Surgical Treatment Of Terrible Triad Of Elbow Using A Lateral Approach

Objective: In fracture-dislocation of the elbow,the terrible triad is a serious and unusual injury,which includes posterior dislocation of elbow,radial head and coronoid process fracture,compared with total lateral collateral ligament tear and partial rupture of medial collateral ligament.This injury had been named "terrible triad" because of its long-term treatment difficulty,poor prognosis,and high incidence of postoperative complications.In recent years,with the further understanding of the anatomy of the elbow joint,the advancement of internal fixation techniques and instruments,and a new understanding of the mechanism of injury,the outcomes of the terrible triad have been improved significantly.However,the surgical approach,the method of fix fractures and repair of the collateral ligaments,particularly medical collateral ligament,are still controversial.The purpose of this article is to explore the surgical technique and clinical outcomes of the surgical treatment of terrible triad of the elbow by a lateral approach only.Methods: Retrospective analysis of 21 patients with terrible triad of elbow,between January 2004 and January 2017,accepted surgical treatment,including 15 males and 6 females,with an average age of 43.57±10.98 years old(range,27-65 years old).All of the patients underwent X-ray and CT three-dimensional imaging examination before surgery to confirm the diagnosis,including 18 cases of type II coronoid process fracture,3 cases of type III(Morrey-Regan classification);15 cases of type II of radial head fracture,6 cases of type III(Mason classification).All of operative process was performed by a lateral approach.Fractures of coronoid process were fixed with 2 headless bone screws,while radial head fracture fixed by 2-4 screws.All torn lateral collateral ligament were repaired with suture anchors.No medial collateral ligament is needed to repair after fractures fixation and the lateral collateral ligament repair.All patients were reviewed in the clinic.The function of the elbow was evaluated by X-ray examination,physical examination and Mayo Elbow Performance Score(MEPS).X-ray was done for the assessment of fracture healing.Physical examination could check the stability of elbow and the motion range of flexion-extension and pronation-supination.MEPS can quantify the function of elbow,while the classification is as follows: excellent: >90,good: 75 to 89 points,medium: 60 to 74 points,poor: <60 points.Results: All of 21 patients back to clinic,with an average follow up time of 31.81±17.79 months(12-72 months),for physical examination,functional assessment and radiographs.At the final follow-up,each patients had presented a stable elbow joint.19 patients had no pain and the function of elbow can meet daily life.2 patients reported mild pain and limited elbow motion.They were considered to have complications of traumatic arthritis,which were considered to be related to late functional exercise and joint degeneration,and no secondary surgery was needed.The average of extension-flexion ranged from 15±7.4°(0°-30°)to 130±13.31°(100°-140°),and the average of pronation-supination was 140±18.25°(95°-170°).The mean Mayo Elbow Performance Score value was 87.14±8.94(70-100),which correspond to eight excellent results,eleven good results,two fair results.The rate of excellent and good is 90.48%.The mean time of fracture union was 16 weeks(12-18 weeks).Conclusions: The lateral approach is a good choice for the treatment of the terrible triad injury and can achieve satisfactory outcomes.The elbow joint remains stable postoperatively and patients can perform functional exercise early.After anatomical reduction and fixation of radial head and coronoid process fractures,and repair lateral collateral ligament on its humerus insertion,the medial collateral ligament repair appears to be unnecessary.