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Is Repair of a Small Coronoid Fracture Required in the Surgical Treatment of Terrible Triad Injury of the Elbow?

Hand and Microsurgery Centre, Department of Orthopaedic Surgery, Seikeikai Hospital, Japan

E-mail Address: yasunorikaneshiro@gmail.com

Correspondence to: Yasunori Kaneshiro, Hand and Microsurgery Centre, Department of Orthopaedic Surgery, Seikeikai Hospital, Minamiyasui-cho, Sakai, Osaka, Japan. Tel: +81-72-223-8199, Fax: +81-72-223-3691.

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Koichi YANO

Department of Orthopaedic Surgery, Baba Memorial Hospital, Japan

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Takuya YOKOI

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Hideki SAKANAKA

Hand and Microsurgery Centre, Department of Orthopaedic Surgery, Seikeikai Hospital, Japan

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Makoto FUKUDA

Department of Orthopaedic Surgery, Baba Memorial Hospital, Japan

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, and

Noriaki HIDAKA

Department of Orthopaedic Surgery, Osaka City General Hospital, Japan

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https://doi.org/10.1142/S2424835522500412Cited by:9 (Source: Crossref)

Abstract

Background: Multiple treatment protocols have been described in literature for the treatment of terrible triad injury (TTI) of the elbow. We believe that repair of the medial collateral ligament (MCL) should be performed in preference to repair of a small coronoid fracture if the elbow is unstable after fixation/replacement of the radial head and repair of the lateral collateral ligament (LCL). The aim of this study is to report the outcomes of surgical treatment of patients with TTI associated with a small coronoid fracture in whom the coronoid fracture was not addressed.

Methods: This study is a retrospective case series of 12 consecutive patients who underwent surgery for acute TTI with a small coronoid fracture (9 Regan–Morrey type I and 3 Regan–Morrey type II). Ten patients had complete MCL injuries. All patients underwent repair of the torn LCL and MCL and treatment of the radial head. The coronoid fracture was not surgically treated. At the final follow-up, the range of motion, degree of flexion contracture, Mayo elbow performance score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) were measured.

Results: The mean follow-up period was 13.5 months. At the final follow-up, the mean arc of elbow flexion was 132° and the mean flexion contracture was 10°. The mean arc of forearm rotation was 148°. None of the patients demonstrated elbow instability. The mean MEPS was 92.5 points with seven having excellent results and five having good results. The average DASH score was 11.2 points.

Conclusions: Our results showed that good elbow stability, arc of motion and clinical outcomes could be achieved without repair of small coronoid fractures in the treatment of TTI. The repair of MCL injuries should be given priority over the fixation of small coronoid fractures to regain elbow stability.

Level of Evidence: Level IV (Therapeutic)

Keywords:

