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Revision management of a 17-year-old patient initially treated with radial head excision following terrible triad injury with associated Essex Lopresti

2023; Elsevier BV; Linguagem: Inglês

10.1016/j.xrrt.2023.09.009

ISSN

2666-6391

Autores

John J. Heifner, Gustavo E. Lacau, Jorge L. Orbay,

Tópico(s)

Orthopedic Surgery and Rehabilitation

Resumo

Complex elbow injury resulting from high-energy mechanisms may have associated injury to the interosseous ligament (IOL), namely an Essex-Lopresti injury. The central band of the IOL transfers longitudinally applied loads from the radius to the ulna, restrains proximal migration of the radius in the presence of an absent or deficient radial head, and resists forces that may disrupt the transverse radioulnar relationship. Loss of integrity of the central band can lead to ulnar impaction syndrome and instability during forearm rotation.2Anderson A. Werner F.W. Tucci E.R. Harley B.J. Role of the interosseous membrane and annular ligament in stabilizing the proximal radial head.J Shoulder Elbow Surg. 2015; 24: 1926-1933https://doi.org/10.1016/j.jse.2015.05.030Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar,24Orbay J.L. Levaro-Pano F. Vernon L.L. Cronin M.H. Orbay J.A. Tremols E.J. The parallelogram effect: the association between central band and positive ulnar variance.J Hand Surg Am. 2018; 43: 827-832https://doi.org/10.1016/j.jhsa.2018.03.058Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The indications for radial head excision have narrowed due to improved understanding of radial head function. The radial head provides valgus, transverse, and rotational stability; therefore, loss of the radial head portends chronic dysfunction and instability.14Jeon I.H. Sanchez-Sotelo J. Zhao K. An K.N. Morrey B.M. The contribution of the coronoid and radial head to the stability of the elbow.J Bone Joint Surg Br. 2012; 94: 86-92https://doi.org/10.1302/0301-620X.94B1.26530Crossref PubMed Google Scholar,22Morrey B.F. Tanaka S. An K.N. Valgus stability of the elbow. A definition of primary and secondary constraints.Clin Orthop Relat Res. 1991; Apr: 187-195Google Scholar,25Orbay J.L. Mijares M.R. Berriz C.G. The transverse force experienced by the radial head during axial loading of the forearm: a cadaveric study.Clin Biomech. 2016; 31: 117-122https://doi.org/10.1016/j.clinbiomech.2015.10.007Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar There is increasing evidence for adverse effects following excision of the radial head including unsatisfactory function, increased tension on the central band, and forearm laxity.3Beingessner D.M. Dunning C.E. Gordon K.D. Johnson J.A. King G.J. The effect of radial head excision and arthroplasty on elbow kinematics and stability.J Bone Joint Surg Am. 2004; 86: 1730-1739https://doi.org/10.2106/00004623-200408000-00018Crossref PubMed Scopus (199) Google Scholar,31Sears B.W. Johnston P.S. Ramsey M.L. Williams G.R. Glenoid bone loss in primary total shoulder arthroplasty: evaluation and management.J Am Acad Orthop Surg. 2012; 20: 604-613https://doi.org/10.5435/JAAOS-20-09-604Crossref PubMed Scopus (108) Google Scholar Importantly, excision may be contraindicated in the presence of IOL injury.12Hildebrand A.H. Zhang B. Horner N.S. King G. Khan M. Alolabi B. Indications and outcomes of radial head excision: a systematic review.Shoulder Elbow. 2020; 12: 193-202https://doi.org/10.1177/1758573219864305Crossref PubMed Scopus (8) Google Scholar Clinical manifestations of excision include ulnar impaction at the wrist and longitudinal instability.8Green J.B. Zelouf D.S. Forearm instability.J Hand Surg Am. 2009; 34: 953-961https://doi.org/10.1016/j.jhsa.2009.03.018Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar,13Hotchkiss R.N. Displaced fractures of the radial head: internal fixation or excision?.J Am Acad Orthop Surg. 1997; 5: 1-10Crossref PubMed Google Scholar Terrible triad injuries often occur due to high-energy mechanisms. Though they are classically described as a posterolateral external rotation injury pattern, there is evidence of posteromedial rotatory patterns.27Rhyou I.H. Lee J.H. Cho C.H. Park S.G. Lee J.H. Kim K.C. Patterns of injury mechanism observed in terrible triad.J Shoulder Elbow Surg. 2021; 30: e583-e593https://doi.org/10.1016/j.jse.2020.12.015Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Axial and rotatory forces result in fractures to both anterior osseous structures—the radial head and coronoid—and the ligamentous stabilizers at the direction of dislocation. Recent attention has been placed on early postoperative rehabilitation, as extended immobility may result in poor function and morbidity.6Corbet C. Boudissa M. Dao Lena S. Ruatti S. Corcella D. Tonetti J. Surgical treatment of terrible triad of the elbow: retrospective continuous 50-patient series at 2 years' follow-up.Orthop Traumatol Surg Res. 2023; 109: 103057https://doi.org/10.1016/j.otsr.2021.103057Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,28Ring D. Hannouche D. Jupiter J.B. Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow.J Hand Surg Am. 2004; 29: 470-480https://doi.org/10.1016/j.jhsa.2004.01.005Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar We present a revision case of terrible triad injury with associated Essex-Lopresti in a teenage patient who was initially treated with radial head excision and ulnohumeral pinning. This case was treated with radial head arthroplasty, repair of the IOL central band, and a temporary internal joint stabilizer. The patient’s legal guardian provided informed consent for the case data to be published. A 17-year-old male who sustained a terrible triad injury during high-velocity motor vehicle accident was acutely treated with closed reduction and casting (Fig. 1). At four weeks postinjury, he was found to be dislocated in the cast and was surgically treated. The radial head was deemed irreparable and was excised, and the ulnohumeral joint was pinned (Fig. 2). Following six weeks of immobilization, the pins were removed, and rehabilitation was initiated. The patient presented to us approximately 14 weeks postinjury—10 weeks postoperatively. Clinical investigation demonstrated an elbow arc of motion of 15 degrees, a pronosupination arc of motion of 20 degrees, and symptoms of high ulnar nerve palsy (Videos 1 and 2). Radiographic investigation demonstrated proximal migration of the radial stump and a positive ulnar variance of plus two millimeters compared to neutral ulnar variance on the contralateral side (Fig. 3). This finding suggested an injury to the central band, which altered the longitudinal relationship between the radius and ulna. The decision was made for surgical treatment with radial head arthroplasty and repair of the central band with a suture construct. Given the stark loss of motion and revision intervention, early postoperative mobilization was deemed an imperative aspect of the postoperative course. Thus, an internal joint stabilizer (IJS; Skeletal Dynamics, Miami, FL, USA) was used to protect the ligament repairs and allow early motion.Figure 2Lateral radiograph following ulnohumeral pinning and radial head excision, performed approximately five weeks postinjury after failed conservative treatment at an outside institution.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3(a) Anteroposterior and (b) lateral radiographs demonstrating excised radial head and proximal migration of the radius. (c) Posteroanterior radiographs demonstrating positive ulnar variance at the right wrist (d) compared to neutral ulnar variance on the contralateral side.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Separate incisions were made to access the proximal and distal insertions of the central band. The Thompson approach was used to expose the proximal insertion of the central band between extensor carpi radialis brevis and extensor digitorum communis. This is located just proximal to the insertion of the pronator teres. A distal ulnar approach between extensor carpi ulnaris and flexor carpi ulnaris was used to expose the distal insertion, which is approximately six centimeters proximal to the ulnar head. A custom drill guide was used to create bone tunnels at approximately 30 degrees in relation to the longitudinal axis of the bone (Fig. 4), which is consistent with anatomic investigations.7Farr L.D. Werner F.W. McGrattan M.L. Zwerling S.R. Harley B.J. Anatomy and biomechanics of the forearm interosseous membrane.J Hand Surg Am. 2015; 40: 1145-1151.e2https://doi.org/10.1016/j.jhsa.2014.12.025Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,33Skahen 3rd, J.R. Palmer A.K. Werner F.W. Fortino M.D. The interosseous membrane of the forearm: anatomy and function.J Hand Surg Am. 1997; 22: 981-985Abstract Full Text PDF PubMed Scopus (144) Google Scholar This may minimize suture fraying on the sharp internal borders of the radius and ulna. A mini TightRope (Arthrex, Naples, FL, USA) suture construct was passed from proximally through the radius to distally through the ulna with