Revision management of a 17-year-old patient initially treated with radial head excision following terrible triad injury with associated Essex Lopresti
Ontology highlight
ABSTRACT:
SUBMITTER: Heifner J
PROVIDER: S-EPMC10840582 | biostudies-literature | 2023 Oct
REPOSITORIES: biostudies-literature
Similar Datasets
Project description:BackgroundWe analyzed association between viewing two-dimensional computed tomography (2D CT) images in addition to radiographs with radial head treatment recommendations after accounting for patient and surgeon factors in a survey-based experiment.MethodsOne hundred and fifty-four surgeons reviewed 15 patient scenarios with terrible triad fracture dislocations of the elbow. Surgeons were randomized to view either radiographs only or radiographs and 2D CT images. The scenarios randomized patient age, hand dominance, and occupation. For each scenario, surgeons were asked if they would recommend fixation or arthroplasty of the radial head. Multi-level logistic regression analysis identified variables associated with radial head treatment recommendations.ResultsReviewing 2D CT images in addition to radiographs had no statistical association with treatment recommendations. A higher likelihood of recommending prosthetic arthroplasty was associated with older patient age, patient occupation not requiring manual labor, surgeon practice location in the United States, practicing for five years or less, and the subspecialties "trauma" and "shoulder and elbow."ConclusionsThe results of this study suggest that in terrible triad injuries, the imaging appearance of radial head fractures has no measurable influence on treatment recommendations. Personal surgeon factors and patient demographic characteristics may have a larger role in surgical decision making. Level of evidence: Level III, therapeutic case-control study.
| S-EPMC10277712 | biostudies-literature
Project description:BackgroundThe terrible triad injury (TTI) of the elbow is a combination of a posterolateral dislocation of the elbow joint combined with fractures of the radial head and coronoid process most often caused by a fall on an outstretched hand. The injury pattern was named for its poor outcomes and high complication rates following surgical repair, but increased understanding of elbow anatomy and biomechanics has led to the development of standardized surgical protocols in an attempt to improve outcomes. Most existing literature on terrible triad injuries is from small retrospective cohort studies and surgical techniques to improve outcomes. Therefore, the purpose of this scoping review is to provide an overview of the functional outcomes, prognosis, and complications following current surgical treatment of TTIs.MethodsA scoping review was performed to evaluate the literature. In total, 617 studies were identified and screened by 2 reviewers, with 43 studies included for qualitative analysis. These 43 studies underwent data extraction for functional outcomes using the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder, and Hand score (DASH) and were stratified accordingly. Secondary outcome measures assessed in the study were a range of motion (ROM) and complication rate.ResultsThe average MEPS was 90 (excellent) from a total of 37 studies with 1609 patients, and the average DASH score was 16 from 16 studies with 441 patients. Another 6 studies with a total of 127 patients reported a mean Q-DASH score of 13. A total of 39 studies consisting of 1637 patients had a mean forearm rotation of 135 degrees, and 36 studies consisting of 1606 patients had a mean flexion-extension arc of 113 degrees. Among the studies, there was a 30% complication rate with a need for revision surgery in 7.8% of cases. The most common complications were radiographic evidence of heterotopic ossification (11%) and ulnar nerve neuropathy (2.6%).Discussion/conclusionsThis study shows that current surgical treatment for terrible triad injuries has resulted in improved outcomes. Based on primary outcome measures using MEPS and DASH scores, almost all of the studies have highlighted good or excellent functional outcomes. This highlighted the marked improvement in outcome scores since the term was coined, suggesting that terrible triad injuries may no longer be so terrible.
