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 Table of Contents  
Year : 2022  |  Volume : 37  |  Issue : 2  |  Page : 89-90

Bilateral elbow terrible triad case report

Dept. of Orthopedics, TMMC&RC, Moradabad, India

Date of Submission25-Jul-2022
Date of Acceptance06-Sep-2022
Date of Web Publication19-Oct-2022

Correspondence Address:
Shubham Aggarwal
Dept of Orthopedics, Teerthanker Mahaveer medical college and research center, Delhi Road, Moradabad, 244001, UP
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_14_22

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A 33-year-old male presented to our casualty department with pain and swelling accompanied by bony deformity over bilateral elbows post an episode of high-energy trauma. Plain radiographs and 3d-CT were done which showed Terrible Triad injuries to both the elbows. Different surgical managements were planned and executed in both elbows according to the fracture patterns. The postoperative period was uneventful and the patient was under continuous follow-up. At the 1-year follow-up patient showed good radiological and functional recovery.

Keywords: Coronoid fracture, elbow dislocation, radial head fracture, radial head replacement, terrible triad

How to cite this article:
Saraf A, Bishnoi S, Hussain A, Aggarwal S. Bilateral elbow terrible triad case report. J Bone Joint Dis 2022;37:89-90

How to cite this URL:
Saraf A, Bishnoi S, Hussain A, Aggarwal S. Bilateral elbow terrible triad case report. J Bone Joint Dis [serial online] 2022 [cited 2022 Nov 29];37:89-90. Available from: http://www.jbjd.in/text.asp?2022/37/2/89/358794

  Introduction Top

The elbow joint is the 2nd most commonly dislocated joint with Posterolateral dislocation being the most common instability following an acute trauma[1]

The terrible triad was first described by Hotchkiss[2] as “a fracture of the radial head associated with the fracture of the coronoid process of the ulna and posterior dislocation of the elbow”. It was called the “terrible triad” due to poor bone healing and the range of motion wasn’t well achieved even in a long run. The mechanism of injury is its determinant which usually occurs from falling on the extended and supinated arm, with valgus stress on the elbow.[2],[3] The axial force transmitted to the ulno-humeral joint led to radial head and coronoid fractures following the posterior dislocation. It’s not only the bony structures but also the ligaments mainly the radial collateral ligament complex and medial collateral ligament along with capsule which is damaged, causing a definite elbow instability.

We present a rare case of complex trauma around the elbow because of two reasons. It was a bilateral terrible triad and the treatment was different for each elbow.

  Case Report Top

We present a case of a 33-year-old male who presented in our emergency ward with pain, swelling, and deformity over the bilateral elbow after sustaining a high-energy trauma (hit by a bull). The patient fell on his extended arms. After giving the pain management, plain radiographs of the bilateral elbow were done which showed a bilateral terrible triad.

Closed reduction was performed by the traction and countertraction method under the effect of analgesia followed by an elbow slab. Both the elbows were found to be clinically unstable at less than 30 degrees of elbow flexion.

Post reduction, plain radiographs were done followed by CT Elbows with 3-Dimensional reconstruction. CT showed posterolateral dislocation, mason type 4 radial head fracture, mayo type 3B (unstable comminuted) olecranon fracture and Regan-Moorey type 1 coronoid fracture on the right side and posterolateral dislocation, mason type 2 radial head fracture and mayo type 1A (Undisplaced noncomminuted) olecranon fracture on the left side.

We chose different methods of management for both the elbows due to different fracture configurations. For the right elbow, we used both lateral and medial approaches to the elbow. Radial head replacement with a metal prosthesis, olecranon plating, and repair of the coronoid fracture, anterior capsule, radial collateral ligament, and medial collateral ligament repair was done on the 4th post-traumatic day. For the left elbow, only 1 ulno-humeral k-wire was done. Both the elbows were kept in above-elbow slabs for a period of 4 weeks in a neutral position after which the ulno-humeral pin over the left side was removed. The slab was then converted to a hinged elbow brace and range of motion exercises (flexion-extension and pronation-supination) were started increasing to 20 degrees weekly.

