Case Series of All-Arthroscopic Treatment for Terrible

Triad of the Elbow: Indications and Clinical Outcomes

Sung Hyun Lee, M.D., Kyeong Hoon Lim, M.D., and Jeong Woo Kim, M.D., Ph.D.

Purpose: To evaluate the results of all-arthroscopic treatment of the terrible triad of the elbow, a combination of elbow
dislocation, radial head dislocation, and coronoid process fracture, and its complications. Methods: We performed a
retrospective review of consecutive patients with terrible triad who underwent all-arthroscopic treatment between January
2011 and December 2016. All-arthroscopic treatment was performed in the unstable elbows after manual reduction. Clinical
evaluation was performed at least 2 years postoperatively. Patients with another fracture in the upper extremity and previous
fracture of the affected elbow were excluded. A radial head fracture that was stable enough to reduce or involved less than
25% of the articular surface for partial excision and Regan-Morrey classification type I and type II coronoid process fractures
were treated arthroscopically. Range of motion, radiologic outcomes, surgical complications, and the Mayo Elbow Perfor-
mance Score were evaluated at the final follow-up. The Mann-Whitney test was used for statistical analysis. Results: A total
of 24 patients met the inclusion criteria, and the average age was 47.6 years. Coronoid process fractures were fixed in all
patients, by use of Kirschner wires in 15 (62.5%) and pullout sutures in 9 (37.5%). Radial head fractures were treated using
screw or K-wire fixation in 4 patients (16.7%); only the fragment of the fracture was resected in 11 patients (45.8%). In all 24
cases (100%), the lateral collateral ligaments were repaired. At the final follow-up, the mean flexion contracture angle was
4.8
 1.1
and the mean flexion angle was 132.5
 6.3
. Clinical scores were satisfactory, with a mean Mayo Elbow Per-
formance Score of 93 points. However, nonunion of coronoid fractures was observed in 4 patients (16.7%). There was 1 case
of pin-site irritation. Conclusions: All-arthroscopic treatment for the terrible triad can provide an excellent safety profile
without the need for a large incision if the indications are met. Level of Evidence: Level IV, therapeutic case series.

E lbow arthroscopy has historically been considered

a challenging procedure given the relatively
confined joint space and proximity of surrounding
the type of fracture, arthroscopic surgery may be per-
formed even for severe fractures such as the terrible
triad.
neurovascular structures.1 However, with advance- The term “terrible triad of the elbow” (TTE) joint was
ments in experience, technique, and instrumentation, coined by Hotchkiss7 because of the greater difficulty in
elbow arthroscopy has emerged as a safe and effective managing this entity and the poor results obtained,
means of treating a wide range of acute and chronic particularly compared with simple dislocation of the
elbow pathologies.1-3 Several types of elbow fractures elbow, and has been used in the literature since then.8,9
are amenable to arthroscopic treatment, including Furthermore, stiffness is a frequent complication,
coronoid fracture, radial head fracture, and lateral ranging from capsular fibrosis to heterotopic ossification
collateral complex injury.2-6 Therefore, depending on with a bony block to motion.10,11 Attempting to avoid
these complications, previous studies have supposed
that applied algorithmic approaches to manage each
From the Department of Orthopedic Surgery, Wonkwang University Hos- injury in the triad have shown more promising
pital, Iksan, Republic of Korea. results.8,10-12 In addition, previous studies have sug-
The authors report the following potential conflicts of interest or sources of
gested that arthroscopic management of some types of
funding: This study was supported by a Wonkwang University research grant
in 2019. Full ICMJE author disclosure forms are available for this article elbow fractures has several advantages, including
online, as supplementary material. improved visualization, better wound healing, and
Received February 24, 2019; accepted September 2, 2019. preservation of critical soft-tissue structures.1-4 How-
Address correspondence to Jeong Woo Kim, M.D., Ph.D., Department of ever, only a few studies have investigated the clinical
Orthopedic Surgery, Wonkwang University Hospital, 344-2 Shinyong-dong,
outcomes of arthroscopic treatment of TTE.1-4
Iksan, Jeollabuk-do, Republic of Korea. E-mail: serina@wonkwang.ac.kr
Ó 2019 by the Arthroscopy Association of North America The purpose of this study was to evaluate the results
0749-8063/19235/$36.00 of all-arthroscopic treatment of TTE and its complica-
https://doi.org/10.1016/j.arthro.2019.09.014 tions. We hypothesized that all-arthroscopic treatment

