performed if instability was found or in cases in which there were preoperative MRI findings of MCL body rupture or avulsion. For patients with type III soft-tissue injury, and those with type II soft-tissue injury who had serious valgus instability (5 patients), the MCL was repaired through an anteromedial skin incision and suture anchors were usually used to repair the avulsion of the MCL from the medial humeral epicondyle (Fig. 3A and B). Mid-substance tears of the MCL and accompanying tears of the common flexor–pronator muscle complex were repaired with direct suture using number 1 or 2 non-absorbable suture. After repair, the elbow valgus stability was immediately restored. A hinged external fixator was not used in any cases. The wounds were closed in layers, and then a sterile dressing was applied. Drains were not routinely used.
Postoperative management A hinged plastic brace was applied after surgery and used for 6 weeks postoperatively in all patients. For patients with type I softtissue injuries, the elbow was immobilised at 908 of flexion using the brace with the forearm in full pronation to avoid posterolateral instability and to protect the LCL repair when they were not
Fig. 2. (A) The anteromedial skin incision started from the medial humeral epicondyle and paralleled the axis of the flexor pronator. (B) The coronoid fracture was exposed and fixed through the ‘‘over-the-top’’ approach. (C) Intraoperative fluoroscopy (AP view) showed that the coronoid fracture was well reduced and fixed with buttress plates, and the humeroulnar articulation was restored. (D) Intraoperative fluoroscopy(lateral view) showed that the coronoid fracture was well reduced and fixed with buttress plates, and the humeroulnar articulation was restored.
Please cite this article in press as: Zhang C, et al. Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People’s Hospital. Injury (2014), http://dx.doi.org/10.1016/j.injury.2013.12.012
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JINJ-5607; No. of Pages 7 C. Zhang et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
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Fig. 3. A patient with type III soft-tissue injury. (A) The MCL and common flexor–pronator muscle complex were avulsed from the epicondyle. (B) Suture anchors were applied for repair, and the medial complex of the elbow was restored.
performing rehabilitation exercises. For patients with type II or type III soft-tissue injuries, the arm was fixed with the brace at neutral rotation at 908 of flexion when they were not performing rehabilitation exercises. Supervised rehabilitation was begun on the second day after surgery for all patients. Active elbow flexion and extension and passive forearm rotation exercises with the protection of the brace lasting for 20 min were performed 3 or 4 times a day with gradual increase of the ROM. For example, the range of elbow motion extension and flexion were set at 0–30– 1108 for 2 weeks, the 0–20–1208 for 2 weeks, and then 0–10–1308 for 2 weeks followed by full range of elbow motion. Indomethacin, 25 mg three times a day for 3 weeks postoperatively was prescribed to prevent heterotopic ossification. All patients received parecoxib, 40 mg twice a day, to relieve pain and allow early active elbow exercise. Evaluation Patients were followed up clinically and radiographically until fracture union and until the plateau stage of elbow motion range was reached. Function and stability of the elbow joint and pain were assessed and results recorded. Radiography was used for identification of synostosis, heterotopic ossification, and joint congruency. The Broberg and Morrey classification[10] was used for evaluating traumatic arthritis. The Mayo Elbow Performance Score (MEPS) was determined for each patient at the final clinic visit. Statistical analysis was performed with the SAS software package (SAS Institute, Cary, North Carolina). A value of p < 0.05 was considered to indicate statistical significance. Results Functional outcomes are shown in Table 2. The mean duration of follow-up was 32 months (range, 24–48 months). At the final follow-up visit, the mean flexion–extension arc of all patients was 126.0 4.88, the mean flexion contracture was 9.52 2.158, the mean flexion was 135.5 4.88, the mean pronation arc was 70.5 2.68, the mean supination arc was 68.6 2.28, and the mean forearm rotation arc was 139.0 4.18. Functional arc motion (a flexion–extension arc of 30–1308 and 1008 of forearm rotation), as determined according to the criteria of Morrey et al.,[11] was achieved in all cases. The mean MEPS was 95.2 points (range, 85–100 points), with 19 excellent cases and 2 good cases. Based on the Broberg and Morrey classification for the radiographic assessment of posttraumatic arthritis, 13 elbows had no evidence of degenerative changes (grade 0), and 8 elbows had grade 1 changes. There were no grade 2 or 3 changes. All coronoid and radial head fractures treated with internal fixation
had solid osseous union on the final follow-up radiographs, except for one patient with a Mason type III radial head fracture who developed radial head nonunion. The patient, however, was asymptomatic with no limitation of forearm rotation. All of the patients maintained a concentric reduction of both the ulnotrochlear and the radiocapitellar articulation, without any evidence of elbow instability. There were six patients with type I soft tissue injuries, 12 with type 2, and three with type 3 soft tissue injuries. Slight heterotopic ossification was evident in two patients, but neither required additional surgery. Several patients experienced transient postoperative median nerve paralysis (1–4 weeks after surgery), with rapid recovery and no after-effects. One patient experienced ulnar nerve symptoms; however, as of the last follow-up visit he declined further explorative surgery. A superficial wound infection occurred in one patient, which healed uneventfully after surgical debridement and antibiotic therapy. The two cases of heterotopic ossification, one case of infection, and one case of ulnar neuropathy occurred in patients with type II soft tissue injuries, and the radial head non-union occurred in a patient with type I soft tissue injury. Other complications such as synostosis, implantation failure, or elbow stiffness or instability were absent. Discussion The purpose of this study was to report the outcomes of a modification of the standard surgical protocol for the repair of terrible triad of the elbow injuries. The results of 21 cases showed that the modified surgical protocol results in good outcomes with minimal surgical and postoperative morbidity. Major findings of the study include: (1) The combination of a lateral approach and the anteromedial approach instead of the posterior approach is an effective method for the treatment of terrible triad of the elbow injuries. (2) The procedures of the surgery are different from those used in the traditional approach. (3) MRI can be used for classification of soft tissue injury, and for planning the surgical treatment. With the improvement of operative strategies for terrible triad of the elbow injuries excellent results of treatment have been reported.[12] Outcomes of our modified surgical approach are similar to or better than other results reported in the literature. A recent review of outcomes of current surgical protocols for the treatment of terrible triad of the elbow injuries by RodriguezMartin et al.[13] reported that with an average of 31 months of follow-up, overall flexion arc was 111.48, averaged flexion was 132.58 with forearm rotation of 135.58, MEPS was 85.6 points, and Broberg–Morrey score was 85 points. Egol et al.[14] reported the results of 29 patients with terrible triad injuries with a minimum of
Please cite this article in press as: Zhang C, et al. Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People’s Hospital. Injury (2014), http://dx.doi.org/10.1016/j.injury.2013.12.012
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JINJ-5607; No. of Pages 7 C. Zhang et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx Table 2 Functional recovery. ROM flexion–extensionROM Pronation-Supination PatientExtensionNo. Flexion (mean arc),8
Pronation/ Supination
MEPS Complications 100 100 90 HO 85 100 90 100 100 95 HO 100 100 85 Infection 90 Radial head nonunion 95 100 90 100 95 90 Ulnar neuropathy 100 95
1 2 3 4 5 6 7 8 9 10 11 12 13
5-140 (135) 10-140 (130) 10-130 (120) 5-140 (135) 10-140 (130) 10-130 (120) 15-135 (120) 5-135 (130) 10-135 (125) 10-140 (130) 15-130 (115) 10-135 (125) 10-140 (130)
70/70 75/70 65/70 60/65 70/70 70/70 75/70 70/70 70/70 70/70 75/70 70/60 70/65
140 145 135 125 40 140 145 140 140 140 145 130 135
14 15 16 17 18 19 20 21
5-130 (125) 10-130 (120) 10-140 (130) 5-135 (130) 10-130 (120) 15-140 (125) 10-130 (120) 10-140 (130)
75/70 70/70 70/65 75/70 70/65 70/70 75/70
145 140 135 145 135 140 145
ROM, range of motion; MEPS, Mayo elbow performance score; HO, heterotopic ossification.
