Terrible Triad Injury of the Elbow

Terrible Triad Injury of the Elbow:Current Concepts

Abstract

Fracture-dislocations of the elbow remain among the most difficultinjuries to manage. Historically, the combination of an elbowdislocation, a radial head fracture, and a coronoid process fracturehas had a consistently poor outcome; for this reason, it is calledthe terrible triad. An elbow dislocation associated with a displacedfracture of the radial head and coronoid process almost alwaysrenders the elbow unstable, making surgical fixation necessary.The primary goal of surgical fixation is to stabilize the elbow topermit early motion. Recent literature has improved ourunderstanding of elbow anatomy and biomechanics along with thepathoanatomy of this injury, thereby allowing the development of asystematic approach for treatment and rehabilitation. Advances inknowledge combined with improved implants and surgicaltechniques have contributed to better outcomes.

Elbow dislocations are catego-rized as simple or complex. A

simple dislocation of the elbow is acapsuloligamentous injury with nofractures; a complex dislocation hasassociated bony injuries. A complexelbow dislocation with associatedradial head and coronoid processfractures was named the terribletriad by Hotchkiss1 because of his-torically poor outcomes. Despite thecomplexities of this injury, an under-standing of the relevant anatomy andthe factors associated with elbowstability allows the application of asystematic algorithm for treatment.This approach can help ensure thatsufficient elbow stability is achievedto allow early motion, thereby lead-ing to improved outcomes in mostpatients. However, despite the bestattempts at reconstruction, evenin those experienced with treatingthese injuries, the final outcome maybe fair or poor, according to report-ing of several clinical series.1,2 Fur-ther research is required to improve

the outcomes of these serious inju-ries.

Anatomy

The elbow consists of bones, liga-ments, tendons, and muscles that in-teract to allow for a stable, pain-freearc of motion. An understanding ofthe specific anatomy of these struc-tures is paramount to the successfultreatment of terrible triad injuries.The proximal ulna consists of twofacets, the greater sigmoid notch andthe lesser sigmoid notch (ie, radialnotch). The greater sigmoid notch ar-ticulates with the trochlea, whereasthe lesser forms an articulation withthe radial head as the proximal radio-ulnar joint.3 The coronoid processprovides an important anterior andvarus buttress to the elbow joint. Itconsists of a tip, body, anterolateralfacet, and anteromedial facet. At theinferomedial border of the anterome-dial facet, the sublime tubercle is the

Paul K. Mathew, MD, FRCSC

George S. Athwal, MD, FRCSC

Graham J. W. King, MD, MSc,FRCSC

Dr. Mathew is Clinical Fellow, Handand Upper Limb Centre, St.Joseph’s Health Care, University ofWestern Ontario, London, Ontario,Canada. Dr. Athwal is AssistantProfessor of Surgery and ConsultantShoulder and Elbow Surgeon, Handand Upper Limb Centre, St.Joseph’s Health Care, University ofWestern Ontario. Dr. King isProfessor of Surgery andConsultant, Hand and Upper LimbCentre, St. Joseph’s Health Care,University of Western Ontario.

Dr. Athwal or a member of hisimmediate family has receivedresearch or institutional support fromWright Medical Technologies.Dr. King or a member of hisimmediate family is affiliated with thepublication Journal of Hand Surgery(American); has received royaltiesfrom Tornier, Wright MedicalTechnology, and Tenet Medical; andis a member of a speakers’ bureauor has made paid presentations onbehalf of and received research orinstitutional support from WrightMedical Technology. NeitherDr. Mathew nor a member of hisimmediate family has receivedanything of value from or ownsstock in a commercial company orinstitution related directly orindirectly to the subject of thisarticle.

Reprint requests: Dr. Athwal, Handand Upper Limb Centre, St.Joseph’s Health Care, 268Grosvenor Street, London, Ontario,Canada N6A 4L6.

J Am Acad Orthop Surg 2009;17:137-151

Copyright 2009 by the AmericanAcademy of Orthopaedic Surgeons.

Review Article

March 2009, Vol 17, No 3 137

insertion site for the anterior bundleof the medial collateral ligament(MCL).3 On the lateral aspect of theproximal ulna, distal to the lessersigmoid notch, the lateral ulnar col-lateral ligament (LUCL) inserts onthe supinator crest.4

The radial head is a slightly ellipti-cal structure that articulates withthe capitellum and the lesser sig-moid notch of the proximal ulna.Hyaline cartilage covers both thearticular dish and most of the articu-lar margin. With the forearm in neu-tral rotation, the lateral portion ofthe articular margin of the radialhead is devoid of hyaline cartilage.This lateral portion of the radialhead, which is devoid of articularcartilage, does not articulate with thecapitellum or the proximal ulna. Theradial head provides an importantanterior and valgus buttress to the el-bow.