| S-EPMC10426592 | biostudies-literature
Project description:BackgroundRadial head excision has historically been a common surgical procedure for the operative management of radial head fractures and post-traumatic conditions. With recent advances in other surgical techniques, controversy exists regarding its indications. This review evaluates the indications and outcomes of radial head excision in traumatic and non-traumatic elbow pathology.MethodsMultiple databases were searched for studies involving radial head excision. Screening and data abstraction were conducted in duplicate. Only studies reporting outcomes for radial head excision were included.ResultsTwenty-seven studies with 774 radial head excision patients were included. The most common indications involved acute excision of comminuted radial head fractures (n = 347) and rheumatoid arthritis (n = 201). Post-operative functional scores after acute excision were reported to be good to excellent. In the chronic setting of rheumatoid disease, radial head excision resulted in improved range of motion, although pain was not effectively relieved.DiscussionOutcomes of radial head excision for acute fracture are good to excellent; however, it should not be performed when concurrent or ligamentous injuries are present. Although some studies compared excision to open reduction and internal fixation or replacement, more data are needed to make proper conclusions. The strength of these conclusions is limited by the quality of included literature.
| S-EPMC7285979 | biostudies-literature
Project description:Background The terrible triad of the elbow (TTE) is a complex injury consisting of simultaneous elbow dislocation or subluxation, radial head fracture, and coronoid fracture. During the initial assessment of a TTE, the typical severity of presenting pain, swelling, and limited range of motion may limit the ability to perform a thorough physical examination and thus divert a clinician's attention away from additional injuries to the ipsilateral upper extremity. Therefore, the purpose of this study was to review the literature for reported cases of concomitant ipsilateral upper extremity injuries associated with a TTE and discuss various strategies to increase clinician awareness to avoid underdiagnosis and missed diagnoses. Methods A systematic review of five databases in four languages (English, Spanish, French, and Portuguese), from inception to May 2021, was conducted. Articles describing a TTE with a concomitant osseous, chondral, ligamentous, or musculotendinous injury occurring on the ipsilateral upper extremity were included. The patients were divided into two groups, those presenting with a classic TTE and concomitant ipsilateral upper extremity injury (group 1) and those in whom a TTE variant was described (group 2). A TTE variant was defined as a combination of osseous and/or chondral injuries to the elbow other than the classic description of TTE, in which at least two of the three classical elements of a TTE (elbow dislocation, coronoid fracture, and radial head fracture) were present in addition to other unique elbow osteoarticular injury. Results Nineteen articles met inclusion criteria and were further analyzed. A total of 27 patients were analyzed, 23 from group 1 and 4 from group 2. Overall, 33 concomitant injuries were documented in group 1, the most common being an olecranon fracture (27.3%), followed by Essex-Lopresti injury, triceps tendon avulsion, and carpal fracture-dislocation with 4 (12.1%) cases each. Group 2 had four patients, all of whom presented with a unique variant of the classically described TTE. Conclusion Despite a characteristic radiographic appearance of the classic TTE, additional injuries of the ipsilateral extremity or variants of the classic TTE may be easily missed, especially in cases resulting from high-energy mechanisms of injury. By analyzing the available data on associated injuries and variants that may occur with a TTE, we hope to increase awareness so that clinicians may recognize these less common but more complex injury patterns.
| S-EPMC10426655 | biostudies-literature
Project description:ObjectiveTerrible triad injury of the elbow (TTIE), comprising elbow dislocation with radial head and coronoid process fracture, is notoriously challenging to treat and has typically been associated with complications and poor outcomes. The objective of this systematic review was to summarize the most recent available evidence regarding functional outcomes and complications following surgical management of TTIE.MethodsMedline, EMBASE, Cochrane Library, and Google Scholar were searched to identify relevant studies, which were included if they were retrospective or prospective in design, involved participants who had TTIE, and were published in English. Outcomes of interest were functional outcomes and complications.ResultsSixteen studies, involving 312 patients, were included in the systematic review. Mean follow up after surgery was typically 25 to 30 months. Mean Mayo elbow performance scores ranged from 78 to 95. Mean Broberg-Morrey scores ranged from 76 to 90. Mean DASH scores ranged from 9 to 31. The proportion of patients who required reoperation due to complications ranged from 0 to 54.5% (overall = 70/312 [22.4%]). Most of these complications were related to hardware fixation problems, joint stiffness, joint instability, and ulnar neuropathy. The most common complications that did not require reoperation were heterotopic ossification (39/312 [12.5%] patients) and arthrosis (35/312 [11.2%] patients).ConclusionsThe results of this systematic review indicate that functional outcomes after surgery for TTIE are generally satisfactory and that complications are common. Further research is warranted to determine which surgical techniques optimize functional outcomes and reduce the risk of complications.