1-year follow-up. The average flexion–extension arc of elbow motion was 109 278, the average pronation–supination arc was 128 448, grip strength averaged 72% of the contralateral extremity, the mean MEPS was 81 (range, 45–100), and the mean Broberg– Morrey score was 77 (range, 33–100) The surgical protocol for terrible triad of the elbow injuries is well established as follows.[4] (1) Use a posterior approach for exposure; (2) Reduce and fix the coronoid fracture first; (3) Use a metal prosthesis in preference to open reduction and internal fixation (ORIF) for the radial head fracture; (4) Repair the LCL complex and the common extensor origin and/or the posterolateral capsule to restore lateral stability; and (5) If residual instability of the elbow joint persists, apply a hinged external fixator. Although this treatment protocol has been proved effective, instability, contracture, re-operation, and progression to arthrosis remain significant problems. We seldom use the posterior approach for terrible triad of the elbow injuries, which is recommended in most articles for access to both the medial and lateral aspects of the elbow,[4,12,13] because of the risk of hematoma formation, heterotopic ossification, and although low a risk of flap necrosis.[15,16,17] We instead prefer a combination of the lateral approach and the anteromedial approach, which is less traumatic and more effective for exposure. First, the radial head fracture and LCL complex injury are repaired through a lateral approach (Kocher approach). The described injury mechanism indicates that the capsuloligamentous structures of the elbow begin to fail from lateral to medial.[18] Therefore, reconstruction of the radial head and the LCL complex helps to restore stability and articulation of the elbow joint, which facilitates coronoid fracture fixation. The radial head is an important secondary stabiliser against valgus loading and posterior translation. Although radial head replacement is typically performed,[4,14,19,20] we prefer to repair the radial head rather than perform excision or prosthesis replacement. Disadvantages of plate fixation of the radial head include the risk of posterior interosseous nerve injury, postoperative loss of forearm rotation, nonunion, and implantation failure.[14,21] However, in our series, the complication rate was relatively low, with only one case of
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asymptomatic nonunion without apparent decrease of forearm rotation. Our limited experience with radial head prosthesis replacement suggests that it is a technically difficult procedure for the treatment of terrible triad of the elbow injuries. First, the height of the radial head should correspond to the height of the excised fragments; however, in cases of radial neck comminuted fractures undersizing of the removed head fragments is common, which can result in elbow valgus instability if accompanied by MCL injury. On the other hand, oversizing of the removed head fragments may cause increasing the height of the radial head and overstuffing of the humeroradial joint, with the potential risk of stiffness and capitellar erosion.[22] Also, biomechanical study has shown that no type of radial head prosthesis can restore elbow valgus stability to the same degree as was provided by the native radial head.[23] Furthermore, Leigh and Ball[24] reported that comparable results can be obtained with repair or replacement of the radial head. If the radial head is totally unrepairable, a modular metal prosthesis is preferable.[4,12] Temporary fixation of LCL complex is performed then. Despite its small size, the coronoid process is an important capital bony stabiliser of the humeroulnar articulation. Posterior dislocation of the ulna relative to the distal humerus can be adequately reduced by stable fixation of the coronoid, achieving congruent articulation.[25,26,27] Different surgical fixation techniques for the coronoid have been proposed. The coronoid can be exposed through a lateral approach facilitated by radial head removal. However, it is difficult to achieve fixation from anterior to posterior.[28] Medial exposures are most often advocated for coronoid fixation.[4,29,30] However, these require a large softtissue dissection and still cannot provide enough exposure, especially for the lateral aspect of the coronoid process. Recently, Reichel et al.[6] described an anterior approach in which the coronoid fracture was addressed by splitting the brachialis muscle at its midline down to the level of the anterior capsule of the elbow. In our technique, an anteromedial skin incision starting from the medial humeral epicondyle that parallels the axis of the flexor pronator is made, and then the ‘‘over-the-top’’ approach described by Hotchkiss[31] is used for exposure of the coronoid process. Then, accurate and stable internal fixation is easily achieved with anteroposterior screws and a buttress plate. Garrigues et al.[29] examined different surgical fixation techniques for coronoid fractures in cases of elbow fracture-dislocation, and reported that the suture lasso technique was more stable than other techniques and had a lower complication rate. We believe that, compared with suture technique, fixation with a buttress plate and screws has a biomechanical advantage of anti-axial force loading, especially for comminuted coronoid fractures, and is technically easier to perform. Once restoration of the bony structure is complete, the softtissue injury should be repaired. The LCL complex can be reattached to the lateral epicondyle with suture anchors or transosseous sutures definitely. The reason why we do an initial temporary fixation of the LCL complex is that the humeral–ulnar joint is usually dislocated or unstable before reduction and fixation of coronoid fracture, whereas after fixation of the coronoid fracture the elbow is more stable and anatomically correct at which time it is more appropriate to perform the definitive repair of LCL complex using the anchor suture technique. This method assists in adjusting the tension of LCL complex to avoid laxity or over-tension. Then, stability of the elbow is evaluated using the hanging arm test and the valgus stress test. At this point, if there is remaining posterolateral instability from approximately 308 to full flexion in one or more positions of forearm rotation or on intra-operative radiographs, we examine the repair of bony and soft tissue and if there is apparent valgus instability the MCL is explored and repaired.
