Journal Pre-proof

Surgical treatment of terrible triad of the elbow: retrospective continuous

50-patient series at 2 years’ follow-up

Clémentine Corbet Mehdi Boudissa Séverine Dao Lena Sébastien

Ruatti Denis Corcella Jérôme Tonetti

PII: S1877-0568(21)00302-9
DOI: https://doi.org/doi:10.1016/j.otsr.2021.103057
Reference: OTSR 103057

To appear in: Orthopaedics & Traumatology: Surgery & Research

Received Date: 26 October 2019

Accepted Date: 31 December 2020

Please cite this article as: Corbet C, Boudissa M, Lena SD, Ruatti S, Corcella D, Tonetti J,
Surgical treatment of terrible triad of the elbow: retrospective continuous 50-patient series at 2
years’ follow-up, Orthopaedics and Traumatology: Surgery and Research (2021),
doi: https://doi.org/10.1016/j.otsr.2021.103057

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Original article
Surgical treatment of terrible triad of the elbow: retrospective
continuous 50-patient series at 2 years’ follow-up

Clémentine CORBET1, Mehdi BOUDISSA1, Séverine DAO LENA2, Sébastien RUATTI1, Denis
CORCELLA3, Jérôme TONETTI1

1 Service Orthopédie et Traumatologie, CHU Grenoble Alpes, Boulevard de la Chantourne,

38700 La Tronche, France.
2 CH Briançon, 24 Avenue Adrien Daurelle, 05100 Briançon, France
3 Service de Chirurgie de la Main et des Brûlés, CHU Grenoble Alpes, Boulevard de la

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Chantourne, 38700 La Tronche, France

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Corresponding author:
Dr Clémentine CORBET
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Service Orthopédie et Traumatologie, CHU Grenoble Alpes,
Boulevard de la Chantourne, 38700 La Tronche, France
e-
ccorbet@chu-grenoble.fr, +33(0)4.76.76.84.33,
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ABSTRACT
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Introduction: Terrible triad (TT) of the elbow is an association at high risk of instability.
Treatment aims to restore joint stability. Lateral collateral ligament (LCL) repair is
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systematic, whereas medial collateral ligament (MCL) repair is only exceptionally necessary.
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The main aim of the present study was to assess clinical results in TT surgery. The secondary
objective was to compare clinical progression with versus without MCL repair.
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Material and methods: A retrospective study included 50 TTs operated on via an isolated
lateral or combined medial-lateral approach. Clinical assessment comprised MEPS,
QuickDASH, VAS, flexion-extension and pronation-supination, and return to work and sport.
Subgroup analysis was made according to associated MCL repair.
Results: 50 patients (19 female, 31 male) were operated on between January 2006 and
January 2017. Mean follow-up was 24 months. At last follow-up, mean MEPS was 89.1, VAS
0.7, QuickDASH 16, flexion-extension 114°, and pronation-supination 137°. Only MEPS was

Page 1 of 20
significantly improved by MCL repair (p = 0.02), with no significant difference in
complications.
Discussion: TT surgery with immediate mobilization gave good long-term functional results,
not significantly improved by MCL repair. The lateral approach should be adopted in first
line, with the medial approach in second line in case of persistent instability after lateral
osteo-ligamentous repair.
Level of evidence: IV; retrospective study
Keywords: elbow joint, dislocation, lateral collateral ligament, instability

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INTRODUCTION

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Terrible triad (TT) of the elbow consists of an association of posterolateral dislocation, radial
head (RH) fracture and coronoid process (CP) fracture, as described by Hotchkiss in 1996 [1].
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It induces severe joint instability. Surgical treatment is mandatory in the vast majority of
cases, to stabilize the joint and allow early mobilization, limiting subsequent functional
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sequelae. Only selected cases are suitable for non-operative treatment [2].

There is at present no consensual decision-tree. Surgery associates CP fixation or anterior

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capsule suture, RH reduction-fixation or replacement, and lateral collateral ligament (LCL)

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repair [3–8].
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Systematic repair of the medial collateral ligament (MCL) is controversial [5, 7, 9–11]. It is
indicated for residual instability after lateral repair, but there are few reports of long-term
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clinical results in homogeneous series [10, 12, 13].

The main aim of the present study was to assess clinical results in TT surgery. The secondary
objective was to compare progression according to associated MCL repair.

MATERIAL AND METHODS

Patients

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A retrospective study was made of patients managed for TT in the University Hospital of
Grenoble, France (figure 1).

