Journal club on terrible triad injury of elbow joint.

1. Journal Club on
“TREATMENT STRATEGY OF TERRIBLE
TRIAD OF ELBOW”
Presented By : Dr. Vipendra Singh
MODERATORS
Dr. Abhishek Pathak
Dr. Mohd. Zuber

2. Presenting a Journal Club on
“Treatment strategy of terrible triad of the
elbow: Experience in Shanghai 6th People’s
Hospital”
Authors : Chi Zhang, Biao Zhong, Cong-feng Luo
Study conducted at 6th People’s Hospital,
Shanghai, China
Level IV study
Published in Journal “Injury” in 2014.

3. Introduction
Terrible Triad Injury of the Elbow
• Elbow Dislocation
• Radial Head Fracture
• Coronoid Process Fracture

6. Why is Terrible Triad Injury Important?
• Because along with the fractures, this leads to the
injury to the Lateral Collateral Ligament (LCL)
Complex.
• Sometimes Medial Collateral Ligament (MCL)
complex may also fail.
• This renders the elbow in an inherently unstable
state and invariably requires surgical intervention.
• Due to the complexity of injury, outcomes are
generally poor and associated with long term
complications like joint stiffness, instability, pain and
arthritis.

7. Objectives
• The purpose of this study is to report the
outcomes of a modified Surgical technique as
compared to the established standard surgical
protocol for the repair of terrible triad of the
elbow injuries.

8. Materials and Methods
• Twenty-one 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.
• All the patients were operated using a
modified surgical technique and followed up
over a period of 24 -48 months.

9. Investigations
• All routine blood investigation were done along
with radiographs.
• 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.
• MRI was done for the assessment of soft tissue
injuries.

10. Classification
Radial head fracture was classified according
to Mason Classification
• Type I : non-displaced radial head fractures (or
small marginal fractures);
• Type II : partial articular fractures with
displacement (>2 mm);
• Type III : comminuted fractures involving the
entire radial head.

11. Soft tissue 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).
• Type II soft-tissue injuries were LCL complex
injuries with MCL injury, but with the continuity
of the MCL remaining complete.
• Type III soft-tissue injuries were LCL complex
injuries with MCL body rupture or avulsion from
the medial humeral attachment.

12. Operative Procedure
• Approach : Lateral approach for radial head
and a separate Anteromedial
approach for coronoid process.
• Operative Steps :
1. Radial head was repaired (not replaced) first
using cannulated screws.
2. LCL complex was then temporarily sutured to
the supra-lateral condyle to provide provisional
stability to elbow joint.

13. 3. This helps in restoring the articulation of the
humero-ulnar joint and facilitates reduction
and fixation of coronoid fracture.
4. Next, an anteromedial skin incision was made
and an ‘‘over the top’’ approach was used to
expose most of the coronoid fracture.
5. After reduction, 3 mm cannulated screws
and/or a T-type buttress plate was used for
fixation of the coronoid fracture.

16. 6. Once bony reconstruction was complete, the
LCL complex injury, in which the lateral
ligament complex was detached from the
humerus was repaired by direct suturing
using non-absorbable sutures.
7. Stability assessment is done with emphasis
on that
• There should be no posterior or posterolateral
instability in flexion-extension movement.
• There should be no valgus instability.

17. STANDARD PROTOCOL MODIFIED PROTOCOL
POSTERIOR APPROACH FOR ELBOW JOINT LATERAL AND ANTEROMEDIAL APPROACH
REDUCE AND FIX CORONOID FRACTURE
FIRST
FIX THE RADIAL HEAD FIRST
REPLACE THE RADIAL HEAD WITH A
METAL PROSTHESIS
REPAIR THE RADIAL HEAD
APPLY A HINGED EXTERNAL FIXATOR IF
RESIDUAL INSTABILITY PERSISTS.
NOT PREFFERED

18. • Post operative Management :
• All the patients were given a hinged plastic
brace with elbow at 90⁰ of flexion for 6 weeks.
• Supervised physiotherapy was begun on the
second day after surgery for all patients with
gradual increase in the range of motion.

19. EVALUATION
• Radiography was used for identification of
synostosis, heterotopic ossification, and joint
congruency.
• The Mayo Elbow Performance Score (MEPS)
was used for assessment of functional
recovery.

20. RESULTS
• All the patients, except one, had solid osseous
union on the final follow-up radiographs
without any evidence of elbow instability.
• The mean MEPS was 95.2 points (range, 85–
100 points), with 19 excellent cases and 2
good cases.

22. COMPLICATIONS :
• Heterotopic ossification : 2 cases; does not
require re-surgery.
• Non union : 1 case; patient was asymptomatic
with no limitation of forearm rotation.
• Infection : 1 case; superficial infection, healed
uneventfully after surgical debridement and
antibiotic therapy.
• Ulnar Neuropathy : 1 case

23. SUMMARY
• 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.

24. STUDY Outcome Inference
Rodriguez-Martin J et al
Outcomes after terrible triads of
the elbow treated with the current
surgical protocols. A review. Int
Orthop 2011;35:851–60.
Overall flexion extension arc : 111.48
Averaged flexion : 132.58
Forearm rotation : 135.58
MEPS : 85.6 points
Modified
protocols have
better results
Egol KA et al
Fracture-dislocation of the elbow
functional outcome following
treatment with a standardized
protocol. Bull NYU Hosp Jt Dis
2007;65:263–70.
Average flexion extension : 109 Average
pronation supination arc : 128
Grip strength averaged 72% of the
contralateral extremity,
MEPS : 81 points
Modified
protocols have
better results
Leigh WB et al
Radial head reconstruction versus
replacement in the treatment of
terrible triad injuries of the elbow.
J Shoulder Elbow Surg
2012;21:1336–41.
No significant difference exists in
outcome related to elbow function in
radial head repair or radial head
replacement group
Radial head
replacement has
no particular
benefit
McKee MD et al
Standard surgical protocol to treat
elbow dislocations with radial head
and coronoid fractures : J Bone
Joint Surg Am 2005;87(Suppl. 1 (Pt.
1)):22–32.
Soft-tissue healing is not adequate
despite restoration of the anatomical
centre of rotation of the elbow by the
hinged external fixator.
Hinged external
fixator has certain
disadvantages on
soft tissue
healing.

25. Study Outcome Inference
Garrigues GE et al
Fixation of the coronoid
process in elbow fracture-
dislocations. J Bone Joint Surg
Am 2011;93:1873
Greater stability with fewer
complications was
achieved with use of the
suture lasso technique for
coronoid fracture fixation.
Suture lasso technique
gives better results than
butress plate or screws.
Reichel LM et al
Anterior approach for
operative fixation of
coronoid fractures in
complex elbow instability.
Tech Hand Surg
2012;16:98– 104
accurate and stable
internal fixation was
achieved with
anteroposterior screws and
a buttress plate by an
anterior approach in which
brachialis muscle was split
at its midline
Anterior approach could be
a better alternative.
Studies in opposition of the current study.

26. THANK YOU