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. 2022 Jun 4:78:103914.
doi: 10.1016/j.amsu.2022.103914. eCollection 2022 Jun.

Terrible triad injury of the elbow: A PROCESS-compliant surgical case series from Eastern Morocco

A Ben Abdellah  1   2 , S Ben Salah  1   2 , S Darraz  1   2 , A Tebbaa  1   2 , O Jelti  1   2 , O Mokhtari  1   2 , I Moulay Rchid  1   2 , Y Rachdi  1   2 , A Lachkar  1   2 , A Najib  1   2 , H Yacoubi  1   2
Affiliations

Terrible triad injury of the elbow: A PROCESS-compliant surgical case series from Eastern Morocco

A Ben Abdellah et al. Ann Med Surg (Lond). .

Abstract

Introduction: The terrible triad of the elbow (TTE) is a lesion associating a dislocation of the elbow, a fracture of the radial head, and a fracture of the coronoid process, with a high potential of complication. The treatment is based on the restoration of bone lesions and external capsular ligament repair. The systematic repair of the medial collateral ligament (MCL) is still debated in the literature. The aim of this study is to evaluate the clinical and functional results of the surgical treatment in a real-world series from Easter Morocco.

Patients and methods: This was a retrospective study of 6 cases of TTE operated by isolated external approach or combined approach (internal or anterior) of the elbow in the department of Traumatology-Orthopedics of the Mohammed VI University Hospital (Oujda Morocco), over a period of 7 years from 2013 to 2020. Radial head and coronoid process fractures were classified according to the Mason and Morrey-Regan classifications, respectively. The following clinical parameters were evaluated: Mayo Clinic Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder and Hand (DASH), Visual Analog Scale (VAS), and arc of mobility in flexion-extension and prono-supination.

Results: 6 male patients treated between May 2013 and December 2020 were included. The median follow-up was 48 months. All patients had frontal and lateral standard X-ray of over and under joints, and computed tomography (CT)-scan was delivered for 5 cases. The elbow dislocation was posterolateral in five cases, and posteromedial in only one patient. Radial head fractures were classified as type I in one case, type II in two cases, and type III in three cases. Coronoid fractures were type I in three cases, type II in one case, and type III in two cases. At the last follow up, the mean MEPS, Quick DASH, and VAS was 81, 28, 0.8, respectively. The mean arc of mobility in flexion was 120° and it was deficient by 20° in extension. In addition, the mean arc of mobility in protonation was 80°, while in supination it was 75°. Regarding complications, we noticed an instability of the elbow on valgus in a single case, elbow stiffness with heterotopic ossification in a single case, ulnar nerve damage in a single case during medial collateral ligament anchoring, and elbow hygroma in one single case.

Conclusion: The surgical management of TTE can provide good and long-term functional results after restoration of the stabilization of bone structures and the lateral ligament complex, without the need to repair the medial collateral ligament.

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Conflict of interest statement

No conflicts of interest to declare.

Figures

Fig. 1
Fig. 1
Standard X-ray of the elbow showing a terrible triad with type 2 fracture of the radial head associated with type 2 fracture of the coronoid process.
Fig. 2
Fig. 2
CT image of the elbow showing a terrible triad with the comminution of the radial head fracture and the size of the fragment of the coronoid process.
Fig. 3
Fig. 3
Standard X-ray of the elbow showing a terrible triad of the elbow with postero-medial dislocation.
Fig. 4
Fig. 4
Intraoperative scope control of radial head osteosynthesis with mini-plate.
Fig. 5
Fig. 5
Intraoperative scope control of radial head osteosynthesis with Herbert screw.
Fig. 6
Fig. 6
Intraoperative image of radial head resection.
Fig. 7
Fig. 7
Functional outcome in a patient operated for a terrible triad.
See this image and copyright information in PMC

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