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2019: pp 1-10 1
2 S. H. LEE ET AL.

of TTE, for which arthroscopic procedures are indicated, all-arthroscopic surgery, and (3) clinical assessment at a
would present satisfactory clinical results with low rates minimum of 2 years postoperatively. The exclusion
of complications. criteria were as follows: (1) another fracture in the
ipsilateral and contralateral upper extremity, (2) open
Methods reductioneinternal fixation (ORIF) of fractures of the
This study was approved by our institutional review radial head or coronoid process if not amenable to
board (No. WKUHIRB 208-03-013). arthroscopic management, and (3) previous fracture of
the affected elbow.
Patient Selection
We performed a retrospective review of consecutive Surgical Algorithm and Technique for All-Arthroscopic
patients with terrible triad who underwent all- Treatment
arthroscopic treatment between January 2011 and All surgical procedures were performed by 1 senior
December 2016. The inclusion criteria were as follows: surgeon (J.W.K.) within 1 week after the onset of
(1) terrible triad with elbow instability after manual trauma. The surgical treatment algorithm of open
reduction (positive drop sign),13,14 (2) treatment with treatment of TTE has been established in recently

Fig 1. Treatment algorithm and indications for all-arthroscopic treatment in patients with terrible triad of elbow. (LUCL, lateral
ulnar collateral ligament; OR/IF, open reductioneinternal fixation; Tx, treatment.)
 ARTHROSCOPY FOR TERRIBLE TRIAD OF ELBOW 3

Fig 2. Arthroscopic partial exci-

sion for radial head fracture fixa-
tion (right elbow). (A)
Arthroscopic view of radial head
fracture. (B) View after excision
of fracture fragment.

published studies.10-12 However, the surgical proced- additional K-wire was inserted 0.5 cm distally and 1 cm
ures were performed step by step with a different medially to guide the wire in a parallel direction. Two
sequence for all-arthroscopic surgery. Arthroscopic or three K-wires were then used, depending on the size
fixation or partial excision of radial head fractures was of the fragment. Thereafter, the K-wire was advanced
performed as the first step, fixation of coronoid process and passed through the fragment while the fragment
fractures or anterior capsular repair was performed as was held using a grasper and the reduction was main-
the second step, and lateral collateral ligament (LCL) tained. Otherwise, coronoid fractures were fixed via
complex repair was performed as the third step. The suture repair. FiberWire (Arthrex, Naples, FL) was used
management of radial head fractures, coronoid process as a fixation suture because of the small fragment of the
fractures, and ligament injuries was based on the fracture. Reduction was performed arthroscopically by
intraoperative findings. The surgical algorithm and in- suturing the surrounding anterior capsule of the coro-
dications for all-arthroscopic treatment of TTE are pre- noid. Moreover, a 2.7-mm drill bit was used to create 2
sented in Figure 1. holes in the ulna toward the coronoid process. These
holes passed through the fracture site and the Fiber-
Radial Head Fracture Wire to create an interosseous suture on the ulna.
As arthroscopic reduction of a radial head fracture When anterior capsular repair was performed, suture
was performed using a probe via the lever-arm method, fixation of the coronoid process was followed by repair
a completely displaced fracture that was not able to be of the lateral ulnar collateral ligament (LUCL).
reduced was treated with open surgery (when the
fracture fragment involved >25% of the articular sur- LCL Complex Repair
face) or arthroscopic fracture fragment excision (when Arthroscopic LCL complex repair was performed us-
the fracture fragment involved <25% of the articular ing a previously described technique2 (Fig 6). Mason-
surface) (Figs 2 and 3). When the fracture fragment of Allen sutures were passed via a shuttle technique, and
the radial head was reducible using a probe, radial head the lateral epicondyle was then fixed with a knotless
fractures were fixed using headless screws or smooth anchor (PopLok; Linvatec, Largo, FL). A spinal needle
Kirschner wires. When the radial head fracture was was passed through the radial head portal to penetrate
stable and the displacement of the articular surface was the LCL complex stump at the joint capsule. A poly-
less than 2 mm, an operation was not performed for the dioxanone suture (PDS; Ethicon, Somerville, NJ) was
radial head fracture. passed through the spinal needle and pulled out
through the proximal anterolateral portal using a
Coronoid Process Fracture grasper (Fig 6 A and B). A shuttle relay was performed
For patients with coronoid process fractures, by connecting the PDS with a high-strength nonab-
arthroscopy-assisted fixation was performed using 1 sorbable suture and was then pulled out through the
of 2 techniques: K-wire fixation or suture repair2,3 proximal anterolateral portal. A second PDS was passed
(Figs 4 and 5). Coronoid fractures were fixed using a through the proximal anterolateral portal from the
K-wire when the fracture fragment was large enough radial head portal, and the nonabsorbable suture was
to penetrate using such a K-wire. To prevent iatrogenic connected with the second PDS. The nonabsorbable
cartilage injury, 1.6-mm K-wires were inserted from suture was then moved back to the radial head portal
the posterior aspect of the ulna in an anterior direction (Fig 6C). One more sequence was repeated with a
to the radial head. With this K-wire used as a guide, an 10-mm gap left between it and the previous stitches.
4 S. H. LEE ET AL.

