Careful attention to each destabilizing element of the injury pattern is essential and places high demands on the surgeon's mastery of the anatomic complexity of the elbow. reported that both the LUCL and LRCL are equally indispensable for elbow stability; thus, both require repair and reconstruction32. One However, you should only perform the exercises that are ordered by your surgeon. (A) Medial view of the elbow bone structures. have reported that almost all patients with dislocation of the elbow joint have some degree of tearing of the MCLC and LCLC9. If they have, the pronator muscles and MCLC should be repaired through a medial surgical approach. He also pointed out that, because these injuries are commonly seen in younger patients, longer‐term studies are needed to determine whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. The terrible triad of the elbow is characterized by great potential for joint instability and an unfavorable prognosis.1, 5 Surgical treatment is the therapy of choice in the vast majority of cases, with the aims of restoration of the anatomy and early mobility. 5.2 3-Dimensional reconstruction CT scan of a right elbow with a terrible triad injury, as viewed (a) laterally and (b) medially The individual components of… Management of Terrible Triad Injuries of the Elbow The Duke Orthopaedic Journal, July 2014-June 2015;5(1):28-34 29 DOJ the body internally rotates about the hand. Methods: Eight patients identified with “terrible triad” injury patterns, including posterior elbow dislocation, radial head fracture and coronoid fracture, were available for a minimum of 11 months follow-up. Ring et al. performed radial head repair on five patients and radial head resection on four patients with the terrible triad injury12. 2019 Feb;98(6):e13054. Can we treat select terrible triad injuries nonoperatively? The anterior band of the MCLC plays an essential role in valgus stability of the elbow33, whereas the posterior band of the MCLC is critical in maintaining elbow posterolateral rotation stability34. Pathology Number of times cited according to CrossRef: Analysis of twenty-five cases of terrible triad injury of the elbow surgically treated with a single lateral approach. 2020 Jun 15;21(1):381. doi: 10.1186/s12891-020-03394-z. As a result, they are often seen by physical therapists for rehabilitation. All in all, the term “terrible triad of the elbow” is no longer accurate. Elbow dislocations make up between 11-28% of all elbow injuries. MCLC repair or hinged external fixation is further required if there is still elbow instability after the standard protocol has been implemented. Fractures of the coronoid process of the ulna, Difficult elbow fractures: pearls and pitfalls, Distribution of coronoid fracture lines by specific patterns of traumatic elbow instability, Management of unstable elbows following complex fracture‐dislocations—the “terrible triad” injury, Current concepts in the management of complex elbow trauma, Reconstruction of the coronoid using an extended prosthesis: an, Reconstruction of the coronoid process with iliac crest bone graft in complex fracture‐dislocation of elbow, Reconstruction of the coronoid process with iliac crest bone graft. Stability should be evaluated intraoperatively after reconstruction. It is rarely possible to provide the patient with a completely normal elbow after the “terrible triad” injury pattern. Computed tomography with three dimensional reconstructions can be helpful in ascertaining the type of injury. Fig. Elbow dislocations are staged depending on the disruption of the following stabilizers: the ulnohumeral articulation, MCL, and LCL. Our own experience with this injury would suggest the mean arc of flexion extension to be from 20°–135° (115° arc) with forearm rotation averaging 135°. This triad has long given orthopedic surgeons headaches. treated 21 cases of terrible triad injuries with a modified surgical technique including fixation or replacement of the radial head and repair of the LCLC through a lateral approach, and simultaneous fixation of the coronoid process and repair of the common flexor muscle and the MCLC through an anteromedial approach. TERRIBLE TRIAD OF THE ELBOW: FUNCTIONAL RESULTS OF SURGICAL TREATMENT. Schemitsch et al. The MCLC is composed of three small ligaments that travel in different directions: the anterior medial collateral ligament, the posterior medial collateral ligament and Cooper's ligament (Fig. reported that Regan–Morrey type I coronoid process fractures have little impact on elbow stability compared with the normal elbow20. Zhang et al. The full text of this article hosted at iucr.org is unavailable due to technical difficulties. Possible postoperative joint stiffness, prosthesis removal or ulnar nerve symptoms may require additional procedures; however, arthritis is usually tolerable. Technically, the surgeon must bring every skill to bear, as soft tissue techniques, fracture repair, and joint arthroplasty are routinely required to adequately treat these complex constellations of injury. Luckily, elbow specialists have come up with sound strategies to restore the best possible stability and function to the elbow joint after a terrible triad. Replacement or repair of terrible triad of the elbow: A systematic review and meta-analysis. COVID-19 is an emerging, rapidly evolving situation. If you do not receive an email within 10 minutes, your email address may not be registered, Terrible triad injuries of the elbow: does the coronoid always need to be fixed? First they would heat up my elbow for several minutes and then stretch my arm to try to lengthen the muscles and tendons. The “terrible triad of the elbow” is a notorious combination of elbow dislocation and fractures of the coronoid process and radial head that has historically been difficult to manage and had an unsatisfactory prognosis36-38, almost unavoidably causing long‐standing postoperative pain, elbow instability and a range of complications. (A) Medial view of the elbow ligaments. 2019 Jan;98(1):e13836. Pre-operatively on the ward • Discuss post -operative rehab ’ Clipboard, Search History, and several other advanced features are temporarily unavailable. Improved experience, techniques, and implants have advanced to the point where restoration of elbow stability can be expected. A functional elbow with an average flexion of approximately 110° can be expected if these protocols are followed. Jeong et al. proposed repairing and fixing the radial head by Kirschner wire to re‐establish elbow stability rather than implementing radial head resection at an early stage13.  |  2020 Jan;8(1):4-9. doi: 10.29252/beat-080102. Therefore, patients and even doctors may harbor doubts about what this so‐called terrible triad is, just how terrible it is, and whether it is possible to achieve a satisfactory prognosis. : a Meta-Analysis instability persists to whether the patient with a … therapy. Primary and secondary constraints, outcomes after terrible triads, or conservatively managed Trauma when active ROM N.B! Ligaments in children under ten years of age ( 1 ):4-9. doi: terrible triad elbow physical therapy they are the frequently! 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