Terrible Triad
synonyms:
Terrible Triad ICD-9
- 832.0_ = closed elbow dislocation; 832.1_ = open elbow dislocation
- 832._0 (dislocation of elbow unspecified)
- 832._1 (anterior dislocation of elbow)
- 832._2 (posterior dislocation of elbow)
- 832._3 (medial dislocation of elbow)
- 832._4 (lateral dislocation of elbow)
- 832._9 (dislocation of elbow other)
- 813.02(closed fracture of coronoid process of ulna)
- 813.12(open fracture of coronoid process of ulna)
- 813.05(closed fracture of head of radius)
- 813.15(open fracture of head of radius)
- 813.06(closed fracture of neck of radius)
- 813.16(open fracture of neck of radius)
Terrible Triad Etiology / Epidemiology / Natural History
- Definition: radial head fracture, coronoid fracture, with elbow dislocation.
Terrible Triad Anatomy
- May have associated extensor or flexor origin avulsions and osteochondral injuries to the capitellum or trochlea.
Terrible Triad Clinical Evaluation
- Generally present with obvious deformity, pain and swelling.
- Document NV exam before and after reduction.
- Lateral pivot shift test=for posterolateral rotatory instability- pt supine, arm overhead. Supination-valgus moment applied during flexion, elbow subluxates usually at @40degrees, additional flexion causes reduction/clunk. Should create apprehension.
- Valgus and varus stress, both in extension and 30 degrees flexion.
- Valgus stress testing performed in full pronation to eliminated posterolateral rotatory instability.
- Document wrist evaluation.
Terrible Triad Xray / Diagnositc Tests
- A/P, lateral and oblique elbow films indicated. Coronoid fractures are often obscurbed by associated radial head fracture.
- Bilateral PA views of both wrists in neutral rotation should be obtained to evaluate ulnar variance in patients with wrist pain.
- CT is best for determining fracture location and comminution.
Terrible Triad Classification / Treatment
Terrible Triad Associated Injuries / Differential Diagnosis
Terrible Triad Complications
- Instability
- Stiffness, most will experience some loss of extention.
- Arthritis
- Infection
- Synostosis
- Painful hardware
- Heterotopic ossification
Terrible Triad Follow-up Care
- Results: 42% excellent results, 36% good, 19% fair, and 3% poor. Mean Mayo Elbow Performance Score was 88 points (range, 45 to 100 points). Flexion-extension arc of the elbow averaged 112° ± 11° and forearm rotation averaged 136° ± 16°. (Pugh DM, JBJS 2004;86A:1122).
- See also Elbow Outcome Measures.
Terrible Triad Review References
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