In addition to the bony supportingstructures, several soft-tissue struc-tures require consideration in thetreatment of terrible triad injuries.The lateral collateral ligament (LCL)consists of the radial collateral liga-ment, the LUCL, and the annular lig-ament.5 As noted, the LUCL origi-nates at an isometric point on the

lateral epicondyle and attaches to thesupinator crest of the proximal ulna.The annular ligament attaches to theanterior and posterior margins of thelesser sigmoid notch. The radial col-lateral ligament originates from thelateral epicondyle and fans out to at-tach to the annular ligament (Figure1). The LCL functions as an impor-tant restraint to varus and postero-lateral rotatory instability.6,7

The MCL consists of an anteriorbundle, posterior bundle, and trans-verse ligament. Of these, the anteriorbundle is of prime importance inelbow stability (Figure 1). The ante-rior bundle originates from theanteroinferior aspect of the medialepicondyle, inferior to the axis ofrotation, and inserts on the sub-lime tubercle at the base of thecoronoid process. The MCL func-tions as an important restraint tovalgus and posteromedial rotatoryinstability.8,9

The muscles and joint capsule alsoprovide stability to the elbow. Theanterior capsule attaches a few milli-meters distal to the tip of the coro-noid process and is typically torn insimple dislocations of the elbow.10

Secondary constraints to elbow sta-bility are provided by the flexor pro-

nator mass, which arises from themedial epicondyle, and the commonextensor origin, which arises fromthe lateral epicondyle. Together,these structures dynamically stabilizethe elbow against valgus and varusforces, respectively.11

Biomechanics

The anatomic features of the elbowthat contribute to stability have beenexamined in various studies and canbe divided into two main categories:primary and secondary. The primarystabilizers of the elbow are consid-ered to be the ulnohumeral articula-tion, the MCL, and the LCL. Thesecondary stabilizers include the ra-dial head, joint capsule, and thecommon flexor and extensor ori-gins.12

The ulnohumeral articulation is theprimary bony supporting structure inthe flexion-extension plane. Morespecifically, beyond 30° of flexion,the coronoid process provides sub-stantial resistance to posterior sub-luxation or dislocation.13 Biome-chanical studies have shown that thecoronoid process is an important el-bow stabilizer in response to axial,

Anatomy of the medial (A) and lateral (B) collateral ligaments of the elbow. (Reproduced from Tashjian RZ, KatarincicJA: Complex elbow instability. J Am Acad Orthop Surg 2006;14:278-286.)

Figure 1

Terrible Triad Injury of the Elbow: Current Concepts

138 Journal of the American Academy of Orthopaedic Surgeons

varus, posteromedial, and postero-lateral rotatory forces.14,15 Largercoronoid fractures have a progres-sively greater influence on elbow sta-bility. Small fractures involving 10%of the coronoid process have beenshown to have little effect on elbowstability in cadaveric biomechanicalstudies.15 In the setting of a simu-lated terrible triad injury, when re-sidual instability was present afterLCL repair and radial head repair orarthroplasty, repair of the MCL wasmore effective than fixation of smallcoronoid fractures in restoring elbowstability.15 In clinical series of terribletriad injuries, most coronoid frag-ments were larger than 10% of thecoronoid process, suggesting thatsurgical fixation of the coronoid pro-cess should usually be performedduring treatment of terrible triad in-juries.

The anterior bundle of the MCL hasbeen shown to be the most importantstabilizer of valgus stress to the elbow,while the radial head acts as a second-ary stabilizer. However, both the radialhead and MCL are required to providenormal elbow stability.16 In the set-ting of an incompetent anterior bun-dle of the MCL, an intact radial headbecomes an extremely important sec-ondary elbow stabilizer. The radialhead also provides axial support tothe forearm and acts as an anteriorbuttress resisting posterior disloca-tion or subluxation. In addition, itindirectly provides varus stability bytensioning the LCL. Partial articularfractures of the radial head have alsobeen shown to alter stability in labo-ratory studies, particularly in the set-ting of ligamentous injuries.13,17 Re-pair of fragments as small as 25% ofthe radial head should be consideredin the setting of terrible triad inju-ries.

Sectioning of the MCL has beenshown to cause gross valgus andinternal rotation instability of theelbow.8,9 Transosseous repair of the

MCL restored elbow stability invitro and should allow for early ac-tive and passive motion. Muscleactivation and forearm supinationstabilize the MCL-deficient elbowwith the arm in the dependent posi-tion. Valgus loading should beavoided while the MCL is healing.8,9

The LCL provides varus and postero-lateral rotatory stability of the el-bow; repair using transosseous su-tures is effective. Muscle activationand forearm pronation stabilize theLCL-deficient elbow with the arm inthe dependent position. Varus load-ing, such as occurs with shoulder ab-duction, should be avoided whileLCL injuries are healing.18

Fracture Classification

Fracture classification systems havebeen developed to address the indi-vidual components of the terribletriad. Mason19 classified radial headfractures into three categories: type I,nondisplaced fracture; type II, dis-placed partial articular fracture withor without comminution; and typeIII, comminuted radial head fractureinvolving the whole head (Figure 2).Hotchkiss21 later modified Mason’sclassification based on clinical exam-ination and intraoperative findingsso that it could help guide treatmentdecisions. In the Hotchkiss modifica-

Mason classification of radial head fractures. A, Type I, nondisplaced.B, Type II, displaced partial articular fracture. C, Type III, comminutedfracture. D, A type IV injury, described by Johnson20 in 1962, indicates anassociated ipsilateral ulnohumeral dislocation.

Figure 2

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tion, type I fractures are those dis-placed <2 mm, with no mechanicalblock; type II are those with >2 mmof displacement that are repairableand may have a mechanical block tomotion; and type III are comminutedfractures that are judged to be notrepairable by radiographic or intra-operative findings and that requireexcision or replacement.