| S-EPMC4022574 | biostudies-literature
Project description:Terrible triad injuries are typically treated surgically to restore elbow stability, as the radial head acts as a secondary stabilizer to valgus stress, while the coronoid provides stability against posterior elbow dislocations. The lateral ulnar collateral ligament (LUCL) is also commonly injured in terrible triad of the elbow injuries, and if not repaired, leads to posterolateral rotatory instability. Depending on the fracture pattern and size, the radial head fracture may be treated with open reduction internal fixation (ORIF), arthroplasty, or excision, whereas the coronoid fracture is most commonly treated with ORIF. If treated, these injuries are managed prior to LUCL fixation to avoid stressing the LUCL repair. We describe a technique for treatment of a LUCL injury with a suture button. When repairing the LUCL, a Kocher approach is used to visualize the LUCL footprint, which is then reattached to the insertion point on the lateral epicondyle using a suture button. The purpose of this study was to provide a step-by-step approach to using this surgical technique and an associated postoperative protocol.
| S-EPMC10907935 | biostudies-literature
Project description:IntroductionThe terrible triad of the elbow (TTE) is a lesion associating a dislocation of the elbow, a fracture of the radial head, and a fracture of the coronoid process, with a high potential of complication. The treatment is based on the restoration of bone lesions and external capsular ligament repair. The systematic repair of the medial collateral ligament (MCL) is still debated in the literature. The aim of this study is to evaluate the clinical and functional results of the surgical treatment in a real-world series from Easter Morocco.Patients and methodsThis was a retrospective study of 6 cases of TTE operated by isolated external approach or combined approach (internal or anterior) of the elbow in the department of Traumatology-Orthopedics of the Mohammed VI University Hospital (Oujda Morocco), over a period of 7 years from 2013 to 2020. Radial head and coronoid process fractures were classified according to the Mason and Morrey-Regan classifications, respectively. The following clinical parameters were evaluated: Mayo Clinic Elbow Performance Score (MEPS), Quick Disabilities of the Arm, Shoulder and Hand (DASH), Visual Analog Scale (VAS), and arc of mobility in flexion-extension and prono-supination.Results6 male patients treated between May 2013 and December 2020 were included. The median follow-up was 48 months. All patients had frontal and lateral standard X-ray of over and under joints, and computed tomography (CT)-scan was delivered for 5 cases. The elbow dislocation was posterolateral in five cases, and posteromedial in only one patient. Radial head fractures were classified as type I in one case, type II in two cases, and type III in three cases. Coronoid fractures were type I in three cases, type II in one case, and type III in two cases. At the last follow up, the mean MEPS, Quick DASH, and VAS was 81, 28, 0.8, respectively. The mean arc of mobility in flexion was 120° and it was deficient by 20° in extension. In addition, the mean arc of mobility in protonation was 80°, while in supination it was 75°. Regarding complications, we noticed an instability of the elbow on valgus in a single case, elbow stiffness with heterotopic ossification in a single case, ulnar nerve damage in a single case during medial collateral ligament anchoring, and elbow hygroma in one single case.ConclusionThe surgical management of TTE can provide good and long-term functional results after restoration of the stabilization of bone structures and the lateral ligament complex, without the need to repair the medial collateral ligament.