REFERENCES

1. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am. April, 2002;84(4):547–551. https://doi.org/10.2106/00004623-200204000-00006. Crossref, Google Scholar
2. Schneeberger AG, Sadowski MM, Jacob HA. Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow. J Bone Joint Surg Am. May, 2004;86(5):975–982. https://doi.org/10.2106/00004623-200405000-00013. Crossref, Google Scholar
3. Domos P, Griffiths E, White A. Outcomes following surgical management of complex terrible triad injuries of the elbow: A single surgeon case series. Shoulder Elbow. July, 2018;10(3):216–222. https://doi.org/10.1177/1758573217713694. Crossref, Google Scholar
4. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. June, 2004;86(6):1122–1130. https://doi.org/10.2106/00004623-200406000-00002. Crossref, Google Scholar
5. Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg Am. October, 2007;32(8):1200–1209. https://doi.org/10.1016/j.jhsa.2007.06.019. Crossref, Google Scholar
6. Lindenhovius AL, Jupiter JB, Ring D. Comparison of acute versus subacute treatment of terrible triad injuries of the elbow. J Hand Surg Am. July-August, 2008;33(6):920–926. https://doi.org/10.1016/j.jhsa.2008.02.007. Crossref, Google Scholar
7. Garrigues GE, Wray WH, 3rd Lindenhovius AL, Ring DC, Ruch DS. Fixation of the coronoid process in elbow fracture-dislocations. J Bone Joint Surg Am. October 19, 2011;93(20):1873–1881. https://doi.org/10.2106/JBJS.I.01673. Crossref, Google Scholar
8. Zeiders GJ, Patel MK. Management of unstable elbows following complex fracture-dislocations—The “terrible triad” injury. J Bone Joint Surg Am. 2008;90(Suppl 4):75–84. https://doi.org/10.2106/JBJS.H.00893. Crossref, Google Scholar
9. Alvarez Munoz M, Pardo Garcia JM, Garcia Lamas L, Porras Moreno M, Jimenez Diaz V, Cecilia Lopez D. Protocolised surgical treatment of terrible triad of elbow. Results and complications. Tratamiento quirurgico protocolizado de las triadas terribles de codo. Resultados y complicaciones. Rev Esp Cir Ortop Traumatol (Engl Ed). July-August, 2019;63(4):281–288. https://doi.org/10.1016/j.recot.2019.02.003. Crossref, Google Scholar
10. Zhang J, Tan M, Kwek EBK. Outcomes of coronoid-first repair in terrible triad injuries of the elbow. Arch Orthop Trauma Surg. September, 2017;137(9):1239–1245. https://doi.org/10.1007/s00402-017-2733-8. Crossref, Google Scholar
11. Beingessner DM, Stacpoole RA, Dunning CE, Johnson JA, King GJ. The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair. J Shoulder Elbow Surg. March-April, 2007;16(2):213–217. https://doi.org/10.1016/j.jse.2006.06.015. Crossref, Google Scholar
12. Hartzler RU, Llusa-Perez M, Steinmann SP, Morrey BF, Sanchez-Sotelo J. Transverse coronoid fracture: when does it have to be fixed? Clin Orthop Relat Res. July, 2014;472(7):2068–2074. https://doi.org/10.1007/s11999-014-3477-1. Crossref, Google Scholar
13. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am. October, 1989;71(9):1348–1354. Crossref, Medline, Google Scholar
14. Mason ML. Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. September, 1954;42(172):123–132. https://doi.org/10.1002/bjs.18004217203. Crossref, Medline, Google Scholar
15. Rodriguez-Martin J, Pretell-Mazzini J, Andres-Esteban EM, Larrainzar-Garijo R. Outcomes after terrible triads of the elbow treated with the current surgical protocols. A review. Int Orthop. June, 2011;35(6):851–860. https://doi.org/10.1007/s00264-010-1024-6. Crossref, Google Scholar
16. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. Terrible triad injuries of the elbow: does the coronoid always need to be fixed? Clin Orthop Relat Res. July, 2014;472(7):2084–2091. https://doi.org/10.1007/s11999-014-3471-7. Crossref, Google Scholar
17. Jeong WK, Oh JK, Hwang JH, Hwang SM, Lee WS. Results of terrible triads in the elbow: the advantage of primary restoration of medial structure. J Orthop Sci. September, 2010;15(5):612–619. https://doi.org/10.1007/s00776-010-1515-8. Crossref, Google Scholar
18. Yang WH, Tian XS, Li BT, Shang J. [Progress on the treatment of terrible triad injury of elbow joint]. Zhongguo Gu Shang. June, 2018;25(6):582–586. https://doi.org/10.3969/j.issn.1003-0034.2018.06.019. Crossref, Google Scholar
19. Hatta T, Nobuta S, Aizawa T et al.. Comparative analysis of surgical options for medial collateral ligament repair in terrible triad injury of the elbow. Orthop Rev (Pavia). September 19, 2016;8(3):6666. https://doi.org/10.4081/or.2016.6666. Crossref, Google Scholar