Two classification systems outlinethe fracture patterns seen in coro-noid process injuries. The first, pro-posed by Regan and Morrey,22 wasbased on the height of the coronoidfragment (Figure 3). A type I fractureinvolved an “avulsion” of the tipof the coronoid process, type IIinvolved a single or comminutedfracture representing ≤50% of thecoronoid process, and type III in-volved a single or comminuted frac-ture of >50% of the coronoid. Theseauthors further classified these typesinto A and B, representing associatedabsence or presence of a dislocation,respectively.

A second classification scheme wasrecently reported by O’Driscollet al23 and is based on the location ofthe fracture in reference to localanatomy. The classification dividesthe coronoid process into the tip, the

anteromedial facet, and the base(Figure 4). These groups are subcate-gorized to better define the anatomicsite of the fracture. Coronoid tipfractures are divided into fragmentsthat are ≤2 mm or >2 mm. Tip frac-tures are most frequently seen in as-sociation with terrible triad injuries.Tip fractures do not usually extendpast the sublime tubercle; therefore,the ulnar attachment site of the MCLis usually intact. Fractures of the an-teromedial facet are divided intothree subtypes. Anteromedial sub-type 1 fractures do not involve thecoronoid tip and extend from justmedial to the tip to just anterior tothe sublime tubercle. Subtype 2 frac-tures are subtype 1 with involvementof the coronoid tip. Subtype 3 frac-tures involve the anteromedial rim ofthe coronoid and the sublime tuber-cle (Figure 4). Basal coronoid frac-tures consist of a fracture throughthe body of the coronoid process andinvolve at least 50% of the coronoid

height. Basal fractures are dividedinto subtype 1, which involves onlythe coronoid process, and subtype 2,which consists of a coronoid bodyfracture in association with an olec-ranon fracture.

Mechanism of Injury

The terrible triad injury is oftencaused by a fall on an outstretchedhand. A posteriorly directed force re-sults from a fall on an extended el-bow, which levers the ulna out of thetrochlea.13 Subsequently, the anteriorcapsule and collateral ligaments un-dergo increased tension and eventu-ally fail. O’Driscoll et al24 describedan additional valgus stress and/orposterolateral “roll-out” that occurswith this injury. The authors postu-lated that, in a fall with the arm ex-tended, the elbow becomes fixed,and the body produces a valgus andposterolateral rotatory moment. Se-quentially, the capsuloligamentous

Coronoid fracture classificationdeveloped by Regan and Morrey.22

Type I fracture, avulsion of tip ofcoronoid process; type II, fractureinvolving ≤50% of the coronoid pro-cess height; type III, fracture involv-ing >50% of the coronoid processheight. (Reproduced with permis-sion from Doornberg JN, Ring D:Coronoid fracture patterns. J HandSurg [Am] 2006;31:45-52.)

Figure 3

Illustration of the coronoid fracture classification according to O’Driscollet al.28 The three types are tip (A), anteromedial facet (B), and basal (C)fractures. Tip fractures are subclassified into two groups, either ≤2 mm or >2mm in size. Anteromedial facet fractures are subclassified into three sub-types (anteromedial rim, rim plus tip, and rim and tip plus the sublime tuber-cle). Basal fractures are subclassified into two groups (coronoid body andbase, and transolecranon basal coronoid fractures). (Reproduced with per-mission from Doornberg JN, Ring DC: Fracture of the anteromedial facet ofthe coronoid process. J Bone Joint Surg Am 2006;88:2216-2224.)

Figure 4



structures of the elbow begin to failfrom lateral to medial.24 The anteriorbundle of the MCL is postulated tobe the last to fail; therefore, an el-bow can theoretically dislocate with-out a complete tear of this structure.As the elbow slides out of joint, frac-tures of the radial head and coronoidprocess frequently occur.25-27

Anteromedial facet fractures donot occur with the same posterolat-eral rotatory instability pattern thatleads to terrible triad injuries.O’Driscoll et al24 suggest that an ax-ial force combined with posterome-dial rotation, varus force, and elbowflexion causes the medial trochlea toabut onto the anteromedial facet ofthe coronoid. This results in an an-teromedial facet fracture with associ-ated disruption of the LCL due to avarus force.23 The radial head is usu-ally not fractured in a varus postero-medial instability pattern, and it istherefore by definition not a true ter-rible triad injury.

Diagnosis and InitialManagement

Patient history and physical exami-nation are vital to the diagnosis andmanagement of terrible triad injuries.The history should include the sever-ity and mechanism of injury. High-energy injuries often involve moreligamentous and osseous disruptionthan do low-energy injuries, whichare more commonly seen in elderly,osteoporotic patients. The mechan-ism of injury is also important be-cause it allows the surgeon to betterpredict which structures are injured.The examination should note anysigns or symptoms of neurovascularinjury and skin or soft-tissue com-promise. An evaluation of the precip-itants of the fall that resulted in theinjury is necessary because the pa-tient may have undiagnosed alcoholdependence, cerebrovascular disease,

or cardiac arrhythmia. Special atten-tion should be directed toward iden-tifying comorbidities and reversibleillness that affect treatment recom-mendations and perioperative risk.

