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Terrible Triad Injuries; Who Needs the Coronoid Fixed? Alternative Treatment of the Terrible Triad Injury
Loukia K. Papatheodorou, MD; Dean G. Sotereanos, MD
University of Pittsburgh, Pittsburgh, PA

Introduction: Elbow dislocation combined with fractures of both the radial head and the ulnar coronoid process ("terrible triad" (TT) injuries) are complex injuries with variable outcomes. We reviewed the results of 14 patients with TT injuries in which Regan-Morrey type I and type II coronoid process fractures were not repaired.
Materials & Methods: Fourteen patients (6 male and 8 female) with an acute TT injury were included in this study. Mean patient age was 52 years (range, 32- 58). The fourteen coronoid fractures included two Regan-Morrey type I fractures and twelve Regan-Morrey type II fractures. Associated radial head fractures were managed with ORIF in three patients, and with prosthetic radial head replacement in eleven patients. All patients were managed with anatomic repair of the lateral ulnar collateral ligament (LUCL) using suture anchors. Intraoperative clinical stability was restored in all patients without fixation of the small or highly comminuted coronoid fracture fragments. Prior to definitive closure, concentric reduction of the ulnohumeral joint was confirmed with fluoroscopic examination through a range of 20o to 130o of flexion-extension in all patients. No subluxation was noted. The elbow was immobilized in a long posterior splint and motion was initiated within one week in all patients with a hinged brace. At follow-up each patient was evaluated with physical and radiographic examination.
Results: The minimum follow-up was twenty-four months (range, 24-56 months). The mean arc of ulnohumeral motion was 122° (range, 75° to 140°) and mean forearm rotation was 135° (range, 40-170°). None of the patients demonstrated instability post-operatively. The average Broberg and Morrey score was 90 (range, 70 to 100) and the average of DASH score was 14 (range, 0 to 38). There were no complications at final follow-up. No patient developed clinically symptomatic heterotopic ossification. Radiographs revealed mild arthritic changes in one patient.
Conclusions: The primary goal of surgical fixation of TT injuries of the elbow is to restore stability sufficient to permit early motion. Our results suggest that TT injuries can be successfully managed without fixation of type I and II coronoid fractures in the setting of clinical intra-operative stability following surgical repair of the LUCL and repair or replacement of the radial head. Based on our findings we challenge the accepted belief that the coronoid must be fixed in all TT patients.


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