Terrible Triad Injuries around the Elbow: It is Still a Puzzle? Prospective Study

The "terrible triad" injury of the elbow, consisting of fractures of the coronoid process and radial head along with posterolateral elbow dislocation and refractory instability, has historically led to poor functional outcomes. Traditional treatment focused on bony injuries, but it is now recognized that soft-tissue injuries must also be addressed. Surgical management aims to restore bony and soft-tissue stabilizers, including fixation of the coronoid process and radial head, repair of ligament complexes, and reduction of elbow dislocation. Studies emphasize the importance of early reduction and tailored treatment. This study discusses means and methods of treating this complex injury, highlighting the significance of addressing both bony and soft-tissue injuries for better functional outcomes.

This is a prospective study conducted at a single center and involved 27 consecutive patients diagnosed with terrible triad injuries around the elbow. The objective was to evaluate functional outcomes and complications associated with surgical treatment of terrible triad injuries around the elbow. From July 2017 to October 2018, 27 patients with terrible triad injuries around the elbow were operated on and evaluated for a minimum of 1 year in terms of functional results using the mean elbow performance score (MEPS) and VAS score. The surgical protocol included coronoid fixation or repair of the anterior capsule, radial head fixation or arthroplasty, and repair of the lateral collateral ligament (LCL) in a sequential manner. The medial collateral ligament was repaired if the elbow remained unstable.On follow-up, mean MEPS scores improved significantly. The final mean range of motion of the operated upper limb was as follows: 28.5° of extension deficit (standard deviation [SD] 9.07, range, 10°-40°), 117.5° of flexion (SD 13.18, range, 90°-130°), 70.9° of supination (SD 10.19, range, 40°-85°), and 65.5° of pronation (SD 9.54, range, 40°-80°) at the end of 1 year. A total of 12 patients had complications. Out of the 12 patients, three had elbow arthritis, two had heterotopic ossification, three had radial nerve neuropraxia, two patients had elbow stiffness, and two patients suffered from ulnar nerve neuropathy.

Surgical intervention in terrible triad injuries around the elbow in the form of coronoid fixation, radial head fixation, or arthroplasty and soft-tissue repair around the elbow gives satisfactory results at the end of 1 year. Addressing each and every component of fracture in a sequential and step-wise manner is associated with good functional outcomes at the end of 1 year.