观察陈旧性恐怖三联征伴关节僵硬患者的手术疗效。

回顾性分析2013年2月至2018年6月行手术治疗的7例陈旧性恐怖三联征伴关节僵硬患者临床资料及随访结果，其中男5例、女2例，平均年龄为（45.14±15.79）岁（18~61岁）。患者从受伤到手术翻修时间平均为（99.57±67.85）d（38~240 d）。伤肘右侧5例、左侧2例。损伤原因：摔伤4例，车祸伤2例，高处坠落伤1例。所有患者无神经损伤表现。桡骨头骨折Mason分型为：Ⅰ型1例，Ⅱ型3例，Ⅲ型2例，Ⅳ型1例；尺骨冠状突骨折分型为：Regan-morreyⅠ型4例，Ⅱ型2例，Ⅲ型1例；按O'Driscoll分型均为冠状突尖部骨折，第1亚型4例，第2亚型2例，第3亚型1例。肘关节处于半脱位状态5例，完全脱位状态2例。切口为内、外侧联合切口或后正中切口联合外侧切口，行关节松解、冠突及桡骨头重建、韧带修复。术后进行规范功能训练，进行早期主动功能锻炼。

所有患者术后均获得随访，随访平均（13.28±4.34）个月，10~23个月。所有患者切口均一期愈合。采用Mayo肘关节功能评分系统（Mayo elbow performance score，MEPS）、Broberg-Morrey评分系统进行肘关节功能评价。术后骨折均愈合，所有患者均无骨折畸形愈合、空心钉退出、空心钉断裂等并发症。末次随访时，MEPS评分：术前为（42.86±11.13）分（35~55分），术后为（85.29±2.75）分（80~89分，P=0.000018）。Broberg-Morrey评分：术前为（33.43±12.79）分（11~48分），术后为（85.57±2.23）分（83~89分，P=0.00004）。视觉模拟评分：术前为（6.43±0.98）分（5~8分），术后为（1.00±0.00）分（0~1分，P=0.000006）。伸直角度：术前为42.14°±10.35°（30° ~60°），术后为18.57°±8.02°（10° ~30°，P=0.0581）。屈曲角度：术前为75.71°±35.99°（20° ~110°），术后为120.00°±8.16°（110° ~130°，P=0.0272）。旋前角度：术前为24.29°±41.58°（0° ~90°），术后为80.00°±5.77°（70° ~90°，P=0.0126）。旋后角度：术前为32.86°±43.09°（0° ~90°），术后为84.29°±15.12°（50° ~90°，P=0.0154）。

临床上需重视肘关节恐怖三联征的早期诊断，以防漏诊和延误治疗。对于陈旧性肘关节恐怖三联征伴关节僵硬患者行手术治疗，并注重早期功能锻炼，能使患者尽早尽快恢复肘关节功能。

The terrible triad of the elbow describes a dislocation of the elbow with associated fractures of the radial head and coronoid process of the ulna. The term'terrible triad’in this context was originally coined by Hotchkissin 1996 in reference to the inherent difficulty in treating these injuries and their historically poor outcomes. This type of injury is easy to cause missed diagnosis and misdiagnosis due to the lack of early understanding of its injury mechanism and fracture characteristics. There are still many patients with old terrible triad of the elbow combined with joint stiffness, whose elbow function is completely inadequate to meet daily needs.ObjectiveTo observe the surgical effect of old terrible triad of the elbow with joint stiffness.

FromFebruary2013 to June 2018, 7 patients (5 males and 2 females) of old terrible triad of the elbow combined with joint stiffness underwent surgical procedure. Their mean age was (45.14±15.79) years (18-61 years) . The clinical data and follow-up results were retrospectively analyzed. The mean time from injury to operation was (99.57±67.85) days (38-240 days) . There were 5 cases of right side and 2 cases of left side. Causes of injuries: 4 cases of fall damage, 2 cases of traffic accidents and 1 case of high fall injury. None of them showed the signs of neurological injury. According to Mason classification of radial head fracture, there were 1 case of typeⅠ, 3 cases of typeⅡ, 2 cases of typeⅢand 1 case of typeⅣ. According to Regan & Morrey classification of coronoid process fracture, there were 4 cases of typeⅠ, 2 cases of typeⅡ, and 1 case of typeⅢ. According to O’Driscoll classification of the tip fracture of ulna coronoid process, there were 4 cases of 1st subtype, 2 cases of 2nd subtype and 1 case of 3rd subtype. The elbow joint was subluxated in 5 cases and completely dislocated in 2 cases.The combination of medial and lateral incisions or the posterior midline approach combined with lateral incision were adopted to perform joint release, reconstruction of coronoid process and radial head and ligament repair. Treatment of radial head fracture: fracture fragment resection was performed in 1 case as the fragment accounted for approximately 10% of the articular surface, compression screw fixation was performed in 1 case with 2.0 mm countersunk screws, radial head replacement was performed in 2 cases, and 3 cases were left undone for good fracture position. Treatment of coronoid process: reconstruction procedure was performed in 2 cases with iliac bone, compression screw fixation was performed in 2 case with 3.0 mm countersunk screws, and 3 cases were left undone for good recovery. Treatment of ligament injury: ligament reconstruction was performed in 2 cases with partial brachial triceps tendon, and ligament repair was performed in 5 cases suture anchors. All of the patients were fixed with hinged external fixators to protect the bone and soft tissue. Standard functional training and early active exercise were conducted after operation.

After operation, all patients were followed up for an average of (13.28±4.34) months (10-23 months) . All the incisions obtained primary healing. The elbow function was evaluated using Mayo elbow performance score (MEPS) and Broberg-Morrey scoring systems. All fractures healed after operation without complications such as deformity, cannulated screw withdrawal, or cannulated screw breakage. At the last follow-up, the preoperative Mayo score was (42.86±11.13) points (25-55 points) , and the postoperative Mayo score was (85.29±2.75) points (80-89 points,P=0.000018) . The preoperative Broberg-Morrey score was (33.43±12.79) points (11-48 points) , and the postoperative Broberg-Morrey score was (85.57±2.23) points (83-89 points) . The preoperative VAS score was (6.43±0.98) points (5-8 points) , and the postoperative VAS score was (1.00±0.00) points (0-1 points,P=0.000006) . The preoperative extension range was 42.14°±10.35° (30°-60°) , and the postoperative extension range was 18.57°±8.02° (10°-30°,P=0.0581) . The preoperative flexion range was 75.71°±35.99° (20°-110°) , and the postoperative flexion range was 120.00°±8.16° (110°-130°,P=0.0272) . The preoperative pronation range was 24.29°±41.58° (0°-90°) , and the postoperative pronation range was 80.00°±5.77° (70°-90°,P=0.0126) . The preoperative supination range was 32.86°±43.09° (0°-90°) , and the postoperative supination range was 84.29°±15.12° (50°-90°,P=0.0154) .

It is necessary to pay attention to the early diagnosis of "terrible triad" of theelbow to prevent missed diagnosis and delayed treatment in clinical practice. Surgical treatment should be carried out for patients with old terrible triad of elbow combined with joint stiffness, and early functional exercise should be paid attention to as well, so as to obtain early and quick restoration of elbow joint function.