Fig 3. Arthroscopic technique for

radial head fracture fixation with
headless screw (left elbow). (A)
Arthroscopic view of radial head
fracture. (B) View after reduction
of fracture using probe. (C, D) The
radial head fracture was fixed
with a headless screw.

Both paired strands of the nonabsorbable suture were removed at an average of 8 to 12 weeks postoperatively
knotted using the modified Mason-Allen method when bone union was identified on radiography in the
(Fig 6D). An anterolateral portal was created using a clinic with patients under local anesthesia.
spinal needle, and the nonabsorbable suture was then
transferred from the radial head portal to this portal for Clinical Evaluation
fixation at the LCL complex footprint. The footprint of ROM, surgical complications, and the Mayo Elbow
the humeral attachment of the LCL complex was gently Performance Score were evaluated at the final follow-
decorticated using a burr or shaver. A predrilled hole up by 2 surgeons (S.H.L. and K.H.L.). Delayed union
directed slightly upward was created using a 4.5-mm or nonunion was measured at the outpatient follow-up
drill bit before anchor fixation. The transferred nonab- via radiography. The anatomic integrity after LCL
sorbable sutures were fixed using 1 knotless suture complex repair was evaluated via magnetic resonance
anchor on the articular side of the LCL complex imaging 6 months after surgery and followed up yearly
footprint of the humeral attachment, with the elbow by ultrasonography.
in a valgus position, through the anterolateral portal
(Fig 6 E and F). Statistical Analysis
Statistical analysis was conducted using SPSS for
Postoperative Management Windows (version 12.0; IBM, Armonk, NY). The
Initially, the elbow was immobilized in a posterior Mann-Whitney test was used to assess the significance
splint while flexed at 90
for 2 to 3 days. Patients were of differences in ROM and clinical scores compared
instructed to perform passive range-of-motion (ROM) with the contralateral elbow at the final follow-up.
exercises, using a hinged brace with a 30
extension A power analysis was performed to evaluate the
block, approximately 3 times a day for 4 weeks after power of group comparisons of the clinical outcomes
surgery. The exercises involved full passive ROM after 4 between the affected and contralateral elbows;
weeks. At 6 weeks postoperatively, strengthening this study achieved a power of 0.75 for detecting
exercises were initiated, and patients returned to differences with an actual a value of .05. G*Power
full activity typically at 3 months. The K-wires were software (version 3.1.9.2; Heinrich-Heine-Universität
 ARTHROSCOPY FOR TERRIBLE TRIAD OF ELBOW 5

Fig 4. Arthroscopic technique for

coronoid fracture fixation using
K-wire (left elbow). (A) Arthro-
scopic view of coronoid fracture.
(B) Reduction of fracture using
probe or grasper under arthro-
scopic view. (C, D) The use of 3 to
4 K-wires will add stability to
fracture fixation.

