Complex Elbow Dislocations and the "Terrible Triad" Injury

The elbow is the second most commonly dislocated joint in adults and up to 20% of dislocations are associated with a fracture. These injuries can be categorised into groups according to their mechanism and the structures injured.

This review includes a literature search of the current evidence and personal experiences of the authors in managing these injuries.

All injuries are initially managed with closed reduction of the ulno-humeral joint and splinting before clinical examination and radiological evaluation. Dislocations with radial head fractures should be treated by restoring stability, with treatment choice depending on the type and size of radial head fracture. Terrible triad injuries necessitate operative treatment in almost all cases. Traditionally the LCL, MCL, coronoid and radial head were reconstructed, but there is recent evidence to support repairing of the coronoid and MCL only if the elbow is unstable after reconstruction of lateral structures. Surgical treatment of terrible triad injuries carries a high risk of complications with an average reoperation rate of 22%. Varus posteromedial rotational instability fracture-dislocations have only recently been described as having the potential to cause severe long-term problems. Cadaveric studies have reinforced the need to obtain post-reduction CT scans as the size of the coronoid fragment influences the long-term stability of the elbow. Anterior dislocation with olecranon fracture has the same treatment aims as other complex dislocations with the added need to restore the extensor mechanism.

Complex elbow dislocations are injuries with significant risk of long-term disability. There are several case-series in the literature but few studies with sufficient patient numbers to provide evidence over level IV.