Terrible Triad

synonyms:Terrible Triad

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 varusstress, 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, lateraland 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

• Surgical repair within 24 hours indicated. Treat Coronoid fracture first, then Radial head fracture, and finally ligamentous and tendinous repair. Surgical technique has been described by McKee et all (McKee MD, JBJS 2005;87Asupp:22).
• Delayed surgery difficult due to swelling.

Terrible Triad Associated Injuries / Differential Diagnosis

• Elbow dislocation
• Coronoid fracture
• Olecranon fracture / dislocation
• Posterolateral rotatory instability
• Radial head fracture
• DRUJ injury

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

• Ring D, JBJS 2002;84A:547
• HotchkissRN, JAAOS 1997;5:1
• Rockwood and Green's Fractures in Adults 6th ed, 2006
• OKU - Shoulder and Elbow 2nd ed, 2002