Düsseldorf, Düsseldorf, Germany) was used for the post fractures (n ¼ 4), open surgery of radial fractures
hoc power analysis. (n ¼ 9), ORIF of coronoid process fractures (n ¼ 2), and
unavailability for a minimum of 2 years of follow-up
Results (n ¼ 3). Consequently, 18 men and 6 women with a
We initially identified 42 patients who underwent mean age of 47.6 years (range, 20-73 years) were
surgery for terrible triad between 2011 and 2016. Of finally included, and the mean follow-up period was
these patients, 18 were excluded in accordance with the 29.8 months (range, 24-50 months). The mean opera-
following exclusion criteria: combined upper-extremity tion time was 151 minutes (range, 95-270 minutes),

Fig 5. Arthroscopic technique for coronoid fracture treatment using FiberWire (right elbow). (A) Arthroscopic view of coronoid
fracture. By use of the arthroscope, the soft tissue is sutured around the fracture fragment. (B) With a 2.7-mm drill bit, 2 holes are
created in the coronoid process that pass through the fracture site. (C) The FiberWire is inserted through the drill hole to place an
interosseous suture on the ulna.
6 S. H. LEE ET AL.

Fig 6. Illustrations and arthroscopic views of arthroscopic lateral collateral ligament (LCL) complex repair (right elbow). (A)
Ruptured LCL complex with posterior arthroscopic soft-spot portal established as viewing portal for LCL complex repair. (C, LCL
complex footprint of humeral attachment; L, LCL complex stump; P, probe.) (B) A spinal needle is passed through the radial head
(RH) portal to penetrate the LCL complex stump and joint capsule. Polydioxanone suture (PDS) is then passed through the spinal
needle and moved outside of the proximal anterolateral (PAL) portal using a grasper. (C) The high-strength nonabsorbable
suture is moved back to the RH portal. (D) One more sequence is repeated with a 10-mm gap left between it and the previous
stitches. Both paired strands of the nonabsorbable suture are knotted using the modified Mason-Allen method. First, 1 limb of
the nonabsorbable suture is passed by a shuttle relay through the ligament. Then, the suture limb is passed in the opposite
direction at about 1 cm from the first passage. A horizontal loop is made. For the third passage, suture limb is passed just medial
to the horizontal strand and forms a modified Mason-Allen stitch. Thereafter, the non-passed limb of suture is passed near the
third passage point of the previously passed limb. (E) An anterolateral portal is made using a spinal needle, and the nonab-
sorbable suture is then transferred from the RH portal to the anterolateral portal for fixation at the LCL complex footprint. The
transferred nonabsorbable sutures are fixed using 1 knotless suture anchor on the articular side of the LCL complex footprint of
the humeral attachment through the anterolateral portal. (F) Complete arthroscopic LCL complex repair and stable elbow joint.

and the mean tourniquet time was 107 minutes (range, patients with MCL and LCL injuries, stability was
55-210 minutes). obtained via only LCL repair. Patient characteristics,
Coronoid process fractures were fixed in all 24 comorbidities, and mechanisms of injury are
patients, by use of K-wires in 15 (62.5%) and ante- described in Table 1.
rior capsular repair including coronoid fracture At the final follow-up assessment, all 24 patients
fragments in 9 (37.5%). Radial head fractures were showed complete resolution of their elbow instability
treated via screw fixation in 4 patients (16.7%), only and a negative result for the lateral pivot-shift test.
the fragment of the fracture was resected in 11 Clinical scores and ROM showed no significant differ-
(45.8%), and nonoperative treatment was provided ence between the affected and contralateral elbows.
in 9 (37.5%). In the analysis of the collateral liga- According to the validated Mayo Elbow Performance
ments, 20 cases (83.3%) of medial collateral ligament Score, the elbow performance was rated excellent in 15
(MCL) injury and 24 cases (100%) of LCL injury patients and good in 9. Clinical scores and ROM are
were found on magnetic resonance imaging. In all described in Table 2.
 ARTHROSCOPY FOR TERRIBLE TRIAD OF ELBOW 7

