Objective To investigate the effectiveness of hinged external fixator with mini-plate to treat terrible triad of the elbow. Methods Between August 2008 and June 2011, 11 patients with terrible triad of the elbow were treated with hinged external fixator combined with mini-plate. There were 9 males and 2 females, aged 22-56 years (mean, 34 years). The injuries were caused by falling from height in 8 cases and traffic accident in 3 cases. All patients were closed injury. The time from injury to operation varied from 8 hours to 7 days (mean, 3.7 days). According to Mason classification standard, all radial head fractures were type IV and complicated by posterior dislocation of the elbow; according to Regan-Morrey classification standard, ulna coronary process fractures were type I in 3 cases, type II in 3 cases, and type III in 5 cases. Results All the patients achieved primary healing of incision after operation and no nerve injury occurred. The patients were followed up 12-20 months (mean, 15 months). Two cases had screw channel infection after 12 weeks of operation, and 1 case had mild heterotopic ossification of the elbow after 4 months of operation. X-ray films showed that all fractures healed from 8 to 20 weeks (mean, 16 weeks). No recurrent dislocation or instability of the elbow occurred. At 12 months after operation, the elbow range of motion (ROM) were 120-145° (mean, 135°) in flexion, 0-25° (mean, 10°) in extension, 50-90° (mean, 70°) in pronation, and 50-80° (mean, 60°) in supination. According to Mayo elbow function evaluation standard, the results were excellent in 5 cases, good in 4 cases, and fair in 2 cases, with an excellent and good rate of 81.8%. Conclusion Hinged external fixator with mini-plate can enhance postoperative stability of the elbow. This therapy is beneficial to early functional exercise and obviously decrease the disability rate caused by complex damage on the elbow.
Objective To review the injury mechanism and the treatment progress of terrible triad of the elbow, and to analyze the direction of further research. Methods Related literature concerning terrible triad of the elbow was extensively reviewed and comprehensively analyzed. Results The main treatment of terrible triad of the elbow is operation. The ultimate goal of treatment is to reconstruct sufficient stability of the elbow. The treatment includes fixation of the coronoid by suture, screw or plate; fixation of radial head by screw and plate, partial or complete replacement of the radial head; fixation of lateral collateral ligament and the medial collateral ligament by bone suture or anchors and the application of the external fixator. These surgical treatments have their own indications and advantages, most get satisfactory results. Conclusion Generally, surgery is needed to maintain the stability of the elbow for patients of terrible triad elbow. However, medial ligament repair or not, the choice of approach, and mechanism of injury still need further study.
Objective To explore the operation procedure and effectiveness of terrible triad of the elbow joint. Methods Between October 2006 and June 2010, 11 cases of closed terrible triad of the elbow joint were treated by operation. There were 8 males and 3 females with an average age of 32 years (range, 21-53 years). The mechanism of injury was fall ing from height in 4 cases and traffic accident in 7 cases. The time from injury to admission was 30 minutes to 9 days. According to Regan-Morrey classification for fractures of the ulnar coronoid, there were 5 cases of type I, 5 cases of type II, and 1case of type III; and according to Mason classification for fractures of the radial head, there were 4 cases of type I, 5 cases of type II, and 2 cases of type III. The elbow joint range of motion (ROM) was (63 ± 9)° at flexion and extension, and the forearm ROM was (71 ± 8)° at pronation and supination. All cases underwent reduction and fixation by lateral approach combined with medial approach according to McKeeps operation process. After operation, the affected l imb was immobil ized with plaster at elbow joint flexion of 90° and in forearm neutral position, then passive physical exercises were carried out, and finally active physical exercises were done after removing plaster at 4 weeks. Results All incisions healed by first intention. Eleven cases were followed up 7-27 months (14.5 months on average). The X-ray films showed good reduction, the cl inical heal ing time was 8-19 weeks with an average of 11 weeks. Mild ectopic ossification of the elbow joint occurred in 3 cases at 6 months after operation, mild degenerative change in 1 case at 18 months after operation. At last follow-up, the elbow joint ROM was (103 ± 14)° at flexion and extension, and the forearm ROM was (122 ± 13)° at pronation and supination, showing no significant difference when compared with the values of normal elbow joint (P gt; 0.05) and significant difference when compared with the preoperative values of affected elbow joint (P lt; 0.05). According to Mayo elbow performance score, the results were excellent in 5 cases, good in 5 cases, and fair in 1 case with an excellent and good rate of 90.9%. Conclusion The surgical treatment of terrible triad of the elbow joint can restore sufficiently elbow stabil ity, allow early motion postoperatively, and enhance the functional outcome.