buttons securing the suture to the bone surfaces.9Hackl M. Andermahr J. Staat M. Bremer I. Borggrefe J. Prescher A. et al.Suture button reconstruction of the central band of the interosseous membrane in Essex-Lopresti lesions: a comparative biomechanical investigation.J Hand Surg Eur Vol. 2017; 42: 370-376https://doi.org/10.1177/1753193416665943Crossref PubMed Scopus (13) Google Scholar The radius was incrementally brought to its anatomic longitudinal alignment using a tensioner. The final position was confirmed by a neutral ulna variance. The case required combined medial and lateral approaches to the elbow. A flexor carpi ulnaris split approach was used medially for ulnar nerve release, scar tissue resection, and capsulectomy, which contributed to restoration of elbow extension. Laterally, a Kocher approach utilized the interval between the anconeus and extensor carpi ulnaris to replace the radial head, perform capsulectomy, and apply the IJS. Following exposure of the lateral aspect of the elbow, the ulnohumeral axis of rotation was identified using instrument guides. The IJS axis pin was placed along the axis of rotation using fluoroscopy for confirmation (Fig. 5).29Salazar L.M. Ghali A. Gutierrez-Naranjo J.M. Hand T.L. Dutta A.K. An unusual terrible triad variant associated with an Essex-Lopresti injury.Case Rep Orthop. 2021; 20218522303https://doi.org/10.1155/2021/8522303Crossref Google Scholar,32Sheth M. Price M.B. Taylor T. Mitchell S. Outcomes of elbow fracture-dislocations treated with and without an Internal Joint Stabilizer of the Elbow (IJS-E): a retrospective cohort study.Shoulder Elbow. 2023; 15: 328-336https://doi.org/10.1177/17585732221088290Crossref PubMed Scopus (3) Google Scholar The proximal radius was prepared for arthroplasty according to the previously described technique (Align; Skeletal Dynamics, Miami, FL, USA).11Heifner J.J. Kolovich G.P. Bolano L.E. Sibley P.A. Gonzalez G.A. Mercer D.M. Revision of failed radial head arthroplasty.Hand (N Y). 2023; ([Epub ahead of print].)15589447231151434https://doi.org/10.1177/15589447231151434Crossref Scopus (1) Google Scholar,21Mercer D.M. Bolano L.E. Rubio F. Bamberger H.B. Figueroa J.S. Gonzalez G.A. A radial head prosthesis that aligns with the forearm axis of rotation: a retrospective multicenter study.Semin Arthroplasty JSES. 2022; 32: 511-518https://doi.org/10.1053/j.sart.2022.02.004Abstract Full Text Full Text PDF Scopus (2) Google Scholar Prosthetic length was determined in relation to the corner formed by the lesser and greater sigmoid notch when evaluated on a true anteroposterior fluoroscopic image with the forearm in supination. The ideal length of the prosthetic head is approximately 2 millimeters distal to the corner of the notches. Following implantation of the definitive prosthesis, a forearm-length jig was placed onto the prosthetic head and at the ulna fovea distally (Fig. 6). A torque-limiting driver fastened the head to stem maintaining the orientation. This process aligned the prosthesis with the forearm axis of rotation. Following prosthesis implantation, the IJS was placed to maintain concentric joint reduction and protect the ligament repair during early mobilization. The baseplate was fixed to the olecranon, and connecting rods were linked to the previously placed axis pin. The lateral collateral ligament complex (LCLC) was repaired with number-two braided suture using a figure of eight configuration.Figure 6(a) Intraoperative image showing preparation of the proximal radius for arthroplasty and (b) alignment of the final implant with the forearm axis of rotation.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The operative arm was maintained in a sling for six days with mobilization beginning thereafter. At three weeks postoperatively, the patient achieved 175 degrees of elbow extension, 120 degrees of flexion, and an arc of pronosupination of 145 degrees. At five months postoperatively, the IJS was removed (Fig. 7), and at 13 months, the patient demonstrated a stable elbow with motion that was comparable to that of the contralateral arm (Videos 3 and 4). The patient reported the ability to resume sporting activities with little noticeable detriment. This case was initially treated at an outside facility with radial head excision and ulnohumeral pinning, and the resultant dysfunction was quite evident. At approximately three months postinjury, our radiographic and clinical evaluation indicated that the patient’s initial injury pattern was likely to have been a terrible triad with associated