This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals. Pai V, Pai V. Use of suture anchors for coronoid fractures in the terrible triad of the elbow. 1 and 2). ", "These journals provide researchers with a platform for rapid, open access scientific communication. Hyperextension can also cause anterior dislocation, as the ulna is levered past the anterior humeral edge and the olecranon fragment pulled posteriorly by triceps as the humerus is driven through the olecranon. Subsequently the structures acting as primary (ulnohumeral joint, MCL, LCL) and secondary (radiohumeral joint, capsule, muscles and tendons crossing the joint) stabilisers have been better understood. Where there is no other fracture and the dislocation is reduced, the treatment should focus less on the function as a stabiliser and more on the function of the radial head in forearm supination and pronation and the prevention of arthrosis [16, 17]. Operative treatment is often complex and should follow a thorough preoperative clinical and radiological assessment. A direct blow to the posterior aspect of the flexed elbow can cause an anterior dislocation with olecranon fracture, as can a hyperextension injury. Fixation of the coronoid process in elbow fracture-dislocations. Even in severely comminuted injuries, the primary aim of surgery should remain to restore the trochlear notch of the olecranon, as good outcomes can still be achieved [57, 59]. Heckman (Eds.) Acta Orthop Traumatol Turc 2012; 46(2): 96-101. ", "In principle, all scientific journals should have open access, as should be science itself. The Open Orthopaedics Journal is seeking energetic and qualified researchers to join its editorial board team as Editorial Board Members or reviewers. Terrible triad of the elbow and the Essex-Lopresti injury are both rare lesions with a historically poor clinical outcome. HHS Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2012; 26(12): 1462-5. An elbow disloc … The combination of elbow dislocation with both radial head and coronoid process fracture is notoriously challenging to treat and, as such, has been termed ‘‘terrible triad’’ injury of the elbow (TTIE) [1]. O’Driscoll SW, Morrey BF, Korinek S, An KN. The stabilizers of the elbow are disrupted from lateral to medial as the forearm supinates and is loaded [23]. A Case of Terrible Triad Injury to the Elbow. Approximately 60% of complex dislocations are caused by a fall from standing height, but the fracture pattern is not always one of inherent fragility, and considerable force is required to sustain a complex dislocation in normal bone. Chemama B, Bonnevialle N, Peter O, Mansat P, Bonnevialle P. Terrible triad injury of the elbow: How to improve outcomes? 25% in one patient series [27] and 18% in another patient series [28] needed delayed operative intervention after nonsurgical treatment of a terrible triad injury. Biomechanics of elbow instability: The role of the medial collateral ligament. CT scanning as an adjunct to diagnosis is invaluable as the true nature of radial head and coronoid fractures may not be apparent on plain radiographs. Olecranon fractures: Treatment options. 4. Historically, the combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture has had a consistently poor outcome; for this reason, it is called the terrible triad. Curr Opin Orthop 2006; 17: 355-63. Hu X, Xiang M, Chen H, Yang S, Tang H, Yang G. Operative treatment of anterior olecranon fracture-dislocation. Submit or solicit at least one article for the journal annually. Introduction. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2013; 27(2): 151-4. Pérez-Ubeda MJ. How should anteromedial coronoid facet fracture be managed? Treatment of olecranon fracture dislocations is well established. He has published over 230 papers, chapters and reviews primarily in the field of chondrocyte biology. AIM OF SURGERY: Reconstruction of the most important ligamentous and osseus structures of the elbow after terrible triad injury via the radial head to the lateral collateral ligament complex (LCL) and if necessary beginning at the coronoid process. Objective Terrible triad injury of the elbow (TTIE), comprising elbow dislocation with radial head and coronoid process fracture, is notoriously challenging to treat and has typically been associated with complications and poor outcomes. Loading in flexion over 30 degrees is more likely to instead produce an olecranon fracture. Traumatic forearm and elbow injuries make up approximately 15% of emergency department visits for upper-extremity musculoskeletal injuries annually (1). Duckworth AD, McQueen MM, Ring D. Fractures of the radial head. Non surgically managed anteromedial coronoid fractures in posteromedial rotatory instability: three cases with 2 years follow-up. The higher the amount of flexion within this arc, the larger the coronoid fragment is likely to be. Traditionally the LCL, MCL, coronoid and radial head were reconstructed, but there is recent evidence to support repairing of the coronoid and MCL only if the elbow is unstable after reconstruction of lateral structures. Anterior elbow dislocation associated with olecranon fractures-review of the literature and case report. This study consisted on a retrospective review of patients who had sustained a terrible triad of the elbow and report the results, including validated functional outcome measures at a long-term follow-up. Dr reports a "Terrible Triad Injury" which is, per the Op Note, Radial head fx, coroniodprocess avulsion fx and collateral ligament disruption. A posteriorly directed force results from a fall on an extended elbow, which levers the ulna out of the trochlea. Operative treatment is necessary for larger fragments and where there is instability with smaller fragments treated non-operatively. [ Links ] Case Rep Orthop 2014. Instr Course Lect. