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A terrible triad is a severe traumatic injury of the elbow. We report a new variety of this clinical entity originating from a rare combination of injuries, namely the fracture-dislocation of the right elbow. The symptoms are acute ischemia of the hand with neurological damage following a sports accident suffered by a professional rugby player. We treated him surgically after immediate reduction of the dislocation. The short-term monitoring was clinical, while in the medium-term it was radiological and electrophysiological. On the whole, our (clinical, electrophysiological, and radiological) results obtained initially, and medium-term during the last consultation were satisfactory. The objective of this study is to draw attention to this clinical and radiological variety, as well as to its neurovascular complications, and to discuss its therapeutic treatment. During the vascular and neurologic exam, we should pay attention to and systematically look for neurovascular complications when treating a similar clinical case

Boussakri, Hassan

Elibrahimi, Abdelhalim

Alassaf, Ihab

Bachiri, Mohammed

ELayoubi, Abdelghani

Elmrini, Abdelmajid

Int J Med Surg. 2014;1(2):56-59. 56
Mediterranean BioMedical Journals
International Journal of Medicine and Surgery
Volume 1, Issue 2, 2014
DOI: 10.15342/ijms.v1i2.47
CLINICAL CASE
THE FALSE EQUIVALENT OF TERRIBLE TRIAD OF ELBOW COMBINED
WITH NEUROVASCULAR DAMAGE IN A RUGBY PLAYER
A NEW CASE REPORT
Dr Hassan Boussakri¹/², MD, Pr Abdelhalim Elibrahimi², MD, Dr Ihab Alassaf¹, MD, Dr Mohammed Bachiri²,
MD, Dr Abdelghani Elayoubi², MD, Pr Abdelmajid Elmrini², MD.
¹ Department of Orthopaedic Surgery (AP4), hôpital de Moulins-Yzeure, Moulins, 03OOO, France.
² Service de chirurgie osteoarticulaire (B4), CHU Hassan II, Fès 3000, Maroc.
Received 13 September 2014; Revised 02 October 2014; Accepted 09 October 2014.
ABSTRACT
Terrible triad is a severe traumatic injury of the elbow. We report a new variety of this clinical entity originating from a rare
combination of injuries, namely the fracture-dislocation of the right elbow. The symptoms are acute ischemia of the hand
with neurological damage following a sport accident suffered by a professional rugby player. We treated him surgically after
immediate reduction of the dislocation. The short-term monitoring was clinical, while in the medium-term it was radiological
and electrophysiological. On the whole, our (clinical, electrophysiological and radiological) results obtained initially, and
medium-term during the last consultation, were satisfactory. The objective of this study is to draw attention to this clinical
and radiological variety, as well as to its neurovascular complications and to discuss its therapeutic treatment. During the
vascular and neurologic exam we should pay attention to and systematically look for neurovascular complications when
treating a similar clinical case.
KEYWORDS: Equivalent of terrible triad, anterior dislocation, elbow, neurovascular lesion, contact sport.
Corresponding author:
Dr Hassan Boussakri, MD. Department of Orthopaedic Surgery (AP4), Moulins Hospital, 03OOO Moulins, France.
Email: boussakri.hassan@gmail.com
Copyright © 2014 Boussakri Hassan et al.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
INTRODUCTION
Terrible triad is a severe traumatic injury of the elbow. It
refers to a posterior dislocation of the elbow associated
with fracture of the radial head and fracture of the
coronoid process (1, 2). This clinical entity was first
described by Hotchkiss in 1996 (1). It is generally caused
by a violent injury of indirect mechanism. We report a
case with a rare combination of a closed injury in the
right elbow secondary to a sport accident. It combines a
reconstructable fracture of the radial head, a fracture of
Boussakri H False Equivalent of Terrible Triad of Elbow
Int J Med Surg. 2014;1(2):56-59. 57
 
the coronoid process and an antero-lateral dislocation of
the elbow. This condition was accompanied by an acute
ischemia and paralysis of the hand.
The objective of our study is to draw attention to this
serious traumatologic entity and to the neccesity of
meticulous, systematic neurovascular exam in case of all
elbow injuries. On the whole, our (clinical,
electrophysiological and radiological) results obtained
initially and medium-term during the last consultation,
were satisfactory.
 
