Tag Archives: Arthroplasty
Hypothesis on the Surgical Management and Outcomes of Terrible Triad Injuries around the Elbow
Vol 9 | Issue 1 | January-June 2023 | page: 21-24 | Haroon Ansari, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i01.202
Author: Haroon Ansari [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Haroon Ansari,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: ansariharoon045@gmail.com
Abstract
Background: The terrible triad of the elbow—radial-head fracture, coronoid fracture and posterolateral dislocation—creates a mechanically unstable joint that commonly leads to pain, stiffness and impaired daily activities when not reconstructed properly. Modern surgical care aims to restore the anterior bony buttress by fixing the coronoid, to preserve or replace the radial head to maintain radiocapitellar contact, and to repair the lateral collateral ligament to regain stability and permit early controlled motion.
Hypothesis: We hypothesize that a disciplined, anatomy-focused operative sequence—fixation or repair of the coronoid, reconstruction or arthroplasty of the radial head as determined by fracture morphology, repair of the lateral collateral ligament, and selective medial-sided repair only if residual instability persists—combined with early supervised mobilisation will restore joint stability, reduce pain and result in meaningful functional gains in adult patients with terrible-triad injuries. Functional success will be measured by improvements in the Mayo Elbow Performance Score, restoration of a functional flexion-extension arc commonly greater than 100 degrees, recovery of near-normal forearm rotation, and acceptable pain scores, while monitoring complications and reoperation rates.
Clinical importance: For surgeons, applying this reproducible protocol improves the likelihood of a stable, functional elbow. Repairing even small coronoid fragments, selecting radial-head replacement when reconstruction is impractical, and reserving medial repair for persistent instability reduce recurrent instability and need for salvage operations. Close follow-up, clear patient counselling about expected recovery and complications, and a structured physiotherapy programme are essential to manage stiffness and restore strength.
Future research: Large multicentre prospective cohorts and randomized trials comparing radial-head fixation versus arthroplasty for defined fracture types, head-to-head comparisons of coronoid fixation techniques, and standardised rehabilitation protocols with long-term follow-up are needed to refine indications and reduce complications. Biomechanical work linking fragment morphology to fixation choice would further reduce practice variability. Studies should include validated patient-reported outcome measures, cost-effectiveness analyses, and subgroup analyses by age and bone quality, and implant survivorship.
Keywords: Terrible triad, Elbow, Coronoid, Radial head, Lateral collateral ligament, Arthroplasty, Fixation, Rehabilitation.
Background
The “terrible triad” of the elbow — a combination of radial-head fracture, coronoid fracture and posterolateral elbow dislocation — was named because, left untreated or treated poorly, it frequently led to pain, recurrent instability and poor function. Early descriptions emphasized that the triad disrupts both the bony constraints (radial head and coronoid) and the soft-tissue stabilizers (lateral collateral ligament complex), producing a mechanically unstable elbow that is difficult to manage without surgery. Hotchkiss popularized the term and highlighted the poor natural history without adequate reconstruction; Regan and Morrey provided the familiar coronoid classification that helps guide fixation decisions; Mason’s classification of radial-head fractures remains central to choosing fixation versus replacement. [1–3]
Biomechanical and clinical work shows that the coronoid is the primary anterior buttress against posterior translation, while the radial head contributes to valgus and radiocapitellar stability. Cadaveric and finite-element studies indicate that even relatively small coronoid tip fragments can be functionally important because they carry capsular and ligamentous attachments that affect stability; conversely, large coronoid defects (type III) reliably require fixation to avoid late instability. The radial head, particularly when comminuted, cannot always be reconstructed — in those cases arthroplasty is used as a spacer to re-establish height and radiocapitellar contact. [4–6]
Contemporary operative practice has therefore adopted a principle-based, stepwise approach: restore the anterior bony buttress (coronoid), restore the radial head (fixation when feasible; arthroplasty when not), repair the lateral collateral ligament (LUCL/LCL) and reassess stability — repairing the medial collateral ligament only when residual instability persists; a hinged external fixator is a salvage option for persistent instability. Studies reporting this sequence show better maintenance of concentric reduction, permit early controlled motion and achieve satisfactory functional scores in most patients, though complication rates remain meaningful. [7–12]
Surgical technique is adapted to fragment size and location: small coronoid tip fractures are commonly stabilized with suture lasso or anchors while larger fragments require screws or buttress plating; anteromedial facet fractures often need medial exposure and buttress fixation because they act as a varus/medial buttress. For radial-head fractures, attempts at reconstruction are reasonable in younger patients when fragments can be anatomically restored; for severely comminuted heads, modular metallic arthroplasty more reliably restores length and radiocapitellar mechanics and avoids proximal migration. Approaches vary (lateral-only versus combined medial and lateral exposures) and each has tradeoffs related to soft-tissue dissection and neurovascular risk. [13–16]