There were 514 elbow dislocations over the 11-year period from January 2006 to January
2017, including 87 patients with TT (16.9%).
Inclusion criteria comprised: TT confirmed on standard X-ray or CT, age at treatment >18
years, and absence of medical contraindications to surgery.
Exclusion criteria comprised: non-operative treatment, treatment by external fixator or
elbow arthroereisis, history of elbow fracture or dislocation, chronic dislocation, and
patients managed elsewhere after reduction of the dislocation.

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Thus 53 patients were included.

Surgical technique
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All included patients underwent surgery after dislocation reduction by external maneuver
and X-ray and CT assessment of the reduced joint.
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Two groups were distinguished according to associated MCL repair:

 MCL-: The Kocher lateral approach was used. Anterior capsule suture or CP fixation
(for Regan-Morrey type 2 or 3 fracture [14]) was performed first when possible, to
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take best advantage of the approach. The RH lesion was treated next: fracture
reduction and fixation by pins, screws or screwed plate, or RH replacement 1 (Figure
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1). The choice between fixation and replacement was based on Mason fracture type
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[15] and the patient’s age. Direct suture or anchor reinsertion2 of the lateral
collateral ligament (LCL) was systematic. Stability was then tested under fluoroscopy.
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No further repair was performed if the elbow was stable.

 MCL+: In case of persistent intraoperative posterolateral instability, a medial

approach was performed for MCL repair, using either direct suture or transosseous
reinsertion by 1 or 2 impacted anchors 3 (Figure 1). CP fixation was performed in

1
CRF II™ implant, Tornier, Montbonnot Saint Martin France
2
Quick Anchor™, Depuy Mitek, Montbonnot Saint Martin, France
3
Quick Anchor™, Depuy Mitek, Montbonnot Saint Martin, France

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 Regan-Morrey type 3 fracture [14], on a medial approach if it could not be done via
the lateral approach. Isolated screw fixation was performed.

Functional results were analyzed according to postoperative immobilization time, and to

type of RH fracture treatment: fixation or replacement.

Data collection
Analysis was performed by an independent observer, based on a pre-established
observation booklet. The following were collected:

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 Table 1 presents the epidemiological data: patient data (age, gender, occupation,
sports activity and level, dominant side involvement), accident data (date and type,
lesion mechanism, associated lesions, time to treatment), and lesion data (time to
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reduction, type of dislocation, Mason RH fracture type [15], Regan-Morrey CP
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fracture type [14], clinical instability after reduction on test under sedation or general
anesthesia). There were no significant intergroup differences in epidemiological
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factors.

 Table 2 presents treatment data: time to surgery, type of HR repair, type of CP and
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anterior capsule repair, associated ligament suture, postoperative strict long-arm

cast immobilization time, complications, and revision surgery. Groups were
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comparable for trauma-to-surgery time, type of RH and CP treatment and type and
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duration of postoperative immobilization.

Figures 2 and 3 show treatments according to RH and CP lesion type.
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 Radiographic and clinical data at last follow-up comprised: flexion-extension and

pronation-supination, Mayo Clinic Elbow Performance Score (MEPS) [16], QuickDASH
score [17], subjective instability, clinical laxity, pain on visual analog scale (VAS),
return to work and to previous job, return to sport at previous level, and joint
centering on last AP and lateral views.

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Page 4 of 20
Statistics
MCL- and MCL+ subgroup analysis used a univariate model with Student t test or Mann-
Whitney test for quantitative variables. Qualitative variable independence was assessed on
chi², or on Fisher exact test when expected frequency in 1 box of the contingency table was
<5. Analyses used RStudio© software (Boston, MA). The significance threshold was set at p
<0.05.

RESULTS

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Data for 50 of the 53 patients operated on during the study period were analyzed, 3 patients
being lost to follow-up. Mean follow-up was 24.2 months. All cases concerned first episodes
of dislocation.
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Clinical and functional results
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Table 3 presents functional results.
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Mean MEPS was 89.1 and mean QuickDASH was 16.

There was a 50% complications rate, and 26% surgical revision rate during the first year post-
trauma: arthrolysis, associated to treatment of any complications in case of specific
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indications for revision.

None of the 4 cases of recurrence underwent revision surgery: 3 very good functional results
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despite dislocation in frail patients, and 1 patient considered non-compliant. The most
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frequent complication was periarticular ectopic calcification (14%). Groups did not
significantly differ in terms of complications.
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MEPS at last follow-up was significantly better in MCL+ (p=0.02).