The physical examination shouldbegin with inspection. Any obviousdeformity of the elbow should raisethe question of dislocation and/orfracture. Furthermore, areas of ec-chymosis may indicate specific sitesof injury; for example, ecchymosis atthe medial elbow may represent anMCL injury. Abrasions, extensiveswelling, and fracture blisters shouldbe identified because their occur-rence may influence the timing ofsurgery. Finally, open wounds shouldbe carefully looked for because theirpresence constitutes a surgical emer-gency. When the patient’s pain al-lows, palpation of the elbow fortenderness, assessment of bony align-ment, and gentle range of motion(ROM) may also suggest the locationof pathology. The joints above andbelow the elbow, in particular thedistal radioulnar joint, should be ex-amined. If the wrist is not examinedin the presence of a radial head frac-ture, then a tear of the interosseousmembrane and distal radioulnarjoint ligaments, the so-called Essex-Lopresti injury, may be missed.Without treatment, this injury willlead to poor outcomes.28 A detailedneurologic examination should beperformed to evaluate the functionof the axillary, musculocutaneous,median, ulnar, and radial nerves.

When, after the history and physicalexamination, preliminary radiographsreveal an elbow dislocation, initial man-agement begins with a closed reductionunder intravenous conscious sedationor general anesthesia. After reductionis achieved, the elbow should bebrought through the ROM to test sta-bility in all planes, with the forearm inpronation, neutral, and supination. Aclosed reduction offers the benefit oflessening pain and soft-tissue swelling,

and it allows for more accurate inter-pretation of radiographs. After the re-duction is achieved, a second neurologicand vascular examination is indicated,and any changes should be noted.

Imaging

Pre- and postreduction imaging in-cludes anteroposterior and lateralradiographs, which should be exam-ined carefully for fracture character-istics and concentricity of the ulno-humeral and radiocapitellar joints. Aline drawn through the center of theradial neck should intersect the cen-ter of the capitellum, regardless ofthe radiographic projection. Thecoronoid process should be closelyviewed on the anteroposterior andlateral images. Lateral radiographsare also used to determine the heightof the coronoid fracture; however,the pattern and extent of the fractureare typically difficult to characterizeon plain radiographs.

Computed tomography (CT) isroutinely used in patients with terri-ble triad injuries to identify fracturepatterns, comminution, and displace-ment, which may not be evident onplain radiographs. The advent ofthree-dimensional CT has further im-proved our understanding of theseinjuries. Three-dimensional imagescan improve the visualization of frac-ture fragments and their location, aswell as fracture line propagation. Inaddition, digital subtraction of thehumerus can isolate areas of the el-bow to allow for better characteriza-tion of fracture patterns.

Treatment

NonsurgicalMost patients presenting with a terri-ble triad injury require surgery1,2

for stabilization; however, somecases may be managed nonsurgically.


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When nonsurgical treatment is to beundertaken, several specific criteriamust be met. After reduction of thedislocation, the ulnohumeral and ra-diocapitellar joints must be concen-trically reduced. The elbow mustalso be sufficiently stable to allowearly ROM, such that the elbowshould extend to approximately 30°before becoming unstable. The con-gruency of the elbow can be evalu-ated fluoroscopically following theinitial reduction performed under se-dation in the emergency department.Alternatively, the congruency of theelbow during active motion can beevaluated fluoroscopically followinginitial splint removal within 10 daysif the patient’s pain allows.

The nonsurgical treatment plan re-quires that imaging, including a CTscan, show a small nondisplaced orminimally displaced radial head orneck fracture that does not cause amechanical block to forearm rota-tion or elbow flexion/extension. Thecoronoid fracture must also be asmall tip fragment as confirmed byCT scans, which are routinely rec-ommended in the evaluation andtreatment of these injuries. In thesecircumstances, the injury may betreated as a “simple” dislocation.

After reduction, an initial period ofimmobilization at 90° of flexion in alight fiberglass splint is recom-mended for 7 to 10 days. This allowsfor a reduction of swelling and a re-turn of muscle tone around the el-bow. Patients are also encouraged towork on isometric biceps and tricepsmuscle contractions. Weekly clinicaland radiographic follow-up is re-quired for the first 4 weeks to ensuremaintenance of a congruous reduc-tion and to ensure that the associatedfractures do not displace.

The optimal nonsurgical manage-ment of terrible triad injuries has notbeen established. After muscle tonereturns to the elbow in 7 to 10 days,active motion is initiated with a rest-

ing splint at 90°, avoiding terminalelbow extension. After 4 to 6 weeks,static progressive extension splintingis added at night to encourage recov-ery of elbow extension. Strengthen-ing is initiated after healing of liga-ment and osseous injuries is assured.

SurgicalMost terrible triad elbow injuries aremanaged surgically. When the pa-tient is deemed medically fit, surgeryis indicated for failure to meet non-surgical treatment criteria, for openwounds, and/or for neurologic orvascular injury. The steps involved insurgical management are presentedas an algorithm in Figure 5.

Several surgical approaches to the el-bow have been described, and the de-cision of which approach to choose iscontroversial. Factors in selecting an ap-proach include fracture and instabilitypattern, soft-tissue injury, and surgeonexperience.

