Management of elbow stiffness after postoperative treatment of terrible triad elbow injury: maintaining mobility and stability using a combined protocol

Stiff elbow is a common problem associated with terrible triad injuries which if not managed properly can lead to significant functional limitations. Here we are describing a case of post-traumatic stiff elbow following terrible triad who presented to us after taking native treatment primarily. He was treated with open arthrolysis and prophylactic ulnar nerve decompression along with rigorous physiotherapy including dynamic splinting with hinge elbow bracing. The results were satisfactory in achieving a functional range of movement according to the patient's vocational need. This study aims to present the prompt management of post-traumatic stiff elbow case along with functional improvement postoperatively in a decisive way. Terrible triad injuries are a group of the rare and severely unstable fracturedislocations following which the chance of recurrent instability, elbow stiffness, and functional limitations increases coherently.1 To perform normal daily activities, painless motion at the elbow joint is very much necessary and critical. Following a traumatic insult, a cascade of events can lead to a decrease in the normal arc of motion and also cause stiffness of the elbow joint.2 Over the last two decades, there has been a lot of speculation revolving around the management of terrible triad injuries.3 Van Riet et al had documented that the majority of the terrible triad injuries need to be managed surgically whereas the non-operative treatment is reserved for a few selected cases. 4 The ones which were not managed adequately had higher chances of turning up into stiff elbow. Post-traumatic elbow stiffness is one of the dreaded complications following terrible triad injuries.3 The aim of managing the case of post-traumatic stiff elbow is to have a painless, near-normal range of motion which can help the patient to do daily activities by himself. We are presenting a case of post-traumatic type- 4 stiff elbow following native bandage treatment and how prompt management has led to satisfactory results.

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Anterior capsule re-attachment in terrible triad elbow injury with coronoid tip fracture

Orthopaedics & Traumatology Surgery & Research ◽

10.1016/j.otsr.2019.09.024 ◽

2019 ◽

Vol 105 (8) ◽

pp. 1575-1583 ◽

Cited By ~ 4

Author(s):

Maxime Antoni ◽

David Eichler ◽

Jean-François Kempf ◽

Philippe Clavert

Keyword(s):

Terrible Triad ◽

Anterior Capsule ◽

Elbow Injury

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Coincidence of Ipsilateral Humeral Shaft, Monteggia and Both Bone Fractures; A Floating Elbow with Significant Recovery

Clinical Orthopaedics and Trauma Care ◽

10.31579/2694-0248/003 ◽

2020 ◽

Vol 2 (1) ◽

pp. 01-03

Author(s):

Seyyed Hosseininejad

Keyword(s):

Open Fracture ◽

Bone Fractures ◽

Shaft Fracture ◽

Humeral Shaft Fracture ◽

Humeral Shaft ◽

Terrible Triad ◽

Elbow Injury ◽

Floating Elbow ◽

Car Accident ◽

Floating Elbow Injury

The coincidence of forearm and humeral shaft fractures results in a “floating elbow” injury necessitating surgical open reduction and internal fixation of all fractures to allocate for maintenance of elbow joint suitable motion and minimizing stiffness. Here we introduce a case of an ipsilateral humeral shaft fracture and Monteggia and both bone fracture with terrible triad open fracture from a pedestrian car accident (PCA) to his right upper extremity.

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Single Pulley Double-strand Anchor Suture Fixation of the Coronoid Process in Terrible Triad of the Elbow Injury

10.21203/rs.3.rs-155381/v1 ◽

2021 ◽

Author(s):

Yih-Wen Tarng ◽

Kai-Cheng Lin

Keyword(s):

Suture Anchor ◽

Case Series ◽

Suture Technique ◽

Coronoid Process ◽

Fixation Method ◽

Type I ◽

Terrible Triad ◽

Level Of Evidence ◽

Elbow Injury ◽

Anchor Suture

Abstract Background: Terrible triad of the elbow injury is difﬁcult to manage, and the role of the coronoid process in instability is very important. We describe a simple, modified suture technique to fix a coronoid process fragment using suture anchor fixation.Methods: Eight patients (3 female and 5 male) with coronoid process injuries with the fragment involving <50% of the total height (Reagan-Morrey type I/II) in terrible triad of elbow injury were included. Patients were treated operatively via a lateral Kocher’s approach, and coronoid process fractures were repaired with a single pulley double-strand suture technique. Structures were addressed in a sequential fashion—the coronoid process, radial head, lateral ulnar collateral ligament.Results: All patients were treated with the single pulley double-strand anchor suture technique and the coronoid process fragment was found to be in good contact with the original avulsion site using the method. The final Mayo Elbow Performance Score was excellent (> 90) in 6 patients and good (between 85 and 89) in 2 patients.Conclusions: The single pulley double-strand suture tie method using a suture anchor is a less invasive and simpler fixation method for the repair of coronoid process fractures in patients with terrible triad of the elbow injuries, and results in good outcomes. Level of evidence: Level IV; Case Series; Treatment Study

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Primary open elbow arthrolysis in post-traumatic elbow stiffness – A comparison of outcomes in severity of elbow injury

Journal of Clinical Orthopaedics and Trauma ◽

10.1016/j.jcot.2020.09.014 ◽

2020 ◽

Author(s):

Alex Murray ◽

Daniel LJ. Morris ◽

Tim Cresswell ◽

Marius Espag ◽

Amol A. Tambe ◽

...