Groups did not significantly differ on the other clinical and functional criteria.

Table 4 presents results according to postoperative strict long-arm cast immobilization time
(</> 2 weeks). Shorter immobilization was associated with significantly better results on
MEPS (p < 0.01), VAS (p=0.02), QuickDASH (p=0.024) and recovery of range of motion (p <
0.01).

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It should, however, be borne in mind that immobilization time had a partly subjective basis:
strict immobilization would be prescribed for more subjectively unstable elbows, with
poorer functional prognosis.

Table 5 presents functional results according to RH treatment. There was only 1 case of RH
resection, with poor outcome: MEPS 70, VAS 6, QuickDASH 41, flexion-extension 65° and
pronation-supination 10°. In case of RH replacement, flexion-extension was better, at the
borderline of significant difference (p=0.051).

DISCUSSION

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Population representativeness
TT is associated with 10% of RH fractures and 11% of elbow dislocations [18–20]. With 53

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TTs in 514 dislocations (10.3%) and 298 RH fractures (17.7%), the present series was
representative.
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Overall surgical outcome
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TT is a complex lesion with uncertain prognosis. The present good clinical and functional
results confirmed the role of surgery, with or without MCL repair. This was in agreement
with the literature reports of functional assessment of standardized surgery in TT [4–6, 21,
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22] and lower dislocation recurrence risk compared to non-operative treatment [20, 23].
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Surgery aims to restore stability so as to allow early mobilization [3–5]. The present results
confirmed this attitude and showed an impact of immobilization time on functional
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outcome.
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Reported complications rates are often high, ranging between 12% and 87%. The present
rate of 50% was higher than for Pugh et coll. (22%), McKee et coll.(18%) or Pierrart et coll.
(12%) but similar to the reports by Mathew et coll. and Watters et coll. (respectively, 74%
and 45%) [24]. This wide variation is due to differences in counting complications and in
follow-up duration.
The main medium-term complication of surgery is stiffness, which is also the main indication
for surgical revision.

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Page 6 of 20
In the present series, external fixation was an exclusion criterion, but is sometimes proposed
for chronic irreducible dislocation or fragile fixation, but with significant secondary stiffness
[5, 24]. Some authors advocate hinged external fixation to minimize stiffness [25–28].
Humero-radial arthroereisis was also an exclusion criterion; it is a little-studied salvage
procedure, reputed to induce stiffness, and should be eschewed.

Radial head treatment

It is now consensual that Mason 2 and 3 fracture in TT should if possible be treated by
internal fixation. Mason 1 fracture may be managed non-operatively, without fixation. In

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Mason 3 fracture without possibility of stable fixation, the radial head should be replaced so
as to optimally reconstruct the lateral bone column [29–33].
We advocate early hardware removal with arthrolysis and mobilization under general
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anesthesia when the hardware causes discomfort (as in 13 of the present cases).
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RH resection is no longer recommended, due to systematic instability reported in the first
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published results in TT [34–38]. Bonnevialle et coll. recently described an option of partial

resection up to a maximum 30% of joint area [5], confirming many previous biomechanical
studies [15, 39–41].
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Although the difference was not quite significant (p=0.051), flexion-extension appeared to
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be better with RH replacement.

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We use a long-stem cemented metal dual-mobility implant: CRF II™ (Tornier, Montbonnot
Saint Martin, France). The question of fixed or mobile bearing remains open. Some authors,
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such as Moon, reported that monopolar implants enhance stability [42]. Others, such as
Pomianowski et coll. [43] or, more recently, Hartzler et coll. [44], found no significant
difference.

Coronoid process treatment

The CP is a central elbow stabilizer, by exerting an anterior blocking effect and by the
anterior capsule and anterior MCL bundle insertions on its anteromedial facet [1, 39–41].
According to Morrey [3], 50% of CP height is enough to ensure sagittal stability.