Despite improvements in technique, the literature documents a substantial complication burden — heterotopic ossification, stiffness, nerve palsies and a nontrivial reoperation rate for stiffness, instability or implant problems. Outcomes are better when reconstruction is performed early, when the reconstruction restores radiocapitellar contact and coronoid buttress, and when early supervised rehabilitation is begun once a stable construct is confirmed. Published series show a majority achieving good to excellent results on validated scores (for example MEPS), but with
Complication and reoperation rates that demand careful patient counselling and meticulous surgical technique. [17–20]
Hypothesis
Primary hypothesis:
When surgeons apply a systematic, anatomy-focused operative sequence — restore coronoid (repair/fixation) → restore radial head (fix or replace) → repair lateral collateral ligament → reassess and address the medial side only if needed — and begin early controlled rehabilitation, patients with terrible-triad injuries will gain significant functional improvement (as measured by MEPS, range of motion and pain scores) with acceptable complication rates. [21]
Secondary hypotheses:
1. Radial-head arthroplasty is more reliable than attempted fixation in severely comminuted radial-head fractures within the terrible-triad pattern, producing more consistent restoration of radiocapitellar contact and reducing late instability or need for secondary procedures. [22]
2. Repair of even small coronoid tip fragments (with a suture lasso or anchor) materially improves early stability compared with leaving them untreated, because capsular and ligamentous insertions on small fragments contribute disproportionately to joint restraint. [23]
3. Routine medial collateral ligament (MCL) repair is unnecessary; selective MCL repair only for persistent instability after anterior and lateral reconstruction minimizes surgical morbidity while addressing instability when indicated. [24]
4. A stepwise algorithm (coronoid → radial head → LCL → reassess → MCL/hinge if needed) results in a majority of patients achieving a functional arc of motion and good/excellent MEPS scores at medium-term follow-up, while keeping reoperation rates within published expectations. [25]
Rationale and plan for measurement:
These hypotheses rest on the mechanical role of the coronoid and radial head and the central role of the lateral collateral complex in resisting posterolateral rotatory and varus-posteromedial failure. Practically, the study measures pre- and post-operative MEPS, active flexion/extension and forearm rotation (goniometer), VAS pain, radiographic maintenance of reduction and evidence of heterotopic ossification. Success is operationalized as a clinically meaningful rise in MEPS category and restoration of a functional arc of motion (commonly >100° flexion-extension and near-normal pronation/supination) with no recurrent dislocation. Complications including HO, nerve palsy, implant failure and need for reoperation are recorded and compared with historical series. [21–25]
Discussion
This series and the thesis literature support the central idea that a disciplined, anatomy-first operative approach converts a once “terrible” injury into one that frequently yields useful function. Restoring the coronoid — even when the fragment appears small — is important because it re-establishes the anterior buttress and the capsular attachments that restrain posterior translation; repair by suture lasso/anchors for tip fragments or screws/plates for larger or anteromedial facet fractures prevents varus collapse and later arthrosis. [1–5]
When the radial head is reconstructable, fixation preserves native anatomy and is reasonable in younger patients. However, when the head is severely comminuted, arthroplasty more predictably restores length and radiocapitellar contact and avoids problems such as proximal migration and late valgus deformity that were seen historically with simple excision. Several comparative series in the thesis point toward lower instability and improved short-term function with arthroplasty in the appropriate setting. [6–9]
Repair of the lateral collateral ligament complex is essential to control posterolateral rotatory instability; the MCL need only be repaired if the elbow remains unstable after reconstituting bony anatomy and repairing the lateral side. Selective MCL repair avoids unnecessary additional medial dissection and its attendant risks. If residual instability persists despite soft-tissue repair, a hinged external fixator offers a temporary stabilizing strategy that allows early motion while soft tissues heal. [10–14]
Outcomes reflect this logic: most patients reach a functional arc of motion and report reduced pain and improved MEPS, but the complication rate remains substantial — heterotopic ossification, nerve symptoms (radial or ulnar neuropraxia), stiffness requiring adhesiolysis, and occasional implant problems are reported across multiple series. Timely surgery, careful reconstruction of coronoid and radial head, judicious use of arthroplasty, meticulous ligament repair and early supervised rehabilitation together reduce but do not eliminate these risks. [15–20]
Clinical importance
For surgeons, this work clarifies a reproducible pathway: restore the coronoid buttress, preserve or replace the radial head depending on reconstructability, repair the lateral collateral ligament, and only address the medial side if residual instability remains. Applying this sequence allows early controlled motion and yields useful elbow function in most patients while recognizing and mitigating common complications through careful technique and dedicated rehabilitation. The practical benefit is fewer recurrent instabilities and better early function compared with historical non-operative care.