Complications replacement.4,17 For displaced type II fractures, Rolla

No complications of the neurovascular structures et al.17 performed fixation arthroscopically without
were observed. However, nonunion of coronoid short-term complications. Excision of the radial head
fractures was observed in 4 patients (16.7%), without remains controversial with respect to indications.15 A
instability and clinical symptoms. In addition, mild previous study suggested that excision is indicated for
widening of the radiocapitellar joint space with comminuted fractures or for small fragments involving
incomplete healing on the 3-month follow-up magnetic less than 25% of the articular surface in low-demand
resonance image was observed in 1 patient, without patients with no concomitant elbow or forearm disor-
instability symptoms. Another patient had ROM der.20 Another previous study reported that satisfactory
limitations (extension-flexion, 5
-110
). However, the clinical outcomes and ROM could be obtained via
clinical score was good, and the patient did not want to arthroscopic resection of the anterior three-quarters of
undergo additional surgical procedures, such as the radial head.4 In our study, arthroscopic reduction
arthroscopic debridement. In addition, there was 1 case with fixation and partial excision were performed in 4
of pin-site irritation, which was a complication of patients (16.7%) and 11 patients (45.8%), respectively,
arthroscopic fixation of coronoid fractures and who achieved satisfactory clinical outcomes and ROM.
completely resolved after pin removal. The ulnar coronoid process plays a major role in
stabilizing the elbow joint.8,21-23 O’Driscoll et al.24,25
Discussion and Doornberg and Ring22 reported that elbow joint
The most important finding of this study was that all- instability may result from a small fracture, such as
arthroscopic treatment of TTE could restore stability Regan-Morrey types I and II. Such fractures may be
enough to permit early rehabilitation. In addition, more complex than previously imagined, and when
satisfactory clinical scores and ROM with no recurrent they are associated with ulnar collateral ligament or
instability and low rates of complications were radial collateral ligament damage, they may conse-
observed. Thus, our primary hypothesis was supported: quently lead to elbow instability. Regan-Morrey type III
All-arthroscopic treatment of TTE presented satisfactory fractures and O’Driscoll anteromedial facet fractures
clinical results with low rates of complications. can cause severe elbow instability; moreover, on the
Many fractures of the elbow can be treated with basis of the extent of bone injury rather than ligament
arthroscopic assistance, including fractures of the injury, surgeons usually opt for the safer and more
coronoid and radial head.1 The most important reliable open fixation.22,24-28 However, the other types
advantage of arthroscopy is that it offers a good view of of fractures may often be ignored during treatment,
the articular surface, which leads to a better under- which makes the outcomes more difficult to predict
standing of the morphology of the fracture lines and than those of type III fractures. Open reduction for
fragments. This facilitates more precise fracture reduc- small coronoid process fractures can be technically
tion control.15-17 Another important advantage is better challenging because it requires extensive exposure of
evaluation of associated lesions than with other tech- the fracture site and may result in the dissociation of the
niques.15,17,18 Minimal additional tissue damage with attached residual anterior capsule.8,29 The damage to
early mobilization, as well as the removal of hemarth- the integrity of the anterior capsule would impair the
rosis and articular debris, decreases the risk of adher- function as a stabilizer. Using arthroscopy can help
ence and creates circumstances that allow a better obtain intra-articular control of fracture reduction,
functional outcome.17,18 However, the techniques are which enables perfect visualization to prevent damage
challenging and have potential complications.1 The to the capsules and protect the blood supply.30,31 In our
available evidence to support the use of elbow study, all coronoid process fractures were treated with
arthroscopy in the management of intra-articular elbow arthroscopy. There were 4 cases of nonunion, which
fractures is of poor quality.19 Most current clinical did not influence the clinical outcomes. We believe that
research findings on these techniques have been nonunion (including fibrous union) did not impact
reported from small case series, and more research is outcomes because restoration of the anterior capsular
needed to evaluate the efficacy compared with other attachment and anterior bony buttress is far more
treatments.14 In addition, no study has evaluated the important than articular incongruity in this area.
clinical outcomes of all-arthroscopic treatment of TTE Savoie et al.18 compared arthroscopic repair or plica-
yet. Our study suggests the indications for and possi- tion of the LUCL in 24 patients versus open repair,
bility of all-arthroscopic treatment of TTE. We observed plication, or reconstruction in 30 patients. They
a low rate of complications with no complications from reported significant improvements in Andrews-Carson
neurovascular damage. scores in each group, with no significant difference
Radial head fractures have been treated conserva- between groups. In addition, Spahn et al.32 performed
tively, with ORIF, with arthroscopic fixation, with electrothermal shrinkage of the LUCL in 21 patients
open or arthroscopic excision, or with radial head and reported significant improvements in clinical
 8
Table 1. Data of Patients Who Underwent All-Arthroscopic Treatment for Terrible Triad