Objective To retrospectively reviewed the operative therapy of the terrible triad of the elbow. Methods From October 2003 to September 2007, 10 cases of terrible triad were treated, with an elbow dislocation and an associated fracture of both the radial head and the coronoid process. There were 3 males and 7 females with the age of 18-66 years. The injury was caused by traffic accidents in 4 cases, fall ing from a height in 4 cases, and tumbl ing in 2 cases. The coronoid process fractures of the patients were 5 cases of type I, 3 cases of type II and 2 cases of type III according to Regan- Morrey classification. The radial head fractures of the patients were 1 case of type I, 6 cases of type II and 1 case of type IIIaccording to Mason classification, and their radial heads of the other 2 patiants were resected before they were in hospital. The general approach was to repair the damaged structures sequentially from deep to superficial, from coronoid to anterior capsule to radial head to lateral l igament complex to common extensor origin. And selected cases were repaired of the medial collateral l igaments and assisted mobile hinged external fixation to keep the forearm fixed in functional rotation position. The function of the elbows were evaluated with the criteria of the HSS2 score system. Results The other wounds healed by first intention except 1 case which had infection 7 days after operation and whose soft tissue defect in posterior elbow were repaired with the pedicle thoracoumbil ical flap. The patients were followed up 6 to 51 mouths (mean 24.9 mouths). The fracture heal ing time was 6 to 20 weeks (mean 9.6 weeks). Six mouths postoperatively, the mean flexion-extension arc of the elbow was 106.5° (85-130°), and the mean pronation-supination arc of the forearm was 138°( 100-160°) respectively. According to the criteria of the HSS2 score, the results were excellent in 4 cases, good in 4 cases, and fair in 2 cases. No compl ications such as stiffness and ulnohumeral arthrosis occurred. The radial nerve injury was found in 1 patient 1 day after operation who was treated with neurolysis, and the nerve function was recovered after 4-6 months. And heterotopic ossification occurred in 6 patients 6 months after operation and radiographic subluxation developed in 1 patient 36 months after operation, and conservative treatment weregiven. Conclusion The terrible triad of the elbow can lead to serious elbow instabil ity and should be treated with operationto restore the anatomic structures, to repair the articular capsule and the collateral l igament, using the adjuvant hinged external fixation and early exercise to avoid immobil ization and recover the articular function.
ObjectiveTo investigate the feasibility of modified classification of terrible triad of the elbow and the effectiveness of treatment strategy which was chosen by modified classification results. MethodsBetween March 2007 and November 2013, 12 cases of terrible triad of the elbow were treated by operation. There were 5 males and 7 females with an average age of 37.2 years (range, 26-74 years). The mechanism of injury was falling from height in 8 cases and traffic accident in 4 cases. The time from injury to operation was 4 to 11 days (mean, 6.8 days). According to the radial head, coronoid process, olecranon, and medial and lateral collateral ligament complexes injury situation, and based on Mason classification standard and O'Driscoll criteria, the classification standard of terrible triad of the elbow was improved. According to classification results, the approach was determined. The fracture reduction and fixation were performed and soft tissue was repaired. ResultsDehiscence of incision occurred in 1 case and was cured after dressing change; primary healing was obtained in the other patients. All the cases were followed up 19-35 months (mean, 21.6 months). The X-ray films showed fracture healing at 10-17 weeks (mean 12.8 weeks). At last follow-up, the mean flexion-extension arc of the elbow was 117.9° (range, 95-135°) and the mean forearm pronation and supination were 77.1° (range, 70-85°) and 62.5° (range, 45-75°). According to Mayo elbow performance score (MEPS), the results were excellent in 4 cases, good in 5 cases, and fair in 3 cases. One patient had valgus deformity of elbow who refused radial head replacement, and 5 cases had heterotopic ossification of the elbow on the X-ray films. ConclusionThe modified classification of the terrible triad of the elbow is simple and practical, based on the damage assessment of bony structures (radial head, coronoid process, and olecranon) and the soft tissue (medial and lateral collateral ligament complexes). The modified classification can be used effectively for guiding treatment decisions.
