Terrible triad of the elbow

Last revised by Calum Worsley on 10 Sep 2022

The terrible triad of the elbow is a severe elbow fracture-dislocation pattern and is so-called because it has poor medium-to-long term outcome. 

The terrible triad primarily occurs in adults; the flexibility of ligaments in children make this constellation unlikely 4. In the upper limb, the elbow is the second most dislocated joint, with fractures associated with ~25% dislocations 5

Most commonly due to a fall onto an outstretched hand, not necessarily high-energy, with the arm in semi-flexion and supination 3. The fall is usually associated with a valgus posterolateral force which disrupts the capsuloligamentous structures sequentially from lateral to medial 5

The terrible triad of the elbow is the association of 1,2:

  1. posterior elbow dislocation 
  2. coronoid process fracture 
  3. radial head fracture

The posterior elbow dislocation usually involves the ulnohumeral joint 5. The coronoid fracture usually involve the tip or are type I fractures (O'Driscoll Classification). Up to 35% or 7 mm of the coronoid may be involved 5

Management can be non-operative or operative. 

Criteria for non-operative management include 5:

  • concentric joint reduction
  • no mechanical block associated with radial head fracture
  • small coronoid fragment
  • stable arc of motion up to 30o from full extension

Operative techniques vary depending on the injury pattern but may include 5:

  • coronoid
    • internal fixation or anterior capsular repair
    • may need grafting either from discarded radial head fragments (if performing radial head replacement) or olecranon process)
  • radial head internal fixation or replacement
  • repair of lateral ulnar collateral ligament (LUCL) to restore lateral stability
  • restore medial stability via medial collateral ligament (MCL) repair or use of external bracing 

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Cases and figures

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