The first decision to be made is thelocation of the skin incision, whichmay be medial, lateral, or posteriorlongitudinal. Historically, a lateralskin incision has been used; however,in the setting of a terrible triad in-jury, a posterior skin incision hasseveral advantages. It allows accessto both the medial and lateral as-pects of the elbow, and it precludesthe need for a second medial skin in-cision should a medial deep ap-proach be required. Also, a posteriorskin incision has a lower risk of in-jury to the cutaneous nerves com-pared with medial and lateral skinincisions.29 In addition, the posteriorskin incision, while longer than theisolated medial and lateral incisions,is more cosmetic and is less easilyseen than the lateral incision. A dis-advantage of a posterior incision isthat the relatively large medial andlateral skin flaps created increase thepossibility of seromas and hemato-mas. Flap necrosis is also a potential

complication, although it is rare inthe setting of trauma.

Once the posterior skin incision ismade, a lateral full-thickness fasciocu-taneous flap is raised. In general, a me-dial fasciocutaneous flap and exposureof the ulnar nerve are not indicated ini-tially because many terrible triad inju-ries can be completely addressed fromthe lateral side. For the deep lateral ap-proach, the interval between the exten-sor carpi ulnaris and anconeus (ie,Kocher interval) is used. Alternatively,the extensor digitorum communis ten-don can be split in the midline. Both ap-proaches allow access to the radial headand the almost invariably disruptedLCL. Often, the injury leaves the lateralepicondyle completely devoid of soft-tissue attachments.

A deep medial approach may berequired if the coronoid fracture can-not be adequately reduced and fixedfrom the lateral side, if repair of theMCL is needed to address persistentinstability, or if the ulnar nerve is in-jured. The ulnar nerve may requireanterior subcutaneous transpositionif it is symptomatic or in the rare cir-cumstance in which it is entrappedwithin the joint. If the flexor prona-tor mass is not disrupted, it can bereflected or split to allow access tothe coronoid fracture and the under-lying MCL.

Hotchkiss30 described the “medialover-the-top” approach for elbowcontracture releases, an exposurethat also allows good visualization ofthe coronoid process. In this ap-proach, the flexor pronator mass issplit, and the anterior half is de-tached and elevated with the brachi-alis and the anterior joint capsule offthe anterior humerus to allow expo-sure of the coronoid fracture. Forlarger coronoid fragments, the wholeflexor pronator mass can be dividedand elevated off the medial epi-condyle and MCL to allow exposureof the entire coronoid process andmedial ulna, a procedure similar to



a submuscular ulnar nerve transpo-sition described by Taylor andScham.31

In the setting of radial head fracturesnecessitating repair or replacement, thecoronoid process can usually be fixedthrough the radial head defect from the

lateral surgical approach. In this case,a targeting guide can be used to pre-cisely position two drill holes enteringthe base of the coronoid fracture fromthe subcutaneous border of the ulna(Figure 6). Alternatively, these drill holescan be done freehand, with a fingertip

placed on the fractured surface of thecoronoid process for triangulation. Anonabsorbable suture is used to graspa portion of the anterior capsule whileencircling small coronoid fragments orbeing passed through drill holes inlarger fragments. Gaining exposure is

Algorithm for the surgical management of terrible triad injury.*Neck osteotomy in preparation for radial head replacement. If fragment size is <25% of the radial head, fragmentexcision may be considered.†Type I coronoid fractures may not require repair.15

(Adapted with permission from Spencer EE, King JC: A simple technique for coronoid fixation. Tech Shoulder ElbowSurg 2003;4:1-3.)

Figure 5


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important in this technique, and releaseof the common wrist extensors from thelateral condyle may be needed to im-prove visualization.

The anterior capsular attachmentto the coronoid fragment or frag-ments should not be released becauseprotecting the attachment enhancesstability. A suture-passing device canbe used to retrieve sutures throughseparate drill holes. The sutures arethen tied with the elbow held re-duced.32 If the coronoid fracturefragment is larger, then small-diameter cannulated screws may beused for fixation in a retrogradefashion from posterior to anterior32,33

(Figure 7). Basal coronoid fractures,which are rarely seen in terrible triadinjuries, can be fixed by means of aplate placed anteromedially or di-rectly medially on the proximal ulna.

Available options in managing the as-sociated radial head fractures are frag-ment excision, open reduction and in-ternal fixation, and radial headarthroplasty. When <25% of the headis damaged, when the fragments are too

small or osteoporotic to fix, and whenthe fragments do not articulate withthe proximal radioulnar joint, they maybe excised if stability of the elbow canbe achieved by secure repair of the coro-noid and collateral ligaments.34,35

The stability of the elbow should beassessed following fragment exci-sion; if residual instability is present,radial head replacement is recom-mended.

If a radial head fracture is deemedrepairable, the hardware used for os-teosynthesis may include counter-sunk traditional screws (Figure 8),headless compression screws (Fig-ure 9), or plates. Fixation is typi-cally performed with 1.5-, 2.0-, or2.4-mm countersunk screws after ananatomic reduction and provisionalstabilization with Kirschner wires.Noncomminuted radial neck frac-tures can be reduced with the use oftwo or three oblique screws to securethe head to the neck.36 Cannulated3.0-mm screws are helpful in thesecircumstances because guidewiresprevent the screws from glancing off

the inner cortical bone of the medul-lary canal.