CASE REPORT
The patient was a 28-year-old French national and
professional rugby player who was admitted to the
Emergency Department with a closed injury of the right
elbow after having suffered an accidental injury at a
training session. The exam showed a swollen, edematous,
deformed elbow without normal anatomical landmarks.
We were struck by the marbled appearance of the hand
with impaired extension of the wrist and the fingers. The
dorsal and palmar sides of the hand had loss of sensation,
while he could not extend or adduct the thumb, giving
the impression of a "paralytic hand". The vascular exam
showed a cold hand. Distal pulses, including the radial
and the ulnar pulse, were absent. The elbow radiographs
(frontal and lateral view) (Figures1a-b) showed a large
antero-external dislocation of the elbow with no fracture
in the olecranon, associated with a large displacement
and a type II fracture of the radial head, according to
Mason classification.
 
Figure 1: Standard radiography of the right elbow. a)
Frontal view showing an external displacement. b)
Lateral view showing the fracture of the radial head
associated with an anterior dislocation.
 
Reduction of the dislocation was done urgently under
general anesthesia (Fig.2). The member was warmed and
monitored. We observed that fingers progressively
regained their color, and radial and ulnar pulse became
palpable. From the neurological standpoint, we first saw
the extension of the thumb, while sensation in the area of
the radial nerve and in the area of the median nerve was
still decreased. Abduction and adduction of the fingers
were still impaired. The elbow was immobilized with a
temporary brachial-antebrachial-palmar plaster splint
(BABP), and with proper analgesia. An additional elbow
scan was performed, which confirmed that the radial head
was fractured and the coronoid process was pulled-out
(Fig.3).
 
Figure 2: Post reduction radiological imaging.
 
 
Figure 3: Scan check with 3D reconstruction.
 