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. 2015 Feb;38(2):e143-6. Leigh WB, Ball CM. Peer-review of articles for the journal, which are in the area of expertise (2 to 3 times per year). These cases are uncommon, but remind us that elbow fracture dislocations and terrible triad injuries are often high-energy, and patients often have concomitant fractures or soft tissue injuries in the ipsilateral limb that may delay recovery if missed. Cases J 2008; 1(1): 168. A terrible triad combines three injuries: dislocation of the elbow, fracture of the radial head, and fracture of the coronoid. Abstract Fracture-dislocations of the elbow remain among the most difficult injuries to manage. Surgical technique. ", "Open access journals are probably one of the most important contributions to promote and diffuse science worldwide. ", "Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content. Br J Surg 1954; 42(172): 123-32. J Bone Joint Surg Am 2002; 84-A(4): 547-51. Subtype I fractures were almost as stable as a normal elbow in varus/ valgus stress and flexion/ extension when the LCL was repaired. Recent studies [31, 33] have shown that reconstruction of the MCL is unnecessary in patients with a stable joint after repair of other structures, and that coronoid fractures do not need to be fixed if there is stability in the range of motion after repair of lateral structures. Fracture-dislocation of the elbow. Rehabilitation considerations in the management of terrible triad injury to the elbow. Contribute and/or solicit Guest Edited thematic issues to the journal in a hot area (at least one thematic issue every two years). A fall from a ladder sends a 65-year-old male patient to the emergency department with left elbow pain. Chung CH, Wang SJ, Chang YC, Wu SS. Terrible triad injuries necessitate operative treatment in almost all cases. Surgical treatment of terrible triad injuries carries a high complication rate with an average of 22% reoperation rate [39]. ", "It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. A spectrum of instability. Hak DJ, Golladay GJ. In this perspective, open access journals are instrumental in fostering researches and achievements. The elbow fracture dislocations tend to occur in distinct patterns dependant on the mechanism of injury. The Open Orthopaedics Journal is an Open Access online journal, which publishes research articles, reviews, letters, case reports and guest-edited single topic issues in all areas of experimental and clinical research and surgery in orthopaedics. There is also consensus opinion that dislocations with radial head fracture should be treated with radial head replacement in Mason III injuries or Mason II fractures where the joint cannot be reconstructed [20-22]. Yang Y, Wang F. Hinged external fixator with mini-plate to treat terrible triad of elbow. Rockwood, Jr. D.P.  |  Clin Orthop Relat Res 2004; (429): 292-300. Epub 2013 Jul 23. Treatment can be non-operative or operative and this will depend on the complexity of the injury as well as the comorbidities of the patient. Arch Orthop Trauma Surg 2013; 133(12): 1665-8. Complex elbow dislocations are injuries with significant risk of long-term disability. Bucholz, J.D. Papatheodorou LK, Rubright JH, Heim KA, Weiser RW, Sotereanos DG. 2009;17(3):137-51. Radial head fractures are classified according to the Mason system [19] (Table 1). Konya MN, Aslan A, Sofu H, Yıldırım T. Biepicondylar fracture dislocation of the elbow joint concomitant with ulnar nerve injury. Clin Orthop Relat Res 1980; (146): 42-52. In some accidents, the elbow dislocates (the radius and ulna are pulled apart from the humerus) without any bones breaking; surgeons call this injury a “simple dislocation” . Orthop Traumatol Surg Res 2010; 96(2): 147-54. Cadaveric studies have reinforced the need to obtain post-reduction CT scans as the size of the coronoid fragment influences the long-term stability of the elbow. Dynamic stability encompasses the congruity of the articulation when the muscles crossing the elbow joint contract to enable movement [7]. Open access journals offer a good alternative for free access to good quality scientific information. Anterior dislocation with olecranon fracture has the same treatment aims as other complex dislocations with the added need to restore the extensor mechanism. 1979;61(1):63-68. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community. Lindenhovius AL, Brouwer KM, Doornberg JN, Ring DC, Kloen P. Long-term outcome of operatively treated fracture-dislocations of the olecranon. Elbow extension with forearm supination and added valgus stress puts most strain on the ulnohumeral joint, radial head and MCL respectively, causing a posterolateral rotational instability pattern of fracture-dislocation which includes posterior dislocation with a radial head fracture and the terrible triad injury with an added coronoid fracture. Fracture of the anteromedial facet of the coronoid process. Whichever algorithm is followed the aim of surgery is the same: to achieve an outcome where the joint is stable and has a pain free functional range of motion. J Bone Joint Surg Am 1987; 69(4): 605-8. Bone Joint J 2013; 95-B(2): 151-9. Strategic approach to O’Driscoll type 2 anteromedial coronoid facet fracture. -, Instr Course Lect. The injury is usually associated with typical soft-tissue disruptions (with common involvement of the lateral collateral ligament complex, elbow joint capsule, as well as the common extensor and flexor-pronator tendons) that are best understood in the context of injury mechanism as well as the role and relevance of the various elbow stabilizers. ", Department of Medicine, Case Western Reserve University, Cleveland, USA, The Guest Edited Thematic Issues are published free of charge, Average publication time of 18 days between final acceptance of revised manuscript and its publication, (Indiana University School of Nursing, USA), (Centre Antipoison-Centre de Pharmacovigilance, France), (St. Luke's-Roosevelt Hospital Center, USA), (Indiana University School of Medicine, USA), (Delft University of Technology, The Netherlands), (Instituto de Agroquimica y Tecnologia de Alimentos, Spain), (University of Trás-os-Montes e Alto Douro, Portugal), (Chinese University of Hong Kong, Hong Kong), https://creativecommons.org/licenses/by/4.0/legalcode, VARUS POSTEROMEDIAL ROTATIONAL INSTABILITY FRACTURE- DISLOCATIONS, ANTERIOR DISLOCATION WITH OLECRANON FRACTURE, Multifragmentory/ Displaced Total Articular, Fracture of less than 50% of height of coronoid, Fracture of more than 50% of height of coronoid, Fracture of the Anteromedial rim and sublime tubercle. When used it should be followed by early mobilisation which is most effective at 30-120 degrees of active extension [54]. J Hand Surg Am 2008; 33(6): 920-6. The pathoanatomy and mechanism of complex dislocations and terrible triad injuries is well understood due to investigations with cadaveric studies [11, 46]. Pipicelli JG, Chinchalkar SJ, Grewal R, Athwal GS. A prospective randomized study. Regan W, Morrey BF. The terrible triad of the elbow is a severe elbow fracture-dislocation pattern and is so-called because it has poor medium-to-long term outcome.. We believe that a dedicated and committed team of editors and reviewers make it possible to ensure the quality of the research papers. Some of the most common injury classification systems cited in … Of these, the MCL is the primary stabilizer in flexion, and its removal will cause instability in all positions except extension [6]. Articles are of uniformly high quality and written by the world's leading authorities. doi: 10.3928/01477447-20150204-91. Fracture dislocations are associated with ligamentous tears and therefore, the function of the radial head as a secondary stabiliser of the elbow joint is important in these types of injuries. (3). The “terrible triad” pattern is so named because the three combined injuries of elbow dislocation, radial head fracture and coronoid fracture significantly increase elbow instability and rate of complications [3-6]. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. Classification and treatment of coronoid process fractures. Operative treatment is usually with tension band wiring or plate fixation followed by early mobilisation. The articles are of high quality and broad scope. World J Orthop 2013; 4(2): 94-7. -, J Shoulder Elbow Surg. Treatment in all these case reports is based on the aim of reconstruction of joint congruency and stabilising structures. J Am Acad Orthop Surg 2000; 8(4): 266-75. J Am Acad Orthop Surg. Hildebrand KA, Patterson SD, King GJ. 1–6 Difficulty in treating patients with this injury is compounded by the lack of information available regarding techniques, results, and complications.  |  These complex trans-olecranon fracture dislocations are relatively uncommon [50]. The Open Orthopaedics Journal is committed to ensuring high quality of research published. This is reflected in two recent reviews of patient data, showing male patients in their fourth or fifth decade [12, 13]. Frequent complications include arthrosis in up to 70% and ulnar nerve dysfunction in up to 25% of patients [60]. If reconstruction of the olecranon is not possible because of severe comminution, osteoporotic bone, concomitant injuries or patient factors then delayed fragment excision and triceps advancement may be used to salvage the extensor mechanism [59]. Type I and II fractures associated with dislocation have good results when treated with closed reduction or ORIF [18], but fractures with more than 3 fragments do poorly when compared with radial head replacement [20, 21]. 2013 Sep;38(9):1774-8. doi: 10.1016/j.jhsa.2013.05.030. The primary static stabilisers of the elbow are the ulnohumeral articulation, the MCL and the LCL [5]. Rhyou IH, Kim KC, Lee JH, Kim SY. With the elbow in more flexion, this pattern can also cause an olecranon fracture. Reconstruction of the coronoid process with iliac crest bone graft in complex fracture-dislocation of elbow. There is consensus opinion in the literature that elbow complex dislocations should be managed by immediate primary closed reduction followed by a thorough clinical examination and CT scan of the elbow. After closed reduction of the dislocation the treatment is the same as for a simple olecranon fracture; restoration of the articular surface with internal fixation and early mobilisation [56, 57, 60]. J Hand Surg Am 2006; 31(1): 45-52. AMCF repair is usually with buttress plating and screw fixation. Transolecranon fracture-dislocation of the elbow. Terrible triad injury of the elbow: current concepts. