Objective To review the injury mechanism and the treatment progress of terrible triad of the elbow, and to analyze the direction of further research. Methods Related literature concerning terrible triad of the elbow was extensively reviewed and comprehensively analyzed. Results The main treatment of terrible triad of the elbow is operation. The ultimate goal of treatment is to reconstruct sufficient stability of the elbow. The treatment includes fixation of the coronoid by suture, screw or plate; fixation of radial head by screw and plate, partial or complete replacement of the radial head; fixation of lateral collateral ligament and the medial collateral ligament by bone suture or anchors and the application of the external fixator. These surgical treatments have their own indications and advantages, most get satisfactory results. Conclusion Generally, surgery is needed to maintain the stability of the elbow for patients of terrible triad elbow. However, medial ligament repair or not, the choice of approach, and mechanism of injury still need further study.
ObjectiveTo compare the effectiveness of transosseous tunnel fixation and drilling fixation for repair of lateral collateral ligament complex (LCLC) in treatment of terrible triad of elbow (TTE).MethodsA clinical data of 50 patients with TTE between June 2012 and January 2018 were retrospectively analyzed. The LCLC was repaired with transosseous tunnel fixation in 22 patients (transosseous tunnel fixation group) and with drilling fixation in 28 patients (drilling fixation group). There was no significant difference between the two groups (P>0.05) in gender, age, fracture side, time from injury to admission, coronoid process fracture classification, radial head fracture classification, and TTE classification. The operation time, intraoperative blood loss, fracture healing time, and complications of the two groups were recorded. At last follow-up, the Mayo elbow performance system (MEPS) score, range of motion of elbow joint, and Broberg-Morrey classification were recorded.ResultsThe operation of two groups were successfully completed. There was no significant difference in the operation time and intraoperative blood loss between the two group (P>0.05). The follow-up time was (24.43±6.84) months in the transosseous tunnel fixation group and (21.55±6.16) months in the drilling fixation group, and the difference was not significant (t=1.534, P=0.132). X-ray films showed that the coronoid process and radial head fractures in the two groups healed, and there was no significant difference in the healing time (P>0.05). At last follow-up, there was no significant difference in the flexion-extension activity, rotation activity, MEPS score, and Broberg-Morrey grading (P>0.05). During the follow-up, there was no re-dislocation or instability of the elbow joint. The incidence of complication was 28.57% (8/28) in the transosseous tunnel fixation group and 27.27% (6/22) in the drilling fixation group, showing no significant difference (χ2=2.403, P=0.121).ConclusionBoth transosseous tunnel fixation and drilling fixation can achieve good results in repair of LCLC for TTE.
ObjectiveTo explore the clinical significance of anterior median approach combined with lateral approach to the elbow joint in the treatment of terrible triad of the elbow.MethodsWe retrospectively collected the data of 63 cases who used the anterior median approach of the elbow joint combined with the lateral approach (group A, n=36) or the medial and lateral approach of the elbow (group B, n=27) in the treatment of terrible triad of the elbow between March 2014 and July 2019. The operation time, postoperative complications, and postoperative Mayo score of the elbow were compared between the two surgical approaches.ResultsThe operation time of group A and group B was (93.78±7.78) and (106.93±10.35) min, respectively, and the difference was statistically significant (P<0.05). The patients in both groups completed operations successfully, without vascular or nerve injury. All the wounds healed by first intention. No redislocation or reoperation occurred. Ten months after operation, there was no significant difference in the excellence rate of Mayo score of the elbow (83.3% vs. 85.2%) or postoperative complication rate (16.7% vs. 14.8%) between the two groups (P>0.05).ConclusionThe anterior median approach of the elbow joint combined with the lateral approach and the medial and lateral elbow approach for the treatment of terrible triad of the elbow are equivalent to the postoperative elbow function recovery. The operation time of the former is shorter than that of the latter, and the anterior approach reveals the coronal process intuitively and sufficiently. In the case that there is no medial ligament injury, the anterior median approach of the elbow joint combined with the lateral approach can be preferred.
Diagnosis and surgical procedures were studied in this paper. Twentyfive cases of insulinoma were treated surgically from 1970 to 1997, in which 10 patients had Whipple′s triad so that the early diagnosis could be made. The sites of tumours were found in 10 out of 12 undergoing. Selective celiac angiongraphy with the accuracy rate of 83%, but B-ultrasonography and CT gave only 10% (4 out of 25) and 40%(8 out of 20) respectively. In this series, 5 cases underwent bodytail pancreatectomy and 20 cases enucleation of insulinoma. Blood glucose levels were tested during operation in 15 cases, and they all reached the normal level one hour after the tumours were completely removed. The authors consider that Whipple′s triad is the main basis in diagnosis of insulinoma. The selective celiac angiongraphy play an important role in detecting and locating the tumour. If diagnosis is made, surgical operation should be taken. The blood glucose monitoring during operation is the hallmark for complete resection of insulinomas.
ObjectiveTo investigate the short-term effectiveness of free radial head reconstruction of coronoid process, artificial radial head replacement, and ulna olecranon internal fixation in the treatment of the complex terrible triad of the elbow.MethodsRetrospective analysis was made on the clinical data of 12 patients with complex terrible triad of the elbow treated with free radial head reconstruction of coronoid process, artificial radial head replacement, and ulna olecranon internal fixation between April 2011 and April 2018. There were 8 males and 4 females with an average age of 44.5 years (range, 26-62 years). The causes of injury included 5 cases of traffic accident, 7 cases of falling from hight. The Regan-Morrey classification of ulnar coronoid process fractures was type Ⅲ; Mason classification of radial head fractures was type Ⅲ in 7 cases and type Ⅳ in 5 cases. The time from injury to operation was 5-14 days, with an average of 6.0 days. The operation time, intraoperative blood loss, and complications were recorded. After operation, X-ray film of elbow joint was reexamined, fracture healing condition was observed, and fracture healing time was recorded. The flexion, extension, and rotation of the elbow joints on the healthy and affected sides were recorded and measured. The elbow function was evaluated according to Mayo elbow function score.ResultsThe operation time was 90-140 minutes (mean, 110 minutes); the intraoperative blood loss was 100-300 mL (mean, 150 mL). None of the patients had vascular injury during the operation. One patient developed numbness in the ulnar nerve innervation area and recovered completely after symptomatic treatment for 1 week. All the 12 patients were followed up 12-22 months, with an average of 16 months. At last follow-up, the fracture healed completely, 1 patient developed ectopic ossification of elbow joint, and 2 patients developed traumatic arthritis of elbow joint. No internal fixation-related complications occurred. There was no significant difference in the range of motion of elbow flexion, extension, pronation, and supination between the affected and healthy sides (P>0.05). The median Mayo elbow function score was 96, and the interquartile range was (94, 97), and the excellent and good rate was 91.7%.ConclusionFor patients with complex terrible triad of the elbow with ulna coronoid process fractures of Regan-Morrey type Ⅲ and radial head fractures of Mason type Ⅲ, Ⅳ combined with ulna olecranon fractures, the free radial head reconstruction, artificial radial head replacement, and ulna olecranon internal fixation, through active rehabilitation function exercise after operation, can achieve more satisfactory short-term effectiveness.