The post reductional treatment consisted of monitoring
the fingers regaining their color, the distal pulses, as well
as administering an anticoagulant at a prophylactic dose.
By the next day, the patient had partially recovered the
extension of the fingers, in particular the index and the
middle fingers and the opposition of the thumb. Sensation
in the area of the median nerve was present with
persistence of tingling sensation and hypoesthesia.
However, the ulnar nerve was completely paralytic. An
electromyogram (EMG) was taken and showed a
decrease in the sensory and motor nerve conduction
velocity in the area of the radial and median nerves. On
the other hand, it showed an absent ulnar nerve
conduction velocity on the forearm and the wrist. In the
second intention, treatment of the bone and ligamentous
damage was scheduled 3 days later, and done by surgery.
Reconstruction of the radial head was performed with
external approach, using micro screws after the reduction.
However, the coronoid process had a small, not
synthesizable fragment. We repaired the anterior capsule
with transosseous sutures. Then, we repaired the lateral
ligament with the same approach using resorbable
anchors, followed by a complimentary immobilization by
BAPB splint (Fig.4). The post-operative follow-up
consisted of clinical monitoring of the pulses and clinical
signes of compartment syndrome, as well as passive
Boussakri H False Equivalent of Terrible Triad of Elbow
Int J Med Surg. 2014;1(2):56-59. 58
rehabilitation of the hand. By the end of the next week,
the patient had fully recovered the extension of the
fingers, as well as the sensation in the area of the median
nerve but the ability of abducting and adducting the
fingers was still completely missing. The patient returned
4 weeks later. The neurologic exam showed a full
recovery of radial and median nerves' neurologic
functions, with persistence of paresthesia in the area of
the median nerve. Furthermore, the tingling sensation still
remained but we saw a sign of approaching moves of
fingers in the area of the ulnar nerve. The EMG showed
normal radial and subnormal median nerve conduction,
and a decrease in the ulnar nerve conduction with
substantial improvement compared to the initial
electrophysiologic results.
Figure 4: Standard radiograph, frontal and lateral view,
after surgical repair in the second intention.
DISCUSSION
Fracture-dislocation of the elbow is a serious disease
entity, and management is often difficult (3). Terrible
triad of the elbow represents a well-defined anatomical￾pathological variety that was first described by Hotchkiss
in 1996 (1). It is characterized by a posterior dislocation
of the elbow associated with a fracture of the radial head
and the coronoid process. Our study is unique because of
the antero-external variety of the elbow dislocation and
because the hand's neurovascular lesion is misleading.
With this resemblance, taking into account the
differences when compared to terrible triad, we called it
"equivalent of terrible triad" associated with a very
serious neurovascular complication.
Anatomically, the elbow is a very stable, mobile joint
complex that suffers mechanical stress in the lever arms.
It is also rich in neurovascular elements, with almost all
of them located on the anterior side that leaves passage to
vascular and nervous elements going to the forearm and
the hand, with the exception of the ulnar nerve, which
passes on the posterior side. Generally, fracture￾dislocations of the elbow are a result of a violent, high￾energy injury. This lesion can be caused by two
mechanisms; either by an indirect mechanism or by a
violent shock directly on the elbow. Two types of lesion
can occur depending on the velocity of the injury and the
combination of the previously described mechanisms.
Isolated dislocation, which can be posterior, anterior or
lateral, and ligament rupture are systematic. In case of
fracture-dislocations, lesion exam is more complex and
includes ligamentous, capsular, bony and neurovascular
damages (4). In our case, as the clinical and anatomical
analyses were complex, we think of the association of at
least two of the above mentioned lesion mechanisms.
Also, we believe that the antero-external dislocation was
complicated with lateral and medial ligament rupture.
The mechanism of the neurovascular lesion was caused
by the stretching of the nerves without a clear section,
and a spasm in the brachial artery, as it was shown by the
nervous and vascular recovery after the reduction.
Anterior dislocations are not uncommon (5). In case of
isolated anterior dislocations, predisposing factors, such
as olecranon aplasia or excessive joint laxity, should be
systematically looked for. Clinically, anterior fracture￾dislocations present with an elbow that is almost
completely extended, with limited supination in the
forearm, and with posterior palpation of the distal
humerus while the surface of the olecranon disappears.
Moreover, the tendon of the biceps protrudes anteriorly
under the skin. Orthopedic treatment generally allows an
easy reduction under general anesthesia, by axial traction
in order to open up the olecranon. This should be
followed by immobilization and rehabilitation. In case of
triceps rupture, a transosseous reinsertion is necessary.
Complexity of bone damage should not prevent the
search for associated lesions, notably those of
neurological or vascular nature, as well as for
compartment syndrome due to the rupture of interosseous
membrane.
In our case, reduction of the dislocation was performed
urgently under general anesthesia. On the third day,
reconstruction of the radial head was performed with an
external approach using micro screws after reduction.
However, coronoid process was in the form of a small,
non-unifiable fragment.
We closed the anterior capsule by with transosseous
sutures. Then, we repaired the lateral ligament with the
same approach using absorbable anchors, associated with
a complimentary immobilization by BAPB splint. Some
other therapeutic options may be possible to treat this
type of fracture, notably prosthesis replacement or
resection of the radial head and repairing the coronoid