If the radial neck is comminuted, aradial neck plate should be consid-ered (Figure 10). Plates must beplaced in the “safe zone,” which isthe region that does not articulatewith the proximal radioulnar joint.37

This is easily identified at surgery byplacing the forearm in neutral rota-tion and applying the plate directlylateral. In fractures involving the ra-dial neck, the posterior interosseousnerve is at risk during the approach;therefore, great care must be takenas dissection is performed distally.Pronation of the forearm moves thenerve away from the surgical dissec-tion. The use of plates requires dis-section along the radial neck and in-terferes with the gliding of theannular ligament; therefore, postop-erative loss of forearm rotation dueto scarring is not uncommon. Addi-tional surgery may be required inthese circumstances for plate re-moval and release of adhesions afterfracture healing. Following plate fix-

Illustration (A) and photograph (B) of a targeting device used to assist in drill-hole placement for retrograde screws orsuture fixation of the coronoid fracture. C, Suturing of the coronoid fragment is most frequently done through the lateralarthrotomy, after which the sutures are drawn through drill holes (arrow) exiting the subcutaneous border of the ulna.

Figure 6



ation of the radial neck, repair of theannular ligament should be per-formed to restore elbow stability.

If there is extensive radial headcomminution, neck comminution, orpoor bone quality, replacement ar-throplasty should be considered. Theimplants available are numerous;however, the use of a modular pros-thesis is preferable because it allowsthe surgeon the latitude to indepen-

dently modify head and stem diame-ters and heights to ensure an optimalfit.34,35 The radial head prosthesis siz-ing is based on the fragments excisedfrom the elbow. The height of theimplant should correspond to theheight of the excised fragments sothat placement of a radial head pros-thesis that is too thick is avoided.The implant should articulate at thelevel of the proximal aspect of the

proximal radioulnar joint, approxi-mately 2 mm distal to the tip of thecoronoid process.

For terrible triad injuries, we thinkthat excision of the radial head with-out replacement is contraindicated. Itis well documented that the radialhead is critical to valgus stabilitywhen the MCL is injured, that theradial head resists posterior displace-ment of the elbow when the coro-

Anteroposterior (A) and lateral (B) injury radiographs of a 38-year-old woman with a right terrible triad injury.C, An intraoperative view through the Kocher interval demonstrates the comminuted, unrepairable radial head fracture.D, Because the fracture was deemed to be unrepairable, an arthoplasty was selected, and a radial neck cut wasperformed. Once the radial head was excised, visualization of the type II coronoid fracture improved. Postoperativeanteroposterior (E) and lateral (F) radiographs demonstrating open reduction and internal fixation of the coronoidfracture with two 3.0-mm cannulated screws and a metallic modular radial head arthroplasty.

Figure 7


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noid process is deficient, and that thehead tensions the repaired LCL to re-sist varus and posterolateral rotatoryinstability. Several authors have re-ported a high incidence of complica-tions with radial head excision in ter-rible triad injuries.17,26,34,35,38,39

Once the bony structures havebeen repaired, the ligamentous struc-tures should be evaluated. The LCLis usually avulsed from its origin onthe lateral epicondyle. Midsubstancetears and avulsion of the LCL fromits insertion on the ulna are uncom-

mon.40 The LCL can be reattached tothe lateral epicondyle with suture an-chors or transosseous sutures (Figure11). The most important step inachieving a successful isometric re-pair is placing the sutures at the cen-ter of rotation of the elbow, which islocated at the center of the capitellarcurvature on the lateral epicondyle.35

We prefer the transosseous techniquebecause it allows strong fixation andtensioning with running locking su-tures in the LCL and common exten-sor origin. If the MCL is intact, the

LCL is repaired with the forearm inpronation; however, if the MCL isinjured, LCL repair is performedwith the forearm in supination toavoid gapping open the medial sideof the elbow by overtightening thelateral repair. Because the LCL is iso-metric, repairs are performed withthe elbow at 90°, the most conve-nient position during surgery.

After repair of the coronoid process,radial head, and LCL, the elbowshould be fluoroscopically examinedfor stability, while it is flexed and ex-tended with the forearm in supination,neutral position, and pronation. In theauthors’ experience, if the elbow re-mains congruous from approximately30° to full flexion in one or more po-sitions of forearm rotation, repair ofthe MCL is not necessary. Thirty de-grees should be considered a guideline;further clinical and biomechanicalstudies are needed to determine the in-dications for MCL repair in terribletriad injuries. If instability is still an is-sue, the MCL should be repaired withthe use of suture anchors or transos-seous sutures, with drill tunnels placedthrough the medial epicondyle and spe-cial care taken to protect the ulnarnerve.8

A, Fixation of a radial head fracture with temporary Kirschner wires andcannulated screw guides. B, Definitive fixation with cannulated countersunkscrews.

Figure 8

Preoperative anteroposterior (A) and lateral (B) radiographs of radial head and coronoid fractures. Postoperativeanteroposterior (C) and lateral (D) radiographs demonstrating fixation of the radial head fracture with multiple headlesscompression screws and fixation of a coronoid fracture with a cannulated screw.

Figure 9



In the rare circumstance that theelbow remains unstable following re-pair or replacement of the radialhead and repair of the coronoid pro-cess, MCL, or LCL, a static orhinged external fixator should be ap-plied to maintain a concentric reduc-tion of the elbow.41 While a dynamicexternal fixator is preferred, the useof a static fixator for up to 3 weeksis also acceptable. In some acutecases, the use of a dynamic fixatormay be considered to protect tenu-ous fixation of comminuted coro-noid fractures. The dynamic fixatoris most commonly employed for de-layed treatment to maintain stabilityof the elbow in the setting of subop-

timal soft-tissue and bony repair.When an external fixator is unavail-able, the placement of a transarticu-lar Steinmann pin to stabilize the ul-nohumeral joint can be employed. Ifused, the pins should be removedearly, within 3 weeks, because oftheir tendency to break and the po-tential for pin-site infection leadingto septic arthritis.