Coronoid Fracture Radial Head Fracture Ligament Injury

Case Sex/Age, Regan-Morrey Mason LCL Complex MCL Duration of Injury
No. yr Classification OP Method Classification OP Method Injury Injury OP Method Follow-Up, mo Mechanism Complication
1 M/31 II K-wire fixation I Conservative Tx Yes No LUCL repair 50 Fall from height None
2 F/67 I Suture repair II Fixation Yes Yes LUCL repair 24 Slip None
3 M/55 II K-wire fixation II Partial excision Yes Yes LUCL repair 24 Slip None
4 F/62 II K-wire fixation I Conservative Tx Yes Yes LUCL repair 24 Slip None
5 F/61 II K-wire fixation II Partial excision Yes Yes LUCL repair 35 Slip None
6 M/41 II Suture repair III Fixation Yes Yes LUCL repair 32 Fall from height Nonunion
7 M/25 II K-wire fixation I Conservative Tx Yes Yes LUCL repair 29 Slip Nonunion
8 F/42 I Suture repair II Fixation Yes Yes LUCL repair 50 Slip ROM limitation
9 M/73 II K-wire fixation I Conservative Tx Yes Yes LUCL repair 27 Slip Incomplete LCL

S. H. LEE ET AL.
complex healing
10 M/72 II K-wire fixation I Conservative Tx Yes No LUCL repair 30 Slip None
11 M/56 I Suture repair II Partial excision Yes Yes LUCL repair 24 Fall from height None
12 M/20 I Suture repair I Conservative Tx Yes Yes LUCL repair 26 Fall from height None
13 M/39 II K-wire fixation II Fixation Yes Yes LUCL repair 28 Fall from height None
14 M/40 II K-wire fixation II Partial excision Yes Yes LUCL repair 27 Passenger traffic None
accident
15 F/61 II K-wire fixation II Partial excision Yes Yes LUCL repair 32 Slip Nonunion
16 M/72 II K-wire fixation II Partial excision Yes Yes LUCL repair 26 Passenger traffic Pin-site irritation
accident
17 F/67 I Suture repair I Conservative Tx Yes Yes LUCL repair 24 Slip None
18 M/28 II K-wire fixation I Partial excision Yes No LUCL repair 36 Slip None
19 M/22 II K-wire fixation II Partial excision Yes No LUCL repair 36 Slip None
20 M/45 II K-wire fixation III Partial excision Yes Yes LUCL repair 26 Fall from height None
21 M/46 I Suture repair II Partial excision Yes Yes LUCL repair 27 Passenger traffic None
accident
22 M/47 II K-wire fixation I Conservative Tx Yes Yes LUCL repair 26 Fall from height Nonunion
23 M/20 II Suture repair I Conservative Tx Yes Yes LUCL repair 26 Slip None
24 M/51 I Suture repair II Partial excision Yes Yes LUCL repair 26 Fall from height None
F, female; LCL, lateral collateral ligament; LUCL, lateral ulnar collateral ligament; M, male; MCL, medial collateral ligament; OP, operative; ROM, range of motion; Tx, treatment.
 ARTHROSCOPY FOR TERRIBLE TRIAD OF ELBOW 9

Table 2. Clinical Scores and ROM at Final Follow-Up nonrandomized nature of the study, which can lead to
selection bias. To prevent bias from the learning curve,
Affected Elbow Contralateral Elbow P Value
arthroscopic surgery was performed for fractures after
MEPS, points 93 (75-100) 100 .31
ROM,
elbow arthroscopic surgery had been performed in
Extension 4.8  1.1 0  0.3 .24 more than 20 cases.
Flexion 132.5  6.3 140  2.4 .34
Supination 85  5.2 90  1.8 .41
Pronation 81.5  4.8 90  1.5 .28 Conclusions
NOTE. Data are presented as mean  standard deviation or mean All-arthroscopic treatment for the terrible triad can
(range). provide an excellent safety profile without the need for
MEPS, Mayo Elbow Performance Score; ROM, range of motion. a large incision if the indications are met.

