Terrible Triad Injury of the Elbow

What is a Terrible Triad Injury of the Elbow?

A Terrible Triad Injury of the Elbow is a severe and complex injury that involves:

  • Elbow Dislocation: The elbow bones are forced out of their normal positions.
  • Radial Head or Neck Fracture: The radial head or neck, part of the radius bone near the elbow, is fractured.
  • Coronoid Process Fracture: The coronoid process is fractured, a triangular part of the ulna bone.


  • X-rays: The primary tool for diagnosing the injury. They help visualise the position of the bones and identify fractures.
  • CT Scans: These are often used to get a more detailed view of the fractures, especially useful for surgical planning.

Treatment Options

  • Surgical Treatment:
    • Open Reduction and Internal Fixation (ORIF): Surgical method to fix the fractures using plates, screws, or rods.
    • Radial Head Arthroplasty: Replacement of the radial head with a prosthetic implant.
    • Lateral Collateral Ligament (LCL) Reconstruction: Repairing the ligament on the outer side of the elbow.
    • Coronoid ORIF: Surgical fixation of the coronoid fracture.
    • Medial Collateral Ligament (MCL) Reconstruction: Repairing the ligament on the inner side of the elbow if necessary.

Causes and Mechanism

  • Causes: Typically occurs from a high-energy impact, such as falling onto an outstretched hand with the arm extended.
  • Mechanism:
    • The elbow is subjected to valgus (outward), axial (along the arm’s length), and posterolateral rotatory (twisting) forces.
    • This combination leads to dislocation and fractures, starting from the lateral side and moving medially.
    • Pathoanatomy:
      • The LCL is the first structure to fail.
      • The anterior capsule of the elbow is injured next.
      • MCL disruption can occur if the force is significant enough.

Anatomy Involved

  • Radial Head:
    • Key to preventing posterolateral rotatory instability (PLRI).
    • Acts as a secondary stabilizer against valgus forces.
  • Coronoid Process:
    • Provides stability to the ulnohumeral joint.
    • Prevents posterior subluxation (partial dislocation) beyond 30 degrees of flexion.
    • The fracture often includes part of the anterior capsule, which aids in repair.
  • Medial Collateral Ligament (MCL):
    • Composed of three parts: anterior bundle (most important for stability), posterior bundle, and transverse ligament.
    • Essential for resisting valgus and posteromedial rotatory forces.
  • Lateral Collateral Ligament (LCL):
    • Comprises four parts: lateral ulnar collateral ligament (LUCL), radial collateral ligament (RCL), annular ligament, and accessory collateral ligament.
    • Crucial for preventing posterolateral rotatory instability.
    • Often avulsed (torn off) from the lateral epicondyle during injury.

Symptoms and Examination

  • Symptoms:
    • Severe pain in the elbow.
    • Clicking and locking sensation, especially when extending the elbow.
  • Physical Exam:
    • May reveal instability patterns (varus or valgus).
    • The distal radial ulnar joint should be checked for Essex-Lopresti injury (a severe injury involving the radial head and the interosseous membrane).


  • Radiographs (X-rays):
    • Essential for evaluating the alignment of the ulnohumeral and radiocapitellar joints.
    • Look for coronoid fractures.
    • Both pre-reduction (before the bones are set) and post-reduction films are needed.
    • Additional wrist and forearm X-rays may be necessary.
  • CT Scans:
    • Provide a detailed view of the coronoid fracture.
    • 3D imaging can help determine the exact nature of the fracture lines.

Treatment Details

Nonoperative Treatment

  • Immobilization:
    • The elbow is immobilized at 90 degrees of flexion for 7-10 days.
    • Indicated in rare cases where the joints are stable, fractures are small, and early range of motion is feasible.
  • Technique:
    • After a week of immobilization, gradual progression to active motion begins.
    • Initial active motion with the elbow at 90 degrees and forearm pronated, avoiding terminal extension.
    • Static progressive extension splinting at night after 4-6 weeks.
    • Strengthening exercises start after six weeks.

Operative Treatment

  • Indications:
    • Required for unstable injuries with significant fractures and dislocations.
  • Techniques:
    • ORIF or Radial Head Arthroplasty: Depending on the fracture type and severity.
    • LCL Reconstruction: Using suture anchors or transosseous sutures.
    • MCL Reconstruction: If instability persists after addressing other structures.
  • Surgical Approach:
    • A posterior skin incision provides access to the elbow’s medial and lateral aspects.
    • This approach is more cosmetic and has a lower risk of injuring cutaneous nerves.
  • Specific Techniques:
    • Radial Head ORIF: Using screws and plates if fractures are less than 40% of the articular surface.
    • Radial Head Arthroplasty: For comminuted fractures (more than three pieces).
    • Coronoid ORIF: Using sutures, suture anchors, screws, or plates.
    • LCL Repair: Reattachment with sutures or anchors at the lateral epicondyle.
    • MCL Repair: Indicated for persistent instability after other repairs.


  • Instability: More common with Type I or II coronoid fractures.
  • Failure of Fixation: Often seen in radial neck fractures due to poor vascular supply.
  • Stiffness: Very common; early ROM exercises are crucial.
  • Heterotopic Ossification: Prophylaxis may be necessary in high-risk patients.
  • Post-Traumatic Arthritis Can result from initial cartilage damage or residual instability.


  • Historically, outcomes have been poor due to:
    • Persistent instability.
    • Joint stiffness.
    • Development of arthritis.
  • Early and appropriate treatment is essential for better outcomes and to minimise complications.
Videos :


Elbow Fracture Dislocation Terrible Triad – Everything You Need To Know – Dr. Nabil Ebraheim

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