Single pulley double-strand anchor suture fixation of the coronoid process in terrible triad of the elbow injury

Sep 29, 2026

Terrible triad of the elbow presents extreme instability combining coronoid process avulsion, radial head fracture, and posterolateral elbow dislocation, where inadequate fixation often causes recurrent instability, limited ROM, and stiffness. Eight patients with Regan-Morrey type I/II coronoid fragments (<50% height) underwent operative repair through a lateral Kocher’s approach using a single pulley double-strand suture with suture anchor fixation, addressing sequential structures. Outcomes were excellent in 6 and good in 2 patients at 6 months. The method is less invasive and simpler with favorable results.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages6

Reading Time15 min

AccessFree to download

INTRODUCTION

Background and clinical challenge

Rationale for coronoid process fixation

METHODS

Study design and patient selection

Surgical technique overview

RESULTS

Patient outcomes and follow-up

J Chin MedAssoc Original article Single pulley double-strand anchor suture fixation of the coronoid process in terrible triad of the elbow injury Kai-Cheng Lina, Wei-Yi Laib,c, Yi-Ping Yangb,c, Yi-Yin Linb,c, Tzu-Wei Linb,c, Chia-Lin Wangb, Hsiao-Yun Taib, Fu-Ting Tsaib, Yi-Ching Tsaib, Yih-Wen Tarnga,c,d,* aDepartment of Orthopaedics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC; bDepartment of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; cSchool of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC; dDepartment of Orthopaedics, National Defense Medical Center, Taipei, Taiwan, ROC Abstract Background: Terrible triad of the elbow injury is difficult to manage, and the role of the coronoid process in instability is very important. We describe a simple, modified suture technique to fix a coronoid process fragment using suture anchor fixation. Methods: Eight patients (three female and five male) with coronoid process injuries with the fragment involving <50% of the total height (Regan-Morrey type I/II) in terrible triad of elbow injury were included. Patients were treated operatively via a lateral Kocher’s approach, and coronoid process fractures were repaired with a single pulley double-strand suture technique. Structures were addressed in a sequential fashion—the coronoid process, radial head, lateral ulnar collateral ligament. Results: All patients were treated with the single pulley double-strand anchor suture technique and the coronoid process fragment was found to be in good contact with the original avulsion site using the method. The final Mayo Elbow Performance Score was excellent (> 90) in six patients and good (between 85 and 89) in two patients after operation 6 months. Conclusion: The single pulley double-strand suture tie method using a suture anchor is a less invasive and simpler fixation method for the repair of coronoid process fractures in patients with terrible triad of the elbow injuries and results in good outcomes. Keywords: Coronoid process avulsion fracture; Pull-out suture; Single pulley double-strand suture; Suture anchor; Terrible triad 1. INTRODUCTION Terrible triad of the elbow is difficult to manage because it is a combination of a coronoid process avulsion fracture, radial head fracture, and posterolateral dislocation of the elbow, which results in extreme elbow instability.1–4 In many cases, surgical fixation is incomplete leading to instability, limited range of motion (ROM), and elbow stiffness.5 The avulsed coronoid process fragment is responsible for most loss of fixation because many surgeons consider it a Regan-Morrey type I/II coronoid process tip fracture.6 Conservative treatment is recommended for Morrey type I/II coronoid process fractures, but they typically occur with simple posterior dislocation without any collateral ligament injury.6 In most cases, the anterior capsule is intact, and closed reduction is sufficient because the elbow is stable. The trauma and injury in terrible triad, however, is different. In terrible triad of the elbow, there is anterior capsule disruption *Address Correspondence. Dr. Yih-Wen Tarng, Department of Orthopaedics, Kaohsiung Veterans General Hospital, 386, Da-Chung 1st Road, Kaohsiung 813, Taiwan, ROC. E-mail address: qm1047@ms35.hinet.net (Y.-W. Tarng). Conflicts of interest: The authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article. Journal of Chinese Medical Association. (2022) 85: 222-227. Received September 9, 2021; accepted October 4, 2021. doi: 10. 1097/JCMA.0000000000000633. Copyright © 2021, the Chinese Medical Association. This is an open access article under the CC BY-NC-ND license ([http://creativecommons.org/licenses/](http://creativecommons.org/licenses/)[ ](http://creativecommons.org/licenses/)[by-nc-nd/4.0/](by-nc-nd/4.0/)) with coronoid process tip avulsion, and a latera

FAQs

Why is the coronoid process fixation critical in terrible triad of the elbow?

Loss of the anterior buttress of the elbow occurs if the coronoid process tip is not fixed, leading to relative elbow instability and posterolateral rotation instability.

What suture technique is described for coronoid process fragment fixation?

A simple, modified single pulley double-strand suture technique using a suture anchor to secure the coronoid process fragment.

How were outcomes evaluated after surgery and what were the results?

The final Mayo Elbow Performance Score was excellent (>90) in six patients and good (85–89) in two patients after 6 months.

Sep 29, 2026

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