Rehabilitation

The final step before leaving theoperating room is to perform a carefulfluoroscopic examination of the elbowto assess any residual instability and to

determine the best position for immo-bilization as well as the safe arc of mo-tion for rehabilitation. If the MCL isintact, the elbow is immobilized in awell-padded fiberglass splint at 90° offlexion, with the forearm in full prona-tion to avoid posterolateral instabilityand to protect the LCL repair. If boththe MCL and LCL have been repaired,the arm should be splinted in neutralrotation. If the LCL has been securelyfixed and the MCL has not, immobi-lization at 90° of flexion and in fullsupination should be considered. Al-though the period of initial immobili-zation will vary with injury, supervisedmotion should generally begin within2 to 5 days after surgery. Patients

Preoperative anteroposterior (A) and lateral (B) radiographs demonstrating a fracture of the radial head and neck witha Regan-Morrey type II coronoid process fracture following closed reduction of an elbow dislocation. C and D, Throughthe Kocher interval (anconeus to extensor carpi ulnaris), the radial head was reconstructed with an anatomic radialneck plate placed in the safe zone, and the coronoid fracture underwent suture fixation. E, Postoperativeanteroposterior radiograph, after lateral ligament repair.

Figure 10


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should begin active flexion and exten-sion, avoiding terminal extension, de-pending on the intraoperative evalua-tion of stability. Full active forearmrotation is permitted with the elbow in90° of flexion to protect the collateralligament repairs.

If residual instability is a concern,the use of an overhead rehabilitationprotocol is helpful, with the patientlying supine and the humerus/armpositioned vertically. This positionuses gravity to maintain joint com-pression; it also decreases patient ap-prehension. A resting splint with theelbow at 90° and the forearm in theappropriate position of rotation isused between exercises for 6 weeks.A gradual increase in terminal ex-tension is permitted as healingprogresses. It is the practice of theauthors to prescribe a static progres-sive extension splint employed atnight. This is begun at the 6-weekmark to ensure that sufficient healingof the bony and ligament repairs hasoccurred. Strengthening is initiatedat 8 weeks once osseous and liga-ment healing is secure. The postoper-ative rehabilitation protocol will

vary depending on the injury pattern;however, the primary goal is to beginearly elbow motion while maintain-ing a concentric joint reduction andprotecting bony and soft-tissue re-pairs.26,34,35 When a static externalfixator is used, it is typically re-moved within 3 weeks to avoid stiff-ness. A gentle manipulation may berequired at the time of fixator re-moval to facilitate regaining motion;however, great care must be takenbecause there is a risk of fracture aswell as of heterotopic bone forma-tion. With an articulated externalfixator, early motion is started assoon as the soft tissues allow, andthe fixator generally is removed be-tween 3 and 8 weeks postopera-tively as ligament and bone healingprogress.

The optimal rehabilitation of terri-ble triad injuries is unknown. Basedon biomechanical studies7-9 and theauthors’ clinical experience, the de-scribed rehabilitation protocols havebeen useful in allowing early motionwhile maintaining stability, particu-larly in the setting of tenuous frac-ture fixation or ligament repairs.

Outcomes

Relatively few studies have docu-mented the outcomes of terrible triadinjuries of the elbow. Pugh and Mc-Kee27 reported a mean arc of flexionof between 20° and 135° and meanrotation of 135°. A delay in treat-ment or revision surgery resulted in a20% greater loss of motion com-pared with acutely treated injuries.Up to 25% of the patients needed re-vision surgery for residual instability,stiffness, or removal of hardware.

In a multicenter series, 36 patientsunderwent fixation or replacement ofthe radial head, repair of the coronoidwhen possible, and fixation of ligamen-tous and capsular injuries.34 At amean follow-up of 34 months, theauthors reported a flexion-extensionarc averaging 112° ± 11°, with fore-arm rotation averaging 136° ± 16°.At follow-up, 15 patients were ratedas excellent, 13 as good, 7 as fair,and 1 as poor by the Mayo ElbowPerformance Score. Patient compli-cations were noted in this study; twopatients required revision surgery for

A, The lateral collateral ligament is repaired through drill tunnels to the isometric point on the lateral epicondyle. Notethe bare lateral epicondyle, resulting from tearing of the lateral collateral ligament and common extensor originfollowing an elbow dislocation. Two wires, functioning as suture passers, have been placed through the bone tunnels.B, The extensor origin is repaired as a second superficial layer.

Figure 11



synostosis, one for recurrent instabil-ity, four for contracture release andimplant removal, and one for awound infection. The authors con-cluded that the outcomes were di-rectly related to the period of im-mobilization; patients who hadprolonged immobilization did not doas well.

