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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.
  • Most common pattern of cornoid fracture is a transverse fracture of 2 mm to 3 mm of the tip.
  • Mechanism of injury: typically valgus and supination.

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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