The Terrible Triad of the Elbow

By McKenna Sobers 5-22-2013

AT 3301 Dr. Jordan Utley, PhD, LAT, ATC

The Terrible Triad of the Elbow Section 1: Introduction to the pathology The terrible triad of the elbow is a traumatic injury caused when posterolateral dislocation, radial head fracture, and coronoid fracture has occurred in the elbow. <PHOTO 1: ELBOW> DISLOCATION> (Blomberg) This term is used because of the many complications that can occur with this injury. Damage to the bone and soft tissues can lead to instability, malunion or nonunion. (Medical Media Group) Incidence of the pathology This injury is most commonly caused by simple falls with arms outstretched to catch oneself. (Veillette) Fractures are most commonly found in adolescent athletes, resulting from a fall directly onto a flexed elbow or hyperextension mechanism. (Starkey) <VIDEO 1: TERRIBLE TRIAD OF THE ELBOW> Etiology These injuries are not very common and usually occur when falling on an outstretched hand. All terrible triad injuries require surgical repair. (Veillette) The pressure of catching body weight while arms are locked straight pushed the forearm backwards causing a dislocation, radial head fracture, and the coronoid fracture and results in axial load and supination and valgus moments at elbow (Medical Media Group) <PHOTO 2: ELBOW> Section 2: Anatomy and Physiology of the Injury Anatomy The elbow is made up of three bones: Humerus, Ulna, and Radius. The distal end of the humerus forms a muscle attachment site for the medial and lateral epicondyles. The ulna forms the medial border of the forearm and articulates with both the humerus and the radius. The radius is the thumbside of the forearm and articulates with a disc shape and concave shape so it can glide and rotate on the capitellum which significantly enhances the elbows stability. The elbow joint is a modified joint, like a hinge. It relies on bony and ligamentous structures for stability. The ligament that provides valgus support is the ulnar collateral ligament (UCL) which is also referred to as the MCL of the elbow. The ligament that provides varus support is the lateral ulnar collateral ligament. (LUCL) It is the most important lateral stabilizing structure. The muscles associated with the elbow are the biceps brachii, brachialis, brachioradialis, triceps brachii, pronator teres, and pronator quadratus. There are two bursae in the elbow: the subcutaneous olecranon bursa, and the subtendinous olecranon bursa. Because the olecranon process is such a bony structure and protrudes when arm is bent, bursae help to reduce the wearing down of skin and bone to keep the elbow joint safe. (Starkey) <PHOTO 3: ELBOW ANATOMY> Physiology

The stresses that cause a terrible triad of the elbow injury as indicated above are the stress of falling on an outstretched hand which causes the forearm to be pushed back and cause a dislocation, radial head fracture and coronoid fracture. Section 3: Evaluation of the Injury Signs and Symptoms Patients usually complain of clicking and locking with elbow in extension. There will also be valgus as well as varus instability of the elbow. (Blomberg) It may be painful to bend arm after relocation and can feel unstable. Swelling can occur rapidly which can make it difficult when evaluating the injury. Because the blood vessels and nerves may have crossed the joint, the patients distal neurovascular function must be assessed quickly after the injury. (Starkey) Special Tests Because the terrible triad of the elbow injury includes both a dislocation as well as fractures the examination process for both is included. With elbow dislocations no joint stability tests or special tests are performed. Active range of motion is assessed, neurological screening, and vascular screening are assessed as well as the patients functional level. Imaging techniques may be used such as radiographs, x-rays, and MRIs. With elbow fractures stress tests and joint play tests for joint stability are performed Stress test: for a valgus stress test the patient can be standing, sitting or lying supine. The humerus should be internally rotated and elbow flexed to 10-25 degrees. The examiner should be standing lateral to the joint being tested with one hand supporting the lateral elbow with the fingers reaching behind the joint to palpate the medical joint while the opposite hand grasps the distal forearm. Valgus force is applied to the joint. This procedure should be performed with the elbow at different degrees of flexion. A positive test is indicated by increased laxity or pain, or both compared with the opposite arm. For a varus stress test the patient should be sitting or standing and the elbow flexed to 25 degrees. The examiner should stand medial to the joint being tested with one hand on the medial elbow with fingers reaching behind the joint to palpate the lateral joint line while the opposite hand grasps the distal forearm. A varus force is applied to the elbow. A positive test is indicated by increased laxity compared with the opposite side, and/ or pain can be produced. <VIDEO 2: STRESS TESTS> Joint Play: Joint play for the elbow can be done for three different areas, the humeroulnar, radioulnar, or radiohumeral. For the humeroulnar the patient should be supine with elbow in 70 degrees of flexion, and the examiner places thumbs on the proximal ulna while stabilizing the distal forearm between their forearm and body and then applies a distracting force to the elbow. For the radioulnar test the patient should be sitting or supine with elbow in 70 degrees flexion and 35 degrees supination. The examiner stabilizes the proximal ulna and applies an anterior and then posterior force to the humeral head. For a radiohumeral test, the patient should be suiting or supine with elbow extended and forearm in supination. The test performed for the radioulnar test is the same for the radiohumeral. A positive test is indicated by hypomobility or hypermobility of the joint. (Starkey)