Please cite this article in press as: Zhang C, et al. Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People’s Hospital. Injury (2014), http://dx.doi.org/10.1016/j.injury.2013.12.012
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JINJ-5607; No. of Pages 7 C. Zhang et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
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Besides exposure of the coronoid process, an anteromedial incision has the additional advantage of exposing the MCL anteromedially. Damage to the MCL and the common flexor– pronator muscle complex can be easily identified and repaired through this incision. In contrast, in the most favorable posterior incision MCL exposure is posteromedial, and frequently requires exposure of the ulnar nerve and can result in ulnar neuropathy. Although it is well known that the MCL functions as a restraint to elbow valgus laxity and posteromedial rotator instability,[32,33] its dysfunction may result in arthrosis of even simple elbow dislocations.[34] Differences of opinion remain on whether to repair the MCL in terrible triad of the elbow injuries. Forthman et al.[19] reported good results in 22 terrible triad cases without MCL repair, and their findings demonstrated that the MCL has the potential to heal (or scar) in a way that restores function by avoiding varus elbow stress. On the other hand, Jeong et al.[5] repaired the MCL structure in 8 of 13 cases of terrible triad injuries without a large medial softtissue dissection, and the rate of postoperative complication was low. More importantly, biomechanical study suggests that transosseous suture repair of both the LCL and MCL helps to restore elbow stability in either the varus or valgus position, and restores active kinematics in the dependent position.[35] In our series, MCL repair was selectively used in the following two conditions (5 of 21 cases): Apparent valgus instability during surgery, and complete medial ligament avulsion or tear, which we classified as type III soft-tissue injury on MRI before surgery. Medium-term follow-up of our patients showed that repair of the MCL did not result in a high rate of complications such as ulnar neuropathy as reported previously. Although good results can be achieved using a hinged external fixator in cases of complex elbow instability,[36,37] we do not prefer this technique for two reasons. First, most patients can achieve immediate elbow stability following the procedure we have described. Second, the use of a hinged external fixator is technically demanding with a relatively high complication rate. The elbow instability after implantation removal found by Pugh et al.[4] and McKee et al.[38] raises the concern that soft-tissue healing is not adequate despite restoration of the anatomical centre of rotation of the elbow by the hinged external fixator. We begin active rehabilitation exercises on the second day postoperatively with the routine use of a hinged plastic brace. With direct repair of the LCL complex, the MCL, and the bony structure, the elbow is stable enough for immediate active-assisted motion, and the muscle strength of the elbow flexor and extensor reinforces elbow stability through dynamic stabilisation. A recent biomechanical study[39] demonstrated that elbows with MCL and LCL injuries should be rehabilitated using active motion in the horizontal or vertical orientation. There are limitations of this study that should be considered. First, the number of patients was relatively small. The operations were all performed by or under the direct supervision of one surgeon and at a single institution, thus the results may not be reproducible by other surgeons or at other institutions. On the other hand, the results showed that the technique provides good results with minimal morbidity.
Conclusions In conclusion, the results of this study indicate that the modified surgical technique we have described results in good to excellent outcomes for the treatment of terrible triad of the elbow injuries with minimal complications or morbidity. Future comparative studies should be performed to further elucidate the optimal protocol for treating these injuries.
Level of evidence Level IV. Conflict of interest statement None of the authors have any conflicts of interest with regards to this research References [1] Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD, editors. 4th ed., Rockwood and Green’s fractures in adults, vol. 1, 4th ed. Philadelphia: Lippincott-Raven; 1996. p. 929–1024. [2] Mehlhoff TL, Noble PC, Bennett JB, Tullos HS. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg Am 1988;70:244–9. [3] Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow and intraarticular fractures. Clin Orthop 1989;246:126–30. [4] Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am 2004;86:1122–30. [5] Jeong WK, Oh JK, Hwang JH, Hwang SM, Lee WS. Results of terrible triads in the elbow: the advantage of primary restoration of medial structure. J Orthop Sci 2010;15:612–9. [6] Reichel LM, Milam GS, Reitman CA. Anterior approach for operative fixation of coronoid fractures in complex elbow instability. Tech Hand Surg 2012;16:98– 104. [7] O’Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect 2003;52:113–34. [8] Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg 1954;42:123–32. [9] Johnston GW. A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Ulster Med J 1962;31:51–6. [10] Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am 1986;68:669–74. [11] Morrey BF, Askew LJ, An KN, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63:872–7. [12] Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg 2009;17:137–51. [13] Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, Larrainzar-Garijo R. Outcomes after terrible triads of the elbow treated with the current surgical protocols. A review. Int Orthop 2011;35:851–60. [14] Egol KA, Immerman I, Paksima N, Tejwani N, Koval KJ. Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Bull NYU Hosp Jt Dis 2007;65:263–70. [15] Levine WN, Cadet ER, Ahmad CS. Shoulder and elbow trauma. London: Jp Medical Ltd; 2012. 216. [16] Mansat P, Morrey BF. Semiconstrained total elbow arthroplasty for ankylosed and stiff elbows. J Bone Joint Surg Am 2000;82:1260–8. [17] Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg 2009;7:137–51. [18] O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440–6. [19] Forthman C, Henket M, Ring DC. Elbow dislocation with intraarticular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg Am 2007;32:1200–9. [20] 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– 6. [21] Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 2002;84:1811–5. [22] King GJ. Management of comminuted radial head fractures with replacement arthroplasty. Hand Clin 2004;20:429–41. [23] Pomianowski S, Morrey BF, Neale PG, Park MJ, O’Driscoll SW, An KN. Contribution of monoblock and bipolar radial head prostheses to valgus stability of the elbow. J Bone Joint Surg Am 2001;83:1829–34. [24] Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg 2012;21:1336–41. [25] Closkey RF, Goode JR, Kirschenbaum D, Cody RP. The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. J Bone Joint Surg Am 2000;82:1749–53. [26] Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. J Bone Joint Surg Am 2004;86-A(5):975–82. [27] Hull JR, Owen JR, Fern SE, Wayne JS, Boardman 3rd ND. Role of the coronoid process in varus osteoarticular stability of the elbow. J Shoulder Elb Surg 2005;14:441–6. [28] Ring D, Jupiter JB. Surgical exposure of coronoid fractures. Tech Shoulder Elbow Surg 2002;3:48–56. [29] Garrigues GE, Wray 3rd WH, Lindenhovius AL, Ring DC, Ruch DS. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am 2011;93:1873–81.
