1、Terrible triad of the elbow 12l肘关节脱位未经治疗而延误超过 3 周即为陈旧性脱位l肘关节脱位常合并关节内或外骨折l关节脱位，关节软骨失关节液的营养而逐渐退变及剥脱l脱位间隙内肉芽及瘢痕充斥，关节囊、侧副韧带与周围组织粘连，复位困难3l人工肘关节置换人工肘关节置换最早用于治疗肘关节各最早用于治疗肘关节各种关节炎，但近十年来已广泛应用于低位种关节炎，但近十年来已广泛应用于低位粉碎、关节面严重破坏、严重骨质疏松的粉碎、关节面严重破坏、严重骨质疏松的老年患者。老年患者。l年龄年龄65岁（发达国家岁（发达国家65岁，发展中国家岁，发展中国家为为60 岁）、剧烈活动少、骨质
2、疏松明显岁）、剧烈活动少、骨质疏松明显、骨折粉碎难以良好复位和有效固定。、骨折粉碎难以良好复位和有效固定。吴新宝，查晔军肘关节损伤诊治在国内的发展现状及展望J/CD中华肩肘外科电子杂志，2016,4(3):130-132王克平、李智明、盛晓赟，等。全肘关节置换治疗老年陈旧性肘关节骨折脱位。临床骨科杂志， 2015, 8; 18( 4):425-428.4病历资料 68岁，女性患者 外伤后右肘关节疼痛3月余，一直未予治疗 现右肘关节肿痛、畸形伴活动受限56术前片677889全肘关节置换术后9术后影像10l肘关节恐怖三联征包括桡骨头骨折和尺骨冠状突骨折及肘关节后脱位，常伴有侧副韧带损伤。1996年
3、Hotchkiss首次介绍了这一概念。 Hotchkiss RN. Fractures and dislocations of the elbow. In:Rockwood CA, Green DP (eds). Fractures in adults. Philadelphia: Lippincott-Raven; 1996.: 929-1024.l2002年 Ring D等和Pugh DM等对此做了详细报导，探讨了其治疗方法和预后效果。 Ring D, Jupiter JB, Zilberfarb J. Posterior dislocation of the elbow with fra
4、ctures of the radial head and coronoid. J Bone Joint Surg Am, 2002, 84:547551. Pugh DM, McKee MD. The “terrible triad” of the elbow. Tech Hand Up Extrem Surg, 2002, 6: 2129.11l损伤机制多见于车祸和坠落伤肘关节在伸直位（屈曲30-过伸15）遭受纵轴方向的高能量压缩剪切暴力造成 Mathew PK, Athwal GS, King GJ (2009) Terrible triad injury of the elbow:cu
5、rrent concepts. J Am Acad Orthop Surg 17: 137151. 12 肱尺关节：铰链骨性咬合对于肘关节稳定性尤其重要; 肱桡关节：对抗外翻应力 桡骨头：前方和外翻支撑13（Regan-Morrey）冠状突骨折块高度 冠状突尖部撕脱骨折 50% 冠状突高度的单纯或粉碎性骨折 50% 冠状突高度的单纯或粉碎性骨折14部分型和所有型为不稳定性骨折15治疗l 新鲜骨折脱位多采用手法复位外固定、切开复位内固定、关节成形术、铰链式外固定支架联合侧副韧带重建术以及肘关节功能位融合等。l 手法复位、关节成形术常导致术后关节不稳定；切开复位内固定术后常伴关节僵硬；关节融合术导
6、致术后肘关节功能受限；铰链式外固定支架联合侧副韧带重建术，临床报道病例较少，疗效尚不肯定。16保守治疗 采取保守治疗肘关节“恐怖三联征” ，一般很难维持肘关节稳定性，并有再脱位的倾向 Guitton TG, Ring D. Nonsurgically treated terrible triad injuries of the elbow: report of four cases. J Hand Surg Am. 2010 35(3):464-467. Kevin Chan, MSc, Joy, MacDermid, etc. Can We Treat Select Terrible Tri
7、ad Injuries Nonoperatively? Clin Orthop Relat Res (2014) 472:20922099.17多数学者主张采取积极的手术治疗l McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ.Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique. J Bone Joint Surg Am. 2005;87(Suppl 1):2232.
8、l Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. J Am Acad Orthop Surg. 2009;17:137151.l Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD.Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg Am. 2004
9、;86:11221130. l Schneeberger AG, Sadowski MM, Jacob HA. Coronoid processand radial head as posterolateral rotatory stabilizers of the elbow.J Bone Joint Surg Am. 2004;86:975982.l Zeiders GJ, Patel MK. Management of unstable elbows following complex fracture-dislocationsthe terrible triad injury. J B
10、oneJoint Surg Am. 2008;90(Suppl 4):7584.18Akash Gupta, David Barei . Ansab Khwaja Single-staged Treatment Using a Standardized Protocol Results in Functional Motion in the Majority of Patients With a Terrible Triad Elbow Injury. Clin Orthop Relat Res (2014) 472:2075208319手术治疗原则恢复冠状突的恢复冠状突的结构及稳定性结构及稳
11、定性恢复外侧柱恢复外侧柱的稳定性，的稳定性，桡骨头固定桡骨头固定或假体置换或假体置换修补外侧副修补外侧副韧带复合体韧带复合体在前臂旋前在前臂旋前30 -130 屈伸判断肘屈伸判断肘关节稳定性关节稳定性修补内侧副修补内侧副韧带韧带如常规修复不如常规修复不能维持关节稳能维持关节稳定，可应用外定，可应用外固定进行辅助固定进行辅助固定固定19l恢复尺骨冠状突稳定性Garrigues GE, Wray WH III, Lindenhovius ALC, Ring DC, Ruch DS. Fixation of the coronoid process in elbow fracture-disloca
12、tions. J Bone Joint Surg Am. 2011; 93(20):1873-1881.20l通过桡骨头骨折内固定或金属假体置换以恢复外侧柱稳定性l Josefsson PO, Johnell O, Gentz CF. Long term sequelae of simple dislocation of the elbow. J Bone Joint Surg Am 1984;66:927-30.l Ring D, Jupiter JB, Zilberfarb J. Roles of the medial collateral ligament and the coronoi
13、d in elbow stability. J Bone Joint Surg Am 200385:568-9.21l修复外侧副韧带及相关结构及必要时修补内侧副韧带l Jeong WK, Oh JK, Hwang JH, et al. Results of terrible triads in the elbow: the advantage of primary restoration of medial structure. J Orthop Sci. 2010;15:612-9.l Toros T, Ozaksar K, Sgn TS, et al. Theeffect of media
14、l side repair in terrible triad injury of the elbow. Acta Orthop Traumatol Turc 2012;46:96-101.22l应用可活动铰链式外固定支架辅助固定以利于早期活动l Forthman CM, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Sur
15、g Am. 2007; 32(8):1200- 1209.l Watters TS, Garrigues GE, Ring D, Ruch DS. Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis? Clin Orthop Relat Res. 2014; 472(7):2128-2135.lZeiders GJ, Patel MK. Management of unstable elbows following complex fracture-dislocations: the “terrible triad” injury. J Bone Joint Surg Am. 2008; 90(suppl 4):75-84. l杨勇,王福川.铰链式外固定架联合微型钢板治疗肘关节恐怖三联征J.中国修复重建外科杂志,2013,27(02):151-154.232424
