Negative Pressure Wound Therapy With Instillation and Dwell Time Used to Treat a Complex Open (Terrible Triad) Injury...

Treating a complex elbow injury known as the terrible triad, combined with a severe soft tissue trauma, is challenging for most orthopedic surgeons and can lead to permanent disabilities and poor functional outcomes if reconstruction is inadequate.

A 75-year-old male with a history of high blood pressure was injured in an accident involving agricultural equipment and presented with a triad injury of the left elbow: a posterolateral dislocation combined with fractures of the radial head (Mason-Johnson Type II) and ulnar coronoid process (Morrey Type 1). Fractures to the radial head and ulnar coronoid process and injuries to the lateral collateral ligament and triceps tendon were repaired, and a local skin flap was preserved to provide adequate soft tissue coverage. A hinged external fixator was applied to maintain elbow alignment and allow early mobilization. Traditional negative pressure wound therapy (NPWT) was applied on the remaining skin defects; when local necrosis and septic arthritis of the elbow were noted, NPWT with instillation and dwell time (NPWTi-d) was initiated. Once a viable wound bed was obtained, a split-thickness skin graft was used to provide total coverage. All wounds and fractures were healed within 8 weeks, the external fixator was removed, and free elbow joint mobilization was allowed. At 3 months, the authors obtained 100°/30°/0° of elbow range of motion with a DASH 3 at 30. At 6 months, the elbow range of motion reached 120°/20°/0° with a clear improvement of DASH score (DASH 6 at 14.2).

Management of this complex elbow injury that featured NPWTi-d contributed to a good result and facilitated coverage of an extensive loss of skin and soft tissue; more importantly, the patient experienced limited discomfort. A larger prospective study is required to support general recommendations for this approach to similar injury.