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JINJ-5607; No. of Pages 7 C. Zhang et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx [30] Ring D, Doornberg JN. Fracture of the anteromedial facet of the coronoid process surgical technique. J Bone Joint Surg Am 2007;89(Suppl. 2 (Pt. 2)):267–83. [31] Hotchkiss RN. Elbow contracture. In: Green DP, Hotchkiss RN, Pederson WC, editors. Green’s operative hand surgery. Philadelphia, PA: Churchill-Livingstone; 1999. p. 667–82. [32] Pichora JE, Fraser GS, Ferreira LF, Brownhill JR, Johnson JA, King GJW. The effect of medial collateral ligament repair tension on elbow joint kinematics and stability. J Hand Surg Am 2007;32:1210–7. [33] O’Driscoll SW, Morrey BF, Korinek S, An KN. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res 1992;(280): 186–97. [34] Eygendaal D, Verdegaal SH, Obermann WR, van Vugt AB, Poll RG, Rozing PM. Posterolateral dislocation of the elbow joint. Relationship to medial instability. J Bone Joint Surg 2000;82A:555–60.
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[35] Pollock JW, Pichora J, Brownhill J, Ferreira LM, McDonald CP, Johnson JA, King GJ. The influence of type II coronoid fractures, collateral ligament injuries, and surgical repair on the kinematics and stability of the elbow: an in vitro biomechanical study. J Shoulder Elbow Surg 2009;18:408–17. [36] Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone Joint Surg Am 2002;84:1630–5. [37] Zilkens C, Graf M, Anastasiadis A, Smajic S, Muhr G, Ka¨licke T. Treatment of acute and chronic elbow instability with a hinged external fixator after fracture dislocation. Acta Orthop Belg 2009;75:167–74. [38] McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures: Surgical technique. J Bone Joint Surg Am 2005;87(Suppl. 1 (Pt. 1)):22–32. [39] Alolabi B, Gray A, Ferreira LM, Johnson JA, Athwal GS, King GJ. Rehabilitation of the medial- and lateral collateral ligament-deficient elbow: an in vitro biomechanical study. J Hand Ther 2012;25:363–72.
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JINJ-5607; No. of Pages 7 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People’s Hospital Chi Zhang, Biao Zhong *, Cong-feng Luo Orthopaedic Department, Shanghai Jiaotong University Affiliated No 6th People’s Hospital, 600 Yishan Road, Shanghai 200233, PR China
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 September 2013 Received in revised form 21 December 2013 Accepted 25 December 2013
Background: Terrible triad of the elbow can be a challenging injury to treat, with a history of well-known complications. The purpose of this study is to report the outcomes of a modification of the standard surgical protocol for the repair of terrible triad of the elbow injuries. Methods: We retrospectively reviewed terrible triad of the elbow injuries treated at our hospital using a modified surgical technique. Our surgical procedure includes fixation or replacement of the radial head and repair of the ruptured lateral collateral ligament (LCL) through a lateral approach. Simultaneous fixation of the coronoid process and repair of the common flexor muscle and medial collateral ligament (MCL) injury were performed through an anteromedial incision. Mayo Elbow Performance Score (MEPS) was determined for each patient at the final clinic visit. The Broberg and Morrey classification was used for evaluating traumatic arthritis. Results: There were 21 patients (21 elbows) included in the analysis, and the mean follow-up period was 32 months (range, 24–48 months). At the last follow-up the mean flexion–extension arc of the elbow was 1268 and the mean forearm rotation was 1398. The mean MEPS was 95 points (range, 85–100 points), with 19 excellent results and two good results. Concentric stability was restored in all cases. Two patients had heterotopic ossification, one patient had radial head nonunion, one patient had a superficial infection, and one patient had ulnar nerve neuropathy. Conclusion: Our surgical strategy for terrible triad of the elbow has the advantage of providing both bony and soft-tissue stability simultaneously, thereby allowing active early motion as well as functional recovery of the elbow. ß 2014 Published by Elsevier Ltd.
Keywords: Elbow Trauma Fracture and dislocation Terrible-triad injury Treatment Coronoid process Elbow approaches
Introduction Elbow dislocation with associated radial head and coronoid process fractures has been referred to as the terrible triad of the elbow by Hotchkiss[1] because of the difficulty of treatment and the consistently poor reported outcomes, especially compared with simple elbow dislocations or fractures.[2,3] Improved understanding of the injury mechanism, the relevant anatomy, and the factors associated with elbow stability have allowed application of a standard protocol for treatment.[4] This protocol is associated with good results with respect to elbow stability and function, and results in satisfactory outcomes in most patients. However, there are still differences of opinion among surgeons as to the best surgical procedure, the choice of fixation technique, and the need for medial collateral ligament (MCL) repair; factors that influence the overall management of these complex
* Corresponding author. Tel.: +86 021 64369181 58071. E-mail address: [email protected] (B. Zhong).
injuries.[5,6] The purpose of this study is to report the outcomes of a modification of the standard surgical protocol for the repair of terrible triad of the elbow injuries that has the advantage of providing both bony and soft-tissue stability of the elbow simultaneously, thus allowing active early motion as well as functional recovery of the elbow. Materials and methods Twenty-three consecutive cases of elbow dislocation associated with fractures of the radial head and coronoid process were identified as terrible triad of the elbow injuries at the Shanghai 6th People’s Hospital between July 2008 and January 2011. Two patients were lost to follow-up prior to definitive assessment of the outcome, leaving 21 patients (21 elbows) for evaluation. There were 17 males and 4 females with a mean age of 38.4 years (range, 17–63 years). The mechanisms of injury were fall from a height (15 cases), sports injury (4 cases), and traffic accident (2 cases). The 21 elbows were treated surgically at a mean of 4 days (range, 2–8 days) after the injury.
