Nonsurgical Approach to Some Terrible Triad Injuries of the Elbow Possible for Select Patients

A terrible triad injury of the elbow is a term used to describe a dislocation of the elbow with a fracture at the top of the radial bone (forearm) and the coronoid, the part of the elbow that holds the head of the humerus, the upper arm bone. Because of the extent of the injury, the usual treatment is open surgery. However, there are sometimes patients who cannot or do not want surgery, so nonsurgical treatment must be done instead. The authors of this article reviewed the cases of four patients who refused or preferred not to have surgery to treat the terrible triad injury.

The first patient, a 32-year-old male, fell from standing height and sustained the elbow injury. X-rays showed there was a posterior dislocation of the elbow and fractures of the radial head and coronoid. Both bones had been displaced (moved out of place), although the radial head had a more severe displacement. Because the patient refused surgery, he was fit with a sling and was told to avoid shoulder abduction, or moving the arm away from the body, for one month.

After three months, the elbow had stabilized but the patient had developed a problem with the nerves running through the elbow, which caused numbness and limited motion of the lower arm. New x-rays showed the bone had healed but joined together in areas where it should not have: at the front of the radial neck. The bone formation also caused a misshapen radial head, the top of the bone. At this point, surgery was done to help release the elbow contracture (bending inward of the elbow). Seven months after the surgery, the patient was able to extend his arm to 140 degrees and was no longer contracted, although one month later, he did report numbness and weakness because of pressure on the nerves extending from the elbow, which was corrected by another surgeon.

The second patient, a 60-year-old woman, also fell from standing height. Her dislocated elbow was reduced (put back into place) and splinted. After removing her splint 10 days later, she returned to the doctor, able to extend her arm to 135 degrees and that her elbow could contract to 25 degrees, and she did not complain of significant pain.

X-rays of the patient's elbow showed that although the fractures for the terrible triad were present, there was not much bone movement. Because the patient had good range of motion and little pain, the decision was made not to operate. She was also told to avoid shoulder abduction, as was the first patient. Fifty-five months after the initial injury, follow up showed that she had 140 degrees movement on contraction and full movement on extension.

The third patient was a 40-year-old male who did manual labor who also injured himself from a standing height. After the elbow was reduced and splinted, x-rays showed that the fractures were not badly displaced. Since the patient had decent motion (flexion of 125 degrees and contraction of 40 degrees) and he did not want surgery, the doctors treated him with a sling, advice to avoid shoulder abduction for one month, and active, assisted range-of-motion exercises for the elbow. Two months later, the patients had returned to his pre-injury level of work. The x-rays did show some deformity and less flexion (only 125 degrees compared to 145 in the non-injured elbow) and some deformity on the radial head. However, the patient did not complain of pain or any nerve issues.

Finally, the fourth patient was a 48-year-old who fell from a mountain bike, dislocating his elbow and sustaining the two fractures. The initial hospital visit resulted in reducing the elbow and splinting. After two days, x-rays showed the fractures and movement of the bone. Although the doctors recommended surgery, the patient refused so treatment involved using a sling, avoiding shoulder abduction for one month, and active assisted elbow range-of-motion exercises.

Seven months after the initial injury, x-rays showed that the bones had aligned and healed and the patient had full range of motion. However, he did complain of mild pain.

In general, the authors found that certain patients with the terrible triad elbow injury can be managed without surgery. They pointed out that the cause of the injury could play a role in how effective nonsurgical treatment may be. The types of fractures the patients had were single, transverse, the type of bone that breaks straight through. Mot unstable fractures are those that are larger and not transverse.

Although one of the case study patients, the first one, did have surgery in the long-run, the cause of the bone build up may not have had anything to do with the nonsurgical and may have occurred anyway.

References: Thierry G. Guitton, MSc, and David Ring, MD, PhD. Nonsurgically Treated Terrible Triad Injuries of the Elbow: Report of Four Cases. In Journal of Hand Surgery March 2010. Vol. 35. No. 3. Pp. 464-467.