At 3 months postoperatively, plain radiographs were done and elbow range of motion was assessed. On the right side, flexion extension was 45–100 degrees, supination 55 degrees, and pronation 75 degrees. On the left side, flexion-extension was 30–120 degrees, supination 80 degrees, and pronation 80 degrees.

The patient was advised to continue the range of motion exercises and again reviewed one year post-operatively. Xray showed union and clinical range of motion was assessed. On the right side, flexion-extension was 30–110 degrees, supination 80 degrees, and pronation 80 degrees. On the left side, flexion-extension was 30–120 degrees, supination 80 degrees, and pronation 80 degrees.

  Discussion Top

Coronoid fracture is the key to ulno-humeral stability and more than 50% should be intact to ensure ulno-humeral sagittal stability.[4] Early intervention is the key to restoring the bony elements, and radial collateral ligament and preventing complications like elbow stiffness. After dislocation reduction, many authors advocate early complete excision of the radial head. However, Broberg and Morrey,[5] as well as Josefsson et al.,[6] underline the risk of instability and osteoarthritis when resorting systematically to that treatment option. Mayo Type II and III fractures require stable osteosynthesis with screws or plates. Reconstructing the ligaments is a stepwise procedure by assessing the instability at each step. Reconstruction of the isometric radial ligament complex for instabilities was first described by Osborne and Cotterill[7] by reinsertion to the center of the lateral epicondyle which refers to the elbow center of rotation.[8] After this, if there occurs persistent instability then a medial approach should be performed for reconstructing the ulnar collateral ligament. If instability still persists despite repair of the medial ligament complex, an external fixator should be placed on the elbow. Cobb and Morrey,[9] along with McKee et al.,[10] have very well explained the use of external fixation in the treatment of complex traumatic elbow injuries.

Our patient was managed surgically on the 4th post-traumatic day with early rehabilitation and followed periodically at intervals. He has excellent results both radiologically and clinically at 1-year follow-up.

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Conflicts of interest

There are no conflicts of interest.

  References Top

O’Driscoll SW, Jupiter JB, King GJW, Hotchkiss RN, Morrey BF The unstable elbow. J Bone Joint Surg Am 2000;82:724-38.  Back to cited text no. 1
Hotchkiss RN Fractures and dislocations of the elbow. In: Court-Brown C, Heckman Bucholz RW, editors. Rock¬wood and Green’s Fractures in Adults. Philadelphia, PA: Lippincott-Raven; 1996.  Back to cited text no. 2
Pugh DM, McKee MD The “terrible triad” of the elbow. Tech Hand Up Extrem Surg 2002;6:21-9.  Back to cited text no. 3
Morrey BF, An KN Stability of the elbow: osseous constraints. J Shoulder Elbow Surg 2005;14:174-8S.  Back to cited text no. 4
Broberg M, Morrey B Results of treatment of fracture- dislocations of the elbow. Clin Orthop 1987;216:109-19.  Back to cited text no. 5
Josefsson PO, Gentz CF, Johnell O, Wendeberg B Dislocaions of the elbow and intraarticular fractures. Clin Orthop 1989;246:126-30.  Back to cited text no. 6
Ring D, Quintero J, Jupiter JB Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 2002;84:1811-5.  Back to cited text no. 7
Sanchez-Sotelo J, Morrey BF, O’Driscoll SW Ligamentous repair and reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg Br 2005;87:54-61.  Back to cited text no. 8
Cobb TK, Morrey BF Use of distraction arthroplasty in unstable fracture dislocations of the elbow. Clin Orthop 1995;312:201-10.  Back to cited text no. 9
McKee MD, Bowden SH, King GJ, Patterson SD, Jupiter JB, Bamberger HB, et al. Management of recurrent, complex instability of the elbow with a hinged external fixator. J Bone Joint Surg Br 1998;80:1031-6.  Back to cited text no. 10


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