process with micro screws if the radial head suffered a
burst fracture, and if the coronoid process is unifiable (1-
3). Otherwise, reduction of the dislocation is systematic
(1). Vascular complication is rare but very serious. It can
affect either the brachial artery or one of its branches (6).
During our literature research, we have found rare cases
presenting with this complication (7), but in our clinic
there were no cases registered that resembled this clinical
and radiological entity. Anatomic and pathologic lesion
of the artery can present in form of vascular spasm,
intimal lesion, acute thrombosis or artery rupture. This
complication remains classic in open fracture-dislocation
Boussakri H False Equivalent of Terrible Triad of Elbow
Int J Med Surg. 2014;1(2):56-59. 59
patterns. If a closed fracture-dislocation occurs, even if it
looks common, vascular emergency should not be
ignored. It presents with disappearance of the radial and
downstream pulse, which not necessarily immediately but
threatens distal blood supply because of several
anastomoses in the area of the elbow. Sometimes the
clinical picture is characterized by acute ischemia, as it
happened in our case. It occurs after a serious elbow
injury, as it is associated with large damage in the
anterior part of the capsule (6). Only the disappearance of
the radial pulse can suggest the diagnosis, and dislocation
must be reduced urgently, as well as arteriography has to
be performed in the operating room, if necessary. If the
downstream pulse does not reappear or if arteriography is
hindered, surgical exploration becomes necessary (8).
Surgical repair may be done by endovascular technique,
while a rupture may be repaired with venous graft,
whether associated or not with surgical repair of the
structure of the antero-internal capsular ligaments. If this
clinical form is typical, special attention should be paid to
more discrete, subacute forms, initially conserving the
pulse (8). It is also necessary to look for early signs of
compartment syndrome. If the lesion is confirmed by the
arteriography, the aforementioned therapies should be
associated with systematic brachial and antebrachial
aponeurotomy. Some authors suggest a systematic
surgical exploration of arterial spasms if doubts persist
after orthopedic treatment. This is to eliminate any
incarceration or focal thrombosis of the brachial artery
after intimal lesion (9). One of the rare cases was
described by Hofmann D et al. as a total rupture of the
brachial artery following a surgically repaired elbow
dislocation. The nerve is most often strained, in
exceptional cases is torn (10). Otherwise, after the
reduction of fracture-dislocations, median nerve may be
incarcerated in the humero-ulnar joint (10), which means
that the treatment of this kind of lesion has not only
medical but also legal consequences.
Thus, our clinical, anatomical and electrophysiological
results may be more significant than that of other authors
in literature (1, 2, 10, 11). We insist that preoperative
planning, as well as surgical treatment should be specific
to each case. Overall, prognosis of these lesions depends
on the swiftness of initial treatment and the complexity of
anatomical lesions.
CONCLUSION
This case is an exceptional case with neurovascular
damage following a variety of terrible triad of the elbow,
secondary to a contact sport accident. In the vascular and
neurologic exam, we should pay attention to and
systematically look for neurovascular complications
when facing a similar case.
PATIENT CONSENT
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
COMPETING INTERESTS
The authors declare no competing interests.
AUTHORS’ CONTRIBUTIONS
The participation of each author corresponds to the
criteria of authorship and contributorship emphasized in
the Recommendations for the Conduct, Reporting,
Editing, and Publication of Scholarly work in Medical
Journals of the International Committee of Medical
Journal Editors. Indeed, all the authors have actively
participated in the redaction, the revision of the
manuscript and provided approval for this final revised
version.
ACKNOWLEDGEMENT
Declared none.
REFERENCES
[1] RN H. Fractures and dislocations of the elbow. In:
Rockwood CA, Green DP, Bucholz RW, Heckman JD,
editors. . Rockwood and Green’s fractures in adults, 1,
4th ed Philadelphia: Lippincott-Raven; 1996: 929—1024.
[2] Yin Y, Zhao Y. [Case-control study on the operative
treatment for terrible triad of the elbow]. Zhongguo gu
shang = China journal of orthopaedics and traumatology.
2014;27(1):41-5.
[3] Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of
the elbow with fractures of the radial head and coronoid.
The Journal of bone and joint surgery American volume.
2002;84-a(4):547-51.
[4] Exarchou EJ. Lateral dislocation of the elbow. Acta
orthopaedica Scandinavica. 1977;48(2):161-3.
[5] Hidalgo Ovejero AM, Garcia Mata S, Ibarra Zulategui P,
Heras Izaguirre J, Martinez Grande M. [Anterior
dislocation of the elbow without associated fracture of the
olecranon. Apropos of a recent case]. Revue de chirurgie
orthopedique et reparatrice de l'appareil moteur.
1988;74(3):257-8.
[6] Grimer RJ, Brooks S. Brachial artery damage
accompanying closed posterior dislocation of the elbow.
The Journal of bone and joint surgery British volume.
1985;67(3):378-81.
[7] Sparks SR, DeLaRosa J, Bergan JJ, Hoyt DB, Owens EL.
Arterial injury in uncomplicated upper extremity
dislocations. Annals of vascular surgery. 2000;14(2):110-
3.
[8] Cormier JM, Firouzabadie H, Delouvrier J. [Vascular
lesions in dislocations of the elbow]. Chirurgie; memoires
de l'Academie de chirurgie. 1975;101(5):349-54.
[9] Hofmann D, Schuz W, Horas U. [Traumatic rupture of the
brachial artery due to a closed elbow joint dislocation].
Der Unfallchirurg. 2011;114(9):816-21.
[10] Fourrier P, Levai JP, Collin JP. [Median nerve entrapment
in elbow dislocation]. Revue de chirurgie orthopedique et
reparatrice de l'appareil moteur. 1977;63(1):13-6.

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The False Equivalent of Terrible Triad of Elbow Combined with Neurovascular Damage in a Rugby Player - A New Case Report

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