Section 4: Associated Differential Diagnoses Monteggia Fractures may be associated with a terrible triad injury. During evaluation of the injury this can be ruled out by evaluating for compartment syndrome which is an elevated interstitial level which can be caused by an open or closed fracture. (eOrif) Olecranon fractures may be associated with this injury. During examination this can be ruled out if the patient can extend the forearm. The olecranon fracture is indicated by the discontinuity of the tricep mechanism. (Blomberg)

Section 5: Prognosis and Recent Research Prognosis After repair the terrible triad injury elbow should be splinted at 90 degrees and full pronation if the MCL is intact and the LCL was repaired, and neutral position if the MCL and LCL were repaired. Range of motion should begin between two to five days after surgery within a stable arc of motion which is determined intraoperatively. A resting splint should be used between exercises for six weeks, static progressive extension night split can begin at six weeks, strengthening exercises should start at eight weeks or when the fractures and ligamentous repairs are secure. (Veillette) Recent Research The terrible triad of the elbow is a difficult injury with historically poor outcomes. The surgeries and results have been improved by experience, different techniques and some implants have helped to restore the stability of the elbow. This surgery requires the surgeons knowledge and skills in soft tissue techniques, fracture repairs, and joint arthoroplasty. (Terrible Triad of the Elbow) The biggest advance in research is just that surgeons are more knowledgeable of this injury and have had experience treating it.

Works Cited
Blomberg, Joshua. Orthobullets. 26 January 2013. 22 May 2013. Clifford R. Wheeless, III, MD. Terrible Triad of the Elbow. 20 February 2013. <wheelessonline.com>. Photo 3 Clinics, Standford Hospital and. Anatomy of the Elbow. 2013. <outpatient.standfordhospital.org>. Photo2

Ebraheim, Nabil A. Terrible Triad of the Elbow Everything You Need to Know- Dr. Nabil. 5 July 2011. <http://www.youtube.com/watch?v=g4Fw1IsmVRU>. Video 1 eOrif. eOrif. 2008. 23 May 2013. <http://eorif.com>. Kodi Kojima, Steve Velkes. Atlas of Internal Fixation. 1998. <www2.aofoundation.org>. Photo 1 Medical Media Group, LLC. eorthopod. 2009-2011. 22 May 2013. <http://eorthopod.com>. Starkey, Chad. Examination of Orthopedic and Athletic Injuries. Philadelphia: F. A. Davis company, 2010. "Terrible Triad of the Elbow." January 2013. Pubmed.gov. 23 May 2013. <http://www.ncbi.nlm.nih.gov>. tsupd11. Varus and Valgus Elbow Stress Tests. 9 October 2009. <http://www.youtube.com/watch?v=96EMB7SWF0I>. Video 2 Veillette, Joseph Bernstein and Christian. Orthopaedics One. 2012. 22 May 2013.