0020–1383/$ – see front matter ß 2014 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.injury.2013.12.012
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Fig. 1. (A) Type I soft-tissue injury: only LCL complex injury. (B) Type II soft-tissue injury: LCL complex injury with partial tear of the MCL. (C) Type III soft-tissue injury: LCL complex injury combined with MCL avulsion injury.
Computed tomography (CT) was routinely used in cases of terrible triad injuries before surgery to identify fracture patterns, comminution, and displacement which may not be evident on plain radiographs. Three-dimensional CT was applied in difficult cases to improve the understanding of the injury. O’Driscoll et al.[7] classified coronoid fractures according to the location of the fracture in reference to local anatomy on CT scan, and we used this classification system in this study. Based on the MasonJohnston classification[8,9] all radial head fractures were type IV because they were associated with a dislocation. However, for the purposes of this study radial head fractures were classified according to the original Mason classification[8]: type I, nondisplaced radial head fractures (or small marginal fractures); type II, partial articular fractures with displacement (>2 mm); and type III, comminuted fractures involving the entire radial head. Soft-tissue injuries in all patients were evaluated with magnetic resonance imaging (MRI), and injuries were categorised into three types. Type I soft-tissue injuries were lateral collateral ligament (LCL) complex injuries without MCL injury; there was rupture or avulsion of the LCL from the lateral epicondyle, as well as the common extensor tendon and posterior capsule (Fig. 1A). Type II soft-tissue injuries were LCL complex injuries with MCL injury, but with the continuity of the MCL remaining complete (Fig. 1B). Type III soft-tissue injuries were LCL complex injuries with MCL body rupture or avulsion from the medial humeral attachment; in some cases the flexor–pronator tendons were torn at the
musculotendinous junction leaving some remaining soft tissue in the medial epicondyle (Fig. 1C). Fracture and soft-tissue details of each patient classification are recorded in Table 1.
Operative technique and protocol All procedures were performed by or under the direct supervision of one fellowship-trained orthopaedic surgeon. An extended lateral approach in combination with a separate medial approach was used in every patient. The radial head fracture was addressed first through a lateral approach (Kocher approach), with a preference for fixation over replacement even in Mason type III radial head fractures. Then, the LCL complex was temporarily sutured to the supra-lateral condyle to provide provisional stability of elbow joint to restore articulation of the humeroulnar joint to facilitate reduction and fixation of coronoid fracture. Next, an anteromedial skin incision was made (Fig. 2A), and an ‘‘overthe-top’’ approach was used to expose most of the coronoid fracture (Fig. 2B). In our approach, the flexor pronator mass is split, taking the anterior half anteriorly with the brachialis, and the anterior joint capsule off the anterior humerus to allow exposure of the coronoid fracture. After reduction, 3.0-mm cannulated screws and/or a T-type buttress plate that is usually used for metacarpal and phalangeal fractures was used for fixation of the coronoid fracture (Fig. 2C and D).
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JINJ-5607; No. of Pages 7 C. Zhang et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx Table 1 Injury and treatment details. Radial head fracture
Coronoid fracture
Soft-tissue injury
Patient No.
Classification— treatment
Classification— treatment
Classification— treatment
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type
Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type
Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type Type
II ORIF III ORIF I ORIF III ORIF III ORIF II ORIF II ORIF III PR II ORIF II ORIF II ORIF II ORIF III ORIF III PR II ORIF II ORIF II ORIF II ORIF III ORIF I ORIF II ORIF
A1 CS A2 CS + BP A2 CS + BP A2 CS + BP B2 CS + BP A1 BP A2 BP A2 CS + BP A2 CS + BP B2 CS + BP A2 BP A2 CS + BP A2 BP A1 CS A2 CS + BP B2 CS + BP A1 CS + BP A2 CS + BP A2 BP B2 BP A1 BP
II LCL AS I LCL AS II LCL AS II LCL AS III LCL AS + MCL AS I LCL AS I LCL S III LCL AS + MCL AS II LCL AS II LCL AS II LCL AS II LCL AS + MCL AS I LCL AS II LCL AS III LCL AS + MCL AS II LCL AS II LCL AS + S I LCL AS II LCL AS + MCL AS II LCL S I LCL AS
ORIF, Open reduction and internal fixation; CS, cannulated screws; LCL, lateral collateral ligament; AS, avulsion suture; BP, buttress plate; MCL, medial collateral ligament; S, suture; PR, prosthesis replacement.
Once bony reconstruction was complete, the LCL complex injury, in which detachment of the lateral ligament complex from the humerus was common, was repaired using suture anchors. Mid-substance tears were repaired with direct suture using
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number 1 or 2 non-absorbable suture. Elbow stability was then evaluated with the goal being concentric stability with no observed posterior or posterolateral subluxation through a flexion–extension arc of 20–1308 with the forearm in neutral rotation. If posterior or posterolateral instability persisted, fixation of the radial head and coronoid process were checked and augmented suturing of the lateral ligament complex was performed if needed. Elbow valgus stability was then tested, and exploration of the medial side was performed if instability was found or in cases in which there were preoperative MRI findings of MCL body rupture or avulsion. For patients with type III soft-tissue injury, and those with type II soft-tissue injury who had serious valgus instability (5 patients), the MCL was repaired through an anteromedial skin incision and suture anchors were usually used to repair the avulsion of the MCL from the medial humeral epicondyle (Fig. 3A and B). Mid-substance tears of the MCL and accompanying tears of the common flexor–pronator muscle complex were repaired with direct suture using number 1 or 2 non-absorbable suture. After repair, the elbow valgus stability was immediately restored. A hinged external fixator was not used in any cases. The wounds were closed in layers, and then a sterile dressing was applied. Drains were not routinely used.
