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Can We Treat Select Terrible Triad Injuries Nonoperatively?

  • Symposium: Traumatic Elbow Instability and its Sequelae
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

While the majority of terrible triad elbow injuries (ulnohumeral dislocation with radial head and coronoid fractures) are managed surgically, nonoperative treatment may be appropriate in selected patients, but results with this approach have been limited by very small studies.

Questions/purposes

We assessed (1) functional outcomes using two validated questionnaires, (2) elbow ROM, strength, and stability, (3) the presence of union and arthritis on radiographs, and (4) complications among a group of patients managed nonoperatively for terrible triad injuries.

Methods

Between 2006 and 2012, we retrospectively identified 12 patients with terrible triad elbow injuries who were treated nonoperatively and met the following criteria: (1) a concentric joint reduction, (2) a radial head fracture that did not cause a mechanical block to rotation, (3) a smaller coronoid fracture (Regan-Morrey Type 1 or 2), and (4) a stable arc of motion to a minimum of 30° of extension to allow active motion within the first 10 days. Eleven patients were available for followup of at least 12 months after the injury (mean, 36 months; range, 12–90 months). Outcome measures included two patient-reported functional outcome measures (DASH, Mayo Elbow Performance Index [MEPI]), a standardized physical examination to record elbow ROM and stability, isometric strength measurements, and radiographic evidence of bony union and elbow arthrosis. Complications were also recorded.

Results

At latest followup, mean ± SD DASH score was 8.0 ± 11.0 and mean MEPI score was 94 ± 9. Mean ROM of the affected elbow was 134° ± 5° flexion, 6° ± 8° extension, 87° ± 4° pronation, and 82° ± 10° supination. No instability was detected. Strength assessments demonstrated the following mean percentages of the contralateral, unaffected elbow: flexion 100%, extension 89%, pronation 79%, and supination 89%. Four patients had arthritic changes on radiographs that did not call for treatment as of latest followup. Complications included one patient who underwent surgical stabilization for early recurrent instability and another who underwent arthroscopic débridement for heterotopic bone.

Conclusions

In selected patients, nonoperative treatment of terrible triad injuries is an option that can provide good function and restore stable elbow ROM. However, nonoperative management requires close clinical and radiographic followup to monitor for any delayed elbow subluxation or fracture displacement.

Level of Evidence

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

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Acknowledgments

The authors thank Ms. Kate Kelly MSc, MPH for her training in the use of equipment required for measurement of outcomes in this study.

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Authors and Affiliations

  1. Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada

    Kevin Chan MD, MSc

  2. Faculty of Health Sciences, Institute for Applied Health Sciences, McMaster University, Hamilton, ON, Canada

    Joy C. MacDermid BScPT, MSc, PhD

  3. Hand and Upper Limb Centre, University of Western Ontario, 268 Grosvenor Street, London, ON, N6A 4L6, Canada

    Joy C. MacDermid BScPT, MSc, PhD, Kenneth J. Faber MD, MHPE, FRCSC, Graham J. W. King MD, MSc, FRCSC & George S. Athwal MD

Authors
  1. Kevin Chan MD, MSc
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  2. Joy C. MacDermid BScPT, MSc, PhD
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  3. Kenneth J. Faber MD, MHPE, FRCSC
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  4. Graham J. W. King MD, MSc, FRCSC
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  5. George S. Athwal MD
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Corresponding author

Correspondence to George S. Athwal MD.

Additional information

Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at University of Western Ontario, London, Ontario, Canada.

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Chan, K., MacDermid, J.C., Faber, K.J. et al. Can We Treat Select Terrible Triad Injuries Nonoperatively?. Clin Orthop Relat Res 472, 2092–2099 (2014). https://doi.org/10.1007/s11999-014-3518-9

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  • DOI: https://doi.org/10.1007/s11999-014-3518-9

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