outcomes. Recently, O’Brien et al.33 reported that acute References

and subacute arthroscopic repairs of the radial ulno- 1. Fink Barnes LA, Parsons BO, Hausman M. Arthroscopic
management of elbow fractures. Hand Clin 2015;31:
humeral ligament are safe and effective procedures for
651-661.
patients with simple elbow dislocation. In our study, 2. Kim JW, Yi Y, Kim TK, et al. Arthroscopic lateral collateral
only 1 patient had mild widening of the radiocapitellar ligament repair. J Bone Joint Surg Am 2016;98:1268-1276.
joint space with incomplete healing. No patient com- 3. Lee JM, Yi Y, Kim JW. Arthroscopically assisted surgery
plained of postoperative instability. for coronoid fractures. Orthopedics 2015;38:742-746.
Considering the MCL’s role as the primary stabilizer 4. Michels F, Pouliart N, Handelberg F. Arthroscopic man-
of the elbow joint, surgical management to repair the agement of Mason type 2 radial head fractures. Knee Surg
torn MCL seems warranted.34,35 Nevertheless, a previ- Sports Traumatol Arthrosc 2007;15:1244-1250.
ous study on simple elbow dislocations showed no 5. Yeoh KM, King GJ, Faber KJ, Glazebrook MA, Athwal GS.
significant differences in clinical outcomes between Evidence-based indications for elbow arthroscopy.
patients who underwent surgical repair and those who Arthroscopy 2012;28:272-282.
6. Steinmann SP. Elbow arthroscopy: Where are we now?
did not.34 Regarding the terrible-triad injury, Forthman
Arthroscopy 2007;23:1231-1236.
et al.11 concluded that MCL repair was unnecessary to
7. Hotchkiss RN. Fractures and dislocations of the elbow. In:
obtain satisfactory outcomes with surgical treatment. Rockwood CA, Green DP, Bucholz RW, Heckman JD, eds.
Toros et al.36 reported no differences in functional Rockwood and Green’s fractures in adults. Ed 4. Philadelphia:
scores between a group with MCL repair and a group Lippincott-Raven, 1996;929-1024.
without it. In addition, Hatta et al.37 supposed that the 8. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD.
effect of MCL repair on elbow motion and function Standard surgical protocol to treat elbow dislocation with
might be small when comparing patients who under- radial head and coronoid fractures. J Bone Joint Surg Am
went MCL repair for TTE and those who did not. Our 2004;86-A:1122-1130.
results support these previous findings; postoperative 9. Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the
elbow function was not necessarily affected by the elbow with fractures of the radial head and coronoid.
J Bone Joint Surg Am 2002;84:547-551.
supplementation of MCL repair in the systematic
10. Egol KA, Immerman I, Paksima N, Tejwani N, Koval KJ.
treatment of the terrible-triad injury. We found
Fracture-dislocation of the elbow functional outcome
20 cases (83.3%) of MCL injury and 24 cases (100%) of following treatment with a standardized protocol. Bull
LCL injury. In all patients with MCL and LCL injuries, NYU Hosp Jt Dis 2007;65:263-270.
stability was obtained via only LCL repair. 11. Forthman C, Henket M, Ring DC. Elbow dislocation with
We cautiously suggest that stability could be obtained intraarticular fracture: The results of operative treatment
without MCL repair if coronoid process fixation without repair of the medial collateral ligament. J Hand
and LCL complex repair are securely performed Surg Am 2007;32:1200-1209.
arthroscopically. 12. Zeiders GJ, Patel MK. Management of unstable elbows
following complex fracture-dislocations-the “terrible
Limitations triad” injury. J Bone Joint Surg Am 2008;90:75-84.
The most significant limitation of this study is the 13. Pierrart J, Bégué T, Mansat P, GEEC. Terrible triad of the
relatively low number of surgical interventions per- elbow: Treatment protocol and outcome in a series of
eighteen cases. Injury 2015;46:S8-S12 (suppl 1).
formed for each indication. The second limitation is
14. Van Tongel A, Macdonald P, Van Riet R, et al. Elbow
that this study presents an analysis of patients treated
arthroscopy in acute injuries. Knee Surg Sports Traumatol
by a single surgeon experienced in elbow arthroscopy. Arthrosc 2012;20:2542-2548.
Elbow arthroscopy is a technically challenging pro- 15. Menth-Chiari W, Poehling G, Ruch D. Arthroscopic
cedure with a steep learning curve and may not be resection of the radial head. Arthroscopy 1999;15:226-230.
suitable for occasional use in the treatment of elbow 16. Menth-Chiari W, Ruch D, Poehling G. Arthroscopic
pathology. Other limitations are the retrospective and excision of the radial head: Clinical outcome in 12 patients
10 S. H. LEE ET AL.

