Nonoperative management of terrible triad injuries: clinical outcomes of 39 cases

Terrible triad injury (TTI) poses therapeutic challenges in joint stability and functional recovery. While surgery has traditionally been preferred, recent interest in nonoperative management for select cases has emerged, with studies suggesting positive outcomes for carefully chosen patients.

This retrospective study, conducted at a tertiary medical center, included patients treated conservatively for TTI between 2014 and 2022. Patients younger than 18 years with open or pathological fractures or multiple injuries were excluded. Conservative treatment was chosen for elbows with good alignment, minimal displacement, and no motion block. Progress was monitored clinically and radiographically. Functional outcomes were assessed using the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score.

Thirty-nine patients (59% male; mean age, 44.7±18.3 years) were included, with a mean follow-up of 78.5±29.4 months. Falls (46%) and scooter accidents (36%) were the primary injury mechanisms. Radial head fractures comprised Mason type 1 (36%), type 2 (54%), and type 3 (10%), while coronoid fractures were Regan-Morrey type 1 (69%), type 2 (28%), or type 3 (3%). Final range of motion averaged 128.2° flexion, with an 8.2° extension deficit and 85° forearm rotation. The MEPS was excellent in 11, good in 19, and fair in 9 patients; the mean DASH score among all fractures was 12.6. Five patients (13%) required subsequent surgery, and mechanical clicking was reported in 16 patients (41%).

Nonoperative treatment of TTI might be a viable option for selected patients, yielding generally satisfactory outcomes and an acceptable complication rate. Level of evidence: IV.