Future direction
Future research should aim for larger, multicentre prospective cohorts or randomized comparisons of radial-head fixation versus arthroplasty in defined fracture patterns, and head-to-head trials of coronoid fixation techniques (suture lasso/anchor vs screws vs medial buttress plating for anteromedial facets). Standardized, protocolized rehabilitation regimens and longer-term follow-up will help define drivers of late arthritis and hardware-related problems. Biomechanical studies that link fragment morphology to a specific fixation strategy would also reduce practice variability.
References
1. Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD, editors. Rockwood and Green‘s fractures in adults. 4th ed. Philadelphia: Lippincott-Raven; 1996. p. 980–981.
2. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am. 1989; 71:1348–1354.
3. Mason ML. Some observations on fractures of the head of radius with a review of one hundred cases. Br J Surg. 1954; 42:123–132.
4. Miyazaki AN, Checchia CS, Fagotti L, Fregoneze M, Santos PD, Andrade L, et al. Evaluation of the results from surgical treatment of the terrible triad of the elbow. (May/June 2014) Vol 49 No.3.
5. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res. 1987; 216:109–119.
6. Hong-wei Chen, Guo-dong Liu, Shan Ou, Jun Fei. Operative treatment of terrible triad of the elbow via posterolateral and anteromedial approaches. Apr 2015.
7. Guanyi Liu, Weihu Ma, Ming Li, Jianxiang Feng, Rongming Xu, Zhijun Pan. Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol.
8. Armstrong AD. The terrible triad injury of the elbow. Curr Opin Orthop. 2005; 16:267–270.
9. Hildebrand KA, Patterson SD, King GJ. Acute elbow dislocations: simple and complex. Orthop Clin North Am. 1999; 30:63–79.
10. Armstrong AD, Dunning CE, Faber KJ, et al. Rehabilitation of the medial collateral ligament-deficient elbow: an in vitro biomechanical study. J Hand Surg. 2000; 25:1051–1057.
11. Closkey RF, Goode JR, Kirschenbaum D, et al. The role of the coronoid process in elbow stability: a biomechanical analysis of axial loading. J Bone Joint Surg Am. 2000; 82A:1749–1753.
12. Wake H, Hashizume H, Nishida K. Biomechanical analysis of the mechanism of elbow fracture–dislocations by compression force. J Orthop Sci. 2004; 9:44–50.
13. Pugh DMW, McKee MD. The terrible triad of the elbow. (2002) 6(1):21–29.
14. Ring D, Jupiter J, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. (2002) 84(4):547–551.
15. Bain GI, Ashwood N, Baird R, Unni R. Management of Mason type 3 radial head fractures with a titanium prosthesis, ligament repair and early mobilisation. (2004) Vol. 86-A: 274–280.
16. Doornberg JN, van Duijn J, Ring D. Coronoid fracture height in terrible triad injuries. J Hand Surg. 2006; 31A:794–797.
17. Ring D, Doornberg JN. Fracture of the anteromedial facet of the coronoid process: surgical technique. J Bone Joint Surg Am. 2007; 89:267–283.
18. Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: results of operative treatment without repair of the medial collateral ligament. 2007.
19. Ring D. Displaced, unstable fractures of the radial head: fixation vs replacement — what is the evidence? 2008.
20. Clarke SE, Lee SY, Raphael JR. Coronoid fixation using suture anchors. 2008.
21. Lindenhovius ALC, Jupiter JB, Ring D, McKee MD. Comparison of acute versus subacute treatment of terrible triad injuries of the elbow. J Hand Surg. 2008; 33A:920–926.
22. Johnson J, King G. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. 2008.
23. Seijas R, Ares-Rodriguez O, Orellana A, Albareda D, Collado D, Llusa M. Terrible triad of the elbow. J Orthop Surg. 2009; 17(3):335–339.
24. Pollock JW, Brownhill J, Ferreira L, McDonald CP, Johnson J, King G. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. 2009.
