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No patients were lost to follow up at time of final data analysis. Postoperative regimen included the use of an arm sling for arm support in the early postoperative period (held in 70° flexion and slight pronation to protect LCL repair), that was converted to a hinged elbow brace 1 week after surgery and physical therapy was initiated to recover elbow range.Ī total of 67 patients were assessed for eligibility, 32 patients were excluded as they did not meet the inclusion criteria, five patients refused to participate in the study, so a final number of 30 patients were enrolled. Stability of the elbow was tested intra-operatively using the hanging arm test, which was performed before and after the LCL was addressed.Īll surgeries were performed by the same surgeon (AL), who is fellowship trained in hand surgery. Neck length was determined by ensuring that the implanted head was flush with the proximal edge of the lesser sigmoid notch when the joint is reduced as well as ensuring there was no gapping in the medial ulno-humeral joint.įinally, the LCL complex was repaired back to the isometric point at the lateral epicondyle, using either non-absorbable sutures passed through drill holes in the epicondyle if bone quality was good, or using suture anchors if bone quality was poor. With radial head replacement, aggregation of the excised head fragments was done to select the implant head size (with a preference to slight under-sizing). There was no radial head excision without replacement. If these criteria were not met, the radial head was replaced (using a modular prosthesis). A decision of radial head fixation (using headless screws and/or small proximal radial plate) was made when there were ≤ 3 articular fragments, with no traumatic delamination of the articular cartilage and no comminution of the radial neck. All coronoid fractures were fixed (using non-absorbable suture lasso, passed through drill holes and tied over the dorsum of the olecranon). Surgical repair and stabilization were carried out from deep to superficial. A typical finding was disruption of the lateral collateral ligament (LCL) complex from the lateral epicondyle. A lateral incision was used in all patients and deep structures were approached through the Kocher interval. The arm was placed over a hand table to allow easy access to the C-arm. Patients were put in the supine position with a tourniquet on the proximal arm. We adopted the operative technique described by Pugh.

The decision of operative management was taken by the senior investigator (SG). Our institution uses the widely accepted algorithmic approach to guide surgical intervention of terrible triad injury. Then the limb was supported in a posterior splint awaiting definitive surgery. Our null hypothesis was that functional results are the same for fixation vs replacement of radial head fractures in treating terrible triad injury of the elbow.Įlbow dislocation was reduced closed in the emergency department under conscious sedation or in the operating room under general anesthesia. The secondary outcomes were to report the Mayo Elbow Performance Score (MEPS), elbow flexion/extension arc and complications (e.g., infection, heterotrophic ossification). The primary outcome was to report the Quick Disability of Arm, Shoulder and Hand (Quick-DASH) at 1 year. The aim of this study was to compare the functional outcome of radial head fixation vs replacement in terrible triad injuries of the elbow. While some studies compared the results of radial head fixation to replacement in isolated radial head fractures, very few reports have tried to compare both treatment modalities in the setting of a terrible triad injury.

The adoption of algorithmic approach and standardized surgical protocols by recent studies in treating this difficult injury resulted in improved patient outcomes. However, the improved understanding of elbow constraints, as well as the improvements in fixation options lead to significant improvements in the treatment of this injury. High rates of complications (e.g., contractures, instability, and pain) has been reported by historical studies. In this uncommon injury, there is loss of the anterior buttress of the coronoid, the valgus buttress of the radial head, and the posterolateral stabilization of the lateral ulnar collateral ligament (LUCL) which results in elbow instability. The combination of posterior elbow dislocation, radial head fracture, and coronoid fracture has been named “terrible triad” as this injury is difficult to treat and yield poor outcomes.