Similar findings were reported byBroberg and Morrey,42 who notedthat immobilization for more than 4weeks led to consistently poor re-sults. It should be noted, however,that a surgeon often has to decidebetween stability and mobilization.In the end, the outcome of managinga stiff congruent elbow is usuallybetter than that of treating a mobileelbow with residual instability andincongruency.23

Forthman et al43 reviewed 34 pa-tients, of whom 30 could be classi-fied as having terrible triad injuries.At a mean follow-up of 32 months,the average ulnohumeral arc of mo-tion was 117° (range, 75° to 145°)and forearm rotation was 137°(range, 0° to 180°). Good to excel-lent results were reported in 77% ofpatients using the system of Brobergand Morrey.42

Complications

Complications are frequently en-countered following treatment forterrible triad injuries. The frequencyof complications is related to the se-verity of the injury. Common com-plications are instability, malunion,nonunion, stiffness, heterotopic ossi-fication, infection, and ulnarneuropathy.25-27,34,43

It was initially thought that insta-bility was more prevalent withRegan and Morrey type III coronoidprocess fractures;22 however, instabil-ity seems to be more common fol-lowing type I or II coronoid frac-tures. This is theorized to occur

because of the frequency of associ-ated ligamentous injuries around theelbow and the technically challeng-ing aspects of obtaining stable inter-nal fixation of these smaller frac-tures. Terada et al44 and Josefssonet al45 also reported that chronic el-bow instability was more common inpatients with smaller fractures of thecoronoid process, particularly whenassociated with a radial head frac-ture. They suggested that even smallcoronoid fractures usually have theanterior capsule attached and, if theyare repaired, joint stability may in-crease. However, a recent biome-chanical study suggests that fixationof small type I coronoid tip fracturescontributes little to stability in spiteof this anterior capsular attachment.Repair of the collateral ligamentswas found to be more beneficial thansuture fixation of the coronoid pro-cess in the treatment of small type Icoronoid fractures.15 However, be-cause in most patients with terribletriad injuries the coronoid fracturesare larger than 10%, excision ornonrepair of coronoid fractures israrely indicated.

Failure of internal fixation is com-mon following repair of radial neckfractures, likely because of poor vas-cularity leading to osteonecrosis andnonunions.46 Hardware migrationcan occur, particularly when smoothKirschner wires are used. Looseningor failure of radial head implants hasbeen reported, although newer de-signs offer much more modularity,thereby allowing for more accurateimplant sizing, which may lead toimproved results.47

Posttraumatic stiffness is a com-mon complication after treatment ofterrible triad injuries of the elbow.The best treatment is prevention,such that at the time of index sur-gery, the elbow should be renderedsufficiently stable to allow earlyROM. Should stiffness occur, thefirst line of treatment is nonsurgical,

with passive stretching and staticprogressive splinting. Turnbucklesplinting should also be considered ifstiffness persists despite therapy andstandard splints. Stiffness that is re-calcitrant to nonsurgical treatmentmay be treated surgically with openor arthroscopic capsular release.

Heterotopic ossification that limitsmotion typically requires an open ap-proach. Ring et al48 reported goodresults with open capsular excisionin 46 patients with posttraumaticstiffness. At a mean follow-up of 48months, there was restoration of afunctional arc of motion of nearly100°. Heterotopic ossification thatbecomes clinically significant is rela-tively uncommon. In a series of 24patients with fracture-dislocations ofthe elbow, only 1 patient developedthis condition, and treatment in thispatient had been delayed by 8 days.42

The use of prophylactic measuresfor heterotopic ossification is con-troversial. Some authors recommendprophylactic measures only for thosepatients with a concomitant headinjury or those who have failed ini-tial surgical treatment.27 Whenprophylaxis is decided upon, we em-ploy indomethacin 100 mg rectallytwice a day for 24 hours, followedby 25 mg orally three times a dayfor 3 weeks. Nonsteroidal anti-inflammatory drugs should beavoided in patients with pepticulcers, asthma, kidney disease, andcardiac disease as well as in theelderly.

Posttraumatic arthritis can occurbecause of chondral damage at thetime of injury as well as because ofresidual elbow instability or articularincongruity.41,49 Treatment optionsinclude débridement, radial head ex-cision, radial head arthroplasty, andtotal elbow arthroplasty.

As with any surgical procedure, in-fection remains a potential complica-tion after surgical fixation of elbowinjuries. Surgical site infections


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around the elbow should be treatedin the same way as any infection thatoccurs around a joint. If the infectionis thought to be superficial, oral orintravenous antibiotics may be used.If the superficial infection is slow torespond or when there is any indica-tion of a deep infection, serial surgi-cal débridement with intravenousorganism-specific antibiotics shouldbe done.

Summary

Terrible triad injuries remain difficultto treat. The surgeon must carefullyexamine and view images of the in-jured arm to determine the extent ofbony and ligamentous injury. Mostauthors agree that prompt surgicalattention with a systematic approachto restore anatomy and provide suffi-cient stability to allow early motionare the key factors for a successfuloutcome. Stiffness, a common com-plication after terrible triad injuries,is generally avoided by stable repairand early mobilization. The long-term outcome of terrible triad inju-ries remains unknown.

References

Citation numbers printed in bold typeindicate references published withinthe past 5 years.

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40. McKee MD, Schemitsch EH, Sala MJ,O’driscoll SW: The pathoanatomy oflateral ligamentous disruption incomplex elbow instability. J ShoulderElbow Surg 2003;12:391-396.

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Terrible Triad Injury of the Elbow

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