25. Micic I, Kim S-Y, Park Me-H, Kim P-T, Jeon I-H. Surgical management of unstable elbow dislocation without intra-articular fracture. Int Orthop (SICOT). 2009; 33:1141–1147.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2020
| How to Cite this Article: Ansari H, Pradhan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P. Hypothesis on the Surgical Management and Outcomes of Terrible Triad Injuries around the Elbow. Journal of Medical Thesis. January-June 2023; 9(1):21-24. |
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Optimizing Surgical Management for Terrible Triad Injuries of the Elbow: A Prospective Outcome-Based Study
Vol 7 | Issue 2 | July-December 2021 | page: 13-16 | Haroon Ansari, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2021.v07.i02.166
Author: Haroon Ansari [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Terrible triad injuries of the elbow—comprising a radial head fracture, coronoid process fracture, and posterolateral dislocation—pose significant challenges in restoring joint stability and function.
Methods and Materials: In this prospective study, 27 adults with closed terrible triad injuries were treated surgically between July 2017 and October 2018. Preoperative evaluation included radiographs and CT scans for fracture classification. The surgical protocol involved radial head fixation or arthroplasty, coronoid reconstruction, and repair of the lateral collateral ligament complex, with selective medial collateral ligament repair based on intraoperative stability tests.
Results: Functional outcomes, as measured by the Mayo Elbow Performance Score, improved from an average of 73.1 at 3 months to 87.0 at 6 months. Serial radiographs confirmed maintained joint reduction and progressive healing, while complications were minimal, with only one case of heterotopic ossification managed conservatively.
Conclusion: Early, individualized, and anatomy-based surgical management of terrible triad injuries leads to significant improvements in elbow stability and function.
Keywords: Terrible triad, Elbow injury, Radial head fracture, Coronoid fracture, Ligament repair, Arthroplasty, Functional outcome.
Introduction:
Terrible triad injuries of the elbow were first described by Hotchkiss [1] as a complex injury pattern involving fractures of the radial head and coronoid process combined with elbow dislocation. The importance of the coronoid process in resisting posterior displacement was emphasized by Regan and Morrey [2], while Mason’s classification [3] has provided a framework for managing radial head fractures over the years. Typically resulting from a fall on an outstretched hand, these injuries subject the elbow to axial load and valgus stress that generate both bony and soft tissue damage [4,5].
Restoration of the bony anatomy is paramount; fixation or replacement of the radial head re-establishes the radiocapitellar articulation, and reconstruction of the coronoid process reconstitutes the anterior buttress of the ulnohumeral joint [6]. Equally, the integrity of the lateral collateral ligament complex (LCLC) is vital to prevent posterolateral rotatory instability [7]. In cases where the medial collateral ligament (MCL) is also compromised, its repair is performed only when intraoperative stability testing reveals persistent medial instability [8]. Intraoperative assessments such as the hanging arm test and fluoroscopic evaluation play a crucial role in confirming the adequacy of the reconstruction [9].
The purpose of this study was to evaluate the clinical and radiographic outcomes of a standardized, yet tailored, surgical approach in managing terrible triad injuries of the elbow. We hypothesized that early, meticulous reconstruction of both bony and ligamentous structures would lead to improved stability and function, as reflected by serial MEPS assessments and radiographic healing.
Materials and Methods
This prospective study enrolled 27 patients (17 males and 10 females) over the age of 18 with closed terrible triad injuries of the elbow treated surgically at our institution between July 2017 and October 2018. Patients with compound injuries, a history of prior elbow infection, or associated fractures of the upper limb that might affect functional evaluation were excluded. Institutional ethics committee approval was obtained and all patients provided informed consent.
Preoperative Evaluation
All patients underwent detailed clinical examination and standard anteroposterior and lateral radiographs of the injured elbow. When plain films were insufficient to delineate fracture details, computed tomography (CT) with three-dimensional reconstruction was performed [10]. Coronoid fractures were classified using the Regan–Morrey system [2]: Type I (tip fractures), Type II (fractures involving ≤50% of the coronoid height), and Type III (fractures involving >50% of the height). Radial head fractures were classified according to Mason’s criteria [3]. Routine laboratory investigations—including complete blood counts, inflammatory markers, and viral screenings—were conducted preoperatively.
Operative Technique
Surgical procedures were performed under general anesthesia, with or without regional block, based on patient factors. Patients were positioned supine or in lateral decubitus, according to the planned surgical approach. In most cases, a lateral (Kocher) approach was used to expose the radial head and LCLC . When the coronoid fracture was not adequately accessible via the lateral window, an additional anteromedial approach was utilized .
For radial head fractures, minimally displaced fractures were managed with open reduction and internal fixation (ORIF), while comminuted fractures were addressed via radial head arthroplasty to restore the radiocapitellar joint [11,12]. The coronoid process was reconstructed according to fragment size; small fragments were managed with suture fixation techniques, whereas larger fragments were secured with cannulated screws or a T-type locking plate [12].
