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Complex Elbow Dislocations (Terrible Triad Injuries)

The elbow joint is one of the most stable and complex joints in the human body, formed by the articulation of the humerus, radius, and ulna. Despite this inherent stability, high-energy trauma or falls can result in elbow dislocations. Among these, complex elbow dislocations, particularly the terrible triad injury, represent one of the most challenging conditions to treat in orthopedic practice.

A terrible triad injury is characterized by three key components:

  • Elbow dislocation
  • Fracture of the radial head
  • Fracture of the coronoid process of the ulna

The term “terrible triad” reflects the historically poor prognosis associated with these injuries due to instability, stiffness, and risk of long-term arthritis. With modern surgical techniques and rehabilitation, outcomes have improved, but management remains difficult.

Mechanism of Injury

Terrible triad injuries are usually caused by high-energy trauma, most commonly:

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  • Fall on an outstretched hand (FOOSH) with the elbow extended and forearm supinated.
  • The force drives the radial head against the capitellum, leading to fracture, while shear forces avulse the coronoid process.
  • The impact disrupts the collateral ligaments, causing elbow dislocation.

This combination results in both bony and ligamentous instability, making the injury complex to manage.

Anatomy and Pathophysiology

Understanding elbow anatomy is essential in evaluating terrible triad injuries.

  • Radial Head: Stabilizes the elbow against valgus and axial loads.
  • Coronoid Process: Acts as an anterior buttress preventing posterior dislocation.
  • Lateral Collateral Ligament Complex (LCL): Provides posterolateral stability.
  • Medial Collateral Ligament (MCL): Provides resistance against valgus stress.

In terrible triad injuries, disruption of these stabilizing structures occurs simultaneously, leading to gross instability and difficulty in restoring joint congruity.

Clinical Presentation

Patients typically present with:

  • Severe pain in the elbow immediately after injury.
  • Gross swelling and deformity.
  • Restricted or impossible movement due to instability and pain.
  • Neurovascular compromise (rare but possible): injury to the ulnar nerve or brachial artery.
  • Bruising and tenderness around the elbow joint.

Diagnosis

Clinical Examination

  • Inspection reveals deformity and swelling.
  • Palpation identifies tenderness over radial head and coronoid process.
  • Neurovascular status must be carefully assessed.

Imaging Studies

  • X-rays (AP and lateral views)
  • CT Scan
  • MRI

Definitive Treatment

Most terrible triad injuries require surgical intervention.

1. Radial Head Fracture Management

  • Fixation with screws or mini-plates: If the fragment is large and reconstructable.
  • Radial head replacement (prosthesis): In comminuted fractures unsuitable for fixation.

2. Coronoid Process Fracture

  • Fixation with sutures, wires, or small plates: Essential for anterior stability.
  • Even small fragments are repaired to restore stability.

3. Ligament Repair

  • Lateral Collateral Ligament (LCL) repair: Routinely repaired to restore posterolateral stability.
  • Medial Collateral Ligament (MCL) repair: Addressed if instability persists after fixing bones and LCL.

4. External Fixation

  • Applied in rare cases with persistent instability despite internal fixation.

Postoperative Care and Rehabilitation

  • Early mobilization is critical to prevent stiffness. Gentle, protected range-of-motion exercises are initiated within days.
  • Splints or hinged braces are often used to control motion while allowing safe rehabilitation.
  • Physiotherapy focuses on regaining motion, strength, and function.
  • Pain management with NSAIDs and adequate support.

Complications

Despite advances in treatment, terrible triad injuries carry significant risk of complications:

  • Elbow stiffness: Due to scarring and prolonged immobilization.
  • Recurrent instability: If fixation or ligament repair fails.
  • Post-traumatic arthritis: Common long-term issue due to cartilage damage.
  • Heterotopic ossification: Abnormal bone formation in soft tissues, leading to stiffness.
  • Nerve injury: Especially the ulnar nerve.
  • Infection: Post-surgical complication, particularly in open injuries.

Conclusion

Complex elbow dislocations, especially terrible triad injuries, are serious and challenging conditions involving dislocation of the elbow with fractures of the radial head and coronoid process. They result from high-energy trauma and compromise both bony and ligamentous stability of the elbow. Diagnosis relies on clinical evaluation and imaging, with CT scans playing a vital role in surgical planning.

Treatment typically involves surgical reconstruction of the radial head and coronoid process, along with ligament repair, to restore stability and allow early motion. Rehabilitation is crucial for recovery, though complications such as stiffness and arthritis remain common. With timely and appropriate management, many patients can achieve satisfactory outcomes, though complete restoration of pre-injury function may not always be possible.

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