Essex-Lopresti. The wrist was ulnar positive, which differed from the ulnar neutral contralateral side on posteroanterior radiograph. It is feasible though less likely that the central band sustained a subclinical injury and became attenuated under the additional stress caused by radial head excision.15Karl J.W. Redler L.H. Tang P. Delayed proximal migration of the radius following radial head resection for management of a symptomatic radial neck nonunion managed with radial head replacement: a case report and review of the literature.Iowa Orthop J. 2016; 36: 64-69PubMed Google Scholar,18Lanting B.A. Ferreira L.M. Johnson J.A. Athwal G.S. King G.J. The effect of excision of the radial head and metallic radial head replacement on the tension in the interosseous membrane.Bone Joint J. 2013; 95-b: 1383-1387https://doi.org/10.1302/0301-620x.95b10.31844Crossref PubMed Google Scholar Our revision management consisted of radial head arthroplasty, repair of the central band, and temporary internal stabilization. There is limited evidence for acute management of terrible triad injury with associated Essex-Lopresti. Salazar et al29Salazar L.M. Ghali A. Gutierrez-Naranjo J.M. Hand T.L. Dutta A.K. An unusual terrible triad variant associated with an Essex-Lopresti injury.Case Rep Orthop. 2021; 20218522303https://doi.org/10.1155/2021/8522303Crossref Google Scholar reported on a 19-year-old with this injury pattern and concomitant distal radius fracture. The LCLC was repaired, the radial head fracture was fixed with screws, a dorsal spanning plate was applied to the distal radius, and the IJS was used for temporary stabilization. At three months, the dorsal spanning plate and IJS were removed, and at final follow-up, the elbow arc of motion was 125 degrees. Ramzi et al26Ramzi Z. Juanos Cabans J. Jennart H. Terrible triad of the elbow with an ipsilateral Essex-Lopresti injury: case report.J Surg Case Rep. 2020; 2020rjaa103https://doi.org/10.1093/jscr/rjaa103Crossref PubMed Google Scholar reported on a 56-year-old who suffered a ground-level fall. Radiographic investigation demonstrated a terrible triad injury of the elbow with an ulnar positive wrist. The LCLC was repaired, and a tightrope device was applied to the distal radioulnar joint. Intraoperative assessment determined that the coronoid and radial head fractures did not require fixation. At eight months postoperatively, the elbow was stable with an arc of motion of 80 degrees. Essex Lopresti injuries are often missed due to the emphasis of examination at the elbow and misinterpretation of the subtle symptoms which may suggest injury to the IOL.29Salazar L.M. Ghali A. Gutierrez-Naranjo J.M. Hand T.L. Dutta A.K. An unusual terrible triad variant associated with an Essex-Lopresti injury.Case Rep Orthop. 2021; 20218522303https://doi.org/10.1155/2021/8522303Crossref Google Scholar Additionally, these injuries may occur from low-energy mechanisms that are less likely to alert the clinician for an Essex-Lopresti injury.30Schnetzke M. Porschke F. Hoppe K. Studier-Fischer S. Gruetzner P.A. Guehring T. Outcome of early and late diagnosed Essex-Lopresti injury.J Bone Joint Surg Am. 2017; 99: 1043-1050https://doi.org/10.2106/jbjs.16.01203Crossref PubMed Scopus (0) Google Scholar Acute treatment of Essex-Lopresti injuries avoids the difficulty of restoring anatomic position to a proximally migrated radius, which can become fixed in that position over time.19Matthias R. Wright T.W. Interosseous membrane of the forearm.J Wrist Surg. 2016; 5: 188-193https://doi.org/10.1055/s-0036-1584326Crossref PubMed Google Scholar Schnetzke et al30Schnetzke M. Porschke F. Hoppe K. Studier-Fischer S. Gruetzner P.A. Guehring T. Outcome of early and late diagnosed Essex-Lopresti injury.J Bone Joint Surg Am. 2017; 99: 1043-1050https://doi.org/10.2106/jbjs.16.01203Crossref PubMed Scopus (0) Google Scholar reported that acute treatment in Essex-Lopresti cases demonstrated superior outcomes compared to chronic treatment, where wrist-related sequalae was frequent. The biomechanical investigation by Hackl et al9Hackl M. Andermahr J. Staat M. Bremer I. Borggrefe J. Prescher A. et al.Suture button reconstruction of the central band of the interosseous membrane in Essex-Lopresti lesions: a comparative biomechanical investigation.J Hand Surg Eur Vol. 2017; 42: 370-376https://doi.org/10.1177/1753193416665943Crossref PubMed Scopus (13) Google Scholar supported central band repair with a TightRope and suture button technique to restore rotatory stability to near-native levels