ObjectiveTo compare the effectiveness of transosseous tunnel fixation and drilling fixation for repair of lateral collateral ligament complex (LCLC) in treatment of terrible triad of elbow (TTE).MethodsA clinical data of 50 patients with TTE between June 2012 and January 2018 were retrospectively analyzed. The LCLC was repaired with transosseous tunnel fixation in 22 patients (transosseous tunnel fixation group) and with drilling fixation in 28 patients (drilling fixation group). There was no significant difference between the two groups (P>0.05) in gender, age, fracture side, time from injury to admission, coronoid process fracture classification, radial head fracture classification, and TTE classification. The operation time, intraoperative blood loss, fracture healing time, and complications of the two groups were recorded. At last follow-up, the Mayo elbow performance system (MEPS) score, range of motion of elbow joint, and Broberg-Morrey classification were recorded.ResultsThe operation of two groups were successfully completed. There was no significant difference in the operation time and intraoperative blood loss between the two group (P>0.05). The follow-up time was (24.43±6.84) months in the transosseous tunnel fixation group and (21.55±6.16) months in the drilling fixation group, and the difference was not significant (t=1.534, P=0.132). X-ray films showed that the coronoid process and radial head fractures in the two groups healed, and there was no significant difference in the healing time (P>0.05). At last follow-up, there was no significant difference in the flexion-extension activity, rotation activity, MEPS score, and Broberg-Morrey grading (P>0.05). During the follow-up, there was no re-dislocation or instability of the elbow joint. The incidence of complication was 28.57% (8/28) in the transosseous tunnel fixation group and 27.27% (6/22) in the drilling fixation group, showing no significant difference (χ2=2.403, P=0.121).ConclusionBoth transosseous tunnel fixation and drilling fixation can achieve good results in repair of LCLC for TTE.
ObjectiveTo explore the clinical significance of anterior median approach combined with lateral approach to the elbow joint in the treatment of terrible triad of the elbow.MethodsWe retrospectively collected the data of 63 cases who used the anterior median approach of the elbow joint combined with the lateral approach (group A, n=36) or the medial and lateral approach of the elbow (group B, n=27) in the treatment of terrible triad of the elbow between March 2014 and July 2019. The operation time, postoperative complications, and postoperative Mayo score of the elbow were compared between the two surgical approaches.ResultsThe operation time of group A and group B was (93.78±7.78) and (106.93±10.35) min, respectively, and the difference was statistically significant (P<0.05). The patients in both groups completed operations successfully, without vascular or nerve injury. All the wounds healed by first intention. No redislocation or reoperation occurred. Ten months after operation, there was no significant difference in the excellence rate of Mayo score of the elbow (83.3% vs. 85.2%) or postoperative complication rate (16.7% vs. 14.8%) between the two groups (P>0.05).ConclusionThe anterior median approach of the elbow joint combined with the lateral approach and the medial and lateral elbow approach for the treatment of terrible triad of the elbow are equivalent to the postoperative elbow function recovery. The operation time of the former is shorter than that of the latter, and the anterior approach reveals the coronal process intuitively and sufficiently. In the case that there is no medial ligament injury, the anterior median approach of the elbow joint combined with the lateral approach can be preferred.