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Page 7 of 20
In most cases of TT, CP fracture is Regan-Morrey type 1, as in 72% of the present series. Such
fractures do not necessarily need to be treated [45–47], although most authors recommend
anterior capsule reinsertion via a lateral approach. Type 2 and 3 fractures, on the other
hand, require stable internal fixation by screw or plate [4, 5, 23]; this can be performed via
the lateral approach in case of RH resection for replacement, or via a medial approach. Ring
[23] recommended a posterior approach, giving easy access to the medial and lateral
columns; we have no experience with this.
The present study used the classification of Regan and Morrey, being easy for both senior
and junior surgeons to apply. In 2018, Thayer et coll. [48] observed that this classification
does not take account of possible involvement of the anteromedial CP facet, and advocated

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its replacement by O’Driscoll’s classification [49], which takes fuller account of medial MCL
bundle involvement. Even so, we consider that systematic preoperative CT associated to
ligament testing under anesthesia provides affective assessment of instability.
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Attitudes to ligament repair
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Many biomechanical studies demonstrated the role of the MCL in elbow stabilization [13,
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40, 50, 51]. Tear or humeral avulsion is almost systematic in dislocation, whether simple or
complex [23, 52, 53]. Repair thus seems a reasonable attitude in case of surgery.
However, systematic MCL repair in simple elbow dislocation did not significantly improve
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long-term results [50]. Benefit in TT is a matter of debate.

Several authors reported no significant improvement in results with MCL repair [4, 5, 7, 23],
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which they considered unjustified in isolated valgus instability with good sagittal stability in
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flexion-extension; a medial approach was performed for persistent instability in flexion-

extension, to restore stability in the useful 30-130° range of motion.
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Other authors advocate repair or systematic reinsertion to prevent chronic posterolateral

instability [54] and post-traumatic osteoarthritis [9, 10, 12], functional improvement being
variable.
Post-dislocation osteoarthritis rates vary from 8% to 67% [7, 10, 24]. It was recently
suggested that risk is proportional to trauma intensity [55, 56].
The present study lacked sufficient follow-up to confirm these findings, and a further study
will be conducted to correlate osteoarthritis risk with absence of MCL repair.

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Page 8 of 20
Intergroup comparison of functional results confirmed the relative lack of benefit of
systematic MCL repair, with significantly better MEPS in case of a combined approach, but
no significant benefit on the other criteria: QuickDASH, VAS, range of motion or return to
work and sport.

There was no significant intergroup difference in complications, but a trend for more
frequent recurrence in MCL- on a simple lateral approach and a greater number of ulnar
nerve complications in MCL+ with a combined approach, logically explained by the anatomic
relations.

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Study limitations
Study limitations comprised:
- retrospective design;
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- follow-up too short to asses osteoarthritis risk;
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- partly subjective clinical assessment;
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- more than 10 surgeons, with strategy determined intraoperatively on stability testing

at the surgeon’s discretion.
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Strengths comprised:
- little loss to follow-up (n=3);
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- larger series than in previous reports, the largest being 45 patients at 24 months for
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Watters [29], 23 patients at 63 months for Bonnevialle [5], 22 patients at 30 months

for Forthman [7], 36 patients at 34 months for McKee [53] and 36 patients at 30
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months for Pugh [4];

- recognized consensual endpoints as used in the international literature: MEPS, VAS,
QuickDASH;
- original study, with few previous comparisons of results according to MCL repair.

CONCLUSION

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Page 9 of 20
The present study confirmed the good results in unstable TT of surgery associated to early
mobilization.
A first-line lateral approach usually allows treatment of the radial fracture and lateral
ligament and anterior capsule lesion, restoring sagittal stability in most cases.
A secondary medial approach is needed for persistent instability in extension, to repair the
MCL and/or CP when this is not feasible via the lateral approach.
The aim of surgery is to restore sufficient stability for immediate mobilization, avoiding strict
immobilization.
The present results did not confirm any superiority of associating MCL repair; systematic
capsule and MCL repair thus cannot be recommended.

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However, follow-up was lacking for analysis of long-term complications such as
osteoarthritis.
A further study would be useful to analyze the long-term effect of MCL repair on
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posteromedial micro-instability, which seems to be a prognostic factor for onset of
osteoarthritis following elbow dislocation.
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Disclosure of interest: the authors have no conflicts of interest to disclose

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Funding: none
Author contributions:
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Clémentine CORBET: article writing

Mehdi BOUDISSA: statistics
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Séverine DAO LENA: data collection

Sébastien RUATTI: data collection
Denis CORCELLA: re-editing
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Jérôme TONETTI: study design

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2010;130(2):241–9.
53. Pugh DMW, McKee MD. The “terrible triad” of the elbow. Tech Hand Up Extrem Surg.
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2002;6(1):21–9.
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for posterolateral rotatory instability of the elbow. J Bone Joint Surg Br. 2005;87(1):54–61.
55. Heijink A, Vanhees M, van den Ende K, et al. Biomechanical considerations in the
pathogenesis of osteoarthritis of the elbow. Knee Surg Sports Traumatol Arthrosc.
2016;24(7):2313–8.
56. Soojian MG, Kwon YW. Elbow arthritis. Bull NYU Hosp Jt Dis. 2007;65(1):61–71.