The LCLC was repaired in all cases—either by direct suture repair or using suture anchors when additional fixation strength was required [13]. Intraoperative stability was assessed using the hanging arm test (Figure 3) and dynamic fluoroscopy. If residual instability was noted, particularly medially, the MCL was repaired via the anteromedial approach [8]. In cases with persistent instability despite reconstruction, a temporary hinged external fixator was applied to maintain reduction while allowing early mobilization [14].
Postoperative Management and Follow-Up
Postoperatively, patients received prophylactic antibiotics—typically a combination of a third-generation cephalosporin and an aminoglycoside—and were immobilized in an above-elbow back slab for three weeks. Following suture removal, a structured rehabilitation program emphasizing gradual active and passive range-of-motion exercises was initiated. Follow-up evaluations were performed at 3 weeks, 3 months, 6 months, and 12 months postoperatively. Functional outcomes were measured using the Mayo Elbow Performance Score (MEPS) and a visual analog scale (VAS) for pain, while radiographic assessments monitored fracture healing, joint congruity, and the development of complications such as heterotopic ossification [15].
Results
The study cohort had a mean age primarily within the 18–30 years group (33.3%), with 55.5% of injuries resulting from two-wheeler accidents. Radiographically, 59.3% of coronoid fractures were classified as Regan–Morrey Type I, 37% as Type II, and 3.7% as Type III. Radial head fractures were managed surgically in 96.3% of patients. All patients underwent repair of the LCLC; intraoperative assessment dictated that 51.9% also required MCL repair.
MEPS improved from an average of 73.1 at 3 months to 87.0 at 6 months postoperatively, reflecting significant restoration of elbow function. Subgroup analysis revealed that patients who underwent LCLC repair using suture anchors had statistically superior improvements in forearm pronation and overall MEPS compared to those managed with direct suture repair (p < 0.05) [13,16]. No significant differences in range of motion or MEPS were observed across different coronoid fracture types (p > 0.05).
Complications were minimal. One patient developed grade 2A heterotopic ossification, according to the Hastings and Graham classification, which led to a temporary limitation in elbow flexion and extension. This complication was managed conservatively with indomethacin and targeted physiotherapy, eventually yielding a functional elbow range [15]. Serial radiographs at immediate, 3-month, and 12-month intervals confirmed maintained reduction, progressive healing, and proper implant positioning.
Discussion
Our study demonstrates that an individualized, anatomy-based surgical approach can effectively restore elbow stability in patients with terrible triad injuries. Early reconstruction of the radial head and coronoid process re-establishes the bony architecture and, when combined with meticulous repair of the LCLC, prevents posterolateral rotatory instability. Our results support the findings of Hotchkiss [1] and Regan and Morrey [2], who stressed the critical role of these structures in elbow stability.
Radial head arthroplasty in cases of comminuted fractures was associated with reliable outcomes, minimizing the risk of malunion and nonunion [11,12]. Similarly, reconstruction of the coronoid process—via suture fixation for small fragments or screw fixation for larger fragments—proved essential in reconstituting the anterior buttress of the elbow. The method of LCLC repair was also crucial; patients receiving suture anchor repair showed statistically better functional outcomes than those managed with direct suturing [13,16]. Selective repair of the MCL based on intraoperative stability testing allowed us to avoid unnecessary medial dissection and reduce the risk of ulnar nerve injury [8].
Condensing our discussion, the key factors for successful management are early intervention, accurate anatomical reduction, and robust soft tissue repair guided by intraoperative assessments such as the hanging arm test and fluoroscopy [9,14]. Despite the relatively small sample size and heterogeneity in fracture patterns, our results are consistent with previous studies advocating for aggressive, individualized surgical management [4–8]. Future studies with larger cohorts and longer follow-up periods are warranted to further refine these techniques and evaluate long-term functional outcomes.
Conclusion
The management of terrible triad injuries of the elbow requires a comprehensive strategy that addresses both the osseous and ligamentous components of the injury. Our prospective study shows that early, meticulous reconstruction of the radial head and coronoid process, combined with robust repair of the LCLC—and selective MCL repair when indicated—results in improved elbow stability and functional recovery. With a structured postoperative rehabilitation program, patients achieved significant improvements in MEPS and overall range of motion over a 12-month period. These findings underscore the importance of an individualized, anatomy-based surgical approach in optimizing outcomes for this challenging injury pattern.
References
1. Hotchkiss RS. The terrible triad of the elbow. Clin Orthop Relat Res. 1996;(332):78–83.
2. Regan EG, Morrey BF. Coronoid process fractures of the ulna. J Bone Joint Surg Am. 1989;71(9):1338–44.
3. Mason ML. Some results of treatment of fractures of the head and neck of the radius. J Bone Joint Surg Am. 1954;36-A:885–8.
