Terrible Triad injuries of the elbow involve a dislocation combined with fractures of the radial head and coronoid process. Although complex and historically challenging, early diagnosis and specialised treatment greatly improve outcomes. This comprehensive guide explains everything patients should know about this significant injury.

What is a Terrible Triad Elbow Injury?

A Terrible Triad elbow injury involves three simultaneous injuries:

• Posterior elbow dislocation (elbow joint forced backward)
• Radial head fracture (break in the radius bone near the elbow)
• Coronoid process fracture (break in a key stabilising part of the ulna bone)

The combination of these injuries leads to severe instability in the elbow joint, making prompt and expert treatment essential to avoid long-term complications like stiffness, pain, and arthritis.

How Does a Terrible Triad Injury Occur?

Typically, a Terrible Triad injury happens due to a fall onto an outstretched hand, forcing the elbow backwards, outward, and twisting it at the same time. This common mechanism is often seen when someone falls onto a straightened arm, especially from a standing height.

This injury progresses through three stages (called the Horii Circle):

1. Lateral Ligament Injury: Damage begins on the outside of the elbow.
2. Capsule Injury: The joint capsule tears, destabilising the elbow further.
3. Medial Ligament and Bone Fractures: The medial ligament tears, and fractures occur in the radial head and coronoid process.

How is a Terrible Triad Injury Diagnosed?

Prompt and precise diagnosis is critical. It involves:

Clinical Examination:

• Pain, severe swelling, and bruising.
• Obvious deformity or inability to move the elbow.
• Nerve assessment (especially ulnar nerve).

Imaging:

• X-rays: Identify fractures and dislocation.
• CT scans: Crucial to accurately understand fracture patterns and plan surgery.
• MRI scans: Occasionally used for detailed soft tissue assessment.

Why are CT Scans Essential?

A CT scan provides detailed, three-dimensional images of bone fractures, enabling surgeons to:

• Precisely identify fracture patterns and severity.
• Plan surgical repairs accurately.
• Detect hidden injuries not visible on standard X-rays.

Treatment Options for Terrible Triad Injuries

Primary Goal: Restore elbow stability for early mobilisation, preventing stiffness.

Non-Surgical Treatment (Rarely used):

• Only suitable for minimally displaced injuries in low-demand patients.
• Short immobilisation period followed by supervised physical therapy.

Surgical Treatment (Mainstay):

Most patients require surgery to restore stability and function. A structured approach involves:

1. Radial Head Treatment:
   • Fixation (ORIF): Suitable if fragments can be repaired.
   • Replacement (Arthroplasty): For severely broken radial heads.
2. Coronoid Fracture Fixation:
   • Sutures or screws for larger fragments.
   • Small fractures often stabilised indirectly.
3. Ligament Repair:
   • Lateral Collateral Ligament (LCL): Typically reattached using strong sutures or anchors.
   • Medial Collateral Ligament (MCL): Repaired if instability persists.
4. External or Internal Joint Stabilisation: Used when instability remains despite initial repairs.

Rehabilitation After Surgery

Rehabilitation is essential to achieving a successful recovery. It includes:

• Early Mobilisation: Gentle elbow movement typically starts within 48 hours after surgery.
• Controlled Motion: Use of hinged braces to protect repairs.
• Strengthening Exercises: Begin around 6–8 weeks post-surgery.
• Specialist Physiotherapy: Regular sessions to prevent stiffness and regain strength.

Common Complications of Terrible Triad Injuries

Possible complications include:

• Elbow stiffness: Most common; reduced by early motion.
• Persistent instability: May occur if repairs are inadequate.
• Heterotopic ossification (HO): Abnormal bone growth causing stiffness.
• Infection or nerve injury: Rare but significant risks.
• Post-traumatic arthritis: Long-term complication, especially after severe injuries.

Early treatment and careful rehabilitation minimise these risks.

Prognosis and Recovery Expectations

Modern treatment and early intervention provide favourable outcomes, though some elbow motion loss is common. Most patients achieve good functional results and return to normal daily activities, though full recovery can take several months.

• Optimal surgery timing: Within two weeks of injury.
• Average recovery period: 6–12 months for complete function.

Clinical Pearls / Key Points

• Early and expert treatment is crucial for good outcomes.
• CT scans significantly enhance treatment accuracy.
• Surgery followed by prompt rehabilitation is typically required.

Patient FAQs

Q: Can a Terrible Triad elbow injury heal without surgery?
A: Rarely. Due to severe instability, surgery is typically required.

Q: How soon after surgery can I move my elbow?
A: Usually within 48 hours, guided by your physiotherapist.

Q: How long does full recovery take after surgery?
A: Typically, full recovery can take between 6 to 12 months, depending on severity and adherence to rehabilitation.

Call-to-Action

For more information, specialist elbow assessments, or to arrange treatment, visit www.TheArmDoc.co.uk. Book your consultation today by calling 020 3384 5588 or emailing Info@TheArmDoc.co.uk.

Disclaimer

This content provides general educational information and should not be used as a substitute for professional medical advice. Always consult your healthcare provider for individual diagnosis and treatment options.

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