ObjectiveTo investigate the short-term effectiveness of free radial head reconstruction of coronoid process, artificial radial head replacement, and ulna olecranon internal fixation in the treatment of the complex terrible triad of the elbow.MethodsRetrospective analysis was made on the clinical data of 12 patients with complex terrible triad of the elbow treated with free radial head reconstruction of coronoid process, artificial radial head replacement, and ulna olecranon internal fixation between April 2011 and April 2018. There were 8 males and 4 females with an average age of 44.5 years (range, 26-62 years). The causes of injury included 5 cases of traffic accident, 7 cases of falling from hight. The Regan-Morrey classification of ulnar coronoid process fractures was type Ⅲ; Mason classification of radial head fractures was type Ⅲ in 7 cases and type Ⅳ in 5 cases. The time from injury to operation was 5-14 days, with an average of 6.0 days. The operation time, intraoperative blood loss, and complications were recorded. After operation, X-ray film of elbow joint was reexamined, fracture healing condition was observed, and fracture healing time was recorded. The flexion, extension, and rotation of the elbow joints on the healthy and affected sides were recorded and measured. The elbow function was evaluated according to Mayo elbow function score.ResultsThe operation time was 90-140 minutes (mean, 110 minutes); the intraoperative blood loss was 100-300 mL (mean, 150 mL). None of the patients had vascular injury during the operation. One patient developed numbness in the ulnar nerve innervation area and recovered completely after symptomatic treatment for 1 week. All the 12 patients were followed up 12-22 months, with an average of 16 months. At last follow-up, the fracture healed completely, 1 patient developed ectopic ossification of elbow joint, and 2 patients developed traumatic arthritis of elbow joint. No internal fixation-related complications occurred. There was no significant difference in the range of motion of elbow flexion, extension, pronation, and supination between the affected and healthy sides (P>0.05). The median Mayo elbow function score was 96, and the interquartile range was (94, 97), and the excellent and good rate was 91.7%.ConclusionFor patients with complex terrible triad of the elbow with ulna coronoid process fractures of Regan-Morrey type Ⅲ and radial head fractures of Mason type Ⅲ, Ⅳ combined with ulna olecranon fractures, the free radial head reconstruction, artificial radial head replacement, and ulna olecranon internal fixation, through active rehabilitation function exercise after operation, can achieve more satisfactory short-term effectiveness.
ObjectiveTo explore the effectivenesss of simple lateral extensor digitorum communis (EDC) split approach combined with loop-plate fixation in the treatment of ulnar coronoid fracture in terrible triad of elbow (TTE).MethodsThe clinical data of 60 patients with TTE who met the selection criteria between January 2015 and May 2018 were retrospectively analyzed. There were 48 males and 12 females, aged from 18 to 60 years (mean, 37.4 years). All the patients were closed fractures. Injury causes included fall injury in 28 cases, falling from height in 20 cases, and traffic accident injury in 12 cases. All patients had no vascular and nerve injury, and the time from injury to operation was 1-14 days, with an average of 4.8 days. The height and size of the fracture of the coronal process were measured by CT and accurate classifications were made. All the 60 patients were treated with simple lateral EDC split approach combined with loop-plate to fix the ulnar coronoid fracture; 20 patients of radial head fracture were fixed with hollow screw, 32 patients with mini-plate fixation, 8 patients with radial head prosthesis replacement; 16 patients with suture and 44 patients with suture anchor to reconstruct lateral collateral ligament complex; 10 patients with residual instability of elbow joint were fixed with hinge external fixator, and others were fixed with adjustable tension brace after operation. Postoperative imaging examination was performed to evaluate fracture healing and complications, such as loosening or breakage of internal fixator, osteoarthritis, and heterotopic ossification, etc. During follow-up, the range of motion (ROM) of the elbow joint was recorded, including elbow flexion, extension, and forearm pronation, supination. Mayo elbow function score system (MEPS) was used to evaluate elbow joint function at last follow-up.ResultsAll patients were followed up 16-24 months (mean, 20.2 months). All incisions healed by first intention after operation, and no complications such as vascular nerve injury, elbow joint instability, internal fixation failure, and infection occurred; the fracture healing time was 9-17 weeks (mean, 11.7 weeks). Four cases developed elbow stiffness after operation, and all underwent elbow joint lysis with internal fixator removal within 12-15 months after operation; 10 cases developed heterotopic ossification without special treatment. At last follow-up, the ROM of elbow flexion ranged from 85° to 135° (mean, 116°), the ROM of elbow extension ranged from 0° to 20° (mean, 11°), the ROM of forearm pronation ranged from 55° to 75° (mean, 70°), and the ROM of forearm supination ranged from 60° to 90° (mean, 83°). The MEPS score ranged from 55 to 100 (mean, 86.1); the effectiveness were excellent in 40 patients, good in 10 patients, fair in 6 patients, and poor in 4 patients, with an excellent and good rate of 83.3%.ConclusionThe simple lateral EDC split approach is fully exposed, and the loop-plate can fix the ulnar coronoid fractures firmly and stably, which can restore the stability of the elbow joint, and the effectiveness is satisfactory.