with post-traumatic arthritis after fracture of the radial 28. Regan W, Morrey B. Fractures of the coronoid process of
head or rheumatoid arthritis. Arthroscopy 2001;17: the ulna. J Bone Joint Surg Am 1989;71:1348-1354.
918-923. 29. Hausman MR, Klug RA, Qureshi S, et al. Arthroscopically
17. Rolla PR, Surace MF, Bini A, et al. Arthroscopic treatment assisted coronoid fracture fixation: A preliminary report.
of fractures of the radial head. Arthroscopy 2006;22:233. Clin Orthop Relat Res 2008;466:3147-3152.
e1-233.e6. 30. Adams JE, Merten SM, Steinmann SP. Arthroscopic
18. Savoie FH III, Field LD, Gurley DJ. Arthroscopic and open assisted treatment of coronoid fractures. Arthroscopy
radial ulnohumeral ligament reconstruction for postero- 2007;23:1060-1065.
lateral rotatory instability of the elbow. Hand Clin 2009;25: 31. O’Brien MJ, Savoie FH III. Arthroscopic and open man-
323-329. agement of posterolateral rotatory instability of the elbow.
19. Yeoh KM, King GJ, Faber KJ, et al. Evidence-based in- Sports Med Arthrosc 2014;22:194-200.
dications for elbow arthroscopy. Arthroscopy 2012;28: 32. Spahn G, Kirschbaum S, Klinger HM, Wittig R. Arthro-
272-282. scopic electrothermal shrinkage of chronic posterolateral
20. Wijeratna M, Bailey KA, Pace A, et al. Arthroscopic radial elbow instability: Good or moderate outcome in 21 pa-
head excision in managing elbow trauma. Int Orthop tients followed for an average of 2.5 years. Acta Orthop
2012;36:2507-2512. 2006;77:285-289.
21. Closkey RF, Goode JR, Kirschenbaum D, et al.; The role of 33. O’Brien MJ, Lee Murphy R, Savoie FH III. A preliminary
the coronoid process in elbow stability. A biomechanical report of acute and subacute arthroscopic repair of the
analysis of axial loading. J Bone Joint Surg Am 2000;82-A: radial ulnohumeral ligament after elbow dislocation
1749-1753. in the high-demand patient. Arthroscopy 2014;30:
22. Doornberg JN, Ring D. Coronoid fracture patterns. J Hand 679-687.
Surg Am 2006;31:45-52. 34. Pichora JE, Fraser GS, Ferreira LF, et al. The effect of
23. Sanchez-Sotelo J, O’Driscoll SW, Morrey BF. Medial medial collateral ligament repair tension on elbow joint
oblique compression fracture of the coronoid process of kinematics and stability. J Hand Surg Am 2007;32:
the ulna. J Shoulder Elbow Surg 2005;14:60-64. 1210-1217.
24. O’Driscoll SW, Jupiter JB, Cohen MS, et al. Difficult elbow 35. Safran MR, Baillargeon D. Soft-tissue stabilizers of the
fractures: Pearls and pitfalls. Instr Course Lect 2003;52: elbow. J Shoulder Elbow Surg 2005;14:179S-185S
113-134. (suppl S).
25. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory 36. Toros T, Ozaksar K, Sügün TS, et al. The effect of medial
instability of the elbow. J Bone Joint Surg Am 1991;73: side repair in terrible triad injury of the elbow. Acta Orthop
440-446. Traumatol Turc 2012;46:96-101.
26. Cohen MS. Fractures of the coronoid process. Hand Clin 37. Hatta T, Nobuta S, Aizawa T, et al. Comparative analysis
2004;20:443-453. of surgical options for medial collateral ligament repair in
27. Manidakis N, Sperelakis I, Hackney R, et al. Fractures of terrible triad injury of the elbow. Orthop Rev (Pavia)
the ulnar coronoid process. Injury 2012;43:989-998. 2016;8:6666.