4. Rietbergen H, Morrey BF. Fractures of the radial head: current concepts. J Bone Joint Surg Am. 2008;90(1):172–82.
5. Pugh DM, Wild LM, et al. Outcomes following surgical repair of terrible triad injuries of the elbow. J Orthop Trauma. 2002;16(7):437–44.
6. Ring D, Jupiter JB, Simpson NS. Operative treatment of complex elbow dislocations: the terrible triad. J Bone Joint Surg Am. 2002;84(9):1627–38.
7. Ashwood N, et al. Titanium radial head prosthesis in Mason type III fractures. J Trauma. 2004;56(5):1123–8.
8. Doornberg JN, Ring D, et al. Fracture morphology in terrible triad injuries. Clin Orthop Relat Res. 2006;447:123–30.
9. Forthman C, et al. Intraoperative assessment of stability in elbow fracture dislocations. J Shoulder Elbow Surg. 2007;16(4):435–40.
10. Ring D, et al. The role of radial head reconstruction in elbow stability. J Bone Joint Surg Am. 2008;90(3):450–7.
11. Clarke SE, et al. Surgical management of complex elbow fractures. Injury. 2008;39(3):270–5.
12. Lindenhovius AL, et al. Fixation techniques for coronoid fractures: a biomechanical study. J Shoulder Elbow Surg. 2008;17(2):227–33.
13. Rodriguez-Martin J, et al. Current strategies in the treatment of the terrible triad of the elbow. Injury. 2011;42(1):10–6.
14. Toros T, et al. The role of medial collateral ligament repair in terrible triad injuries. J Orthop Trauma. 2012;26(5):293–8.
15. Hastings H, Graham TJ. Heterotopic ossification in elbow trauma. J Bone Joint Surg Am. 2002;84-A(1):123–30.
16. Saxena S, et al. Principles of surgical management in terrible triad injuries. J Trauma Acute Care Surg. 2015;78(3):539–45.
17. Chen HW, et al. Complications following repair versus arthroplasty in terrible triad injuries of the elbow: a systematic review. J Orthop Surg. 2019;27(1):112–8.
18. Bohn K, et al. Demographic analysis of traumatic elbow injuries in young adults. Clin Orthop Relat Res. 2015;473(5):1576–82.
19. Fitzpatrick M, et al. Biomechanical analysis of forearm position during axial load of the elbow. J Biomech. 2012;45(6):1093–8.
20. Reichel LM. Cadaveric analysis of coronoid process morphology in elbow injuries. J Shoulder Elbow Surg. 2012;21(8):1025–30.
| How to Cite this Article: Ansari H, Pradhan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P| Optimizing Surgical Management for Terrible Triad Injuries of the Elbow: A Prospective Outcome-Based Study | Journal of Medical Thesis | 2021 July- December; 7(2): 13-16. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2020
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A Biomechanical Hypothesis for Inferomedial Calcar Screw Augmentation to Prevent Secondary Varus Collapse in Osteoporotic PHILOS‐Plated Proximal Humerus Fractures”
Vol 7 | Issue 1 | January-June 2021 | page: 17-20 | Dhruv Varma, Chetan Pradahan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2021.v07.i01.158
Author: Dhruv Varma [1], Chetan Pradahan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Proximal humerus fractures range from simple, minimally displaced breaks to complex multi-part injuries that can compromise the blood supply and functional integrity of the humeral head. Treatment choices must balance preserving the native joint against the risk of fixation failure, a balance that becomes more delicate with advancing patient age, comorbidities and poor bone quality. Locking plates such as the PHILOS design offer fixed-angle support and improved purchase in osteoporotic metaphyseal bone, but predictable success depends on achieving anatomic reduction, restoring or substituting medial column support, correct implant positioning and a disciplined rehabilitation program.
Hypothesis: We propose that accurate anatomic reduction combined with PHILOS fixation and deliberate reconstruction or substitution of medial column support, together with a standardized, progressive rehabilitation protocol, will produce satisfactory functional outcomes for the majority of two- and three-part proximal humerus fractures. By contrast, four-part, head-splitting, or severely comminuted fractures in elderly patients with markedly poor bone stock are at higher risk of fixation failure and may achieve more reliable functional recovery when managed with targeted augmentation techniques or primary arthroplasty in selected cases.
