1 Introduction

Terrible triad was first described by Hotchkiss in 1996¹ as “a fracture of the radial head associated with the fracture of the coronoid process of the ulna and posterior dislocation of the elbow.” The mechanism of such an injury is usually a fall on an extended arm, with the forearm in supination with the presence of additional valgus stress on the elbow. Owing to the contribution of the ligamentous structures to the stability of the joint, surgical intervention is advised to get a stable joint and allow early motion. The challenge for any surgeon is to avoid complications like elbow stiffness while achieving good functional recovery. The poor prognosis of this injury has been well described in the literature; the high instability of the elbow leads to joint stiffness and secondary arthrosis.² There is a dearth of literature regarding any set protocol, which makes it harder to choose the proper technique for solving these cases.

A better knowledge of anatomy and biomechanics is essential for a good outcome.

2 Case report

A 44-year-old man, right hand dominant, without any previous medical condition, came to our trauma department after suffering a fall from a ladder, with his outstretched hands hitting the ground. Usually, falling from a height leads to an axial skeleton fracture, but as our patient landed on his palms, the body weight got transferred to the elbows leading to an elbow fracture. Such a mechanism of injury leading to a bilateral elbow fracture has been very rarely described in the literature. Plain radiographs (Fig. 1) showed a bilateral elbow dislocation with radial head and coronoid process fracture. No external wound was present, but considerable swelling was observed. A 3D CT scan was done to identify fracture morphology. The CT scan showed a Hotchkiss modified Mason Type II radial head fracture, constituting >30% articular area on the right side and a Type I on the left side. The bilateral coronoid process fracture was of Type II Regan Morrey (Fig. 1). An above elbow slab was given, and both the sides were operated upon in the same sitting two days post-injury.

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Fig. 1 Pre-operative x-ray and CT scan of right (a,b) and left elbow (c,d).

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The surgery was done in the supine position, with the patient under regional anesthesia. Recent literature favours use of headless screws as implant related complications can be minimised. The right-side radial head was fixed through a lateral approach using two Herbert screws. Subsequently, the persistence of elbow instability was observed under an image intensifier, and the coronoid was fixed with a suture anchor, along with MCL repair, via an anteromedial approach. LCL repair was also carried out, and the elbow stability was confirmed on the image intensifier. The left radial head fracture fragment involved <10% of the articular surface and was comminuted, so it was excised via a lateral approach. For the coronoid fixation and the LCL repair, an anteromedial approach was used. Elbow stability was confirmed both clinically and under image intensifier guidance. Both the elbows were immobilized post-operatively in an above elbow slab for two weeks to allow for soft tissue healing. Two weeks after surgery, rehabilitation was gradually started in the form of prono-supination exercises and elbow flexion and extension exercises. Indomethacin was given to prevent myositis ossificans. After reasonable strength was achieved on the left side, gradual weight lifting was started. On the right side, the patient was initially advised not to lift weights, which was gradually started at the end of 6 weeks post-operatively. Good functional and radiological outcomes were observed bilaterally at the end of three months (Fig. 2). The left side range of motion was 10–150°, and on the right side, it was 30–130°, and bilaterally pronation supination was 80 and 50°, respectively. At the end of 5 months, the patient resumed his working activities and was able to start his routine functional activities (Fig. 3).

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Fig. 2 Immediate and follow up xray of right (a,b) and left elbow (c,d).

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Fig. 3 Clinical outcome showing satisfactory results (A-F).

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3 Discussion

For any terrible triad injury, the mechanism of injury is always an important determinant. The following sequence of events explains the mechanism of this complex injury; the patient straightened his elbows with forearms going into supination as he fell from a standing height. The transmission of an axial force to the ulnohumeral joint contributed to a posterior dislocation and led to the coronoid and radial head fractures. In our patient, the right arm touched the ground first, causing excessive abduction of the elbow; the subsequent valgus stress drove the fragments of the radial head ulnar wards, resulting in an MCL injury simultaneously. The presence of more comminution of the right radial head might be explained by the initial impact being more on the right side. The goals of treatment in a terrible triad injury are to restore elbow stability, recover congruency of the elbow joint, avoid complications, and allow early joint mobility.³ The standardized protocols proposed by Pugh et al. for terrible triad injuries include reduction and fixation of the coronoid process, restoration of the normal humeroradial anatomy, and the restoration of the capsular integrity and stability of the LCL complex and additionally, an MCL repair if needed.

The elbow can be approached via multiple approaches as described in literature. We chose a combination of the anteromedial and a lateral (Kocher) approach. This provides better exposure, is less traumatic, and allows the surgeon to check the capsuloligamentous structures directly. Multiple papers have shown that fixation of a Mason Type II radial head fracture gives a better functional outcome as compared to arthroplasty.⁴ Therefore, we decided to fix the radial head with two Herbert screws to provide better rigidity while avoiding soft tissue irritation. On the other hand, there is a lack of consensus regarding the management of minimally displaced or small fragments of the radial head. The risk of shattering the fragment during fixation and implant back out; makes the fixation of these small fragments challenging. The radio-ulnar articulation also affects management strategy; the fracture fragment in our case did not affect the joint articulation and was thus excised. Wu et al. studied various treatment modalities for radial head fracture component of terrible triad injury and stated that headless screw fixation is better as compared to plates.⁵ Previous published case reports have used lateral approach and MCL injury was not reported and plates were used for coronoid fixation and radial head fixation. Elbow instability results if MCL is not addressed in spite of good bony fixation.⁶ Jlalia et al. reported bilateral terrible triad injury treated conservatively in pediatric age group.⁷ The presence and treatment of the soft tissue component in terrible triad injuries are given equal importance. The stability of the elbow is dependent on soft tissue repair; MCL and LCL repair provides joint stability and allows functional recovery.⁸ An effective rehabilitation protocol is essential to achieve a reasonable elbow range of motion and early functional recovery. The presence of a more severe injury on the right could be the cause for decreased range of motion on that side as compared to the opposite side. This can be attributed to multiple factors, ranging from the presence of radial head comminution to soft tissue components. The development of elbow stiffness is the most common complication observed following such an injury and was similarly observed in our patient also. In our case, there were no implant-related complications like non-union, loss of forearm rotation, or implant failure.

Here we report a rare case of bilateral terrible triad of elbow with an uncommon mechanism of injury. In our case, we have addressed all injury components- ligamentous and bony and minimal use of hardware for fixation which was not reported in previous such case reports.^9,10 Both sides were treated with two different sets of protocols. The surgical plan is dictated by the anatomy of the fracture fragments, the biomechanics, and a thorough study of the 3D CT scan. The individualization of the operative plan, along with a combination of multiple approaches, provides a reliable method for the management and for the achievement of good functional outcomes in such complex, rare injuries.

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