Management of Elbow Terrible Triad Injuries in a Resource-Constrained Setting

Managing terrible triad injuries of the elbow presents considerable difficulties in restoring joint stability and achieving functional recovery. These challenges are amplified in settings with limited resources, such as restricted implant availability and scarce access to rehabilitation services. This study, conducted at a tertiary care center in South India, assesses the clinical and radiological outcomes following the treatment of terrible triad injuries using a uniform surgical protocol.

A retrospective review of 36 consecutive patients treated between 2018 and 2023 was conducted. All patients underwent surgical management consisting of radial head fixation or arthroplasty, selective coronoid fixation, and routine LCL repair, with MCL repair performed only in cases with persistent valgus instability. Outcomes assessed included the Mayo Elbow Performance Score (MEPS), range of motion, radiographic healing, and complications, with a minimum follow-up of 12 months.

The cohort included 28 males and 8 females (mean age 38.6 years). Radial head arthroplasty was performed in 30 patients (84%), while 6 (16%) underwent ORIF. Coronoid fixation was required in 13 out of the 36 cases. At a mean follow-up of 24 months, the mean MEPS was 86.4 ± 9.2, with 61% excellent and 28% good outcomes. The mean flexion-extension arc was 118° ± 16°, with mean pronation and supination of 72° ± 10° and 68° ± 12°, respectively. Degenerative changes were observed in 22% of patients. Complications occurred in 27% of cases, predominantly postoperative stiffness (n = 5) and transient ulnar neuropraxia (n = 2). No deep infections or implant failures were recorded. Outcomes between the ORIF and arthroplasty groups were comparable.

Adherence to an algorithmic surgical approach-prioritizing radial head stabilization or replacement, selective coronoid fixation, and systematic ligament repair-yields reproducible outcomes in terrible triad injuries, even in resource-limited settings. Stable reconstruction and early mobilization remain the cornerstones of successful management.