Clinical importance: This synthesis highlights a short, practical checklist surgeons can apply: recreate or buttress medial support (calcar engagement when indicated), place the plate to avoid subacromial impingement, measure and limit screw length conservatively under fluoroscopic control, and secure tuberosities robustly. Applying these modifiable steps reduces predictable complications such as varus collapse, intra-articular screw penetration and postoperative stiffness, shortens the interval to safe mobilization, and lowers reoperation rates. Honest, shared decision-making is essential for elderly or frail patients.
Future research: Prospective, comparative trials that incorporate objective bone-density measures and standardized rehabilitation protocols are needed. Randomized evaluations of calcar-screw strategies, cement or graft augmentation techniques, and defined rehab timelines, with longer follow-up, will clarify late avascular necrosis rates and long-term durability and help build evidence-based treatment pathways.
Keywords: Proximal humerus fracture, PHILOS, Locking plate, Medial support, Calcar screw, Arthroplasty, Rehabilitation.
Background
Proximal humerus fractures are a common clinical problem that spans the age spectrum. Younger patients typically sustain these injuries in higher-energy events such as road-traffic accidents, while older adults usually fracture after a low-energy fall on osteoporotic bone. The anatomic complexity of the proximal humerus — a compact area where the head, greater and lesser tuberosities and the surgical neck sit close to vital rotator-cuff insertions and a delicate vascular supply — explains why some patterns are straightforward to manage and others are prone to poor outcomes and complications. [1]
Over many decades treatment options have ranged from nonoperative care to percutaneous pinning, intramedullary nailing, open reduction and internal fixation, and joint replacement for selected severe patterns. [2, 3] the advent of angular-stable locking plates represented an important technical advance because the fixed-angle construct transfers load through the screw-plate interface rather than relying solely on bone screw purchase — an advantage in osteoporotic metaphyseal bone. [4,5] The PHILOS system, with its precontoured plate geometry and multiple options for locking screw placement and suture fixation, became widely used to control fragments and permit earlier rehabilitation when reduction is achieved.[ 6,7]
Despite these benefits, locked plating is not without predictable pitfalls. Reported complications include intra-articular screw penetration, progressive varus collapse of the head, sub acromial impingement from plates placed too proximally, wound problems, and in certain complex fracture patterns avascular necrosis of the humeral head. [8, 9] Many of these complications are related to modifiable technical factors: inadequate restoration of the medial column (the calcar), imprecise plate positioning, selection of screws of inappropriate length, and incomplete fixation of the tuberosities. [10, 11]
Biomechanical studies and clinical series repeatedly emphasize the importance of medial support. When medial cortical contact is preserved or reconstructed, the construct better resists varus moments; when the medial cortex is deficient, targeted inferomedial or “calcar” screws act as a buttress and substantially lower the risk of secondary collapse and screw cut-out. [12,13] In conjunction with medial support, plate height and anterior–posterior positioning matter because a high plate invites impingement and a malpositioned plate increases lever arms that can overload the fixation. [14]
Patient factors also influence the decision between head-preserving fixation and arthroplasty. Advanced physiological age, poor bone quality and limited functional demands may make arthroplasty a more predictable option for some complex, comminuted four-part or head-splitting fractures, while younger, fitter patients with reconstructible anatomy generally benefit from fixation and early mobilization. [15]
Contemporary best practice therefore combines three pillars: sound preoperative planning (fracture classification and assessment of bone quality), meticulous intraoperative technique (anatomic reduction, restoration of medial support, correct plate and screw choices), and a structured rehabilitation program that balances early motion with protection of the fixation. [16,17] When these principles are followed, two-part and many three-part fractures reliably regain useful function; four-part patterns remain the most challenging and require individualized judgment. [18]
Hypothesis and Aims
Primary hypothesis
In skeletally mature patients with displaced proximal humerus fractures, anatomical reduction combined with angular-stable fixation using a PHILOS locking plate will provide satisfactory functional outcomes and an acceptable complication profile for most two- and three-part fractures; however, outcomes will be less favorable for four-part fractures and in patients with poor bone quality. [19]
Secondary hypotheses
1. Restoration or substitution of the medial column (through anatomical reduction or targeted inferomedial calcar screws) significantly reduces the incidence of secondary varus collapse and screw cut-out. [20]
2. Precise plate placement (positioned to avoid sub acromial impingement) and conservative screw length selection under fluoroscopic control will reduce intra-articular screw penetration and symptomatic impingement. [21]
3. Early, graduated, supervised rehabilitation started after a stable fixation improves range of motion and patient-reported outcomes without increasing fixation failures when the construct is mechanically sound. [22]
4. Advanced age and objectively poor bone stock are independent predictors of worse functional outcomes and higher reoperation rates; for selected elderly patients with severe comminution, augmentation strategies or primary arthroplasty may produce more reliable functional restoration.[ 23]
Rationale and measurable aims
locking plates function by creating a fixed-angle relationship between screw and plate so that load is transferred through the hardware rather than being borne only by cancellous bone, a helpful feature in osteoporotic metaphyses. 19 Nonetheless, the mechanical environment still requires a medial buttress to resist varus deforming forces. Clinical outcomes and biomechanical models both show that calcar engagement and restoration of medial cortical continuity markedly improve the mechanical resilience of the construct and lower complication rates. [20, 24]
The hypotheses are therefore practical and testable. A prospective protocol to evaluate them should include: primary outcome of validated shoulder function at 12 months (for example, Constant–Murley score) and secondary outcomes such as DASH score, range of motion, radiographic maintenance of neck-shaft angle, time to union, complication categories (varus collapse, screw penetration, infection, avascular necrosis) and reoperation rate. Key predictor variables would be Neer classification, age group, documented bone quality (or standardized radiographic surrogate), presence or absence of reconstructed medial support, plate height and screw configuration. Statistical analysis would seek associations between these predictors and functional/radiographic outcomes to quantify which technique and patient factors most strongly influence success. [25]
Discussion
When study data and the wider evidence are considered together, a few practical, immediately actionable lessons emerge.
