Terrible triad

Patients with terrible triad usually present with pain, snapping and locking, particularly with the elbow in extension. These symptoms can be severe and debilitating, significantly affecting the patient’s ability to use their arm and perform everyday tasks. During the physical examination, it is important to assess for varus and valgus instability, which may indicate disruption of the elbow’s lateral or medial stabilizing structures. In addition, the distal radioulnar joint (DRUJ) must be carefully evaluated to exclude an Essex-Lopresti lesion, a rare but potentially serious complication of terrible triad.

Imaging plays a crucial role. X-rays are generally the initial imaging modality used. When reading them, it is important to assess the concentricity of the humero-ulnar and humero-radial joints. This helps determine the degree of elbow dislocation and joint congruence. In addition, a lateral radiograph can be particularly useful in identifying a fracture of the coronoid process. Pre- and post-reduction radiographs are necessary to assess the quality of reduction and to evaluate joint alignment after surgery. In some cases, a CT scan may be required to obtain more detailed information, in particular to assess coronoid process fractures and facilitate surgical planning. Depending on the specific clinical scenario, it may be necessary to obtain additional imaging of the wrist and forearm to help identify associated injuries or potential complications, particularly involving the DRUJ or forearm bones.

Treatment usually involves surgical intervention, although in rare cases conservative management may be considered. This approach is only suitable if certain conditions are met: firstly, the humero-ulnar and humero-radial joints must be concentrically reduced, the radial head fracture must not meet the indications for surgical intervention, and the fracture of the coronoid process must be small. In addition, the elbow joint must be sufficiently stable to allow early range of motion. Conservative treatment consists of a period of immobilization of the elbow in 90 degrees of flexion for 7 to 10 days, followed by early range-of-motion exercises. Active movement is initiated with a resting splint at 90 degrees flexion with the forearm pronated, avoiding maximum extension. After 4-6 weeks, a static or articulated progressive extension splint is used overnight to gradually increase extension. Around 6 weeks, a muscle-strengthening protocol can be initiated to improve overall elbow stability. It’s important to note that non-operative management is rare, and surgical intervention is generally the preferred approach.

Surgical treatment generally includes open reduction and osteosynthesis of fractures, and ligament repair or reconstruction. The choice of technique depends on the specific components of the injury and the patient’s general condition. The aim is to restore joint stability, optimize functional results and prevent long-term complications.

Open reduction and osteosynthesis of the radial head fracture involves realigning the fractured fragments and using screws or plates to fix them in place. In cases where the radial head is largely comminuted or irreparable, radial head arthroplasty may be considered. This procedure involves removing the damaged radial head and replacing it with a prosthetic implant to restore joint stability and function.

Lateral collateral ligament reconstruction can be performed to restore lateral stability to the elbow. This procedure involves the use of grafts to reconstruct the torn ligament, providing support and stability to the joint.

Large fractures of the coronoid process often also require open reduction and osteosynthesis. It is important to note that small fractures involving less than 10% of the coronoid process do not confer stability to the elbow and may therefore not require repair.

If instability persists after treatment of the radial head fracture and lateral collateral ligament, the next step may involve reconstruction of the medial collateral ligament. This procedure aims to restore medial stability to the elbow and may also involve the use of a graft.

Complications can arise following a terrible triad. One of the main complications is instability, which is more frequent following small and medium-sized fractures of the coronoid process. Similarly, inadequate reduction or failure to manage ligament injuries can contribute to persistent instability. Failure of osteosynthesis is another complication that can occur, particularly after repair of radial neck fractures. This failure can be attributed to factors such as poor vascularization, which can lead to osteonecrosis and pseudarthrosis. In some cases, further surgery may be required to treat these complications and restore stability. Post-traumatic stiffness is a very common complication of the triad and can lead to limited range of motion. Early initiation of range-of-motion exercises and appropriate physiotherapy protocols are essential to prevent and manage this complication. Heterotopic ossification (abnormal bone formation in soft tissue) can also occur, but prophylactic measures such as medication can be considered. Post-traumatic arthritis is another potential long-term complication that can develop as a result of chondral lesions due to the initial injury, or following residual joint instability. Degenerative changes in the joint can cause pain, stiffness and reduced function over time. It’s important that patients are aware of these potential complications and maintain open communication. Close monitoring, appropriate rehabilitation and prompt intervention can help minimize the impact of these complications and improve long-term outcomes.

Historically, the prognosis has been poor: the complex nature of the injury can make it difficult to restore stability despite surgery. This instability can lead to persistent pain, functional limitation and compromised quality of life. Stiffness is another factor contributing to this prognosis. It can significantly impair range of motion and functional recovery. Finally, post-traumatic arthritis is a major long-term concern. Osteoarthritis causes pain, joint stiffness and functional impairment, further impacting overall prognosis. However, it is important to note that advances in surgical techniques, early mobilization protocols and comprehensive rehabilitation programs have shown improved outcomes. With appropriate management and close follow-up, some patients may achieve better functional recovery and mitigate long-term consequences.