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 Table 1: epidemiological data.

Total MCL- MCL+ p-

value
N 50 31 19
Follow-up (months) 24.2 (3-108) 28.7 (5-108) 16.9 (3-54) 0.077
F/M sex ratio 19F / 31M 11F / 20M 8F / 11M 0.640
Age at accident (years) 47.1 (18 – 84) 49.1 (18 – 84) 43.9 (20 – 80) 0.352
Dominant involvement (%) 40% 41.9% 36.8% 0.721
Type of accident: 0.211
- body-height fall 21 (42%) 11 10 0.369
- fall >2m 21 (42%) 16 5 0.143
- very high energy 8 (16%) 4 4 0.715

f
Associated lesions: 0.544

oo
- ipsilateral limb 7 (14%) 6 1 0.330
- contralateral upper limb 4 (8%) 2 2 0.629

- lower limb 4 (8%) 2 2 0.629

- other
Local preoperative
complications:
8 (16%) pr 5 3 1
NC
e-
- ulnar palsy 2 (4%) 1 1 1
- skin opening 2 (4%) 1 1 1
- arterial lesion 0 0 0 NC
Pr

Mason RH fracture type (16): 0.707

- type 1 3 (6%) 2 1 1
- type 2 27 (54%) 18 9 0.656
- type 3 20 (40%) 11 9 0.592
al

Regan-Morrey CP fracture type

(17): 0.552
- type 1 36 (72%) 21 15 0.594
n

- type 2 12 (24%) 9 3 0.331

- type 3 2 (4%) 1 1 1
ur

Instability on preoperative
testing: 0.183
- no test 19 12 7 0.894
Jo

- no instability 2 (6%) 0 2 NC
- moderate instability 9 (29%) 6 3 0.694
(before 30° extension)
- severe instability (before 20 (65%) 13 7 0.567
60° extension)
Laxity testing: 31 0.961
- varus 22 (71%) 14 8 0.961
- valgus 27 (87%) 17 10 0.961

RH: radial head; CP: coronoid process; MCL: medial collateral ligament; NC: non-calculable.

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 Table 2. Surgical data.

Total MCL– MCL+ p

N = 31 N = 19
Trauma-to-surgery time (days) 2.44 (0 – 16) 2.80 (0 – 16) 1.89 (0 – 6) 0.668
RH treatment: 0.324
- fixation 27 (54%) 19 8 0.186
- replacement 16 (32%) 8 8 0.230
- abstention 6 (12%) 4 2 0.802
- resection 1 (2%) 0 1 NC
CP treatment: 0.094
- bone-suture 15 (30%) 6 9 0.075
- fixation 5 (10%) 3 2 0.922

f
- none 30 (60%) 22 8 0.085

oo
Strict immobilization (days) 21.2 (0 – 47) 22.5 (0 – 47) 19.2 (0 – 45) 0.669

Type of immobilization: 0.081

- long-arm cast 43 (86%) 27 16 0.560
- articulated splint
- none
- external fixator
3 (6%)
4 (6%)
0
pr 1
3
0
2
1
0
0.658
0.982
NC
e-
RH: radial head; CP: coronoid process; MCL: medial collateral ligament; NC: non-calculable.
Pr
n al
ur
Jo

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Table 3. Clinical and functional results in MCL- versus MCL°

Total MCL- MCL+ p

MEPS (/100) 89.1 (52.5 – 86.2 (52.5 – 100) 93.8 (70 – 100) 0.02
100)
VAS (/10) 0.7 (0 – 5) 0.67 (0 – 4) 0.73 (0 – 5) 0.726
QuickDASH (/100) 16 (0 – 59) 18.2 (0 – 52) 15.9 (0 – 59) 0.424
Return to work: 0.660
- same job 41 (82%) 26 15 0.660
- other or none 9 (8%) 5 4 0.660
Return to sport: 0.233
- same level 28 (56%) 20 9 0.233
- lower or none 22 (44%) 11 10 0.233
Mean range of motion (°):
- Flexion 130 (110-140) 131 (110-140) 130 (110-140) 0.872

f
- Extension 14 (0 – 40) 15 (0 – 40) 13 (0 -30) 0.609

oo
- Pronation 73 (0 – 90) 72 (0 – 90) 77 (60 – 90) 0.654
- Supination 62 (0 – 80) 61 (0 – 80) 64 (10 – 80) 0.784
Mean F/E, P/S (°):
- F/E 114 (70 – 140) 110 (70 – 135) 120 (80 – 140) 0.092
- P/S
F / E range (n)
- < 50°
137 (0 – 170)