Postoperative management A hinged plastic brace was applied after surgery and used for 6 weeks postoperatively in all patients. For patients with type I softtissue injuries, the elbow was immobilised at 908 of flexion using the brace with the forearm in full pronation to avoid posterolateral instability and to protect the LCL repair when they were not
Fig. 2. (A) The anteromedial skin incision started from the medial humeral epicondyle and paralleled the axis of the flexor pronator. (B) The coronoid fracture was exposed and fixed through the ‘‘over-the-top’’ approach. (C) Intraoperative fluoroscopy (AP view) showed that the coronoid fracture was well reduced and fixed with buttress plates, and the humeroulnar articulation was restored. (D) Intraoperative fluoroscopy(lateral view) showed that the coronoid fracture was well reduced and fixed with buttress plates, and the humeroulnar articulation was restored.
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Fig. 3. A patient with type III soft-tissue injury. (A) The MCL and common flexor–pronator muscle complex were avulsed from the epicondyle. (B) Suture anchors were applied for repair, and the medial complex of the elbow was restored.
performing rehabilitation exercises. For patients with type II or type III soft-tissue injuries, the arm was fixed with the brace at neutral rotation at 908 of flexion when they were not performing rehabilitation exercises. Supervised rehabilitation was begun on the second day after surgery for all patients. Active elbow flexion and extension and passive forearm rotation exercises with the protection of the brace lasting for 20 min were performed 3 or 4 times a day with gradual increase of the ROM. For example, the range of elbow motion extension and flexion were set at 0–30– 1108 for 2 weeks, the 0–20–1208 for 2 weeks, and then 0–10–1308 for 2 weeks followed by full range of elbow motion. Indomethacin, 25 mg three times a day for 3 weeks postoperatively was prescribed to prevent heterotopic ossification. All patients received parecoxib, 40 mg twice a day, to relieve pain and allow early active elbow exercise. Evaluation Patients were followed up clinically and radiographically until fracture union and until the plateau stage of elbow motion range was reached. Function and stability of the elbow joint and pain were assessed and results recorded. Radiography was used for identification of synostosis, heterotopic ossification, and joint congruency. The Broberg and Morrey classification[10] was used for evaluating traumatic arthritis. The Mayo Elbow Performance Score (MEPS) was determined for each patient at the final clinic visit. Statistical analysis was performed with the SAS software package (SAS Institute, Cary, North Carolina). A value of p < 0.05 was considered to indicate statistical significance. Results Functional outcomes are shown in Table 2. The mean duration of follow-up was 32 months (range, 24–48 months). At the final follow-up visit, the mean flexion–extension arc of all patients was 126.0 4.88, the mean flexion contracture was 9.52 2.158, the mean flexion was 135.5 4.88, the mean pronation arc was 70.5 2.68, the mean supination arc was 68.6 2.28, and the mean forearm rotation arc was 139.0 4.18. Functional arc motion (a flexion–extension arc of 30–1308 and 1008 of forearm rotation), as determined according to the criteria of Morrey et al.,[11] was achieved in all cases. The mean MEPS was 95.2 points (range, 85–100 points), with 19 excellent cases and 2 good cases. Based on the Broberg and Morrey classification for the radiographic assessment of posttraumatic arthritis, 13 elbows had no evidence of degenerative changes (grade 0), and 8 elbows had grade 1 changes. There were no grade 2 or 3 changes. All coronoid and radial head fractures treated with internal fixation
had solid osseous union on the final follow-up radiographs, except for one patient with a Mason type III radial head fracture who developed radial head nonunion. The patient, however, was asymptomatic with no limitation of forearm rotation. All of the patients maintained a concentric reduction of both the ulnotrochlear and the radiocapitellar articulation, without any evidence of elbow instability. There were six patients with type I soft tissue injuries, 12 with type 2, and three with type 3 soft tissue injuries. Slight heterotopic ossification was evident in two patients, but neither required additional surgery. Several patients experienced transient postoperative median nerve paralysis (1–4 weeks after surgery), with rapid recovery and no after-effects. One patient experienced ulnar nerve symptoms; however, as of the last follow-up visit he declined further explorative surgery. A superficial wound infection occurred in one patient, which healed uneventfully after surgical debridement and antibiotic therapy. The two cases of heterotopic ossification, one case of infection, and one case of ulnar neuropathy occurred in patients with type II soft tissue injuries, and the radial head non-union occurred in a patient with type I soft tissue injury. Other complications such as synostosis, implantation failure, or elbow stiffness or instability were absent. Discussion The purpose of this study was to report the outcomes of a modification of the standard surgical protocol for the repair of terrible triad of the elbow injuries. The results of 21 cases showed that the modified surgical protocol results in good outcomes with minimal surgical and postoperative morbidity. Major findings of the study include: (1) The combination of a lateral approach and the anteromedial approach instead of the posterior approach is an effective method for the treatment of terrible triad of the elbow injuries. (2) The procedures of the surgery are different from those used in the traditional approach. (3) MRI can be used for classification of soft tissue injury, and for planning the surgical treatment. With the improvement of operative strategies for terrible triad of the elbow injuries excellent results of treatment have been reported.[12] Outcomes of our modified surgical approach are similar to or better than other results reported in the literature. A recent review of outcomes of current surgical protocols for the treatment of terrible triad of the elbow injuries by RodriguezMartin et al.[13] reported that with an average of 31 months of follow-up, overall flexion arc was 111.48, averaged flexion was 132.58 with forearm rotation of 135.58, MEPS was 85.6 points, and Broberg–Morrey score was 85 points. Egol et al.[14] reported the results of 29 patients with terrible triad injuries with a minimum of
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JINJ-5607; No. of Pages 7 C. Zhang et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx Table 2 Functional recovery. ROM flexion–extensionROM Pronation-Supination PatientExtensionNo. Flexion (mean arc),8
Pronation/ Supination
MEPS Complications 100 100 90 HO 85 100 90 100 100 95 HO 100 100 85 Infection 90 Radial head nonunion 95 100 90 100 95 90 Ulnar neuropathy 100 95
1 2 3 4 5 6 7 8 9 10 11 12 13
5-140 (135) 10-140 (130) 10-130 (120) 5-140 (135) 10-140 (130) 10-130 (120) 15-135 (120) 5-135 (130) 10-135 (125) 10-140 (130) 15-130 (115) 10-135 (125) 10-140 (130)
70/70 75/70 65/70 60/65 70/70 70/70 75/70 70/70 70/70 70/70 75/70 70/60 70/65
140 145 135 125 40 140 145 140 140 140 145 130 135
14 15 16 17 18 19 20 21
5-130 (125) 10-130 (120) 10-140 (130) 5-135 (130) 10-130 (120) 15-140 (125) 10-130 (120) 10-140 (130)
75/70 70/70 70/65 75/70 70/65 70/70 75/70
145 140 135 145 135 140 145
ROM, range of motion; MEPS, Mayo elbow performance score; HO, heterotopic ossification.
