Elbow - Terrible Triad Injury

The notes on this page are written as a source of information to both patients and health professionals. It is a general overview and its content should not be seen as direct medical advice. Further information regarding diagnosis and treatment specific to your condition can be made via a consultation with Dr Amaranath.

Anatomy of the elbow

Stability of the elbow is achieved by both bony and soft tissue structures. The bony stabilisers include the ulnohumeral joint, radial head and the coronoid process of the ulna. The soft tissue structures include the lateral and medial collateral ligaments.

What is a terrible triad injury?

A terrible triad injury commonly follows an elbow dislocation and involves 3 components:

  1. Fracture of radial head

  2. Fracture of the coronoid process

  3. Collateral ligament injury (Lateral +- medial)

The combination of these injuries leads to an unstable elbow joint and without treatment can overtime cause to ongoing pain, instability and joint arthritis. 

What are the common causes?

Commonly, it is a traumatic injury following a fall onto an outstretched arm. The elbow then dislocates and either self-reduces or requires a reduction in hospital.

What are the preferred Investigations/Imaging?

  1. Plain X-Ray of the Elbow - This should include an Anterior/Posterior and Lateral views. This helps confirm the dislocation and the post reduction of the elbow. 

  2. CT scan of the Elbow - This is commonly used to further quantify and accurately diagnose the fractures in the radial head and coronoid.

What are the treatment options?

  1. Non-operative – This treatment may be reserved for undisplaced fractures and where the elbow is clinically stable. Following confirmation of a reduced joint on X-ray the elbow is initially immobilised and a progressive physiotherapy programme commenced.

  2. Radial Head Fixation + Collateral Ligament Repair – In the majority of patients this will be the treatment required. It involves a skin incision (open approach) with the use of screws to fix the radial head fracture (or radial head replacement if not reconstructable) and coronoid fracture, along with repair of the collateral ligaments using a bone anchor and sutures.

What does the rehabilitation/recovery involve?

To find out more about rehabilitation and recovery after upper limb surgery please see our Rehabilitation Protocols here.