following simulation of Essex-Lopresti injury. Clinically, this construct has demonstrated satisfactory outcomes when treating acute Essex-Lopresti injury.4Brin Y.S. Palmanovich E. Bivas A. Sagiv P. Kotz E. Nyska M. et al.Treating acute essex-lopresti injury with the TightRope device: a case study.Tech Hand Up Extrem Surg. 2014; 18: 51-55https://doi.org/10.1097/bth.0000000000000036Crossref PubMed Scopus (0) Google Scholar The authors describe the repair as maintaining tension throughout the pronosupination arc, which off-loads the injured central band and radial head, allowing healing. Understanding of surgical treatment for terrible triad injury has improved. There is established agreement for the following surgical algorithm: fixation or replacement of the radial head, repair of the LCLC, and fixation of the coronoid in the setting of an appropriate fragment size. Despite improved clinical outcomes following surgical management, the rate of complication remains high in aggregate reporting.16Klug A. Gramlich Y. Wincheringer D. Hoffmann R. Schmidt-Horlohe K. Epidemiology and treatment of radial head fractures: a database analysis of over 70,000 inpatient cases.J Hand Surg Am. 2021; 46: 27-35https://doi.org/10.1016/j.jhsa.2020.05.029Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar,17Kyriacou S. Gupta Y. Bains H.K. Singh H.P. Radial head replacement versus reconstruction for the treatment of the terrible triad injury of the elbow: a systematic review and meta-analysis.Arch Orthop Trauma Surg. 2019; 139: 507-517https://doi.org/10.1007/s00402-019-03111-zCrossref PubMed Scopus (15) Google Scholar Recent investigations have identified early mobilization as integral to achieving favorable outcomes following terrible triad injury.6Corbet C. Boudissa M. Dao Lena S. Ruatti S. Corcella D. Tonetti J. Surgical treatment of terrible triad of the elbow: retrospective continuous 50-patient series at 2 years' follow-up.Orthop Traumatol Surg Res. 2023; 109: 103057https://doi.org/10.1016/j.otsr.2021.103057Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,23Ohl X. Siboni R. Surgical treatment of terrible triad of the elbow.Orthop Traumatol Surg Res. 2021; 107102784https://doi.org/10.1016/j.otsr.2020.102784Abstract Full Text Full Text PDF Scopus (12) Google Scholar The kinematic and mechanical importance of the radial head continues to be elucidated. In many cases, function and stability may be compromised in the presence of radial head excision. These complications have even greater implications in young patients. Recent evidence demonstrates that excision is being utilized less frequently, and the use of arthroplasty has experienced a large increase.16Klug A. Gramlich Y. Wincheringer D. Hoffmann R. Schmidt-Horlohe K. Epidemiology and treatment of radial head fractures: a database analysis of over 70,000 inpatient cases.J Hand Surg Am. 2021; 46: 27-35https://doi.org/10.1016/j.jhsa.2020.05.029Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Zhang et al34Zhang D. Benavent K.A. Dyer G.S.M. Earp B.E. Blazar P. Acute radial head resection for fracture: are we likely to miss an Essex-Lopresti injury?.Ortop Traumatol Rehabil. 2021; 23: 263-270https://doi.org/10.5604/01.3001.0015.2363Crossref PubMed Scopus (1) Google Scholar reported on 11 cases of acute radial head fracture treated with excision that demonstrated satisfactory clinical outcomes and stability at a mean of 36 months postoperatively. Their retrospective analysis was intended to determine the likelihood of a missed Essex-Lopresti based on the outcome data. The authors concluded that, following intraoperative determination of longitudinal stability, radial head excision for acute fracture is a safe procedure. This position is consistent with Hildebrand et al,12Hildebrand A.H. Zhang B. Horner N.S. King G. Khan M. Alolabi B. Indications and outcomes of radial head excision: a systematic review.Shoulder Elbow. 2020; 12: 193-202https://doi.org/10.1177/1758573219864305Crossref PubMed Scopus (8) Google Scholar who concluded that although radial head excision resulted in good to excellent results for acute fracture, excision may be contraindicated with concomitant ligamentous disruption. Stiffness is common following surgical management of traumatic elbow injury and may be exacerbated following extended immobilization. Previous reports describe immobilization beyond two weeks as a substantial risk factor for elbow stiffness following complex injury.10He X. Fen Q. Yang J. Lei Y. Heng L. Zhang K. Risk factors of elbow stiffness after open reduction and internal fixation of the terrible triad of the elbow joint.Orthop Surg. 2021; 13: 530-536https://doi.org/10.1111/os.12879Crossref PubMed Scopus (6) Google Scholar,20McKee M.D. Bowden S.H. King G.J. Patterson S.D. Jupiter J.B. Bamberger H.B. et al.Management of recurrent, complex instability of the elbow with a hinged external fixator.J Bone Joint Surg Br. 1998; 80: 1031-1036Crossref PubMed Google Scholar Akhtar et al1Akhtar A. Hughes B. Watts A.C. The post-traumatic stiff elbow: a review.J Clin Orthop Trauma. 