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The Role of External Fixation When Treating Terrible Triad Injuries
Karan Dua, MD; Andrew Fischer, BS; Raymond A. Pensy, MD; W. Andrew Eglseder, MD; Joshua M. Abzug, MD
University of Maryland School of Medicine, Baltimore, MD

Introduction
'Terrible triad' injuries of the elbow consist of a posterior elbow dislocation with concomitant fractures of the coronoid process of the ulna and radial head. The purpose of this study was to evaluate the usefulness or lack thereof of placing a static external fixator to be used as a removable brace when treating patients with terrible triad injuries.

Materials and Methods
A retrospective review was performed of patients treated for a terrible triad injury at a level-1 trauma center over a 15-year period. Patient demographics were examined and outcome data was recorded regarding complication rates and post-operative range of motion (ROM). Statistical analysis was performed using two-tailed fisher's exact and t-tests assuming unequal variances. Additionally, data was analyzed when matching for age, body mass index (BMI), and presence of concurrent injury.

Results
93 terrible triad injuries were reviewed including 13 that were treated with open reduction and internal fixation (ORIF) with the addition of a static external fixator and 80 treated with ORIF alone. Patients treated with ORIF and an external fixator were older than those treated with ORIF alone (average 51 vs. 45.7 years). In the ORIF with external fixator treatment group, 61.5% (8/13) had concurrent injuries compared to 33.8% (27/80) of patients who underwent ORIF alone. 20% of patients (16/80) treated with ORIF alone needed a reoperation compared to only 1 of 13 patients (7.69%) initially treated with ORIF and the addition of an external fixator. The rationale for reoperation included capsulectomy, heterotopic ossification removal, hardware removal, and recurrent elbow subluxation. Patients initially treated with ORIF and an external fixator had greater forearm pronation/supination and elbow flexion earlier in the rehabilitation period, but less elbow extension. The average arc of motion was greater in patients treated with ORIF and an external fixator later in the rehabilitation period. In obese patients (BMI ? 30), ORIF with an external fixator allowed for significantly better forearm supination at the first and second follow-up evaluations.

Conclusion
The addition of a static external fixator when performing ORIF of terrible triad injuries serves to function as a rigid brace, which can be unlocked for supervised physical therapy leading to better postoperative ROM and lower reoperation rates, especially in obese patients.


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