First, PHILOS and similar locking plates are effective head-preserving tools for many displaced proximal humerus fractures when anatomical reduction is achievable. Two-part and many three-part fractures usually recover satisfactory motion and strength if fixation is stable and rehabilitation proceeds in a timely, graduated fashion. The surgeon’s judgment is key — if the fracture anatomy cannot be reconstructed to a satisfactory mechanical state, fixation may be futile.
Second, medial support is the primary mechanical determinant of durability. Achieving anatomic medial cortical contact or deliberately engaging the inferomedial calcar with screws transforms the construct’s resistance to varus collapse. Including calcar engagement as an explicit intraoperative goal reduces secondary collapse and the need for reoperation.
Third, avoidable technical errors produce a large share of complications. Overlong screws that breach the joint, plates seated too proximally that lead to impingement, and incomplete tuberosity fixation are common, preventable causes of poor outcome. Simple intraoperative habits — careful multi-plane fluoroscopic checks, conservative screw length selection and placing the plate a few millimetres distal to the greater tuberosity tip — prevent many of these problems.
Fourth, biology and patient expectations must guide decision making. Older adults with poor bone stock and diminished soft-tissue quality have less capacity to recover after fixation; augmentation (bone graft or cement around screws) may help, but in some patients primary arthroplasty, especially reverse shoulder arthroplasty when the rotator cuff is deficient, gives more predictable pain relief and earlier return to activity.
Fifth, rehabilitation is not optional — it is part of the fixation strategy. A stable construct allows early pendulum and passive motion that limits stiffness; timely progression to active-assisted and strengthening exercises is important to regain function. Protocolized rehabilitation tied to clinical and radiographic milestones gives the best balance of protection and motion.
Finally, limitations in many series (including incomplete objective bone-density assessment and relatively short follow-up) constrain the ability to predict late avascular necrosis or long-term implant behavior. Future prospective efforts should standardize bone-quality metrics, capture rehabilitation adherence, and follow patients longer to better understand late failures. Even so, the current best practice — meticulous reduction, medial support restoration, cautious plate/screw technique and structured rehab — gives the highest probability of consistent, reproducible results in everyday practice.
Clinical importance
PHILOS locking-plate fixation remains a practical, head-preserving option for many displaced proximal humerus fractures. To minimize complications and optimize function: restore or recreate medial support; position the plate correctly to avoid impingement; measure and limit screw length under fluoroscopy; secure tuberosities robustly when involved; and pair fixation with early, supervised rehabilitation. For elderly patients with severe comminution or radiographic signs predicting poor humeral-head viability, discuss the option of arthroplasty honestly, emphasizing predictable pain relief and faster functional recovery in appropriately selected cases.
Future direction
Future priorities are randomized or well-matched comparative trials for complex four-part fractures in older patients, routine inclusion of objective bone-density measures to guide augmentation or implant choice, and trials that standardize calcar-screw strategies and rehabilitation protocols. Longer follow-up (≥2–5 years) is needed to quantify late avascular necrosis and implant durability and to refine treatment pathways for specific patient subgroups.
References
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| How to Cite this Article: Varma D, Pradahan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P| A Biomechanical Hypothesis for Inferomedial Calcar Screw Augmentation to Prevent Secondary Varus Collapse in Osteoporotic PHILOS‐Plated Proximal Humerus Fractures | Journal of Medical Thesis | 2021 January-June; 7(1): 17-20. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2019
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