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The goal of treatment for these injuries is to restore the bony and Acta Orthop Traumatol Turc 2014; 48(1): 102-5. Some observations on fractures of the head of the radius with a review of one hundred cases. The creation of the trauma network in the UK has concentrated subspecialists geographically and this will lead to more opportunities for collaborative research in these relatively uncommon but severe injuries. There is no unifying classification system for complex dislocations or terrible triad injury. The authors declare no conflict of interest, financial or otherwise. Guitton TG, Ring D. Nonsurgically treated terrible triad injuries of the elbow: Report of four cases. There have also been reported terrible triad fractures with triceps avulsion [65]. J Bone Joint Surg Am 2009; 91(6): 1448-58. A terrible triad injury refers to a posterior dislocation of the elbow associated with radial head and coronoid process fractures. Non-operative treatment has been shown to be successful in patients with small minimally displaced coronoid fractures [47]. This type of elbow injury is typically due to low or high energy falls onto an … Definition and Injury Mechanism of the Terrible Triad • The terrible triad of the elbow is defined as the combination of • fractures of the radial head and • ulnar coronoid process • dislocation of the elbow joint (Fig. Clin Orthop Relat Res 2014; 472(7): 2092-9. Epidemiology. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. There seems to be a trend in the literature towards repairing lateral structures only, applying stress to the joint then only repairing medial structures if there is instability [31-34]. Axial loading across the joint in these positions puts most stress on the anterior part of the ulnohumeral joint causing coronoid fracture and dislocation. Clipboard, Search History, and several other advanced features are temporarily unavailable. Treatment aims to restore the articular surface and extension mechanism of the elbow. Complex elbow dislocations are injuries with significant risk of long-term disability, which may be made worse with inappropriate treatment due to a missed diagnosis. Professor Malemud is on the editorial board of several rheumatology, immunology and musculoskeletal journals and is Editor-in-Chief of the Journal of Clinical and Cellular Immunology and Global Vaccines and Immunology. J Bone Joint Surg Br 2006; 88-B(SUPP I 192). Primary closed reduction should first be performed followed by CT scanning of the elbow to assess for other injuries that could lead to instability. JBJS Rev 2014; 2(1): e3. ", "There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Bryce CD, Armstrong AD. They are an outstanding source of medical and scientific information. Fracture-dislocation of the elbow functional outcome following treatment with a standardized protocol. Can we treat select terrible triad injuries nonoperatively? The origins of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) complexes avulse from the epicondyles and the anterior capsule fails with a transverse fracture of the coronoid tip. The “terrible triad” injury is classically described as a combination of a coronoid process and radial head fractures, as well as a posterolateral elbow dislocation. J Orthop Sci 2010; 15(5): 612-9. The results of elbow dislocations with associated radial head and coronoid fractures (the so-called “terrible triad” of the elbow) are often poor as a result of arthrosis, recurrent instability, and/or stiffness from prolonged immobilization. Terrible triad injuries were initially treated with operative repair of all the damaged structures; LCL, Radial head, coronoid and MCL. ", "Open access journals make up a new and rather revolutionary way to scientific publication. Moon JG, Bither N, Jeon YJ, Oh SM. There is no specific classification for the terrible triad injury, but instead the radial head fractures and coronoid fractures are classified separately. J Am Acad Orthop Surg. The terrible triad injury is often caused by a fall on an outstretched hand. The terrible triad of the elbow is a difficult injury with historically poor outcomes. These had a concentric reduction with stability beyond 30 degrees of extension after closed reduction. Effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch. The aim of surgery is to stabilise the joint by repairing either the LCL, coronoid fragment or both structures. For this reason, it has been called the “terrible triad injury” of the elbow [3] Terrible triad injuries can lead to pain, recurrent instability, sti ness, and posttraumatic arthritis if not properly treated [6]. J Shoulder Elbow Surg 2005; 14(5): 519-23. J Bone Joint Surg Am. 2001;50:89-102 Elbow subluxation and dislocation. 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