2021; 19: 125-131https://doi.org/10.1016/j.jcot.2021.05.006Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar concluded that early mobilization in the postoperative traumatic elbow is an essential component of achieving a favorable outcome. Consistent with the case report of Salazar et al,29Salazar L.M. Ghali A. Gutierrez-Naranjo J.M. Hand T.L. Dutta A.K. An unusual terrible triad variant associated with an Essex-Lopresti injury.Case Rep Orthop. 2021; 20218522303https://doi.org/10.1155/2021/8522303Crossref Google Scholar we applied an IJS to protect the LCLC repair and to allow early mobilization, which began at one week postoperatively. The internal joint stabilizer is a temporary device that provides stability and offloading of the soft tissues during the healing phase. Importantly, this option allows early mobilization and does not utilize external components. Another internal stabilization option is transarticular pinning which provides an environment that is conducive for ligamentous healing, but there is a high risk for stiffness with longer periods of immobilization, as demonstrated in the current case.10He X. Fen Q. Yang J. Lei Y. Heng L. Zhang K. Risk factors of elbow stiffness after open reduction and internal fixation of the terrible triad of the elbow joint.Orthop Surg. 2021; 13: 530-536https://doi.org/10.1111/os.12879Crossref PubMed Scopus (6) Google Scholar Hinged external fixation allows mobilization, but pin-track complications and functional inefficiency may reduce the utility of this option.5Cheung E.V. O'Driscoll S.W. Morrey B.F. Complications of hinged external fixators of the elbow.J Shoulder Elbow Surg. 2008; 17: 447-453https://doi.org/10.1016/j.jse.2007.10.006Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar There are three important elements to this case that were critical to attaining a satisfactory outcome. First, the recognition of injury to the central band, which destabilizes the forearm. The radiographic and clinical signs that may yield a high index of suspicion for this injury pattern include an ulnar positive wrist that differs from the contralateral side, pain at the level of the distal radioulnar joint, and limited forearm rotation. The central band was repaired to provide longitudinal stability to the forearm and restore an anatomic radioulnar relationship. This option maximized the potential for functional recovery. Second, replacement of the radial head, which re-established length and stability following failed radial head excision and proximal migration of the radius. Third, the initiation of early mobilization to mitigate stiffness and maximize function. We used an internal joint stabilizer to maintain a concentric joint and provide the capacity to withstand the forces of early motion. This is a unique case of revision surgery following failed radial head excision and ulnohumeral pinning in a 17-year-old who suffered a terrible triad injury with associated Essex-Lopresti. Our choice in treatment reflects the condition of the patient at revision presentation, which may differ from the optimal treatment at injury presentation. Our access to investigations performed at injury presentation was limited due to initial management at an outside institution. Thus, we postulate on the injury pattern based on the presentation at three months following initial surgical intervention. The short-term favorable outcomes indicate that recognition of concomitant injury in complex elbow trauma is a crucial aspect of appropriate management. Further, current evidence is clear that radial head excision and extended elbow immobilization are indicated within narrowed confines. We performed revision management following failed radial head excision and ulnohumeral pinning in a 17-year-old who suffered a terrible triad injury with associated Essex-Lopresti. Radial head arthroplasty, repair of the central band, and temporary internal elbow stabilization yielded dramatic improvements in function.

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