Keyword(s):

Elbow Stiffness ◽

Elbow Injury ◽

Post Traumatic ◽

Elbow Arthrolysis

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Bilateral radial head fracture with unilateral terrible triad injury in a military

10.21203/rs.3.rs-104588/v1 ◽

2020 ◽

Author(s):

MOURAD BENNANI ◽

Taoufik Cherrad ◽

Mouad Guendbar ◽

Hassan Zejjari ◽

Jamal Louaste ◽

...

Keyword(s):

Radial Head ◽

Radial Head Fracture ◽

Elbow Dislocation ◽

Lateral Collateral Ligament ◽

High Energy ◽

Rehabilitation Program ◽

Surgical Indication ◽

Terrible Triad ◽

Elbow Injury ◽

The Right

Abstract Background: The combination of coronoid process fracture, radial head fracture, and elbow dislocation has earned the moniker “terrible triad” by virtue of its challenging treatment and historically poor outcomes. Bilateral radial head fracture with unilateral terrible triad injury is an unprecedented presentation. It raises questions regarding the mechanism of injury, the surgical indication and the rehabilitation program. Case presentation: We report a case of a 29-year-old man presenting a unilateral terrible triad injury of the right elbow and a left radial head fracture after he fell off his motorcycle. The patient underwent open reduction and internal fixation of the radial head with repair of the lateral collateral ligament for the right elbow while the left radial head fracture was treated by a short-term immobilization in a posterior splint. We have reached good results 2 years after the injury: The Mayo Elbow Performance Score was 100 for both elbows. Conclusion: The few available data suggest that bilateral elbow injury involving a terrible triad occurs mainly in male young patient as a result of a high energy trauma. Bilateral radial head fracture with unilateral terrible triad injury is unprecedented. Well adapted surgical indication followed by optimal rehabilitation program are the two keys to obtain good results.

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Single-staged Treatment Using a Standardized Protocol Results in Functional Motion in the Majority of Patients With a Terrible Triad Elbow Injury

Clinical Orthopaedics and Related Research ◽

10.1007/s11999-014-3475-3 ◽

2014 ◽

Vol 472 (7) ◽

pp. 2075-2083 ◽

Cited By ~ 24

Author(s):

Akash Gupta ◽

David Barei ◽

Ansab Khwaja ◽

Daphne Beingessner

Keyword(s):

Terrible Triad ◽

Elbow Injury ◽

Standardized Protocol ◽

Staged Treatment

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What Factors Are Associated With Elbow Stiffness After Operation of Terrible Triad Injury？

10.21203/rs.3.rs-141475/v1 ◽

2021 ◽

Author(s):

Jian Zhu ◽

Xiangtian Deng ◽

Xiaodong Cheng ◽

Zhanchao Tan ◽

Hongzhi Hu ◽

...

Keyword(s):

Risk Factors ◽

Logistic Regression ◽

Upper Limb ◽

High Energy ◽

Functional Evaluation ◽

Terrible Triad ◽

Elbow Stiffness ◽

Related Factors ◽

Limb Injuries ◽

Functional Scores

Abstract Background: The elbow stiffness is a common complication after operation of terrible triad injury (TTI) and significantly impair the patients’ activities of daily living, while the risk factors have yet to be clearly identified. The goal of this study was to examine the patient-related, injury-related, and treatment-related factors for elbow stiffness after operation of terrible triad injury.Methods: Between January 2013 and December 2019, 71 patients at two tertiary-care referral centers underwent operation of terrible triad injury were respectively reviewed. Range of motion (ROM), Mayo elbow performance scores (MEPS), Broberg-Morrey scores were used for functional evaluation. According to the ROM, the patients were categorized into stiffness group and non-stiffness group. The former had < 100° of extension-flexion ROM and the latter had > 100°. The patient-related, injury-related, and treatment-related factors were extracted from the medial records. The multivariant logistic regression were performed to identify the independent factors.Result: At a mean follow-up of 35.9 months (12-68 months),13 patients were classified into the stiffness group and 58 patients in the non-stiffness group. The stiffness group had significant worse functional scores compared to the non-stiffness group. Patients in the stiffness group were more likely to be Mason type III fracture, high-energy injuries, to have longer time between injury and surgery, ipsilateral upper limb injuries, and other fractures in body. However, multivariant logistic regression analysis revealed that time between injury and surgery > seven days, concurrent ipsilateral upper limb injuries and high-energy injury were independent factors that increased the risk of elbow stiffness after operation of terrible triad injury.Conclusions: The patients underwent operation for terrible triad injury should be informed the probability of elbow stiffness when concurred ipsilateral upper limb injuries and operations should be conducted without delay. Knowledge of these risk factors will be helpful for guiding prophylaxis and early intervention in patients with high risk of elbow stiffness after operation of terrible triad injury.

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