1-year follow-up. The average flexion–extension arc of elbow motion was 109 278, the average pronation–supination arc was 128 448, grip strength averaged 72% of the contralateral extremity, the mean MEPS was 81 (range, 45–100), and the mean Broberg– Morrey score was 77 (range, 33–100) The surgical protocol for terrible triad of the elbow injuries is well established as follows.[4] (1) Use a posterior approach for exposure; (2) Reduce and fix the coronoid fracture first; (3) Use a metal prosthesis in preference to open reduction and internal fixation (ORIF) for the radial head fracture; (4) Repair the LCL complex and the common extensor origin and/or the posterolateral capsule to restore lateral stability; and (5) If residual instability of the elbow joint persists, apply a hinged external fixator. Although this treatment protocol has been proved effective, instability, contracture, re-operation, and progression to arthrosis remain significant problems. We seldom use the posterior approach for terrible triad of the elbow injuries, which is recommended in most articles for access to both the medial and lateral aspects of the elbow,[4,12,13] because of the risk of hematoma formation, heterotopic ossification, and although low a risk of flap necrosis.[15,16,17] We instead prefer a combination of the lateral approach and the anteromedial approach, which is less traumatic and more effective for exposure. First, the radial head fracture and LCL complex injury are repaired through a lateral approach (Kocher approach). The described injury mechanism indicates that the capsuloligamentous structures of the elbow begin to fail from lateral to medial.[18] Therefore, reconstruction of the radial head and the LCL complex helps to restore stability and articulation of the elbow joint, which facilitates coronoid fracture fixation. The radial head is an important secondary stabiliser against valgus loading and posterior translation. Although radial head replacement is typically performed,[4,14,19,20] we prefer to repair the radial head rather than perform excision or prosthesis replacement. Disadvantages of plate fixation of the radial head include the risk of posterior interosseous nerve injury, postoperative loss of forearm rotation, nonunion, and implantation failure.[14,21] However, in our series, the complication rate was relatively low, with only one case of
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asymptomatic nonunion without apparent decrease of forearm rotation. Our limited experience with radial head prosthesis replacement suggests that it is a technically difficult procedure for the treatment of terrible triad of the elbow injuries. First, the height of the radial head should correspond to the height of the excised fragments; however, in cases of radial neck comminuted fractures undersizing of the removed head fragments is common, which can result in elbow valgus instability if accompanied by MCL injury. On the other hand, oversizing of the removed head fragments may cause increasing the height of the radial head and overstuffing of the humeroradial joint, with the potential risk of stiffness and capitellar erosion.[22] Also, biomechanical study has shown that no type of radial head prosthesis can restore elbow valgus stability to the same degree as was provided by the native radial head.[23] Furthermore, Leigh and Ball[24] reported that comparable results can be obtained with repair or replacement of the radial head. If the radial head is totally unrepairable, a modular metal prosthesis is preferable.[4,12] Temporary fixation of LCL complex is performed then. Despite its small size, the coronoid process is an important capital bony stabiliser of the humeroulnar articulation. Posterior dislocation of the ulna relative to the distal humerus can be adequately reduced by stable fixation of the coronoid, achieving congruent articulation.[25,26,27] Different surgical fixation techniques for the coronoid have been proposed. The coronoid can be exposed through a lateral approach facilitated by radial head removal. However, it is difficult to achieve fixation from anterior to posterior.[28] Medial exposures are most often advocated for coronoid fixation.[4,29,30] However, these require a large softtissue dissection and still cannot provide enough exposure, especially for the lateral aspect of the coronoid process. Recently, Reichel et al.[6] described an anterior approach in which the coronoid fracture was addressed by splitting the brachialis muscle at its midline down to the level of the anterior capsule of the elbow. In our technique, an anteromedial skin incision starting from the medial humeral epicondyle that parallels the axis of the flexor pronator is made, and then the ‘‘over-the-top’’ approach described by Hotchkiss[31] is used for exposure of the coronoid process. Then, accurate and stable internal fixation is easily achieved with anteroposterior screws and a buttress plate. Garrigues et al.[29] examined different surgical fixation techniques for coronoid fractures in cases of elbow fracture-dislocation, and reported that the suture lasso technique was more stable than other techniques and had a lower complication rate. We believe that, compared with suture technique, fixation with a buttress plate and screws has a biomechanical advantage of anti-axial force loading, especially for comminuted coronoid fractures, and is technically easier to perform. Once restoration of the bony structure is complete, the softtissue injury should be repaired. The LCL complex can be reattached to the lateral epicondyle with suture anchors or transosseous sutures definitely. The reason why we do an initial temporary fixation of the LCL complex is that the humeral–ulnar joint is usually dislocated or unstable before reduction and fixation of coronoid fracture, whereas after fixation of the coronoid fracture the elbow is more stable and anatomically correct at which time it is more appropriate to perform the definitive repair of LCL complex using the anchor suture technique. This method assists in adjusting the tension of LCL complex to avoid laxity or over-tension. Then, stability of the elbow is evaluated using the hanging arm test and the valgus stress test. At this point, if there is remaining posterolateral instability from approximately 308 to full flexion in one or more positions of forearm rotation or on intra-operative radiographs, we examine the repair of bony and soft tissue and if there is apparent valgus instability the MCL is explored and repaired.
