Outcomes of coronoid-first repair in terrible triad injuries of the elbow

Clinical outcomes of terrible triad injuries (TTIs) of the elbow are historically poor. To date, it is still debatable whether the coronoid needs to be fixed and if so, how and in which sequence.

Between 2010 and 2013, 13 patients were treated surgically for acute TTIs of the elbow at a Tertiary Level 1 Trauma Centre by a single surgeon, using a standardized protocol, which included coronoid-brachialis complex fixation via pull-through trans-osseous sutures, radial head fixation or prosthetic replacement and a repair of the lateral ulnar collateral ligament. Repair of the medial collateral ligament (MCL) was done if valgus-stress test demonstrated persistent instability. Patients were then followed-up with clinical and radiological evaluation by the senior author until fracture union and elbow range of motion reached a plateau. Outcomes measured were range of motion, DASH scores and MEPS, as well as surgical complications.

Intraoperative stability was achieved in all 13 cases, MCL repair was required in 3 cases and application of external fixation was not required in any case. Patients were followed-up for an average length of 27.7 months and the minimum follow-up period was 12 months. The average age of patients was 46.4 years (range 35–79 years old) at the time of trauma. This included eight Regan–Morrey Type I and five Regan–Morrey Type II coronoid fractures, with ten Mason Type I/II and three Mason Type III radial head fractures. The average arc of ulno-humeral motion was 105.0° (range 80°–135°). The average flexion contracture was 15.0° (range 0°–40°). The average supination-pronation arc was 114.9° (range 0°–180°). The average MEPS was 85 of 100 (range 45–100) and the average DASH score was 21.2 of 100 (range 1.7–61.2). A single case of radio-ulnar synostosis, heterotropic ossification and two cases of recurrent elbow instability were noted.

The coronoid-first surgical approach, using a suture-lasso fixation method, has technical benefits for us and showed good clinical success in our series. This is important with postero-medial rotatory instability being common in our series of TTIs. We emphasize not to miss a TTI in an apparently isolated low Mason class radial head fracture.