The Terrible Triad Miracle

The terrible triad injury of the elbow is a fracture-dislocation
injury consisting of a radial head fracture, coronoid fracture...


Introduction
The terrible triad injury of the elbow is a fracture-dislocation injury consisting of a radial head fracture, coronoid fracture and dislocation of the elbow [1][2][3][4][5]. It was first described by Hotchkiss in 1996 and named so due to the poor outcomes experienced by these patients [1]. Despite surgical management these injuries often go on to develop various complications: recurrent instability, stiffness, posttraumatic arthritis, heterotopic ossification and fixation failure. This injury is relatively uncommon and studies attempting to analyze outcomes often have a low number of subjects [1]. We present a case of a terrible triad injury with exceptional range of motion outcomes within a short time frame (Figure 1 and 2).  to the joint. The exposed radial head was in one large piece and several smaller pieces which included 3 pieces amenable to fixation. The anterior capsule incision was then extended to access the coronoid fracture. Fragmented cartilage pieces from the ulnohumeral and radiocapitellar joint were removed from the joint.
An attempt to fixate a larger coronoid fragment was made; however, the piece further fragmented, and fixation was no longer possible. A 1.8 mm suture anchor was then placed for suture fixation of the anterior capsule following radial head fixation. The larger radial head fragments were reduced and fixated using two mini headless screws placed with compression. Hard copy radiographs were obtained after closure and confirmed reduction of the fracture with concentric elbow joint reduction and placement of hardware. Table 1 highlights the post-operative management of this patient along with his active range of motion at each visit. outcomes: the patient was young and healthy, the anterior capsule was stabilized to the coronoid, the radial head was fixed rather than replaced and the patient was progressed cautiously with close monitoring in a hinged elbow brace. The patient was also kept in a static splint for the first month of treatment without motion or PT.
There is increasing support for active elbow motion days after surgery in order to recruit the dynamic stabilizers of the elbow [3]. The idea that the elbow should never be immobilized is often viewed as dogma [4]. In the case of this patient, a more conservative rehab approach was utilized secondary to concern that formal physical therapy might stress the fixation too soon. The patient remained immobilized until 4 weeks post-operatively, at which point a hinged elbow brace prescription was given. The hinged brace was not fully unlocked until 8 weeks post-op. Additionally, formal physical therapy was delayed because of confidence that this patient would be compliant with home exercises. Given patient compliance and close monitoring, he was given a home exercise program six weeks post-operatively and a formal physical therapy referral at eight weeks post-operatively. While there is growing consensus that the coronoid fracture should be addressed due to its role in humeroulnar sagittal stability [1][2][3][4][5]; Chemama et al.
recommend that type 1 coronoid fractures may be neglected. In this case we opted to reinsert the capsule via anchors for improved humeroulnar joint stability [5]. In addition to coronoid stabilization, we fixated the native radial head despite it being in greater than 3 pieces. An argument can be made that fixation of the radial head should be attempted prior to replacement. Watters et al found that arthroplasty had similar results to fixation; however, they further concluded that long-term studies need to be performed to identify the impact of late complications of arthroplasty such as loosening.
In a young patient, the risk of arthroplasty revision in the long run may outweigh the risks carried by fixation [6] (Figure 4).

Conclusion
We report a case of a terrible triad injury in a young male who achieved an exceptional outcome despite early and extended immobilization of the joint. Despite recent trends to mobilize the joint early, the patient was able to achieve satisfactory outcomes in a short period of time. Furthermore, the joint was adequately stabilized through addressing the coronoid fracture and fixating a highly comminuted radial head.