Abstract
BACKGROUND: Terrible triad of the elbow (TTE) is a complex dislocation associating radial head (RH) and coronoid process (CP) fractures. There is at present no reproducible anatomic model for TTE, and pathophysiology is unclear. The main aim of the present study was to create and validate an anatomic model of TTE. Secondary objectives were to assess breaking forces and relative forearm rotation with respect to the humerus before dislocation. METHODS: An experimental comparative study was conducted on 5 fresh human specimens aged 87.4 ± 8.6 years, testing 10 upper limbs. After dissection conserving the medial and lateral ligaments, interosseous membrane and joint capsule, elbows were reproducibly positioned in maximal pronation and 15° flexion, for axial compression on a rapid (100 mm/min) or slow (10 mm/min) protocol, applied by randomization between the two elbows of a given cadaver, measuring breaking forces and relative forearm rotation with respect to the humerus before dislocation. RESULTS: The rapid protocol reproduced 4 posterolateral and 1 divergent anteroposterior TTE, and the slow protocol 5 posterolateral TTE. Mean breaking forces were 3,126 ± 1,066 N for the lateral collateral ligament (LCL), 3,026 ± 1,308 N for the RH and 2,613 ± 1,120 N for the CP. Comparing mean breaking forces for all injured structures in a given elbow on the rapid protocol found a p-value of 0.033. Comparison of difference in breaking forces in the three structures (LCL, RH and CP) between the slow and rapid protocols found a mean difference of -4%. Mean relative forearm rotation with respect to the humerus before dislocation was 1.6 ± 1.2° in external rotation. CONCLUSIONS: We create and validate an anatomic model of TTE by exerting axial compression on an elbow in 15° flexion and maximal pronation at speeds of 100 and 10 mm/min.