Terrible triade of the elbow: Practical conduct (About 20 cases)

Introduction: The terrible triad of the elbow (TTE) combines elbow dislocation, fracture of the radial head and coronoid process, and was individualized as a clinical entity by Hotchkiss in 1996 [1]. It follows trauma involving valgus of the elbow, supination of the forearm and axial compression. This trauma induces injury to the radial collateral ligament complex, which extends towards the capsule, reaching the ulnar collateral ligament compartment Material and methods: This work consistes of a prospective study of 20 cases of unfortunate elbow triad treated at the "Aile IV" Orthopedic Traumatology Department of CHU Ibn Rochd in Casablanca, during the period spread between January 2018 and January 2023. Long-term results were assessed using the Mayo Clinic Elbow Performance Score (MEPS). Results: The preferred approach is the posterolateral or lateral Cadenat approach. 12 type III radial heads were treated with mini-plates after tabletop reconstruction, 7 were treated with screws and one head was resected due to the impossibility of osteosynthesis. 11 type 1 coronoid process fractures were treated with capsular reinsertion, and the remainder with screw fixation. The lateral collateral ligament was repaired in all patients by anchoring. The medial collateral ligament was affected in 06 of our patients after intraoperative stability testing, requiring suture and anchor repair. Overall, the MEPS score ranged from 50 to 96%, with an average of 81%, including 7 excellent, 7 good, 2 good and 4 poor results. Discussion: Described by HotchKiss in 1996, the terrible elbow triad is a rare entity accounting for only 10% of radial head fractures. Several authors advocate systematic reconstruction of the radial head, coronoid process and lateral ligament plane to limit complications. The radial head represents an important element of stability in forced valgus and posterior translation. Type II radial head fractures, and where possible type III fractures, should therefore be preserved and osteosynthesized. The coronoid process is the key element in the stability of the humero-ulnar joint. 50% of the height of the coronoid process is required to ensure sagittal stability of the humero-ulanr joint. Conclusion: Only the restoration of elbow integrity by repairing all structures, using a standardized surgical protocol, can achieve good functional results. The aim of treatment is to restore osteoligamentous stabilization in the sagittal plane, enabling early post-operative mobilization and minimizing the risk of post-traumatic stiffness.