1 (2%)
pr
129 (0 – 170)

0
151 (50 – 170)

1
0.154
0.350
NC
e-
- 50 < x < 110 15 (30%) 10 5 0.319
- > 110 34 (68%) 18 16 0.525
Total complications 25 (50%) 14 11 0.382
Pr

Early complications: 0.899

- total 11 (22%) 7 4 0.899
- recurrence 4 (8%) 4 0 NC
- ulnar palsy 5 (10%) 2 3 0.355
al

- sepsis 3 (6%) 3 0 NC
- other 2 (4%) 1 1 1
n

Late complications: 0.279

- total 15 (30%) 11 4 0.351
ur

- CRPS 3 (6%) 2 1 1
- non-union 3 (6%) 2 1 1
- peri-articular 7 (14%) 5 2 0.694
Jo

calcification
- other 3 (6%) 3 0 NC
Revision within year: 0.197
- total 13 (26%) 10 3 0.320
- arthrolysis +/- 13 (26%) 10 3 0.320
hardware removal 3 (6%) 3 0 NC
- ulnar nerve 1 (2%) 1 0 NC
- recurrence 0 0 0 NC
MCL: medial collateral ligament. F/E: flexion / extension. P/S: pronation / supination.
CRPS: complex regional pain syndrome. NC: non-calculable.

16
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 Table 4. Clinical and functional results according to immobilization < versus > 2 weeks.

Total < 2 weeks > 2 weeks p

N 50 23 27
MEPS 89.1 (52.5 – 100) 96.1 (52.5-100) 83.5 (77.5-100) < 0.01

f
VAS 0.7 (0 – 5) 0.17 (0 - 5) 1.0 (0-3) 0.02

oo
QuickDASH 16 (0 – 59) 15.8 (2.3 – 59) 20.7 (0-36.4) 0.024
F/E 114 (70-140) 124 (110-140) 105 (70-140) < 0.01
P/S 139 (0-170) 164 (150-170) 116 (0 – 170) < 0.01

pr
F/E: flexion / extension. P/S: pronation / supination.
e-
Pr
n al
ur
Jo

17
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Table 5. Clinical and functional results according to radial head fixation versus
replacement.

Total Fixation Replacement p

N 43 27 16
MEPS 89.1 (52.5 – 100) 86.8 (57.5 – 100) 93.7 (77.5-100) 0.095
VAS 0.66 (0-4) 0.8 (0-4) 0.3 (0-4) 0.13
QuickDASH 15.9 (0-52.3) 17.8 (0-52.3) 16.1 (0-31.8) 0.28
F/E 116 (70-140) 112 (70-140) 122 (85-140) 0.051
P/S 139 (0-170) 135 (0-170) 145 (70-170) 0.92

f
F/E: flexion / extension. P/S: pronation / supination.

oo
pr
e-
Pr
n al
ur
Jo

18
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Figure 1
1A: Left elbow lateral view before dislocation reduction. 1B: AP view after reduction. 1C:
Lateral view after reduction.
RH fracture visible on all views. CP fracture just visible on lateral views.
1D: Postoperative AP view. 1E: Postoperative lateral view. RH screw fixation and LCL and
MCL reinsertion by impacted anchors.

f
oo
Figure 2 pr
Raw treatment distribution according to RH and CP lesion type. RH: radial head; CP:
coronoid process
e-
40
Pr

35

30 13

25 3
al

20 1

15 6
n

21
23 2
10
ur

13 6
5
3 3 4 1
Jo

0
RH Mason 1 RH Mason 2 TR Mason 3 PC Regan- PC Regan- PC Regan-
Morrey 1 Morrey 2 Morrey 3

RH replacement Fixation Resection Abstention Bone suture

19
Page 19 of 20
Figure 3
Extrapolated percentage treatments according to RH and CP lesion type. RH: radial head; CP:
coronoid process
120

100 5
11
17
80 30 36
50

60 50
100 78
40

f
65 64

oo
50
20
33
11
0
RH Mason 1 RH Mason 2 RH Mason 3

TH replacement Fixatin Resection

pr CP Regan-
Morrey 1

Abstention
CP Regan-
Morrey 2

Bone-suture
CP Regan-
Morrey 3
e-
Pr
n al
ur
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20
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