| S-EPMC9207080 | biostudies-literature
Project description:BackgroundThis study aims to evaluate the surgical techniques and outcomes of treating elbow dislocations with coronoid and radial head fractures, commonly referred to as the terrible triad of the elbow (TTE), through a single olecranon osteotomy.MethodsA retrospective analysis was performed on 73 patients diagnosed with TTE between January 2015 and April 2022. The cohort included 44 men and 29 women, with an average age of 40.0 ± 15.1 years (range, 18-68 years). Among these patients, Mason Type I, II, and III fractures were identified in 11, 42, and 20 cases, respectively, while Morrey Type I, II, and III fractures were observed in 45, 23, and five cases, respectively. All patients underwent treatment via a single olecranon osteotomy. The average interval between injury and surgery was 5.6 ± 1.6 days (range, 3-8 days). Elbow function was assessed using the Mayo Elbow Performance Score (MEPS), pain was measured via the Visual Analogue Scale (VAS), and quality of life was evaluated using the SF-36 questionnaire.ResultsPatients were followed for 15 to 60 months (mean, 37.1 ± 13.3 months). All coronoid and radial head fractures achieved complete healing, with an average recovery time of 4.3 ± 1.1 months (range, 3-6 months). By the final follow-up, all patients had regained normal elbow function. The mean elbow flexion was 124.4° ± 9.2°, extension was 9.6° ± 6.5°, and the total range of flexion-extension was 114.8° ± 11.7°. Forearm pronation averaged 77.3° ± 4.8°, supination 79.2° ± 6.5°, and total forearm rotation 156.5° ± 8.4°. The mean MEPS was 89.3 ± 6.4, with 36 patients achieving excellent scores and 37 obtaining good scores. Preoperative VAS scores averaged 8.78 ± 1.11, which significantly dropped to 0.97 ± 0.83 at the final follow-up (p = 0.000). The SF-36 preoperative PCS and MCS scores were 45.77 ± 3.59 and 60.67 ± 3.91, respectively, with postoperative improvements to 93.85 ± 2.65 (p = 0.000) and 95.79 ± 3.11 (p = 0.000).ConclusionThis retrospective analysis indicates that a single olecranon osteotomy could be a viable treatment option for TTE. However, additional research involving a control group is essential to substantiate the efficacy of this technique.
| S-EPMC11572344 | biostudies-literature
Project description:The range of diagnostic and therapeutic applications of needle arthroscopy (NA) continue to expand due to advances in image quality and resolution. Minimally invasive techniques can be augmented by the smaller camera size and reduced fluid use made possible by NA. Small-bore arthroscopy presents opportunities for use in smaller joints, such as the elbow, where applications of standard arthroscopic equipment may be limited by small anatomic spaces and fluid extravasation. In this Technical Note, we present our technique for NA-assisted treatment of terrible triad injuries, specifically in the setting of an intact radial head. The technique describes a stepwise approach to arthroscopically aided fixation of the coronoid process, followed by open reconstruction of the lateral collateral ligament complex.
| S-EPMC8252851 | biostudies-literature
Project description:ObjectiveComplex elbow fractures are common injuries in young adults. Results in recent studies with various operative treatment protocols are equivocal. We compared the results of radial head arthroplasty, excision with osteosynthesis in such injuries at two follow-ups 1 year apart.MethodsThirty-five patients of complex elbow fracture-dislocations including, posterior/anterior olecranon dislocation of elbow, terrible triad injury, anteromedial facet of coronoid fracture, Type IV Monteggia fracture-dislocation and unclassified elbow dislocation were enrolled. They were managed operatively by standardized protocol similar to McKee et al. radial head reconstruction with miniplates, lag screws or non-operative treatment for undisplaced fractures. Arthroplasty of radial head with cemented prosthesis + LCL repair with suture anchor/transosseous tunnel was done. Coronoid and olecranon fixation was always performed. Patients were evaluated as follows: Q-DASH score, MEPI, pain according to VAS, range of motion, complications and radiographic findings and fracture union, and elbow instability.ResultsThe mean length of follow-up among the patients was 18 months. There were statistically significant differences between the DASH score/MEPS between radial head excision and replacement/reconstruction. Instability was significantly reduced in those with LCL reconstruction. Excising the comminuted radial head without replacement had the worst outcome. Best PROM was reported in patients with osteosynthesis.ConclusionProvided a standard protocol is applied, radial head osteosynthesis has preferable outcomes in terms of patient-related outcomes as compared to arthroplasty, although not statistically significant. Radial head excision though has acceptable outcomes but there is a restriction of movements especially flexion-extension. Acceptable rate of complications major or minor warrants need of secondary surgical procedures or a staged treatment.
| S-EPMC7609614 | biostudies-literature