Please cite this article in press as: Zhang C, et al. Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People’s Hospital. Injury (2014), http://dx.doi.org/10.1016/j.injury.2013.12.012
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JINJ-5607; No. of Pages 7 C. Zhang et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
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Besides exposure of the coronoid process, an anteromedial incision has the additional advantage of exposing the MCL anteromedially. Damage to the MCL and the common flexor– pronator muscle complex can be easily identified and repaired through this incision. In contrast, in the most favorable posterior incision MCL exposure is posteromedial, and frequently requires exposure of the ulnar nerve and can result in ulnar neuropathy. Although it is well known that the MCL functions as a restraint to elbow valgus laxity and posteromedial rotator instability,[32,33] its dysfunction may result in arthrosis of even simple elbow dislocations.[34] Differences of opinion remain on whether to repair the MCL in terrible triad of the elbow injuries. Forthman et al.[19] reported good results in 22 terrible triad cases without MCL repair, and their findings demonstrated that the MCL has the potential to heal (or scar) in a way that restores function by avoiding varus elbow stress. On the other hand, Jeong et al.[5] repaired the MCL structure in 8 of 13 cases of terrible triad injuries without a large medial softtissue dissection, and the rate of postoperative complication was low. More importantly, biomechanical study suggests that transosseous suture repair of both the LCL and MCL helps to restore elbow stability in either the varus or valgus position, and restores active kinematics in the dependent position.[35] In our series, MCL repair was selectively used in the following two conditions (5 of 21 cases): Apparent valgus instability during surgery, and complete medial ligament avulsion or tear, which we classified as type III soft-tissue injury on MRI before surgery. Medium-term follow-up of our patients showed that repair of the MCL did not result in a high rate of complications such as ulnar neuropathy as reported previously. Although good results can be achieved using a hinged external fixator in cases of complex elbow instability,[36,37] we do not prefer this technique for two reasons. First, most patients can achieve immediate elbow stability following the procedure we have described. Second, the use of a hinged external fixator is technically demanding with a relatively high complication rate. The elbow instability after implantation removal found by Pugh et al.[4] and McKee et al.[38] raises the concern that soft-tissue healing is not adequate despite restoration of the anatomical centre of rotation of the elbow by the hinged external fixator. We begin active rehabilitation exercises on the second day postoperatively with the routine use of a hinged plastic brace. With direct repair of the LCL complex, the MCL, and the bony structure, the elbow is stable enough for immediate active-assisted motion, and the muscle strength of the elbow flexor and extensor reinforces elbow stability through dynamic stabilisation. A recent biomechanical study[39] demonstrated that elbows with MCL and LCL injuries should be rehabilitated using active motion in the horizontal or vertical orientation. There are limitations of this study that should be considered. First, the number of patients was relatively small. The operations were all performed by or under the direct supervision of one surgeon and at a single institution, thus the results may not be reproducible by other surgeons or at other institutions. On the other hand, the results showed that the technique provides good results with minimal morbidity.
Conclusions In conclusion, the results of this study indicate that the modified surgical technique we have described results in good to excellent outcomes for the treatment of terrible triad of the elbow injuries with minimal complications or morbidity. Future comparative studies should be performed to further elucidate the optimal protocol for treating these injuries.
Level of evidence Level IV. Conflict of interest statement None of the authors have any conflicts of interest with regards to this research References [1] Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD, editors. 4th ed., Rockwood and Green’s fractures in adults, vol. 1, 4th ed. Philadelphia: Lippincott-Raven; 1996. p. 929–1024. [2] Mehlhoff TL, Noble PC, Bennett JB, Tullos HS. Simple dislocation of the elbow in the adult. Results after closed treatment. J Bone Joint Surg Am 1988;70:244–9. [3] Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow and intraarticular fractures. Clin Orthop 1989;246:126–30. [4] Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am 2004;86:1122–30. [5] Jeong WK, Oh JK, Hwang JH, Hwang SM, Lee WS. Results of terrible triads in the elbow: the advantage of primary restoration of medial structure. J Orthop Sci 2010;15:612–9. [6] Reichel LM, Milam GS, Reitman CA. Anterior approach for operative fixation of coronoid fractures in complex elbow instability. Tech Hand Surg 2012;16:98– 104. [7] O’Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD. Difficult elbow fractures: pearls and pitfalls. Instr Course Lect 2003;52:113–34. [8] Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg 1954;42:123–32. [9] Johnston GW. A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Ulster Med J 1962;31:51–6. [10] Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg Am 1986;68:669–74. [11] Morrey BF, Askew LJ, An KN, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981;63:872–7. [12] Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg 2009;17:137–51. [13] Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, Larrainzar-Garijo R. Outcomes after terrible triads of the elbow treated with the current surgical protocols. A review. Int Orthop 2011;35:851–60. [14] Egol KA, Immerman I, Paksima N, Tejwani N, Koval KJ. Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Bull NYU Hosp Jt Dis 2007;65:263–70. [15] Levine WN, Cadet ER, Ahmad CS. Shoulder and elbow trauma. London: Jp Medical Ltd; 2012. 216. [16] Mansat P, Morrey BF. Semiconstrained total elbow arthroplasty for ankylosed and stiff elbows. J Bone Joint Surg Am 2000;82:1260–8. [17] Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg 2009;7:137–51. [18] O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440–6. [19] Forthman C, Henket M, Ring DC. Elbow dislocation with intraarticular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg Am 2007;32:1200–9. [20] 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– 6. [21] Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 2002;84:1811–5. [22] King GJ. Management of comminuted radial head fractures with replacement arthroplasty. Hand Clin 2004;20:429–41. [23] Pomianowski S, Morrey BF, Neale PG, Park MJ, O’Driscoll SW, An KN. Contribution of monoblock and bipolar radial head prostheses to valgus stability of the elbow. J Bone Joint Surg Am 2001;83:1829–34. [24] Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. J Shoulder Elbow Surg 2012;21:1336–41. [25] Closkey RF, Goode JR, Kirschenbaum D, Cody RP. The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. J Bone Joint Surg Am 2000;82:1749–53. [26] Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. J Bone Joint Surg Am 2004;86-A(5):975–82. [27] Hull JR, Owen JR, Fern SE, Wayne JS, Boardman 3rd ND. Role of the coronoid process in varus osteoarticular stability of the elbow. J Shoulder Elb Surg 2005;14:441–6. [28] Ring D, Jupiter JB. Surgical exposure of coronoid fractures. Tech Shoulder Elbow Surg 2002;3:48–56. [29] Garrigues GE, Wray 3rd WH, Lindenhovius AL, Ring DC, Ruch DS. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am 2011;93:1873–81.
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